Applied Radiology

Dr. Mirvis is the Editor-in-Chief of this journal and Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

In our specialty in particular, we all want to have and use the latest available technology in our practices. For most radiologists, a large part of the attraction of our work is playing with all the cool toys, sometimes referred to as diagnostic imaging equipment, that come to us through the steady march of science, technology, and competitive vendors. We have become very proud of our high-tech glitzy domain and its awe-inspiring gizmos.

At a recent scientific meeting, I had a brief conversation with a radiologist from another hospital that was something like this:

Me: "Hi, how ya doin'?"

Him: "Oh fine, I just got two new 16-slice CTs in my section."

Me: "Oh, I see, how wonderful" (said with limited sincerity). I replied further without complete veracity and more than anything to be irksome,"Well, I guess then I'm fine too, 'cause we just got a 40-slice CT and two new slice 'em and dice 'em turbo-charged workstations, and a new fellow who invented perfusion CT" (just more salt in the wound).

Him: "Oh, wow" (looking at the ground). "So how are your dogs?"

Once the bravado was behind us, we settled into a more relaxed conversation.

The point is, of course, that we really embrace our technology and, perhaps, at least as academics, partly define our value as radiologists by what new equipment we can cajole, beg, and coerce (or blackmail) from department chairs, administrators, and vendors. Of course, veteran radiologists know full well that they were much better in their day making accurate diagnoses with the limited tools available to them. A former fellow informed me that he did not yet have a multidetector CT in their emergency department. I felt like he was more unfortunate than a crippled street urchin. Imagine-the cruel injustice of it. Single-slice CT for emergencies…how can he function under such primitive conditions?

Needless to say, we are amazingly fortunate in the United States to have widespread access to very advanced medical technology, which is certainly exemplified by diagnostic imaging and intervention devices. In some other countries I have visited, they are delighted to have our castoff equipment and seem to do quite well with it.

In our incessant drive to bring the latest technology to bear, I wonder how often we ask ourselves if we really need it. Is this new machine really going to make a difference for patient care or efficient practice? Does what I do in my practice really require this device? Some examples might be: do I really need 3T MRI or will a state-of-the-art 1.5T be adequate? Are 16 detector rows that much better than 4? Do I need a PET/CT or will just a PET scanner and a CT suffice? There is no shortage of similar examples.

Most academic radiologists and a fair number who are not in academia would never even want to ask these questions. That's the adminis-trator's job. We are in the business to ride the crest of the wave, to work with the most ultra-whiz-bang devices, and, for some, to write papers for everyone else to see how wonderful and absolutely necessary this stuff is and how jealous they should be. A rare scientific paper tells us that some new contraption will start fires or make your patients glow for hours or wastes money like confetti. No one wants to read that stuff; it's worse than pleasant stories on the evening news.

As a specialty, we should not assume that each new technologic "break-through" should ultimately become the standard of care. Fortunately, we are usually very careful in our analysis and application of new technology. Also, what we, in the ivory towers of academia, consider the new standard of care for imaging equipment and procedures, can, in some cases, cast institutions without the same capabilities in a negative light as they fall below the "high-end" standard. The cost of upgrading, replacing, and adding equipment should be tempered with an objective understanding of how this decision will actually positively impact patient care. The discipline for us to do this in a credible fashion is something few of us have or want to have. Given the continuing upward spiral of medical costs, with a heavy emphasis on accelerating imaging utilization, we had better develop that discipline, or a bureaucracy will impose it, perhaps without the finesse and knowledge needed to allow the really significant improvements to reach everyday care.