The Hospital Oracles

There were oracles in China around 1200 BC who could see the future in ox bones and turtle shells. They would inscribe them with characters, anoint them with blood, heat them up until they shattered, and “read” the fracture patterns to divinate future events. Royals would ask about rainfall, about warfare, about their own health. There were oracles everywhere in the ancient world; in Greece, Africa, and America, people sought the advice of those mystics who could see things they couldn’t.

Oracles still exist in the modern world, except they don’t use ox bones and turtle shells or live in mountaintop temples inhaling hallucinogenic volcanic fumes or whatever. Instead, they use photons and magnets, and you can find them in dark reading rooms deep in the depths of hospitals, staring at humongous monitors and scrolling away and whispering secrets into dictation handsets. Yes, now we call them radiologists.

Okay, they’re not actually oracles, but having observed how other doctors rely on them, they might as well be. Upon interviewing the patient, a medicine doc elicits an ambiguous history of abdominal pain and, by golly, on physical exam their abdomen seems to hurt… Next step, Abdominal CT! The doc puts an order on the computer, waits a few hours, and then receives his arcane answer in the form of a radiological report. In it, an eloquent description of internal physical findings, a succinct radiological impression, and possibly even recommendations for next steps. “They seem like people with answers,” the medicine folk sometimes say.

Sometimes, if the medicine doc seeks an urgent answer, he might go downstairs to the lair of  the oracles: the radiology reading room. The medicine doc can watch along as the radiologist flips briskly through stacks of images of familiar anatomy. Yet, everything looks the same as every other scan he’s seen, filled with indecipherable details which all seem equally unimportant. The radiologist scrolls seemingly at random, eyes wandering lazily about, muttering archaic terms like “hypointense” and “fat stranding” and “beam hardening artifact.” And then all of a sudden, “yeah, this patient has acute appendicitis. Tell the surgeons they might need to do an open procedure. Also he he’s broken a few ribs in the past, he probably has daily reflux, and he has a 20% chance of having a heart attack in the next 5 years.” And the medicine doc will be like “wtf how do you know that.”

Seriously, it’s fun watching radiologists do their thing. They just, see. But they’re not bizarre mystics huddling around smoke pits and there’s no sorcery; those X-rays and CTs and MRIs contain in their pixels and voxels all the information that anyone with eyes can see. Radiologists are just doctors with trained eyes, disciplined search patterns, and a lot of practice.

And it’s a funny field where until you train up that vision, you’re kinda useless. On my two-week elective with them I contributed nothing but my pestering questions, and that was totally okay. I’m familiar with this sort of learning curve; this reminded me of when I taught orgo, and my students thought I was a wizard because with the molecules and reactions, I could just, see. I’m on the bottom rung of radiology from where I can admire their vision, and I wonder how long it’d take me to acquire it.

To be fair, radiologists do seem like out-of-place non-doctor professionals because they work in dark cubicles in front of three oversized monitors and don’t see patients ever. However, they also know more about diagnostic workups and treatment algorithms than most. In fact, much of their day is protocol-ing: ensuring doctors don’t order wrong tests. When radiologists “read,” they exercise exquisite understanding of the human body, much more than medicine who treats it like a sack of electrolytes or psych who treats it like a brain container. Finally, radiologist display otherworldly calm as they all seem to remain quite nice, even when constantly interrupted to answer phone calls and allaying panicked doctors.

Radiology has the precarious position of being built on some of medicine’s most sophisticated technologies. I’m a physics major, and all I know about MRIs (sort of) is that they look at hydrogen atoms as they process in magnets or something. Their PACS (picture archiving and communication system) shuttles terabytes every day. And the infrastructure is expensive! Those monstrous 30” high-def 6K monitors are $13k each, and an MRI magnet is upwards of $1 million!

The field is expanding as all of medicine relies more and more on their divination, for better or for worse. Frankly, the physical exam is now a lost art… Someone walks into the emergency room complaining of chest pain: Chest X-ray! A trauma case gets wheeled into the ED: CT pan-scan! Neuro complaints: head CT, then head MRI! A bedbound patient: daily Chest X-rays! Gyn anything: Ultrasound! However, radiology going to be the first specialty rendered obsolete by advancing technology. Radiology techs are indispensable, but image processing will become powerful enough in the next 25-50 years to supplant radiologists. But until then, the hospital oracles will be there, in the dark reading rooms, comfortably caffeinated, divining the secrets locked inside those scans.