The neurologist in the DGH: how to survive without on site neuroradiolgy

hat would be my advice to a young neurologist, boldly birthing from the womb of the neurosciences ivory tower training ground to practice in the reality of medicine that is found in the district general hospital (DGH)?How could it be possible to survive without the skills of the ever available super-expert neuroradiologist and the safety net of the all embracing specialist centre?The basic principles are of course simple common sense, and the specifics depend upon knowing and understanding radiologically useful neuroanatomy and the range of normal appearances.My remarks are directed primarily to the newly appointed consultant as she (or he) takes up a post which involves a mixed neurological practice of the hub and spoke variety or one based mainly in a district hospital.Established consultants will have either resolved the problems or alienated the local general department by insisting that all of her (or his) important examinations are referred up to the neuroradiology department for a ''proper report''.This is not the way forward that I would recommend!Instead I suggest you follow my simple survival course. FUND RADIOLOGICAL SUPPORT cAt your consultant interview, and before you accept your consultant post, make sure that the employing authority has implemented the Royal College of Radiologists guideline for ensuring that extra funds are made available to support your imaging needs.This is equivalent to two sessions of radiology time per new consultant neurologist and one additional session for a replacement post.In this way it will be possible to benefit directly the local radiology service (make a friend for life) or to expand the specialist service in the neuro-centre so that a neuroradiologist can regularly visit the local hospital and forge links benefiting both services.This gives the local radiologist someone with whom they can discuss difficult neurological cases, and allows the neuroradiologist to visit the local hospital to help and advise on cases or scanning protocols and to take part in multidisciplinary meetings.We have found this a great benefit, especially for the neuroradiologists, as the food supplied at the local interdisciplinary meeting far exceeds that at the ''ivory tower''! MAKE FRIENDS WITH THE LOCAL RADIOLOGISTSThis may sound too obvious but it is possible to make working relationships more difficult than they need be if you remain known to your colleagues only as an almost illegible signature on a request card.On your first day at the hospital go to the radiology department, introduce yourself to the consultants, and set up a meeting where you can discuss the type of service they have to offer and the type of service you require.Single out one or two you think you will best be able to work with, and groom them to be your local specialist neuro-imager (see later).Consider making a donation to their library of such excellent neuroradiology textbooks as Anne Osborn 1 or Scott Atlas 2 to stimulate interest and give support. CHECK OUT THE LOCAL IMAGING TECHNOLOGYMost district hospitals will have access to multidetector computed tomography (CT) and 1.5 Tesla magnetic resonance (MR) imaging, and they may be more modern than you have been familiar with.The radiologists will know very well what the scanners are capable of-for example, diffusion MR or submillimetre CT angiography-so ensure that you are familiar with any technical limitations and work around them.The vast majority of your imaging needs can be met with basic MR and multidetector CT.It is unlikely that you will require anything (except catheter angiography and neuro-interventional treatments) that cannot be provided by a general radiology department. ACCESS TO EXAMINATIONSWaiting times differ from hospital to hospital, with many general departments having stringent demands placed upon them for the investigation of patients with possible cancer.If you do have a iii39 www.