Preoccupied radiologists miss gorillas in their midst

When Dr. William Brody began his annual oration at the RSNA meeting with an exercise in selective perception, it wasn't entirely in jest. Radiologists were amused when, preoccupied with counting basketball passes, they missed a gorilla marching across the presentation screen. But serious lessons were to be learned from Brody, a board-certified radiologist and president of Johns Hopkins University.

A gorilla does lurk in radiology's midst, and it threatens the profession with obsolescence. The specific form that threat will take is difficult to identify. Often, consensus opinion about the next big thing in radiology has been wrong. Take digital subtraction angiography, a technology that Brody himself championed in the early 1980s. DSA was ultimately overshadowed by an unanticipated development called MRI.

But Brody was clear about where and why the next major threat might emerge. It will come from the combination of radiologist complacency and improving computer technologies. Better integrated circuits have led to smarter computer-assisted detection software. This will soon lead to computers that can diagnose disease better than radiologists, he said.

The addiction of some radiologists to big incomes from high interpretation volumes and their willingness to outsource work to third parties only increase their vulnerability.

"The idea that you can send images off to India, or that you can read all the CTs at the end of the day, is a bad thing for the specialty," he said. "It invites insurers to sell medical imaging off to the lowest bidder."

Radiologists can defend themselves by improving resident training, he said. Resident education should emphasize an interactive style of practice that brings radiologists into frequent contact with patients and referring physicians.

Brody urged radiologists to emulate Johns Hopkins radiologist Dr. Elliot K. Fishman. Fishman is a high-volume CT radiologist, but he also performs many procedures, personally starting IVs and supervising scanning, Brody said.

The profession would also be more secure if radiologists took image-guided therapy more seriously. While computer algorithms may become better at diagnosis, nothing beats a physician personally performing surgery. With increasing frequency, surgery will be percutaneous, minimally invasive, and image-guided.

"Image-guided therapy is the future. If radiology wants a piece of that, it must invest more into training people in being expert and interested in doing invasive procedures," he said.

Because of the uncertainty of the next big issue in radiology, resident education needs to be steeped in basic science. Training people in today's technology only assures their future obsolescence.

Other prominent radiologists agree with Brody's views.

Only a handful of academic radiology departments require their trainees to do research as part of their training, unlike surgery, internal medicine, and pathology where such research requirements are the norm, according to Dr. Stanley Baum, professor emeritus of radiology at the University of Pennsylvania.

"The opportunities for radiology are enormous, but only if original research is done in our departments. There is a revolution occurring in science, and we have to become a part of it," Baum said.

PET/CT should have opened the eyes of all radiology to the potential of molecular imaging, said Dr. James Thrall, radiologist-in-chief at Massachusetts General Hospital. Molecular imaging methods will be used for diagnosis, and image guidance will be adopted to deliver molecular and gene therapies. Radiology residency curricula need to be revised to reflect this new direction.

Radiologists need to use imaging to direct patient care instead of merely reporting findings, said Dr. Hedvig Hricak, director of radiology at Memorial Sloan-Kettering Cancer Center. She agrees with Thrall's assertion that radiologists must continue to perform research.

"In this way, they will always add value to the work of physicians and other specialties, and they will move the practice of medicine forward," she said.