| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Letters to the Editor |
Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
Editor:
I enjoyed the article by Dr Williamson (1) and the commentary by Dr Arenson (2) in the December 1998 issue of Radiology, which extol the "electronic transformation of radiology" and paint an exciting picture of our future. However, these authors do not discuss the few potential adverse repercussions of this digital revolution.
Picture archiving and communications systems (PACS) permit large imaging departments to interpret off-site images from widely disparate locations in a single central location. However, the reverse is also true. The current installation of PACS in the radiology department at my institution probably will mean that all musculoskeletal images will be interpreted in the orthopedic clinic rather than in the radiology department. That decision was encouraged by my colleagues in orthopedics and by an administration interested in creating multidisciplinary centers of excellence in multiple specialties. It will promote interdisciplinary interaction and undoubtedly will benefit most patients. However, it also will separate musculoskeletal imagers from the remainder of the radiology department. Similar amalgamation can be anticipated in other subspecialties. This departmental fragmentation is contrary to the physical design of most modern radiology departments, where there are spacious general reading rooms in which most images are interpreted and consultations are rendered. Many chairpersons of radiology departments may resist this erosion of camaraderie and allegiance.
PACS may adversely affect more broadly based radiology subspecialties such as emergency radiology. Computed and digital imaging, along with PACS and teleradiology, permit emergency department images to be interpreted online by remotely located imaging specialists in the musculoskeletal, chest, or neurology sections. Training fellows in academic centers can now have convenient online exposure to emergency images. I suspect that PACS will curtail the development or expansion of dedicated emergency imaging and perhaps even result in intradepartmental turf battles in those departments where these sections are already established.
I look forward to the comments of Drs Williamson and Arenson on these and other divisive issues resulting from this electronic transformation of our specialty.
References
Department of Diagnostic Radiology, Mayo Clinic 200 First Street SW, Rochester, MN 55905
Dr Hall raises a very interesting issue. PACS and teleradiology have begun to transform the practice of radiology. This technology offers obvious benefits, but will there be less desirable effects? What new practice patterns will emerge as we adopt this new technology? And will some of these patterns make radiologists uncomfortable?
1. Diagnostic images can be delivered rapidly to clinicians, with or without radiology reports, thus reducing the need for clinicians to come to the radiology department and potentially decreasing the interaction between radiologists and clinicians.
2. After-hours images from multiple hospitals and emergency departments can be interpreted online at a central location.
3. Subspecialty radiologists can perform primary interpretation, consultation, or overreading of images obtained at remote sites.
4. Instead of assigning radiologists to modalities, images from multiple modalities can be distributed to subspecialty radiologists, so a musculoskeletal radiologist interprets the musculoskeletal images from several modalities, a genitourinary radiologist interprets the genitourinary images from the same modalities, and so on.
5. As Dr Hall mentions, some radiologists may interpret images in clinical areas to be near the patients and clinicians they serve.
6. Timely radiology services can be delivered to locations that are too small to justify a full-time radiologist on-site.
All of these functions are being tried today, but it is not certain which of them will be widely adopted. Other practice patterns certainly will be tried, as well. All of these new patterns will require changes in radiologists' behavior, and some may favor some groups of radiologists over others.
Radical change often involves discomfort, and the electronic transformation of radiology will involve some changes that make radiologists uncomfortable. On the other hand, radiologists are a very adaptable group—witness the changes that our specialty has embraced over the past 25 years. New technology will require changes in our behavior and thoughtful choices on our part, but if we constantly try to do what is best for patients, I believe that PACS and teleradiology ultimately will strengthen our specialty.
We can be sure that PACS and teleradiology will radically change traditional patterns of radiology practice, but, in the final analysis, we probably cannot predict the most profound effects of this technology. As Edward Tenner (1) says of new technology, "the real benefits usually are not the ones that we expected, and the real perils are not those we feared." The next few years will be very interesting ones for radiology!
References
Department of Radiology, University of California, San Francisco 505 Parnassus Avenue, San Francisco, CA 94143-0628
Dr Hall, in his letter responding to the article by Dr Williamson (1) and my commentary (2), raises concerns about the effect of PACS on the traditional practice of radiology. Dr Hall describes a scenario in which a musculoskeletal radiologist was moved from the radiology department to an orthopedic clinic to join a multidisciplinary team. Dr Hall correctly identified the potential with PACS for the interpreting radiologist to be located in an area other than where the images were obtained.
Many institutions, including UCSF Stanford Health Care, are experimenting with service lines, in which physicians and other health care workers are brought together to focus more on the convenience and coordination of care for the patient, thus crossing traditional departmental boundaries. Certainly, PACS can make the radiologist more mobile. Dr Hall argues that the relocation of subspecialty or general radiologists to these remote areas fragments the department. I argue that most of our departments already are fragmented with what could be characterized as "fiefdoms" in subspecialty areas. The neuroradiologists often have more in common with the neurologists and the neurosurgeons than with other radiologists. Likewise, the mammographers interact with the breast surgeons more than with other radiologists. We have great difficulty in finding subjects for grand rounds that are of interest to many of our faculty, yet attendance at the neuroscience rounds is excellent.
Certainly, the model of radiologists sitting in a large reading room, frequently interacting with each other, and showing each other cases of interest is attractive for personal reasons. Patients and their referring physicians benefit from the additional professional input provided by such joint image review. Yet large departments are often fragmented, with dedicated outpatient areas, separate reading rooms, and subspecialty differences. PACS permits the most flexibility to match workload with the best location for each radiologist on the basis of multiple factors such as referring physician location, patient location, and off-hours coverage. In Dr Hall's example, emphasizing the close relationship between the orthopedist and the musculoskeletal radiologist may prevent erosion of turf in that subspecialty area, thus enhancing the care of the patient.
Dr Hall also raised the concern about the demise of emergency radiology because of the ease with which images can be sent to the subspecialist. Dr Hall correctly suggests the possibility of competition among these specialists. I believe that the patient in the emergency department benefits from our subspecialty expertise and that PACS allows for coverage from many sections in the department. The challenge with this distributed approach is ensuring timely interpretations. Radiologists serving patients in the emergency department cannot read the cases in batch mode. These cases must be handled in nearly real time. Some would suggest a return to the "wet reading" desk, but I believe modern technology can help us. Automatically paging the appropriate subspecialty radiologist when images are available on the workstation can speed interpretation and improve our service to patients in the emergency department and their physicians. Off-hours coverage is certainly enhanced by PACS. We also may be able to avoid the turf battles now being waged and often lost with emergency department physicians.
But I have not yet answered Dr Hall's question about the threat to emergency radiology as a subspecialty. With PACS, the emergency radiologist can be located practically anywhere, can seek advice from other subspecialty radiologists conveniently, and can read other cases to balance the workload with other radiologists and adjust to peaks and valleys in emergency cases. The decision to have a particular image interpreted by the emergency radiologist versus another subspecialist must be made on the basis of the individual radiologist's expertise, availability, and interest. In my opinion, the future of emergency radiology is enhanced by PACS, not threatened by it, but emergency radiology probably will become less encompassing than is currently the case in many institutions.
References
This article has been cited by other articles:
|
|
 |
|
  F. M. Hall and J. H. Harris Jr Emergency Radiology Dr Harris responds: Radiology, September 1, 2001; 220(3): 827 - 828. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
