Editorial: Moonwalk

By Stuart E. Mirvis, MD, FACR
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Dr. Mirvis 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. Spoiled GRASS 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 causes.

In the meantime, we should all learn to smooth out that moonwalk. Now, if we could only sing too...

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Editorial: Moonwalk.  Appl Radiol. 

November 12, 2007
Categories:  Section

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