Radiologists pledge to recapture sonography

October 19, 2006

Going from gloom to bloom at a seminar yesterday, radiology luminaries dissected the latest practice trends, technological developments, and clinical applications in ultrasound use and turf. Their conclusions, to be published in a major radiology journal, should indicate if radiologists will choose to relinquish control of ultrasound for good or reclaim a modality that could thrive in the hands of experts through the next decade.

Going from gloom to bloom at a seminar yesterday, radiology luminaries dissected the latest practice trends, technological developments, and clinical applications in ultrasound use and turf. Their conclusions, to be published in a major radiology journal, should indicate if radiologists will choose to relinquish control of ultrasound for good or reclaim a modality that could thrive in the hands of experts through the next decade.

The seminar, Strategic Planning for the Future of Ultrasound in Radiology, took place at the 2006 Society of Radiologists in Ultrasound meeting in San Francisco.

Radiologists face an environment in which most clinical practitioners think they can perform diagnostic ultrasound. The future could thus reflect the words of Dr. Roy A. Filly, who in 1988 predicted that ultrasound would become the new stethoscope, recalled Dr. John J. Cronan, chair of diagnostic imaging at Brown University's Rhode Island Hospital in Providence.

"As we look at the proliferation of ultrasound instruments in the hands of untrained physicians, we can only come to the unfortunate realization that diagnostic sonography truly is the next stethoscope: poorly utilized by many but understood by few," Cronan said.

The shortage of radiologists, an obesity epidemic that curtails ultrasound's utility, a payment system that excessively rewards CT and MRI, and the multislice CT revolution may have facilitated the migration of ultrasound to other specialties. Cronan recently wrote an editorial expanding on these and other related issues (JACR 2006 Sept. 3;[9]:645-646).

Other medical specialties have embraced ultrasound because radiologists have not dug any foxholes. But complacency is also in large part to blame, Cronan said.

"Life is very good as it is," he said.

Several handheld ultrasound scanners have become disruptive rather than sustaining technologies. The clinical market's drive for these cheaper low-end products could severely undermine the continuous development and improvement of high-end ultrasound technology, said Dr. Harvey L. Neiman, executive director of the American College of Radiology.

Radiology as a field must be alert to disruptive technologies and promote and take advantage of sustaining technologies. Sonologists in particular must decide how to expand their role in the coming decades and what direction they need to take, Neiman said.

"Standing still is not an option for survival," he said.

Offshore outsourcing of radiology studies also raises a threat, particularly for ultrasound, considering the outstanding skills of sonologists in Brazil, China, India, and Russia. The ACR has lobbied lawmakers aggressively to make sure overseas readers meet U.S. radiology standards.

Protectionist barriers will not be enough, however, to contain the demand for healthcare services from countries with quality and cost comparative advantages. Radiologists in the U.S. need to advance their competitive edge by leading sophisticated research and development, Neiman said.

"Part of this is self-preservation," he said. "But it is important to realize that regulation always breaks down eventually."

The lack of approval by the FDA of ultrasound contrast agents has considerably weakened the prospects for advanced applications. The development of tissue-specific microbubble agents could revolutionize clinical practice in such diverse areas as molecular imaging, intervention, computer-aided detection, and fusion imaging, said Dr. Barry Goldberg, director of the diagnostic ultrasound division at Thomas Jefferson University Hospital's radiology department. But contrast approval remains in limbo, despite concerted efforts by the ACR and the American Institute of Ultrasound in Medicine.

"I guess I could make a very short talk and say, 'in 10 years probably the FDA will approve ultrasound contrast agents'," Goldberg joked. "However, I believe we truly are making progress and I expect that approval will come within the next several years," he said.

On the bright side, the development of new ultrasound technologies could expand current boundaries. Miniaturization, 2D arrays and transducers on a chip, optical acoustics, and a number of other ultrasound applications contradict the idea that ultrasound is a mature, static modality, said Dr. Jonathan Rubin, a professor of radiology at the University of Michigan.

"Ultrasound is probably, with MRI, the most interesting imaging technique out there. There are going to be dramatic changes in the future, and we will definitely see them happen. The future of ultrasound is bright. It's going to change everything and change it in ways we can't even predict," Rubin said.

It was the talk on volume flow and particularly the description of a new technology known as photo or opticoacoustics, which combines light and ultrasound imaging, that really captured the audience's imagination. This opens the possibility to scan through large body mass and even bone.

"There's tremendous opportunities, because the high-end stuff is what radiologists do, and if we are smart enough we are going to still be doing this in the future. Ultrasound has a real future in radiology. I'm just pessimistic about how radiologists view this," Rubin said.

Many radiologists truly believe they can save ultrasound for radiology. But it won't happen as they currently know it, said Dr. James Borgstede, ACR president.

"We must accept competition and enhance our skills to compete. We must market better to our referral base. Nonradiologist volume will grow, but ours will continue to grow as well as long as we keep doing quality imaging research. From now on, we must play offense," Borgstede said.

For more information from the Diagnostic Imaging archives:

Ultrasound unlocks the gates of drug delivery

Ultrasound-guided therapy from U.K. intrigues North American interventionalists

Contrast saves ultrasound in FAST fading ER role

Three-D polishes ultrasound's image, pumps up demand