Luminaries make pledge to recapture 'lost' sonography

Radiologists face a choice between relinquishing control of ultrasound for good or reclaiming a modality that could thrive in their hands through the next decade. An indication of which way the specialty is leaning can be gleaned from an October seminar in which luminaries dissected practice trends and applications in use of ultrasound.

The seminar, held during the 2006 Society of Radiologists in Ultrasound meeting in San Francisco, focused on strategic planning for the future of ultrasound in radiology. The group's conclusions are expected to be published in 2007 as a consensus document.

In 1988, Dr. Roy A. Filly predicted that ultrasound would become the new stethoscope. That day may be at hand, given that radiologists now work in an environment in which most clinical practitioners believe they can competently perform diagnostic ultrasound, said Dr. John J. Cronan, chair of diagnostic imaging at Brown University's Rhode Island Hospital in Providence.

"As we look at the proliferation of ultrasound instruments in the hands of untrained physicians, we can only come to the unfortunate realization that diagnostic sonography truly is the next stethoscope: poorly utilized by many but understood by few," Cronan said.

The shortage of radiologists, an obesity epidemic that curtails ultrasound's utility, a payment system that excessively rewards CT and MRI, and the multislice CT revolution have facilitated the migration of ultrasound to other medical specialists. Those specialists have embraced ultrasound because radiologists have not protected their turf. But complacency is also in large part to blame, Cronan said.

"Life is very good as it is," he said.

Several handheld ultrasound scanners have become disruptive rather than sustaining technologies. The clinical market's drive for these cheaper low-end products could severely undermine the continuous development and improvement of high-end ultrasound technology, said Dr. Harvey L. Neiman, executive director of the American College of Radiology.

Radiology as a field must be alert to disruptive technologies and promote and take advantage of sustaining technologies. Sonologists in particular must decide how to expand their role in the coming decades and what direction they need to take, Neiman said.

"Standing still is not an option for survival," he said.

Offshore outsourcing of radiology studies also raises a threat, particularly for ultrasound, considering the outstanding skills of sonologists in Brazil, China, India, and Russia. The ACR has lobbied lawmakers aggressively to make sure overseas readers meet U.S. radiology standards. Protectionist barriers will not be enough, however, to contain the demand for healthcare services from countries with quality and cost comparative advantages. Radiologists in the U.S. need to advance their competitive edge by leading sophisticated research and development, Neiman said.

The lack of FDA approval of ultrasound contrast agents has considerably weakened the prospects for advanced applications. The development of tissue-specific microbubble agents could revolutionize clinical practice in such diverse areas as molecular imaging, intervention, computer-aided detection, and fusion imaging, said Dr. Barry Goldberg, director of the diagnostic ultrasound division at Thomas Jefferson University Hospital in Philadelphia.

But contrast approval remains in limbo, despite concerted efforts by the ACR and the American Institute of Ultrasound in Medicine.

On the bright side, the development of new ultrasound technologies could expand the current boundaries. Miniaturization, 2D arrays and transducers on a chip, optical acoustics, and a number of other ultrasound applications contradict the idea that ultrasound is a mature, static modality, said Dr. Jonathan Rubin, a professor of radiology at the University of Michigan in Ann Arbor.

"With MRI, ultrasound is probably the most interesting imaging technique out there. There are going to be dramatic changes in the future, and we will definitely see them happen. The future of ultrasound is bright. It's going to change everything and change it in ways we can't even predict," Rubin said.

Volume flow and a technology known as photo or opticoacoustics, which combines light and ultrasound imaging, are two new techniques that open up new opportunities, including the possibility of scanning through large body mass and even bone, Rubin said.

Dr. James Borgstede, president of the ACR, put the matter into perspective.

"We must accept competition and enhance our skills to compete. Nonradiologist volume will grow, but ours will continue to grow as well as long as we keep doing quality imaging research. From now on, we must play offense," he said.

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FACTORS INFLUENCING ULTRASOUND PRACTICE

• Lack of interest in ultrasound by radiology
• Self-referral
• Compact ultrasound
• Lack of trained technologists
• "Stagnant" technology
• Relatively poor reimbursement
• Acceptance of ultrasound as the "new stethoscope"
• Commoditization of imaging

Source: Dr. John J. Cronan