RANZCR Trailblazers

The Role of the Expert

A large body of expertise and knowledge resides in the membership of the College, gained over many, many years of scientific research and on-the-ground practice. Inside News is pleased to highlight this expertise and introduce the ongoing series RANZCR Trailblazers. We start the series with excerpts from three oral history interviews made in 2015 by the then College archivists, Ms Eva Stokes-Blake and Ms Michelle Goodman.

Experts and expertise have been in more demand than ever during the pandemic experienced in all corners of the globe; as has the crucial sharing of expertise, most clearly demonstrated in the collective ‘race’ to develop a vaccine for the SARS-CoV-2 virus that has dominated health care since early 2020.

Expertise is fed by specialisation, long experience, the pleasure of collaboration and fundamental curiosity for your subject.

“Consider, for instance, the way in which [these] reflections help us to see the need to abandon the orthodox view that experts are those blessed with incontrovertible truths, as if they are substitutes for priests and shamans, and instead to re-imagine experts as specialists who know from long experience some of the worst mistakes that can be made in their field. […]

Experts, seen in this new way, operate as contrarians. They are specialists in contrapuntal reasoning. […] It is much better to see experts as people who know that they do not fully know. Experts have a strong sense of wonder about the world. They are aware that their judgments always teeter on the brink of error.” 1

As one of the 2015 interviewees, Professor Mark Khangure, notes,

I fundamentally believe that you start off with information then you have knowledge, then you have wisdom. Your final practice is knowledge and wisdom, it is not all information, I think the information is hidden in there. It's been applied, it's been gained. This is experience which you actually can't get on a short-term basis.

We thank Michelle Goodman and Eva Stokes-Blake for laying the ground with their extensive work. We would also like to invite your expressions of interest to actively participate in clinician-to-clinician interviews of RANZCR Trailblazers (of your nomination), more details will be available soon on our website. Interviews can be made face-to-face at RANZCR2022 ASM or now in your home city or via an online meeting.

Eva Stokes-Blake interviews Associate Professor Nina Sacharias

ESB: Throughout the course of your career I believe you have specialised in breast and breast cancer awareness, and recently had a breast cancer clinic named in your honour?

NS: A pink bus.

Associate Professor Nina Sacharias

ESB: Could you tell me little bit more about how you got involved in breast clinics?

NS: I seemed to get involved because they needed someone. Breast screening was coming on in Australia and of course in Melbourne, I had a senior radiologist there, Dr Colin Lang, who had seen mammography in the States, with Dr Robert Egan of Houston. He came and grandfathered me. We did mammography, quite slowly. It was very fortuitous really, because the first patient was sent by a surgeon because he thought she had a malignant lump and we did our mammogram and thought it was a cyst. So that was win number one. Win number two was the same surgeon sent a patient to query many cysts, and there were some cysts but there was also a small cancer. So this man was convinced there was a place for it (mammography).

We gradually grew up and changed from film, industrial film which Dr Egan used, we then used xerography which was a blue picture, and then xerography was a bit high in dosage as was the first film, so we changed back to film, as film was safer, or digital now, everything is digital now.

Then something else came along because you get tired of one thing. So then I embraced angiography (blood vessel radiology of both the venous line and arterial line) the arteries were there, and I had to do something with them, some you could dilate, some you could block and so I got a good result. Then I particularly liked the work in the head. I got into screening in a bigger way, then I had this lovely, well, pink bus made… two of them go around the country areas in Victoria and do mammography there for ladies who cannot travel too far into town.

ESB: With your teaching both within the College and in the hospital environment, is there anything you would like to reflect on? Maybe some students that stick in your mind or how the process of education has changed over the years?

NS: I think the process progressed with the equipment, there’s no doubt that once you had a different machine, you would use it, even if you don’t have to. The field of machines was much wider, and then I guess it really became more interesting. I really think the change of the equipment made all the difference because in the good/bad days, we had plain film and barium, barium work and started angiography. I think it was 1968 I saw the first carotid angiogram in Adelaide hospital. I saw it in the field that you could use these various things and it grew from there, then I put up a list of what was correct for what disease, you find that there’s a bit of help from each one of them. You do plain films, it might be good, or you might do a CT and then no, I must have MRI, no neurosurgeon works without an MRI and that’s how it goes and then there’s various sorts of nuclear expressions of the science. There’s all these things to do, you can’t just do one to get a diagnosis.

ESB: Recently you were honoured with the Order of Australia, congratulations again, would you like to reflect on and

NS: It was a surprise. In fact, I never ever, ever, thought about that. All I did, I did because I thought I could do it, because it was there to do. I think people thought I was a bit different because I stayed with the students.

ESB: Is there any achievement that stands out in your mind?

NS: I was in some respects doing things and procedures that other people weren’t. What’s this thing about doing things where angels fail? Don’t tread…

I was very careful in what I did, I didn’t ever push it, so if I was inside a patient and things weren’t as expected, then I came out and thought about it for a couple of days, then put it to the patient, that’s what we’ll do, are you prepared to take the risk? So perhaps, I was never afraid to show I don’t know and would do something about it. Most people were happy to accept it and I had very few complications.

ESB: As an industry mentor, do you have any advice for upcoming radiologists?

NS: I think radiology is a fantastic area or field because its embraces anything that happens to the body and it has found a place in everything that happens. I think you need to be grateful and embrace it with joy. So much to do. I think nowadays the pressure in getting work done, in private, just as much as public, is a little bit against quality.

Sometimes you look at a chest film and see nothing, you do it again and you see something that’s not quite right then you do another film and then there is something. Now that takes three times as long. You need to push harder.

Clin Prof Robert (Nobby) Bourne

Clinical Professor Robert (Nobby) Bourne recalls his days as a trainee

I was a first-year resident medical officer (RMO); we weren’t called interns then.

I decided I want to specialise.[…] In general practice, you'd know something about everything, and I would rather know a fair bit about a particular thing.

[…] I found radiation therapy straightforward because it was only a first part and a second part with a couple of subjects in each. And so, it was a matter of knuckling down, which I did immediately. And that's where I remember the first part was anatomy and physics. And of course, one has to study while being, as I was, a second year RMO and just married, you had to knuckle down and you worked till midnight two nights a week and the weekends, one weekend in three or one weekend in four, and you had to do a night round every day of the week except Saturday, which meant you couldn't do that till after 10 pm. So, one had to work in the remaining available time.

And for the second part, which used to be radiotherapy and pathology, I took 18 months over that and I was assisted greatly by the people at the Radium Institute in particular Dr Kevin Mead who helped me with the more detailed matters. He was an expert clinician and Dr Keith Mohar who was the deputy director was very good on general principles.

So between the two of them, I slotted in well and so I became a radiotherapist after just two and a half years of study. A far cry from what happens now.

And his time as an examiner

I was an examiner for a long time with Dr David Green who was senior examiner until 1985 and he was a really excellent examiner but I don't know if candidates now realise how few candidates there were. You would sometimes have one; two or three would be the norm. On one occasion we got to six, the heavens nearly burst but Dr Green felt and I agreed with him when you have so few candidates that stand if you change the membership of the examination it would be very hard to keep the standard the same for candidates through the years.

So it then remained just David and myself with observers. I want to say that because some people might say, well, it's not right to have so many examiners but normally if you are conducting an exam and you have 20 candidates, the results should form a bell curve and if nobody's answering this [question] or has a clue what it’s about, you can use the pool to see if your standard is right but you can't make a bell curve out of one candidate or even three.

Michelle Goodman: What sort of pass rate was there? Did people tend to pass or did it vary from year to year? They were quite difficult exams.

If you only had two candidates and one failed, it was a 50 per cent pass rate, you see. Well there was a significant failure rate almost always, but not always. Though they would get through the next time. So it wasn't a given that the person would pass and I’ll just say that some candidates were much better than others.

Professor Mark Khangure

Professor Mark Khangure

I have been a great advocate that the radiologists should be specialists, should articulate the fact that he or she is a specialist doctor and not a technician who only provides the imaging. […] I think personally also there's been a great lack of initiative on part of the radiology fraternities, not just in Australia, right around the world, in not shouting from the rooftops of what radiology has achieved.

If you look at all of the major advancements in medicine and surgery, they actually hinge on an initial discovery or development in radiology. […] Yet most of the patients actually say my doctor, you know, treated me with this, it’s not the radiologists. And I when I was doing interventional neuroradiology, I made it absolutely quite clear that I had an outpatients’ clinic; we actually saw the patient, saw all of the relatives, saw the follow up, had equal admitting rights with neurosurgery for patients who were admitted to the ward or to the intensive care unit because I think that we really have to be clinicians first and foremost.

[…] I think that really from the point of view as being the sort of professional side of the equation, other than to maintain every step of the way that the patient comes first, we actually have to have the quality and standards. And if you can't do something, you're not trained to do it, it's appropriate to say no rather than actually do something half-hearted and damage the patient.

[…] The next development after MRI was PACS. You now have a situation where you can have a conversation with colleagues interstate, overseas and they can look at the same dataset so you have this real speed and expertise in providing for your patients.

I mean, nobody knows everything. So sometimes you have an inkling that you really want other opinions and this allows other opinions to be sought very rapidly.

And I think that's also allowed radiology to subspecialise, whether it's a hospital or private practice, solo practices now are virtually non-existent, you have got a group, you've got a group with several different skills, it's only the hands-on procedure that requires the radiologists on site. You can supervise but if you're looking at the imaging study as an opinion, PACS allows it to be seen anywhere. That is wonderful. That has made a huge change into the specifics of patient management.

My next thought process is whether the training structure in the College needs to change as people start looking at more in the way of subspecialisation. You take three body areas where you spend your three, two years and that's what you're examined on and that's your scope of practice. After those three, you might do a fellowship in one, so you are really highly specialised in one, you're really good at two, you don't do the rest. I think you need three at least in order to cover the on call and coverage hospital and in private practice. We're already looking at a separate body interventional cover from neuro interventional cover from general radiology cover. So basically, there's already a process because the person at the other end to whom you're reporting wants value add, he doesn’t want a generalist. He's asking you, he or she is asking you, for a specialist opinion, and I'm afraid I've yet to meet a radiologist who's a specialist in the entire field of medicine, surgery, obs and gyn, paediatrics and psychiatry, it just does not happen.

I think the next step might be recertification. And the question is, how do you do that? I mean, if you ask people to resit the exam, you know, you fail because you are not a generalist anymore.

I mean, I fundamentally believe that you start off with information then you have knowledge, then you have wisdom. Your final practice is knowledge, and wisdom is not all information, I think the information is hidden in there. It's been applied, it's been gained. This experience, which you actually can't get on a short-term basis.

So the College has changed, is changing and it's going to change further. I think, you know, radiology has a huge future if we grasp it.

References

Keane, J. Thoughts on Uncertainty, Journal of Social and Political Philosophy 1.1 (2022): 1–13 DOI: 10.3366/ jspp.2022.0003