from dure
undergoing in the future.
5. Even
if surgery
patency,
term
a complete as a first
this
gain
documented
higher
with
procedures
surgical
coronary
bypass
procedure
provided
would
be substantially
morbidity
and mortality
(when
grafting
compared
greater
offset
diologist,
proce-
has limited
responsibilities
long-
by the
interventional
enhanced
procedures).
liability
and
responsibility
with the patient. Primary care
physicians,
cific obligations
to
to communicate
as defined
ogists.
plasty (or another bypass procedure
The primary
care physician,
therefore,
between
radiologist
the
and performing
a
1.
Johnston
KW.
of balloon 2. 3.
Femoral
and
angioplasty.
popliteal
Radiology;
arteries:
reanalysis
of results
1992; 183:767-771.
Wilson SE, Veith FJ, Hobson RW, Williams RA. Vascular surgery principles and practice. New York: McGraw Hill, 1987; 348, 366. Doubilet P, Abrams HL. The cost of underutilization. N EnglJ
Med 1984; 310:95-102.
Dr
Johnston
responds:
I agree with some of the points made in Dr Gibson’s letter. In particular, percutaneous transluminal angioplasty (PTA) is often performed at an earlier stage in the patient’s disease. In-
deed,
the patient
profile femoral
and the extent popliteal PTA
of disease
reported
in
my article about is in sharp contrast to those of patients that normally undergo arterial reconstructive procedures at my institution. In most cases, angioplasty and surgery are not competitive treatments but are complementary. The long-standing collaboration and cooperation between the interventional radiologists and vascular surgeons at my institution attest to the importance we attach to the selection of the treatment that is optimum for each patient. On the basis of my experience and the results published by others, I have concluded that good long-term results of femoral popliteal PTA are obtained only for PTA of stenoses with good runoff. I do not imply that PTA should not be considered in patients who have a low chance of long-term success, especially if the risks and benefits of alternative treatment tech-
niques
are also low. I suggest that PTA and surgery should be carefully in similar patients not to assess just the late patency also the relative safety and cost of the procedures.
Thus, compared rate but
a direct
the
relationship
patient.
with
They
have
the patient,
the patient
(2,3).
Conversely,
the
view
spe-
to maintain
decisions regarding
all relevant
courts
have
duty
to make disclosure
management, to provide reasonable formed consent, and to communicate
about in-
diagnoses
to
the responsibility
of
the consultant as limited to communication with and advice the clinicians (4). In fact, courts have held that augmentation the consultant’s role may interfere with the relationship between
the
These
primary
court
care
physician
and
no longer
may act to safeguard
decisions
Many
women
the
“consultant” rectly with
References
re-
directly
by the courts,
6. Angioplasty and other nonsurgical interventional procedures can legitimately be performed at an earlier stage in the patient’s disease because of the substantially lower morbidity and mortality associated with these procedures. In conclusion, angioplasty and/or other current interventional techniques should be used in a complementary fashion with surgical bypass in the treatment of patients with peripheral vascular disease. Regarding these procedures as competitors does patients with this disease a disservice. If a patient is a candidate for either procedure and the angioplasty procedure can be performed at a lower risk for the patient, then data exist to support treating that patient in all cases first with angio-
interventional technique) at a later date if necessary.
with
to patient care (2). Now, however, a number of radioloare involved in freestanding mammography centers and, additionally, may perform biopsy of nonpalpable lesions. Consequently, and under these circumstances, the radiologist has
(2,3) associated with
as a consultant,
gard gists
now
the
patient
are self-referred and
to of
(5,6).
radiol-
for mammography.
will not act as a shield
patient.
Consequently,
the
radiologist must be prepared to communicate the patient to enable her to make an informed
sion. This may an appropriate
entail explanation of the findings specialist for further evaluation. increasing numbers of cases relating
and
di-
deci-
referral
to
Despite to information disclosed relative to informed consent, the courts have not yet applied these arguments to the radiologist (5). Future courts, however, will likely find this theory persuasive as the distinction between the duties of the consultant and the clinician becomes nebulous. Thus, the radiologist must be prepared to accept primary care responsibilities for the patient to avoid potential liability in a malpractice situation. References 1. 2.
Kline TJ, Kline TS. Radiologists, communication, and resolution a medicolegal issue. Radiology 1992; 184:131-134. Townsend v Turk, 266 Cal Rptr 821, 218 Cal App 3d 280 (Cal App
5: 4
Dist 1990). 3.
Mahannah
237 Cal Rptr
v Hirsh,
140,
191 Cal App
3d 1523
(Cal
School
of
App
Dist 1987). 4. 6.
Townsend Townsend Mahannah
U
US
5.
v Turk, v Turk,
266 Cal Rptr 821,824. 266 Cal Rptr 821,826. v Hirsh, 237 Cal Rptr 140, 145.
Evaluation
of Renal
Colic
From: F. Graham Department Medicine 300 Pasteur
Sommer, MD of Radiology, Drive,
Stanford
Stanford,
University
CA 94305-5105
Editor:
I am writing
K. Wayne
Johnston,
Division of Vascular 200 Elizabeth Street,
U
Hospital
in regard to the recent article by Haddad et al in the July 1992 issue of Radiology (1), which compared the effectiveness of ultrasound (US) combined with kidney, ureter, bladder (KUB) radiography with that of intravenous urography (IVU) in the initial evaluation of renal colic. I wish to emphasize an important technical point with respect to the US evaluation of renal colic. Although Haddad et al confirm the effectiveness of KUB radiography and US indicated in some prior studies (2,3), results of some trials have indicated a substantial problem with false-negative results (4,5). I evaluated these studies in an attempt to analyze this van-
PA 19096
ability
MD
Radiologists,
Surgery, Toronto,
Toronto Ontario,
General Canada
Communication,
and
Hospital M5G 2C4
Resolution
5
From: Tess
J.
Kline,
Department
JD,
and
Tilde
S. Kline,
of Pathology,
100 Lancaster
Avenue,
Lankenau
Wynnewood,
MD
Editor: In our article in the July 1992 issue of Radiology (I) we stated that “[T]he radiologist should be cautious of direct communication with the patient except in emergency. . . . [Cjonsultant specialists rarely enter into a relationship similar to that of the primary care physician and the patient.” Traditionally, the ra-
Volume
185
Number
#{149}
3
and
have
noticed
that
the
importance
of patient
hydra-
tion before performing sonography my colleagues and I described this
has not been stressed since technique in 1984 (2). Patients with renal colic are often dehydrated, and I think it is important to make the point that before performing sonography for diagnosis of renal colic-primarily on the basis of asymmetric
drated
pelvicaliceal
orally
or
intravenously
dilatation-the for
patient optimal
results.
must
be
In one
Radiology
hystudy
#{149} 909
1
undergoing in the future.
5. Even
if surgery
patency,
term
a complete as a first
this
gain
documented
higher
with
procedures
surgical
coronary
bypass
procedure
provided
would
be substantially
morbidity
and mortality
(when
grafting
compared
greater
offset
diologist,
proce-
has limited
responsibilities
long-
by the
interventional
enhanced
procedures).
liability
and
responsibility
with the patient. Primary care
physicians,
cific obligations
to
to communicate
as defined
ogists.
plasty (or another bypass procedure
The primary
care physician,
therefore,
between
radiologist
the
and performing
a
1.
Johnston
KW.
of balloon 2. 3.
Femoral
and
angioplasty.
popliteal
Radiology;
arteries:
reanalysis
of results
1992; 183:767-771.
Wilson SE, Veith FJ, Hobson RW, Williams RA. Vascular surgery principles and practice. New York: McGraw Hill, 1987; 348, 366. Doubilet P, Abrams HL. The cost of underutilization. N EnglJ
Med 1984; 310:95-102.
Dr
Johnston
responds:
I agree with some of the points made in Dr Gibson’s letter. In particular, percutaneous transluminal angioplasty (PTA) is often performed at an earlier stage in the patient’s disease. In-
deed,
the patient
profile femoral
and the extent popliteal PTA
of disease
reported
in
my article about is in sharp contrast to those of patients that normally undergo arterial reconstructive procedures at my institution. In most cases, angioplasty and surgery are not competitive treatments but are complementary. The long-standing collaboration and cooperation between the interventional radiologists and vascular surgeons at my institution attest to the importance we attach to the selection of the treatment that is optimum for each patient. On the basis of my experience and the results published by others, I have concluded that good long-term results of femoral popliteal PTA are obtained only for PTA of stenoses with good runoff. I do not imply that PTA should not be considered in patients who have a low chance of long-term success, especially if the risks and benefits of alternative treatment tech-
niques
are also low. I suggest that PTA and surgery should be carefully in similar patients not to assess just the late patency also the relative safety and cost of the procedures.
Thus, compared rate but
a direct
the
relationship
patient.
with
They
have
the patient,
the patient
(2,3).
Conversely,
the
view
spe-
to maintain
decisions regarding
all relevant
courts
have
duty
to make disclosure
management, to provide reasonable formed consent, and to communicate
about in-
diagnoses
to
the responsibility
of
the consultant as limited to communication with and advice the clinicians (4). In fact, courts have held that augmentation the consultant’s role may interfere with the relationship between
the
These
primary
court
care
physician
and
no longer
may act to safeguard
decisions
Many
women
the
“consultant” rectly with
References
re-
directly
by the courts,
6. Angioplasty and other nonsurgical interventional procedures can legitimately be performed at an earlier stage in the patient’s disease because of the substantially lower morbidity and mortality associated with these procedures. In conclusion, angioplasty and/or other current interventional techniques should be used in a complementary fashion with surgical bypass in the treatment of patients with peripheral vascular disease. Regarding these procedures as competitors does patients with this disease a disservice. If a patient is a candidate for either procedure and the angioplasty procedure can be performed at a lower risk for the patient, then data exist to support treating that patient in all cases first with angio-
interventional technique) at a later date if necessary.
with
to patient care (2). Now, however, a number of radioloare involved in freestanding mammography centers and, additionally, may perform biopsy of nonpalpable lesions. Consequently, and under these circumstances, the radiologist has
(2,3) associated with
as a consultant,
gard gists
now
the
patient
are self-referred and
to of
(5,6).
radiol-
for mammography.
will not act as a shield
patient.
Consequently,
the
radiologist must be prepared to communicate the patient to enable her to make an informed
sion. This may an appropriate
entail explanation of the findings specialist for further evaluation. increasing numbers of cases relating
and
di-
deci-
referral
to
Despite to information disclosed relative to informed consent, the courts have not yet applied these arguments to the radiologist (5). Future courts, however, will likely find this theory persuasive as the distinction between the duties of the consultant and the clinician becomes nebulous. Thus, the radiologist must be prepared to accept primary care responsibilities for the patient to avoid potential liability in a malpractice situation. References 1. 2.
Kline TJ, Kline TS. Radiologists, communication, and resolution a medicolegal issue. Radiology 1992; 184:131-134. Townsend v Turk, 266 Cal Rptr 821, 218 Cal App 3d 280 (Cal App
5: 4
Dist 1990). 3.
Mahannah
237 Cal Rptr
v Hirsh,
140,
191 Cal App
3d 1523
(Cal
School
of
App
Dist 1987). 4. 6.
Townsend Townsend Mahannah
U
US
5.
v Turk, v Turk,
266 Cal Rptr 821,824. 266 Cal Rptr 821,826. v Hirsh, 237 Cal Rptr 140, 145.
Evaluation
of Renal
Colic
From: F. Graham Department Medicine 300 Pasteur
Sommer, MD of Radiology, Drive,
Stanford
Stanford,
University
CA 94305-5105
Editor:
I am writing
K. Wayne
Johnston,
Division of Vascular 200 Elizabeth Street,
U
Hospital
in regard to the recent article by Haddad et al in the July 1992 issue of Radiology (1), which compared the effectiveness of ultrasound (US) combined with kidney, ureter, bladder (KUB) radiography with that of intravenous urography (IVU) in the initial evaluation of renal colic. I wish to emphasize an important technical point with respect to the US evaluation of renal colic. Although Haddad et al confirm the effectiveness of KUB radiography and US indicated in some prior studies (2,3), results of some trials have indicated a substantial problem with false-negative results (4,5). I evaluated these studies in an attempt to analyze this van-
PA 19096
ability
MD
Radiologists,
Surgery, Toronto,
Toronto Ontario,
General Canada
Communication,
and
Hospital M5G 2C4
Resolution
5
From: Tess
J.
Kline,
Department
JD,
and
Tilde
S. Kline,
of Pathology,
100 Lancaster
Avenue,
Lankenau
Wynnewood,
MD
Editor: In our article in the July 1992 issue of Radiology (I) we stated that “[T]he radiologist should be cautious of direct communication with the patient except in emergency. . . . [Cjonsultant specialists rarely enter into a relationship similar to that of the primary care physician and the patient.” Traditionally, the ra-
Volume
185
Number
#{149}
3
and
have
noticed
that
the
importance
of patient
hydra-
tion before performing sonography my colleagues and I described this
has not been stressed since technique in 1984 (2). Patients with renal colic are often dehydrated, and I think it is important to make the point that before performing sonography for diagnosis of renal colic-primarily on the basis of asymmetric
drated
pelvicaliceal
orally
or
intravenously
dilatation-the for
patient optimal
results.
must
be
In one
Radiology
hystudy
#{149} 909
1
