The assessment of usefulness of the qualification card and ultrasonographic consultation.

I am pleased to review the article of Dr. Zbigniew Pilecki et al.(, published in the issue no. 50.

In the comments below, I shall omit the matters concerning the usefulness of the qualification card proposed by the Authors and I shall focus on the second broadly discussed issue, namely the role of surgeons and imaging diagnosticians in the diagnostic process. “Diagnostic process” is understood as all actions, ranging from gathering information from various sources, ordering it, assigning to known disease patterns, to making a therapeutic decision. The fact that the authors undertook the subject, which is somewhat avoided in the medical literature, is their large contribution. The availability of new possibilities of soft tissue imaging, which were previously unknown, and on the other hand, the introduction of new surgical techniques, e.g. arthroscopy techniques in orthopedics, require the reconsideration of surgeons’ and radiologists’ tasks. To make their cooperation effective and beneficial for patients, a range of conditions must be fulfilled. First of all, their roles should be specified – everyone should perform functions according to their training and qualifications. Furthermore, due to the fact that a large part of the imaging scan results is usually presented in a written form, it is crucial to communicate in one language: the words used must mean the same thing for both physicians. Using numerical data or at least, common divisions is indicated. For instance, tear of the supraspinatus tendon with 5 mm retraction constitutes a more precise and valuable piece of information for a surgeon than tear of the supraspinatus tendon with slight retraction. Establishing a common jargon requires common meetings and congresses, which, unfortunately are too few. We may have an impression that our specialties develop separately.

In their work, the Authors presented three models of role division and cooperation between a surgeon and radiologist. They justly criticized the common behavior of patients who, when a problem appears, usually report to an imaging diagnostician in order to perform an ultrasound examination. Such situations should not take place for numerous reasons. It happens, for instance, that so-called referred pain which the patient localizes in a knee may be caused by a pathology of the hip, and the pain in the shoulder may result from cervical radiculopathy or ever from a lung tumor. Therefore, hip or shoulder imaging and focusing on these areas may have tragic consequences. Personally, I do not know how a radiologist in his or her ultrasound office is supposed to solve the patient's problem by simply performing a given examination.

I share the opinion of the Authors that prior to undertaking a fragmentary diagnostic actions by means of imaging, a thorough clinical examination should be performed which is the only way to indicate the site of the pathology. It allows for a qualification of some possibly visible lesions in sensitive imaging examination as clinically silent.

I would like to write a few words about a fundamental problem, i.e. scanty referrals made by clinicians. It is understandable that radiologists would like the surgeons to provide them with as much information gathered during a clinical examination as possible. However, we must become aware of the fact that such information may affect the radiologist's interpretation of an image and suggest a pathology, which in fact is not present. From the point of view of methodology, the results of the examinations performed by radiologists would be the most reliable without providing them with any information from other sources(. This may be compared to blind clinical trials, which have greater value than those whose results are already known by examiners. Unfortunately, it seems that for many important reasons, this is not possible and even undesirable. It is not possible to transfer the rules of clinical trials to everyday diagnostic practice. The problem itself, however, is worth considering. I know many cases from my own experience, where erroneous diagnosis of an orthopedist included in a referral was repeated by an imaging diagnostician. Is it the power of suggestion? Or maybe too great faith in the accuracy of a clinical diagnosis?

Each time I meet with radiologists, we have diverse opinions concerning conducting a clinical examination by a radiologist prior to performing the ordered examination. This problem was also brought up in the discussed publication. The Authors consider this a good practice. My opinion is different for many reasons. The first one has already been mentioned, i.e. the possibility that information obtained from a different source might affect the findings. The second reason results from the division of responsibilities – I am convinced that clinical examinations should be performed by clinicians. They are adequately trained and possess essential abilities. A clinical examination is by no means easy. It brings the greatest amount of information necessary to establish a diagnosis and its performance and interpretation require appropriate experience. During the interview, the examiner must decipher the meaning of the words which patients use when describing their problems. He or she must evaluate the intensity of the problem. For instance, shoulder pain with the intensity of 3–4 in NRS scale that occurs in a young patient after playing tennis and passes spontaneously, will have a different diagnostic significance than constant pain with the intensity of 9–10 in a 60-year-old patient with neoplastic history(.

During physical examination, a physician performs tests which need to be learned. Moreover, the sensitivity and specificity of none of them is 100%. Therefore, a physician must be able to judge them adequately. This is why, I doubt that an average radiologist, when forced to diagnose a whole spectrum of diseases of all organs, will be able to master the knowledge and gain skills that are essential to perform such a clinical examination. Besides, the training program in the field of radiology and imaging diagnostics does not include such issues. It is possible that a clinical examination conducted by an imaging diagnostician may result from insufficient information obtained from the referring physician. If this is the case, we must determine what information is essential so that physicians could perform actions according to their competence and to eliminate the need of reciprocal “help.”

The discussed publication is concluded in the following way: The effect must lead to the understanding of the role and competences of each side: surgeon must examine and then operate and diagnostician has to perform preoperative and postoperative examination(. I cannot agree with such a division of responsibilities. Therefore, I propose an old tested way, i.e.: A surgeon diagnoses a patient with the help of a clinical examination and available selected additional examinations (imaging scans, laboratory tests, electromyography). Next, on the basis of the gathered information, the surgeon, if necessary, proposes a surgical treatment. After the procedure, he or she monitors the patient. If needed, additional examinations are ordered.

To sum up, I believe that the Authors justly paid attention to the problem of optimal use of available imaging examinations in which the rules of cooperation between a clinician and imaging diagnostician must be clearly determined. It does not mean, however, that the ideas they present and promote are not controversial and that they should be accepted without criticism. We must consider the presented problems and discuss them together. This is the best solution for everyone.