Do radiologists have a future?
n the last six months, I have heard three talks on the future of radiology within medicine – two by radiologists and one by a cardiologist. All speakers concurred that while radiology has a future, radiologists do not. If you look around, you might agree.
Radiology involves more clinical contact than, for example, laboratory medicine, and is at the crossroads of all clinical disciplines. It nonetheless remains an auxiliary tool for medicine and surgery. A surgeon can cut patients and perhaps help them; a gastroenterologist can prescribe pills and stop the diarrhea of a patient. And radiologists – what can they do? Make beautiful x-rays to look at?
"Independent radiologists do not exist, patients do not come straight to them. Radiologists are always dependent on referrals from other physicians."
Independent radiologists do not exist, patients do not come straight to them. Radiologists are always dependent on referrals from other physicians.
The profession of radiologist developed from clinicians who used x-rays as only a part of their daily diagnostics to physicians who were occupied with performing the increasingly more complicated and time-consuming x-ray examinations for the referring clinician. But, because medicine was not so specialized as it is today, radiologists were still required to have a strong general clinical background.
When specialization in medical disciplines accelerated after World War II, general radiology followed suit. Neuroradiology and, in some countries, pediatric radiology, became sub-specialities. It is now obvious that the general radiologist cannot cope with the overwhelming flood of radiological knowledge and procedures that include not only detailed anatomy and morphology, but also metabolic studies, dynamic and kinetic functional studies, as well as complex and sophisticated new technologies.
During the last twenty years, radiological examinations have changed tremendously. Conventional x-ray examinations are now only a minor part of the available imaging armament in many countries. The general radiologist who does not adapt to permanent changes in the fields by sub-specializing is extremely vulnerable. For specific questions, many referring physicians perform the x-ray examinations themselves to ensure quality and save time and money – or make money.
Some clinicians argue that patients benefit when both diagnostics and therapy are performed by someone with a clinical background. Sophisticated electronics and computerized techniques have largely replaced craftsmanship, enabling non-radiologist physicians to easily perform “radiological” techniques on their own and forego seeking the professional advice of radiologists.
New imaging technologies are also attractive to non-radiologist physicians. In most institutions, ultrasound is no longer or has never been part of the radiological domain and specific areas of x-ray angiography are routinely performed by non-radiologists. On another front, MR imaging for specialized applications, such as cardiac and musculoskeletal imaging, may soon be adopted by non-radiologists. Radiologists will be replaced by more clinically knowledgeable cardiologists, orthopedic surgeons, gastroenterologists – and dentists.
The fight of radiologists to exclusively own and operate x-ray and imaging equipment was lost long ago. Likewise, the fight of interventional radiologists to exclude other disciplines from “their” domain is probably doomed to fail. Only where diagnostic radiology is a simple and boring service for other medical disciplines will it continue to exist untouched.
The practice of diagnostic radiology does not include any treatment and, in many instances, lacks direct patient contact. Although it was part of my radiological training to see and talk to the patient before x-rays were taken, this is not done in most cases. The radiologists neither sees nor examines the patient directly, although the clinical history provided by the referring physicians is usually insufficient. The interpretation of the images is based only on the images themselves, increasing the chance for error.
Under such circumstances, it is not far fetched to think that the radiologist could be easily replaced by a service engineer or even by pattern recognition software on a computer. Some physicists with medical background have moved into radiology because they understand the latest technology better than radiologists. They can not only program and operate a computer, but even repair television sets and MR scanners. They do not come close to being physicians, however.
To survive, radiologists must focus on clinical relevance and sub-specialization, either by organ group or by technology. For the sake of the patient, organ group sub-specialization, similar to that of surgeons and internal physicians, seems more sensible and useful than sub-specialization according to technologies. Technologies change, but organs remain the same.
In this context, sub-specialization means acquiring a relevant knowledge so that one is an equal partner of the referring clinical physician. If I cannot talk to a neurologist or neurosurgeon about specific aspects of the central nervous system, they will soon stop talking to me about it and will rightly believe that they can perform and interpret imaging procedures better than I can.
"How do you know? You’re only a radiologist, aren’t you?"
Or, moving to another discipline: What do you know about treatment of knee injuries? Do you know what is important to see and describe on plain x-rays, CT scans or MRI examinations? If so, you belong to the minority among general radiologists – you are already sub-specialized.
If we look at this issue from the service-to-the-patient perspective, why shouldn’t I, as head of a radiological department, hire a cardiologist or ask for cooperation when I know that this specialist has a better knowledge of the clinical relevance of specific cardiological examinations, and when I cannot get an adequately trained radiologist for the job?
Referring physicians, especially young ones, often are unsure about what to do with a patient and hesitate to make diagnostic or therapeutic decisions. They therefore send the patient for yet another examination. Have you ever resisted performing such unnecessary tests, only to be told:
“How do you know? You’re only a radiologist, aren’t you?”
You can survive by convincing your fellow physicians that you are their competent partner – you understand the case history, can select the appropriate diagnostic imaging method and propose a sensible course for the monitoring of therapy and follow-up.
Unfortunately, radiologists remain divided on most of these issues. Some of the radiological societies are immersed in internal political fights, with their functionaries competing to keep their sinecure. If radiologists do not unite among themselves and find a common goal, the circle will close and radiologists will sink into the lower ranks of the medical profession.
1. Guareschi G. Mondo piccolo, Don Camillo. Milan: Rizzoli 1948. The little world of Don Camillo. New York: Pellegrini and Cudahy, 1950.