Dr. Staab is Radiology Branch Chief in the Biomedical
Imaging Program at the National Cancer Institute in Rockville,
MD. He is also a member of the editorial advisory board of this
This issue of Applied Radiology focuses on management of imaging
services and general radiology. With the myriad of changes taking
place in the imaging sciences, I would like to discuss two
important issues that may affect the future direction of general
radiology: the core business of radiology and who will do all that
is being asked.
The value of the information obtained from imaging studies for a
wide variety of disease processes is far greater than anyone might
have predicted. In fact, only a few years ago the doomsayers
predicted the decline, if not the extinction, of diagnostic
imaging. Among the concerns that led to these predictions was the
perceived high cost and misuse of "high technology."
I will not refer directly to these articles predicting the
future of imaging and the need for its specialists, but many
influential individuals and societies suggested that too many
radiologists were being trained. Even radiology-specific entities
joined in the fray. Some academic institutions responded by
decreasing the number of resident training positions.
In the 1990s, there was a general trend redirecting potential
radiologists toward primary care and away from high technology.
This was further fueled by a decrease in Federal support for
specialty training and a corresponding increase in primary care
training. Radiology and other subspecialty groups in medicine,
particularly those heavily involved in diagnostic and therapeutic
technology, are now short of trained physicians to meet the demands
of the current system.
Today, imaging is being applied to all fields of medicine.
Physiological imaging of normal and abnormal structures, in
combination with improved morphological imaging, has provided many
new insights into normal and pathophysiological disease states.
Imaging is used by most clinicians to solve problems quickly and
accurately, so patients can be moved through the system efficiently
and effectively. The new advances made in the understanding of
disease with the genome and other molecular breakthroughs have
increased the need for noninvasive examinations of perturbations of
these structures from the effects of drugs and other therapies on a
cellular and molecular level. Robotic technology is being applied
to surgical and interventional procedures of all types. Biomarker
technology is developing rapidly to identify patients at high risk
for various disease states.
Presently, there is an increased demand on imaging sciences for
assistance in the screening and evaluation of these patients. These
and other factors have led to a real shortage of radiologists.
Unfortunately, this shortage will not be resolved quickly. Others
have already pointed out that the shortage of radiologists will
increase dramatically with the aging of the baby boomer
Success should encourage contemplation of what changes can be
made. Already, many other physicians are performing imaging studies
and becoming proficient in their focused areas of interest.
Radiology departments are implementing new methods to increase
productivity, including information technology such as PACS, but
this will only solve part of the problem. The emergence of
computer-aided detection methods will also help. Still, it is no
longer realistic that all, or even most, imaging will remain the
province of radiology.
So, the answers to two important questions may make a difference
in the future of our specialty. They have already been asked
repeatedly, but perhaps now is the time for different answers. How
should we train radiologists for the future? Should we try to
identify a core business and concentrate our education and practice
in a more defined area? Some radiologists could continue to
subspecialize after the core training. Or should every radiologist
continue to be trained in all imaging areas, with the changes in
practice patterns taking place in the marketplace instead? The idea
to limit the core of our training is not new, but it should be a
topic of conversation and thoughtful consideration by everyone in
radiology. The American Board of Radiology deliberates on these
issues continually, but is rightfully very conservative in their
approach. They are directed in part by the mood of the radiology
community, so everyone should consider this matter seriously.
For good reason, we believe that radiologists are the imaging
experts and are the most cost-effective providers of imaging
services, but there are not enough of us. Could we develop another
cadre of individuals as assistants, so we can deliver more of the
services required? Certainly this is being done in most other
medical specialties. These are only a few thoughts to provoke your
interest and discussion at the next
coffee break; perhaps you can provide others.