Stephen D. Brown

Beyond Substance Abuse: Stress, Burnout, and Depression as Causes of Physician Impairment and Disruptive Behavior

Disruptive physician behavior may diminish productivity, lead to medical errors, and compromise patient safety. The purpose of this paper is to review how common psychological conditions such as depression, stress, and burnout may drive disruptive behavior in the workplace and result in impaired patterns of professional conduct similar to what is seen with substance abuse. Problems related to these psychological morbidities may be more effectively managed with improved understanding of the conditions and behaviors, their associated risk factors, and the barriers that exist to reporting them. Further research and educational programs are warranted to address how these conditions might affect radiology.

Professional Norms Regarding How Radiologists Handle Incidental Findings

The author reviews the dilemmas posed by incidental radiologic findings and provides an analysis of factors that underlie how radiologists handle them. Particular attention is paid to professional standards that mediate clinical decision making and communication in the setting of risk. The author concludes that individual radiologists should report the incidental findings they detect and use existing evidence-based recommendations when possible. Such recommendations, however, face their own challenge in maintaining consistency with norms around risk-related decision making in other clinical realms.

Do Differences in the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists Positions on the Ethics of Maternal–Fetal Interventions Reflect Subtly Divergent Professional Sensitivities to Pregnant Women and Fetuses?

As therapeutic interventions that are designed for the direct benefit of the fetus have evolved, pediatric specialists along with obstetricians have become increasingly engaged in the management of pregnancies that are complicated by fetal disorders. Do the 2 groups of medical specialists hold differing “world views” on the nature of the maternal–fetal relationship that could have an impact on decision-making? A direct comparison of the positions of the ethics committees of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists concerning maternal–fetal conflicts and fetal therapy reveals subtle but telling differences. Compared with the American College of Obstetricians and Gynecologists policy, the American Academy of Pediatrics statement accords somewhat less weight to maternal decision-making and is more tolerant of overriding maternal refusal of interventions that are recommended for fetal benefit. In doing so, it may oblige pregnant patients to assume greater risk and tolerate diminished autonomy. We urge leaders from both disciplines to meet and seek consensus so that a common approach and language can guide treatment of the patients whom we share.

Microethics: the ethics of everyday clinical practice.

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case-based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from moral philosophy, including consequentialism, deontology, and principlism. In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice.

The etiology and significance of fractures in infants and young children: a critical multidisciplinary review.

This paper addresses significant misconceptions regarding the etiology of fractures in infants and young children in cases of suspected child abuse. This consensus statement, supported by the Child Abuse Committee and endorsed by the Board of Directors of the Society for Pediatric Radiology, synthesizes the relevant scientific data distinguishing clinical, radiologic and laboratory findings of metabolic disease from findings in abusive injury. This paper discusses medically established epidemiology and etiologies of childhood fractures in infants and young children. The authors also review the body of evidence on the role of vitamin D in bone health and the relationship between vitamin D and fractures. Finally, the authors discuss how courts should properly assess, use, and limit medical evidence and medical opinion testimony in criminal and civil child abuse cases to accomplish optimal care and protection of the children in these cases.

CT-guided radiofrequency ablation of pediatric Wilms tumor in a solitary kidney

Although recent results of percutaneous imaging-guided radiofrequency ablation (RFA) of various tumors in adults are promising, RFA of tumors in children has been performed in only a small number of cases. We describe the treatment of Wilms tumor in a solitary kidney in a 5-year-old girl using percutaneous CT-guided RFA. The procedure provided short-term palliation in this child for whom partial or total nephrectomy carried high risk and low likelihood of success. Although it might only be useful ultimately as a temporizing measure, oncologists and surgeons might wish to consider RFA in children who would otherwise require dialysis and renal transplantation or who are poor surgical candidates. Various specific technical issues differentiate pediatric from adult tumor ablation, including the amount of intra-abdominal fat, need for smaller grounding pads, and potential systemic effects of tissue heating.

AJR Teaching File: Intraventricular Mass

Radiologic Description Unenhanced axial CT of the head and brain shows a hyperdense, well-circumscribed 2-cm mass in the atrium of the right lateral ventricle (Fig. 1A). Scant rim calcifications are seen. Only mild adjacent vasogenic edema is seen, and there are no findings of hydrocephalus. Subsequent contrastenhanced MRI reveals the mass to be isointense to gray matter on T1-weighted sequences and hypointense compared with the cortex on T2-weighted imaging, with mild surrounding edema present (Figs. 1B and 1C). The lesion avidly enhances after gadolinium administration (Fig. 1D).

Spontaneous anastomosis of the esophagus in esophageal atresia

An operative technique is described for the management of babies with esophageal atresia, where primary anastomosis is either impossible or unsuccessful. The procedure has been performed on six patients. One infant subsequently required resection of a resultant stricture, and one developed a recurrent tracheoesophageal fistula. All six infants required several esophageal dilatations. No patient required dilatation beyond the age of 5 months and all are now swallowing normally and thriving.

Differing Attitudes Toward Fetal Care by Pediatric and Maternal-Fetal Medicine Specialists

OBJECTIVES: The expansion of pediatric-based fetal care raises questions regarding pediatric specialists’ involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists’ attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations. METHODS: We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%). RESULTS: FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001). CONCLUSIONS: Pediatric and obstetric specialists differ considerably regarding pediatric specialists’ role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.

Stepping Out Further from the Shadows: Disclosure of Harmful Radiologic Errors to Patients

Direct radiologist-to-patient disclosure of harmful radiologic errors comports with our profession’s aspirations toward enhanced patient care, professionalism, and visibility; obstacles to disclosure may be mitigated with education and research and managed by radiology guidelines.