I liked Michael Jackson when he was a little kid fronting for the Jackson 5. He was a cute little guy, and he had a great voice. As he grew older, he became more sophisticated and added a lot of great moves to his repertoire of talents. My favorite was the moonwalk, the great illusion of walking forward while really moving backward all the time. Only recently have I realized how much of a metaphor that famous step has become for practicing radiology.
is the Editor-in-Chief of this journal and a Professor of
Radiology, Diagnostic Imaging Department, University of Maryland
Medical Center, Baltimore, MD.
I liked Michael Jackson when he was a little kid fronting for
the Jackson 5. He was a cute little guy, and he had a great voice.
As he grew older, he became more sophisticated and added a lot of
great moves to his repertoire of talents. My favorite was the
moonwalk, the great illusion of walking forward while really moving
backward all the time. Only recently have I realized how much of a
metaphor that famous step has become for practicing radiology.
What I mean is something almost everyone in our specialty
experiences every day. The technology we apply to our craft has
certainly become more sophisticated. Imagine reading off film on
alternators again. (I realize many radiologists still practice in
this fashion, and I apologize to you in making this point.) For
example, if you are used to having PACS and MDCT, going back to
film would probably lead to rapid-onset psychosis. We all know that
CT scanning at ¡Ü1 mm creates a lot of images per study. Since the
technology to do this exists, we use it. Do we really need it? Most
such "perceived improvements" soon become necessities.
Worse, perhaps, is that the improvements intended for very
specific applications become obscenely generalized. If it's good
for one thing, it must be good for everything. Each time a new MRI
sequence is created, it also slips into the standard of practice.
No doubt some of these sequences are extremely useful for specific
applications, but they somehow show up all the time, and they are
almost impossible to kill. I think some MR physicists just like
creating clever acronyms.
is one of my favorites. I see it every day in front of my house. I
am going to create my own personal sequence¡the FUBARN technique:
Fundamentally Useless, But Also Really Necessary.
What happens in radiology is like what happens in government.
New programs are always being added, promoted by special interests,
and we all wind up paying the price whether we use or need them or
not. No matter how anachronistic or counterproductive some
government programs become, they persist because no one has the
guts (political will) to take the scalpel in hand.
The other enemy in all of this is "diagnosis creep." This is a
disease affecting most of our referring physicians. Now anyone with
chest pain becomes a "triple rule-out." Anyone with a headache
needs a CT and maybe also an MRI. Anyone who trips and falls needs
a total-body scan. A potential forearm fracture requires elbow and
wrist radiographs, even if you can hit those joints with a reflex
hammer and get no painful reaction. Since we can rule them out so
efficiently now, everyone has a possible pulmonary embolism,
dissection, brain tumor, active splenic bleeding, etc. I could go
on forever with similar examples.
So what have some of these technologic advances meant to our
specialty? In some situations, we can, in fact, detect disease
earlier in its course, provide a more accurate diagnosis more
quickly, and follow the progress of treatment more precisely, among
many other positive impacts. These imaging advances have led to
radiology becoming the center of diagnosis and of immense
importance in medical care.
On the other side, we are interpreting a huge number of images
more quickly. Considering the varieties of image manipulation tools
offered by workstations, we really have potentially an infinite
number of images. By necessity, we must spend less time on each
study. Perhaps we miss more findings. Perhaps we succumb to earlier
career burnout. As ever more studies ooze into the STAT
classification, we are pressured further to provide very rapid
interpretations for more studies. Now every one takes priority.
No doubt the future holds more of the same. Perhaps we need to
take another look at how we do business. Maybe we do not need to
see all those CT images or all those MR sequences. Perhaps we can
refocus our efforts to get our referring physicians to look harder
at which imaging studies are really required, so that the patients
with real indications get worked up with the focused attention they
deserve and not as part of the hoard. Perhaps some follow-up
studies can be based on clinical factors, not just on the interval
since the last study. Perhaps results from the peer-reviewed
literature can be applied to validating the appropriateness of
selected imaging tests. Perhaps the height of the bar to file
malpractice cases can be raised considerably. On this last point,
let me "opine" that our politicians¡ªall of them¡ªshould be
extremely ashamed as they bemoan the ever-increasing cost of
medical care in our country while defending one of its major
In the meantime, we should all learn to smooth out that
moonwalk. Now, if we could only sing too...