Never forget the importance of intent

Intention deserves more attention in modern radiology, according to a recent commentary published in Academic Radiology, because it’s intent that separates living, breathing radiologists from decision-making machines.

Richard B. Gunderman MD, PhD, of the department of radiology at Indiana University School of Medicine, and colleagues wrote about the importance of intention in radiology, detailing the different ways it can affect performance.

The entire healthcare industry is rapidly shifting toward quality over quantity, with more and more focus on the measurement of various quality measures. However, in the eyes of Gunderman et al., there’s more to a radiologist than his or her turnaround times or patient reviews.

“To gain insight into the true quality of radiologists' work, it is not sufficient merely to add up the numbers,” the authors wrote. “It is necessary to know not only what the radiologist or the radiology department is doing, but also the intentions that lie behind the actions. A radiologist who is simply trying to avoid penalties or earn rewards extrinsic to the patient care, education, research, or professional service is simply not as laudable as a radiologist who is doing much the same thing out of a belief that sincere commitment to such activities is an essential part of a professional and/or personal mission.”

Gunderman’s team said this is more than just a problem with how practicing radiologists are evaluated, because the attitude can spill over into how medical students are judged as they are still learning the skills required to practice radiology.

“Our system of education has become so behaviorally focused—so preoccupied with the behaviors in which learners engage, as observed from the outside—that we are in danger of overlooking their inner moral development,” the authors wrote. “There is a big difference between becoming an admirable physician or human being and merely learning to follow the rules, and we are often so focused on the latter that we neglect the former.”

A radiologist’s intentions, the authors explained, can often influence how one may assess their performance.

They provided an example where two victims of a serious car accident both have hypotension, multiple fractures, and abdominal bruising. The victims are taken to two different emergency departments and see two different on-call radiologists. When one radiologist decides which body protocol to use, they consider the dose of ionizing radiation the patient may be exposed to and the long-term effects that radiation could have on the patient. A risk-benefit analysis occurs, and the double effect--“the harmful effects of a beneficial act are justified if the act is good”--is considered.

The second radiologist comes to the same conclusion as the first, with one big difference: no risk-benefit occurred. The second radiologist was thinking only of reimbursements.

“Despite the results which were identical to those at the first hospital, the second radiologist would have failed the test of the double effect, and most observers would agree that the radiologists' actions were not ethically equivalent,” the authors wrote.

Gunderman’s team emphasizes that this difference between actual radiologists and, say, a computer such as IBM’s Watson, can’t be forgotten as technology continues to change the entire healthcare industry.

“It is time that radiologists and other physicians reaffirm the difference between caring and mere care,” the authors wrote. “Recognizing the distinction between caring about patients and merely caring for them is what makes us fundamentally human and our work humanizing, rather than serving as robotic automatons on an assembly line. Ultimately, we become what we aspire to be.”