Nabile M. Safdar, MD, University of Maryland School of Medicine; Nancy Knight, PhD

As imaging becomes all digital and electronically driven, radiologists find themselves increasingly removed from direct contact with patients. Ad hoc reports of inappropriate radiologist comments about patients are not uncommon. This “state-of-the-reading-room” study was designed to gather: (1) data about the frequency of radiologist comments about assumed race, culture, religion, sexual orientation, sex, or body habitus of patients; and (2) information about how both radiologists and trainees perceive such comments. Based on ad hoc and historical reports about negative remarks about perceptions of patients' racial, gender, or culture, we designed the study to assess whether such remarks persist in the current high-tech, automated environment of the modern reading room setting. The results of more than 100 completed surveys will be presented, along with additional commentary on the extent to which such comments are perceived as detrimental to the practice and training environment.

United States academic radiology department chairs were solicited by e-mail to invite radiologists and trainees to participate in an anonymous, IRB-approved online survey. The survey was pretested on a group of residents and attendings, and the questions were reviewed by a faculty-level expert in survey construction. Participants gave consent online before responding to 33 multiple choice and free response questions about the frequency of overheard remarks, the responses to such remarks, and whether these remarks were perceived as offensive. Results of the first consecutive 100 respondents were aggregated and analyzed for statistical significance.

Although 52% of respondents stated that they always avoided making inappropriate comments about patients, a much larger majority reported having overheard such comments with varying frequency. Participants were given the opportunity to expand on their survey results by providing free-text elaborations of their experience. Numerous free-text descriptions of offensive comments heard in radiology reading rooms were offered, the most frequent concerning patient physical characteristics (body habitus and anatomic dimensions), sexual orientation, or gender. One paradoxical observation was that a few older radiologists indicated never hearing an inappropriate comment in their entire career, whereas many younger respondents expressed discomfort with the fact that they heard such comments from attendings every day. Only a small percentage (8%) of respondents reported ever responding to, or following up on, inappropriate comments.

Radiology is the only discipline in medicine in which physicians at all levels of training and expertise sit in close proximity to one another for long periods of time to perform the tasks that define their specialty. Throughout the 20th century, much image interpretation in large institutions took place in the so-called “ballroom” setting: a large room lined with light boxes or other film viewers and desk/seating combinations at which radiologists could dictate their findings. These rooms were hubs of activity, with technologists coming and going to answer questions and film librarians, aides picking up and delivering films, trainees receiving instruction from senior radiologists, and referring clinicians consulting on the status of their patients. Throughout this period, radiology was largely a male domain. As late as 2006 women represented only 25% of medical graduates, choosing radiology as a specialty.[1-5] And, like much of medicine in the United States, radiology included few minorities in its 20th-century ranks, a challenge that persists today, with radiology among the lowest specialty choices of African American medical graduates (6). As an environment isolated from patients, radiology reading rooms in many institutions acquired reputations for ribaldry and irreverent humor. Depending on the occupants at any given time, practical jokes and sometimes off-color stories lightened the repetitive workload.

The modern all-digital reading room environment differs from that of the last century in several ways. Imaging informatics technologies have largely eliminated technologies and referring physicians from reading rooms. The result is a quieter and even more isolated environment. Both the literal and metaphorical distances between the radiologist and patient have increased. The majority of radiologists never see or speak to the human beings whose images are represented in their work. The work itself is more stressful, with new modalities producing thousands of images in a single study where once only a few images would have been interpreted. The cultural make-up of the reading room is gradually changing as well. Although women and African Americans still make up a small proportion of trainees, increasing numbers of new radiologists in the United States are of Asian or Middle Eastern origin or descent. The result is a new mix of radiologists in an altered environment. Ad hoc reports of persistent patterns of gender-, racial-, and cultural-based derogatory comments, then, are troubling.

In preparing for this study, we conducted interviews with older radiologists from across the United States and heard a number of stories that could be categorized as “local legends” of reading room antics. We also heard examples of racial-, gender-, and cultural-based comments shared by radiologists at their viewing stations. Those comments might be about patients, staff, or general social observations. A number of radiologists recounted stories of individuals whose routine comments about women, different cultures, and nonwhite races were inflammatory and (even by standards of earlier decades) grossly inappropriate. Yet, these comments were tolerated by colleagues, staff, and trainees as eccentricities. Perhaps more troubling was the pervasive perception by radiologists interviewed in preparation for this study that such comments, although toned down, remain an “inevitable” and ultimately “harmless” part of the reading room environment. We heard numerous reports of such comments made, even in the presence of fellow radiologists who were members of the groups targeted by such comments.

The results of this study supported these early observations and indicate that the problem of negative remarks about patients persist and are tolerated at the same time that many radiologists, in particular trainees, are deeply troubled by them. This is a phenomenon that has not been reported in the literature. The time seems appropriate for a broader discussion of the quality of reading room interactions to define challenges that may require remedial action in the future.

Significant variations in perceptions of the professional tone of discourse in the radiology reading room were documented in this multi-institutional survey and may suggest differences in institutional cultures and individual sensitivities. A lack of professionalism in reading rooms may affect interpersonal relationships, discourage open communication, and serve to widen the metaphorical barrier between radiologists and their patients. This aspect of radiology practice is one that is almost universally acknowledged to be the problematic and may be heightened and facilitated in the increasingly isolated modern reading room, but to our knowledge has never been discussed or described in a public forum.