Whither the CR?

By David Weiss, MD, Virginia Tech Carilion School of Medicine
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Dr. Weiss is Physician Coordinator, Imaging Informatics at Carilion Clinic and Associate Professor of Radiology at the Virginia Tech Carilion School of Medicine. He is a member of the Applied Radiology Editorial Advisory Board. Email: dlweiss@carilionclinic.org

By whatever name—plain film, CR, DR—the projection radiograph is the Rodney Dangerfield of radiology. For an entire generation of radiologists about to retire, this modality was the staple diagnostic tool throughout their training and early practice. For the past several decades, however, it has taken a backseat to the sexier, more expensive high-tech studies. The training, skill, and experience needed for in-depth computed radiography (CR) interpretation is about to be lost.

The typical radiology residency consists of multiple sections, each with a mix of cross-sectional imaging and CR. Some of these divisions concentrate training on cross-sectional imaging while abandoning the simple CR to a dusty midden, often read by a semiretired part-time radiologist. Many of these highly experienced physicians have an almost Zen-like ability to combine subtle, almost imperceptible findings into an accurate diagnosis.

It is hardly surprising that CR experience is a low priority among trainees. Even though these images still constitute 50% of many practices, they are, in subtle and not-so-subtle ways relegated to second-class citizenship. The RVU value of a one-view chest radiograph is laughable. Consequently, productivity measured by this standard is much easier to achieve with computed tomography (CT) and magnetic resonance (MR). In some institutions, the down-market CR is not even included in the random peer review process, reinforcing an environment of “who cares.”

With the advent of digital imaging, some technologists trained with conventional film radiography have had difficulty making the transition. Their technique is sometimes poor, with overexposed images that cannot be “corrected” by grayscale adjustment. Moreover, radiologists may have an incomplete understanding of this phenomenon. Photon saturated images can be passed as adequate, when in fact significant clinical findings are being obscured. The viewing conditions so critical to mammographers are often not optimized when reading CR, yet the same principles apply. Even when given a sophisticated PACS workstation and private reading area, some radiologists continue reading in bright light and at suboptimal viewing distances.

In my current practice, our pulmonary medicine fellows are the ones most interested in chest radiograph interpretation. They receive regular conferences and frequent instruction on this topic. For decades, orthopedists have interpreted their own images. Other specialties are doing the same. In 1 or 2 more generations of radiology residents, we may lose the craftsmanship, nurtured over decades, that is necessary for accurate CR interpretation.

To maintain this skill, we should consider adjusting radiologist-training schedules. If time is an issue, the residency could be expanded. Alternatively, interventional radiology could become a separate specialty, a phenomenon that is already de facto in many institutions. This would create more time for specific CR training. Perhaps we should decide whether to continue to embrace CR at all. We could very easily abandon these relics to our clinician colleagues and concentrate on what we now consider truly important, the high-tech cross-sectional study.

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Whither the CR?.  Appl Radiol. 

October 28, 2011



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