Radiology's future needs clinical subspecialization

June 1, 2007

Pictures produced by medical imaging modalities are becoming easier for clinicians to read. At the same time, the volume of information generated in radiology departments is increasing at a rapid rate. Put these two elements together, and you have an argument for greater subspecialization in radiology.

Pictures produced by medical imaging modalities are becoming easier for clinicians to read. At the same time, the volume of information generated in radiology departments is increasing at a rapid rate. Put these two elements together, and you have an argument for greater subspecialization in radiology.

One thing that limits the number of people who interpret radiological images is the unfamiliar format. A series of 2D slices looks quite different from the view of patients that clinicians and surgeons are used to seeing. The technology is available to create 3D "real life" views, but this type of reconstruction is generally regarded as an add-on, rather than as part of the routine workflow. Three-D reconstructions also tend to be lower resolution than 2D slices. So for diagnostic detail, radiologists generally opt for 2D.

In the fairly near future, however, we are likely to see 3D images generated instantly, with resolutions comparable to today's 2D views. The detail on these images will make them increasingly relevant as diagnostic and presurgical planning tools. Inclusion of functional information, possibly at the molecular level, could also assist in clinical decision making.

Specialist surgeons and physicians are likely to have a better understanding of the anatomy and physiology of an organ system in their field of interest than a general radiologist. Given that the images will be presented in a more familiar format, why should they wait for a general radiologist to read them?

For radiologists to retain their role as the experts in image interpretation, they will need not only a thorough understanding of imaging, but also a detailed understanding of anatomy and pathophysiology. It is clearly unrealistic to expect most people to gain that knowledge across every field. The answer has to be subspecialization. Commercial moves to harness the expertise of superspecialist radiologists through teleradiology to provide expert opinions in particularly difficult cases are just the beginning of a major shift in the pattern of practice.

I am not predicting the death of general radiology. Subspecialization in medical and surgical disciplines has not eliminated the need for general practitioners. But if radiologists take no interest in the emergence of highly detailed, user-friendly images, then clinicians and surgeons will simply organize their own department-based image interpretation. If we can train people to have the same pathophysiological knowledge of an organ system as a specialist clinician, and a better understanding of the imaging, then this type of subspecialty radiologist will have a significant role in clinical departments and will be able to drive imaging forward.

Of course, subspecialization is not a realistic option in hospitals and clinics where resources-and radiologists-are scarce. This shift toward more clinically integrated radiology should begin in large institutions, in countries where healthcare is most advanced and investment in radiology is greatest.

If we don't recognize that this change is coming and try to collaborate with clinicians in this manner, there is a danger that clinician-led image interpretation will evolve in an unplanned way. That would undoubtedly disadvantage patients.

Surely it makes sense for radiologists to take advantage of their clinical colleagues' expertise. Looking back at the turf wars between cardiologists and radiologists, what would have happened if the cardiologists had said, "We're happy for radiologists to handle all of the cardiac imaging."? The radiologists would have thrown up their hands in horror and said, "We can't do it. There aren't enough of us!" At the same time, I believe that practitioners offering a cardiac radiology service need to have a detailed understanding of cardiac anatomy and pathophysiology.

Many radiologists already have quite clinically oriented jobs. Most-if not all-radiologists worked as clinicians during the early stages of their medical careers. Should putting the "clinical" back into clinical radiology be that difficult?

PROF. ADAM is a professor of interventional radiology at King's College London. This column expands on themes discussed by Prof. Adam in a lecture to the European Society of Radiology leadership meeting in Vienna, December 2006, on future challenges in radiology. It does not represent the views or aims of the ESR.