Hans Blickman, MD

All medical procedures, including imaging and image interpretation, are relatively risky. But the fact that we make mistakes doesn't mean that we can't control and minimize them.

Today, the multidisciplinary approach and so-called disease pathways are commonplace, and care is centered on patients themselves. We like to think that our digital radiology department is at the center of a well-run medical establishment, the spider in the middle of the web. Procedures are workflow-oriented, and considerable attention is paid to efficiency and quality.

As radiologists, we have to ensure that everything in our part of the chain works smoothly. We need to optimize our workflow and constantly evaluate what kind of information we are delivering, as well as its quality. This is not just about delivering reports on time. The report must make sense, and it must be read and acted upon by the person who requested it.

It should be possible to store, retrieve, and read images made in the radiology department and to send these images wherever they are required 24 hours a day, seven days a week. This could be to another department, another hospital or clinic, or to a colleague who is reporting images from home. The infrastructure to do this must be managed and maintained by the organization as a whole.

The problem with going digital is that your great achievement of today is your baseline for tomorrow. For example, the orthopedic surgeon who was previously happy waiting 72 hours for a report now gets angry if reports do not arrive within minutes of a patient's return from radiology!

How can you maintain this high level of service? We decided that all image-containing data produced at our hospital-the MR images, endoscopy views, pathology results, and neurostereotactic planning data, for example-should be maintained at a single previously identified location. The images need to be archived, but they must still be retrievable virtually instantaneously.

You have an online cache of images that await interpretation, reported images, and data that might be needed when the patient returns, perhaps in three months or even three years. You also need to be sure that when the data are archived, nothing is lost.

Clearly, we are talking about a significant number of terabytes. You will need double-if not triple-redundancy for data security and handling. All the individual imaging data sets and multimedia data sets will need careful protection.

Process management applies to our whole way of working. You might not have to check for dust in film cassettes any more, but you do have to check that the shades of grey you see on the monitor have not faded and that the workstation is not too slow.

Systemwide monitoring of all the database servers and all computers is our next challenge. There is nothing worse than finding that a reporting workstation is not functioning when you have an extensive list of cases to review. We have modified a commercially available system that shows with a green, orange, or red light whether equipment is working, needs watching, or requires immediate action. This visual alert allows the whole system to be checked quickly at the start of each day. Any problems can then be taken care of at once, minimizing downtime.

Our aim is to anticipate problems before they arise. For example, we monitor the storage capacity of the workstation in the angio intervention suite to prevent loss of 3D functionality. We do not want to be faced with an emergency case in the middle of the night and find that digital equipment cannot be used because the hard disk is full.

What about QA of radiologists as well as systems? All of us risk making an erroneous diagnosis. You can never eliminate that risk, but you can minimize it. Double-reading is one option. Peer review is another. Four eyes "see" more than two.

In short, good process management is essential in this digital, patient-centered environment. QA undoubtedly has an associated cost, but so does litigation. 

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Residency training in radiology is being standardized across the European Union. This is crucial, given the many threats to the very existence of imaging departments. There is a shortage of radiologists in EU countries. Medical graduates who want start radiology residencies need to know more and more. Many trainees are also opting to work part time, but they still need to be supervised.

The end product that we are delivering to referring physicians is increasing rapidly in volume and changing in complexity. As more hospitals consider acquiring a PACS and migrating to an electronic patient record, staffing issues arise. Who will direct this process of going digital and furnish and interpret the online images? Should we have supertechs, hobby-radiologists, or some new entity?

Radiology is a recognized specialty in all 42 member nations of the European Society of Radiology. Many of these countries also recognize neuroradiology and pediatric radiology as subspecialties. Yet the qualifications for entering a radiology residency vary, and there is no computerized way of matching those graduates interested in diagnostic radiology with available training places.

The new five-year residency curriculum developed by the ESR education committee is a big step forward. Residents will undergo a mixture of didactic and practical training over the first three years. Teaching will be structured more flexibly in the remaining two years so trainees can develop sufficient competence to function autonomously as general radiologists or subspecialize. All of this must be completed in a 46-hour week, in accordance with EU rules on working time.

Today, however, we also have to instruct trainees in image manipulation, implications of robotic-led therapy, minimally invasive technology, and virtual techniques. Imaging has moved, and continues to move, into spheres of nanotechnology, personalized medicine, artificial intelligence, and molecular imaging. None of us really knows how this will affect the training of future imaging specialists.

We can image a lymph node the size of a match head and detect whether it contains malignant metastatic disease. We can monitor brain surgery in real-time using MRI. But consider how much time this consumes in terms of pre-, peri- and postprocedural image manipulation-and at what cost!

What are the implications for radiology training? Who will decide the protocols, make the 3D reconstructions, and run the computer-aided detection packages? What skills do these individuals need, and how will they obtain them? Do we accept that these trainees will operate outside of radiology's sphere, or do we work as a team to find the best solution?

A number of institutions have already begun to address these issues. The simplest option is to use supertechnologists or staff members with an existing interest in postprocessing and image manipulation. Computer-savvy radiologists and residents have often carried out this type of work in their "spare" time. Another option has been to use medical physicists and IT personnel, though these individuals are sometimes hampered by insufficient medical knowledge. We could also combine medicine and clinical physics, an approach taken by the Technical Medicine degree available at the Technical University Twenthe in close cooperation with Radboud University Medical School here in the Netherlands. Last, as at Massachusetts General Hospital in Boston, U.S, we could try yet another solution: dedicate a group of trained personnel, whose work-and this is crucial-is reimbursed, to image manipulation.

The conclusion is clear. We expand the training of radiology residents, or we seek new players with different skill sets. Perhaps the answer requires a combination of both approaches. Either way, we need to think who should be part of the modern imaging team.

If we are to control our own destiny in the diagnostic chain, we must train the next generation of radiologists in more than a core curriculum. This may mean training as physician extenders personnel with enough medical knowledge to understand the implications of imaging on the diagnostic and therapeutic process who also possess sufficient technical and engineering knowledge to support the same. Expansion of the residency curriculum in the short term is highly unlikely. These people will therefore need to be integrated into residency programs in a piggy-back fashion, possibly learning alongside residents for a specified period of time.

PROF. BLICKMAN is chair of radiology at UMC St Radboud, Nijmegen, the Netherlands. This column is based on his lecture at the Management in Radiology conference in Budapest, Hungary, October 2006.

Residency training in radiology is being standardized across the European Union. This is crucial, given the many threats to the very existence of imaging departments. There is a shortage of radiologists in EU countries.

Hans Blickman, MD

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Training must change as radiology evolves