Guest Editorial: What, are we nuts?

By David L. Weiss, MD
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Dr.Weiss is the Clinical Section Head of Imaging Informatics, Geisinger Health System, Danville, PA.He is also a member of the editorial board of this journal.

I am sitting in a mountain cabin on the Sunday after the RSNA annual meeting, recovering from another week of social and professional hyperstimulation. Snow from an early December storm covers the skylights, creating a subdued light that, sadly, is reminiscent of the PACS reading room to which I will be returning tomorrow. My reverie shifts to anxious anticipation as the peacefulness of the afternoon gives way to thoughts of the chaos of the clinical fray. A quick check of the online schedule--an innovation I have, until recently, happily done without for 20 years--tells me my assignment. I will be covering mammography tomorrow. I wonder how many days behind we are. Surely after the costly and time-consuming installation of full-field digital mammography in July, we must be better off than last year. Not so. The backlog is greater than ever, as radiologist efficiency has suffered in the stampede to soft-copy mammographic interpretation. Were we right to turn to this immature technology that has yet to demonstrate clinical benefit for all patient cohorts? Perhaps we made a tactical error in making the switch at this time.

As a recent shell-shocked refugee from a small private practice, many ask my opinion of the contrast with my current, more academic position in a much larger department. Small private practice, I reply, is dog-eat-dog, but in academics, it is the other way around. The timeless constant is the endless assembly-line supply of images waiting to be manufactured into a radiologic diagnosis. Radiologists have, to some extent, become the 21st century pieceworkers; we have supplanted the sartorial laborers of the Industrial Revolution, who were paid by how fast they could attach buttons and lace in dangerous and uncomfortable sweatshops. Some laborers of this era worked at home--eerily foreshadowing today's grid-working teleradiologists. We must be crazy to emulate this shameful period in history.

Just what is my specific beef with digital mammography? One word: workflow. Most, but not all, radiologists are reporting longer interpretation times for digital mammography versus film-screen mammography. In many ways, reading protocols are more sophisticated than their PACS cousins. However, they are often fully operable for only a specific vendor brand. In many enterprises, multiple vendors are used across a system because of complex political or economic reasons. Even if a single vendor is in use, outside studies for comparison or second interpretation are often not adequately accommodated.

Worklist functionality has also not kept pace. Digital mammography vendors seem to have learned little from the conventional PACS experience, even when the same manufacturer produces both systems. Better accommodations for multiple concurrent readers and more sophisticated filtering functions are required.

Conventional PACS vendors are still designing their software around the mouse and the hopelessly parachronistic computer keyboard. At least mammography vendors are taking a step forward in using an alternate user interface device. Yet this technology could also be improved with the inclusion of more user configurability. Not all navigation commands are currently available on these devices, which still require the distraction of a pulldown menu. This imperfect user interface remains in direct opposition to our primary goal of detecting subtle findings with minimal distraction. "Eyes-free image interpretation" should be the rallying cry of worker unity.

I reserve my most sulfurous resentment, however, for some of the specialty BI-RADS report-creation software. These have not kept pace with the current state-of-the-art reporting systems. With the decreased efficiency of soft-copy reading, it is even more important to minimize extraneous tasks at the workstation, and the majority of these relate to creating a report. The look-away time that some reporting systems require is simply unacceptable. Point-and-click technology must give way to hybrid reporting that combines speech recognition with the structure necessary for data tracking and patient notification. Moreover, this software must be fully integrated with the worklist and navigation features of digital mammography.

What was that? I'm certain I heard a muffled crash through the drifting snow. A tree falling in the woods? No, it sounded more like one of our vendor advertisers hitting the floor. At the risk of being labeled a plodding Luddite, I should expand these thoughts.

No, we did not err in moving to this technology. After all, PACS in its infancy arguably suffered from similar detractions. The current flaws in digital mammography workstations are not permanent; they are merely a self-limited case of adolescent acne. With guidance from IHE profiles, vendors will become more interoperable. Conventional PACS workstations are rapidly becoming suitable for digital mammography. Stereotactic biopsies and needle placements are now much faster, improving patient comfort as well as radiologist efficiency. Ultimately, integration with CAD findings should allow the automated creation of a full report needing only a single radiologist command for report approval and sign-off. In less than 2 years, we will have a markedly decreased dependence on old films or digitized prior studies, streamlining the now hybrid comparison process. Tissue equalization already makes subtle lesion detection in dense breast tissue easier. Tomosynthesis and stereoscopic viewing should further increase diagnostic accuracy. No, this is not an immature technology, but rather a simple case of taking one step back before two steps forward.

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Guest Editorial: What, are we nuts?.  Appl Radiol. 

January 16, 2008

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