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Letters to the Editor |
Department of Radiology, Saint Vincent Hospital, 25 Winthrop Street, Worcester, MA 01604-4593
Editor:
The article by Dr Williamson (1) and the commentary by Dr Arenson (2) superbly point out the incredible effect that computers, PACS, radiology information systems, and their multiple applications will have on the future of the practice of radiology. However, I must take strong exception to Dr Williamson's statement (particularly since he speaks for the Society for Computer Applications in Radiology) that the majority of radiologic examinations do not require the presence of a radiologist. He probably meant to say—although I am not a mind reader, nor do I have the power to put words in his mouth—that the interpretation of a radiologic image does not require the physical presence of a radiologist at the site where the radiologic examination is performed.
As is so commonly done, Dr Williamson ignores the multiple other functions of the radiologist. Who consults with the clinician to ensure that the appropriate examination is requested? Who carefully analyzes the patient's condition with the clinician and suggests a myriad of other diagnostic possibilities? Who educates the clinicians, house officers, and students? Who does quality control and works with the technologists to ensure that the best quality image is obtained with the least amount of radiation? Who develops new technologies and designs their use if the radiologist is not in constant contact with the clinician and patient? And, finally, who communicates with the patient, protects him or her from substandard practice, and is his or her advocate?
Dr Williamson will probably say that the radiology practice I described does not exist. I would respond that radiology must be practiced in this manner if the specialty is going to continue.
Finally, I will end this letter by stating that I know of a superb group of radiologists, all well trained in the United States and practicing in a foreign country, who will be extraordinarily pleased to send written interpretations for the "majority of radiologic examinations" for a small fee.
An on-site radiologist is a necessity.
References
Department of Diagnostic Radiology, Mayo Clinic 200 First Street SW, Rochester, MN 55905
I can hardly argue with Dr Janower's comments regarding the important functions that radiologists perform in addition to the interpretation of images; I have recently written on the subject myself (1). On the other hand, I believe Dr Janower has missed the point of my remarks about the virtual radiology department. The fact that most radiologic examinations do not require the presence of a radiologist at the site of the examination does not mean that implementing an electronic radiology department will result in wholesale interpretation of radiologic images by off-site radiologists. Rather, the major effect of implementing such a department will be to allow the distribution of work to be optimized within a practice. As stated in my article (2), in the virtual radiology department "radiologists can be distributed to the locations where their presence is needed, and images can be distributed to the radiologists wherever they are located."
Perhaps an example from my institution will clarify the concept. Pediatric images are obtained at more sites on our campus than can be covered by our pediatric radiology staff. Even if we did have a sufficient number of radiologists, it would be inefficient to assign a pediatric radiologist to each of these sites, because the number of pediatric examinations at some of the sites is insufficient to occupy a full-time radiologist. Nevertheless, the vast majority of our pediatric images are interpreted promptly by a pediatric radiologist, because these images are obtained electronically and are thus available for interpretation wherever the pediatric radiologist is located. Pediatric radiologists move around the campus obtaining and interpreting images, consulting with clinicians, teaching, and performing other duties. Meanwhile, they are able to interpret images obtained elsewhere on the campus. Thus, pediatric patients benefit from the expertise of a pediatric radiologist, even if one is not present at the site of the examination.
PACS and teleradiology make off-site interpretation possible, but I do not believe this will be a major effect of this technology. Optimization of work within a practice will be a much more important result of the virtual radiology department.
References
Department of Radiology, University of California, San Francisco 505 Parnassus Avenue, San Francisco, CA 94143-0628
Dr Janower, in his letter of response to the article by Dr Williamson (1) and my commentary (2), raises important concerns about the effect of teleradiology on the practice of radiology as we know it. I wholeheartedly agree with his arguments on the importance of the radiologist's presence for teaching, consulting, quality assurance, and communication with referring physicians, technologists, and patients.
Our experiences at the UCSF and with TeleQuest, the national academic teleradiology service, have further convinced me of the importance of such on-site presence. Although our remote interpretations—of mostly computed tomographic and magnetic resonance images—provide the subspecialty expertise the referring physicians and their patients desire, we depend very heavily on the on-site radiologists who inject contrast material and provide those services Dr Janower describes.
Successful practicing radiologists know the value of these personal services. Our referring physicians develop confidence and trust in our consultations largely on the basis of the quality of our interpretations and the wisdom of our guidance. But they also grow to have confidence in us because of the almost daily personal interactions with us.
The challenge for teleradiology is to reach equilibrium between the local on-site radiologist's activities and the remote radiologist's interpretations. The subspecialty expert should also be involved in protocols and quality assurance and needs to have a personal interaction with the on-site radiologist. Does the on-site physician need to be a radiologist? Certainly, other physicians could inject the contrast material, but the quality assurance, consulting, teaching, and personal communications concerning the appropriate procedures and the interpretation results require a radiologist.
In his article, Dr Williamson presented the concept of a virtual radiology department. He described the importance of an on-site radiologist to perform procedures that require patient contact. He also described what some would call reverse teleradiology, which involves bringing cases to a radiologist who is at a particular site because of the need for patient contact, but the local volume of work does not require full-time effort.
The rapid growth in use of the World Wide Web for purchasing services and goods may change the public's view of the importance of personal interactions. But for now, I do not believe Dr Janower needs to worry about the faceless, remote radiologist who does not deal with the important issues he raised.
References
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