Radiology faces the future: promise and challenges ahead

In the hundred-plus years of its existence, radiology's achievements as a diagnostic tool are perhaps overshadowed only in the context of society's advances as a whole. Indeed, imaging's amazing 20^th century seems to parallel nicely with the transformation of our larger world, from horse and buggy to Jetta, and from the abacus to the Apple.

In "Radiology at the Turn of the Millennium," (Radiology, January 2000; 214:1 pp. 15-23) authors Dr. Alexander R. Margulis and Jonathan H. Sunshine, PhD, take a thoughtful look at radiology now and beyond: as medicine, as a specialty, and as a battleground for turf wars and other forces that could ultimately tear it apart.

Describing the state-of-the-art in each modality, including recent advances in digital, cross-sectional and interventional radiology, the authors assert that, although imaging has now become indispensable in patient care, careful statesmanship will be required to clear the many hurdles that face radiology, and medicine as a whole.

The most dramatic advances have occurred in the past 25 years, with the advent of CT, MRI, ultrasound, interventional radiology and nuclear medicine, areas that were either embryonic or simply did not exist previously. By 1995, the authors state, these emerging fields generated fully 73% of the productivity in radiology.

While imaging in every modality is becoming more precise, functional and metabolic imaging have also come to fore, driven by steady improvements in biologically specific contrast media for all modalities, especially MR. Advances in computing power and miniaturization have also spurred progress, the authors note. Future workstations will even allow simultaneous viewing of ultrasound, CT and MR images, and ultimately the option of image fusion, say the authors.

While developments in the next 25 years promise to be dramatic, the authors caution that each new advance will have to pass three tests in order to prove its worth:

• Will it produce diagnostically accurate images?
• Will it be of substantial value in ordinary, day-to-day practice?
• Will the health dollars be there to pay for those advances that are found to be clinically valuable?

Radiology will become increasingly filmless and digital in the developed nations, say the authors, with cheaper, smaller, and physician-friendlier workstations. Meanwhile, less-developed nations will continue to play perennial catch-up, severely constrained by finances.

Advances in flat-surface digital detectors will make even bedside radiography directly digital, producing high-quality images that will be fed into networks at hospitals, homes and referring physicians' offices. At the same time, better software will allow extensive manipulation of images and data, both current and archived. Repeat exposures are needed less frequently when imperfect images can be adjusted for optimum display qualities.

Digital imaging will continue to fuel the growth of teleradiology, say the authors, with its ability to provide 24-hour access to second readings, and vastly better access to medical imaging in remote communities. On the downside, however, are the loss of direct patient contact that teleradiology brings. Despite its drawbacks, the authors believe that the cost savings associated with teleradiology will remain a powerful argument for its growth. In an interesting side note, the authors say that radiologists' fears of teleradiology as a threat to diagnostic imaging have made interventional radiology more attractive to them.

Low cost and real-time cross-sectional imaging capabilities have combined to make ultrasound the most popular cross-sectional modality in the world, the authors say, and in many parts of the world, the only cross-sectional approach available.

Along with major advances in resolution and noise reduction of the newer machines, improvements in contrast media and Doppler techniques will ensure the modality's continued growth, according to the authors, a picture clouded only by the higher cost of the latest ultrasound machines.

Especially with the advent of helical and electron-beam equipment, CT has become the preferred method in the U.S. for initially assessing many acute abdominal conditions, lung metastasis, primary lung neoplasm, obstructive airway disease, stroke, fractures, renal disease and many other conditions. Meanwhile, 3-D angiographic images are making CT a serious competitor to conventional and even MR angiography, especially in the use of electron-beam CT to detect and assess coronary calcifications, and in the less-invasive thin-section CT approach to angiography, the authors state.

At the same time, improved software has increased patient throughput, making CT techniques easier to perform and more useful than in the past. Software advances have also enabled virtual endoscopic procedures as a noninvasive replacement for conventional endoscopy in many cases. Large-bore CT scanners with in-room monitors are being used for image-guided surgery, and CT fluoroscopy is becoming more widespread. Nevertheless, radiation exposure remains an issue in CT, and is being addressed by the imaging industry.

Better imaging techniques and more sophisticated machines are finally enabling MRI to fulfill its initial promise of becoming the ultimate imaging technique, say the authors. The dizzying array of new applications includes high-quality angiography, spectroscopic imaging, imaging with contrast agents, and medical source imaging -- and on the horizon, functional imaging beyond the brain -- to name just a few. Assessment of tumors is also well suited to MR imaging.

MRI will become an essential part of the operating theater during this decade, the authors predict. Proton MR spectroscopic imaging is now being used to assess the spread of prostate cancer, and will be applied to other diseases in the future. While MR angiography with contrast media is finding wider clinical use, it faces rapidly growing competition from helical and electron-beam CT angiography.

Digital fluoroscopy, along with applications in ultrasound, CT and MR, have given renewed vigor to interventional radiology procedures, say the authors, and industry has seized on the rapidly growing market for devices to support the new applications. Image-guided procedures are reducing costs and advancing the quality of patient care for many procedures, such as abscess drainage, ablation of liver metastases, and introduction of stents through obstructing lesions or through abdominal aortic aneurysms.

While research into new radiopharmaceuticals, techniques and equipment continues to advance PET, its high cost, both in equipment and personnel, has generally limited its use to large medical and university centers, the authors state. However, new, whole-body PET systems cost no more than some gamma cameras, enabling more widespread use of the technology.

Among the most promising developments are advances in single-photon imaging, with peptides and other receptor agents producing high-quality images based on receptor uptake, according to the authors. While research continues in the use of monoclonal antibodies, clinical results for these applications have generally fallen short of expectations. A notable exception, say the authors, is the imaging of cancer in the prostate with the use of an indium 111-labeled monoclonal antibody.

Many factors have contributed to the public's changed perception of physicians, from compassionate healer to just another kind of businessman. Among them is the lack of time available for each patient and steadily rising healthcare costs, coupled with widespread awareness of high physician salaries, say the authors.

The perceptions aren't easily dismissed, considering that the U.S. consistently ranks low in life expectancy and infant mortality, despite spending more of its gross domestic product on healthcare (13.5%) than any other nation. Moreover, technology is responsible for much of the rise in healthcare costs. The authors cite a 1990 study showing that only 3.5% of healthcare costs were attributable to radiology, but note that overall, high-tech imaging has seen one of the highest expenditure growth rates in recent years.

With advances in image quality, clinician specialists are increasingly able to read their own clinical diagnoses -- often quite accurately. In order to retain their clinical value, say the authors, radiologists will need to become knowledgeable in all aspects of physiology, pathology and the latest therapies available in the respective organ systems. They will also need to be experts in the various imaging modalities available for the specific clinical problem addressed. Interventional radiology can also lower costs compared with open surgery. Like specialists, radiologists will need to hone their skills for effective communication with generalists, the authors state.

Managed care offers a way for radiologists to demonstrate their economic value in the diagnostic process, by recommending the specific imaging procedure that will likely provide the diagnosis with the fewest tests and other associated costs. Radiologists should be trained to perform well planned cost-effectiveness and outcome studies, say the authors.

Rather than focusing on producing striking images of the interior of the human body, radiologists will increasingly have to prove the value of those images in order to get paid. Beyond familiar concepts such as sensitivity, specificity, and the predictive values that emanate from high-quality trials, radiologists will need to demonstrate that imaging makes a real difference in what the treating physician does to the patient, perhaps even being required to show a positive effect of their work on the patient's health status.

Managed care, global fees and discrepancy between primary care and procedures all fuel the growth of turf wars, say the authors. While radiologists believe that specialists have invaded their turf, most acutely in angiography, ultrasound and nuclear medicine, specialists believe that radiologists are encroaching on their territory.

Non-radiologists clearly dominate in ultrasound; the authors cite a 1998 study showing that the radiology portion of the $890 million U.S. ultrasound market amounted to only $269 million. The authors suggest that turf wars can be minimized by having teams of radiologic specialists and subspecialists work together and support each other, and having radiologists work more closely with primary care physicians.

Although the motivation for radiologists to join forces with related departments is understandable, both for economic reasons and to avoid turf wars, the authors suggest that by maintaining their main affiliation in radiology whenever possible, radiologists are better able to keep up with technological advances in the field, and thus increase their value to the related non-radiological departments.

Ultimately, say the authors, it is not enough for radiologists to claim they are better at imaging than clinicians. They must demonstrate their value in sound research and credentialing processes, and successfully demonstrate the value of their methodology to clinicians and decision-makers.

The government is trying to control healthcare costs largely by administrative bureaucracy, say the authors, most often by limiting reimbursement. Once again, the authors state that activism and public education are the only effective ways to combat the trend.

For all its difficulties, say the authors, radiology continues to attract the best and brightest students, and continues to grow in importance worldwide, with technology trickling slowly but inexorably to the less-developed nations. Through advances in technology, computers, and collaboration with molecular and evidence-based medicine, radiology is destined to remain a powerful force in clinical diagnosis.

By Eric Barnes
AuntMinnie.com staff writer
January 20, 2000

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