Teleradiology: Will we be returned to the darkness?

November 1, 2008

I have always loved allegory. Asan art form, it can cause us toexamine our beliefs, to reflect onthe influences that govern ourlives.

I have always loved allegory. As an art form, it can cause us to examine our beliefs, to reflect on the influences that govern our lives.

Take the film Gremlins, for example. The director may not have intended this blockbuster to reflect real life, but it offers remarkable similarities with the life of the everyday radiologist.

Gremlins is a tale about a small and inoffensive race of rather cute beings, Mogwai, who shun the light, avoid water, and must not be fed after midnight. Transgression leads to an evergrowing number of mutant Mogwai- the gremlins-that wreak havoc across the community. The story implies that the mutation occurs by accident, though it is difficult to avoid the conclusion that an evil force was at work.

Radiologists used to be pale and pasty beings that thrived best in dark corners of the hospital. Indeed, many traveled to work wearing special goggles that would protect them from the full rays of the sun until they could enter their natural, dimly lit environment. Only then would they relax in front of the vague green phosphorescence from the x-ray viewing screen.

We were not necessarily creatures of the night, but we flourished after dark. “Brighty light” was used occasionally, but only for particular problems. It would be pejorative to suggest that we avoided water, but the request “wet film please” often caused apoplexy. It is not clear exactly when we ate after midnight- probably at a Congress dinner.

At some stage, we escaped from the dark and emerged into the light. Changing technology, imaging applications, and the rise of image-guided therapy brought many advantages to patients in terms of diagnostic accuracy and safety. These changes brought advantages for the radiology community, too. The range and variety of our work increased, we met and interacted with patients, we became an integral part of multidisciplinary teams, collaborated with our clinical colleagues, and became involved with treatment.

This is where the allegory fails. The radiologist's escape has been for the good.

Or has it? What about the influences of evil at work? Take teleradiology. Now, there is the work of the devil! It is difficult to determine what we have done to deserve this. Perhaps, like the gremlins, we were having too much fun? Or are we just being reclaimed by some other being and returned to eternal darkness, to the PACS workstation and the interminable stream of images? Hysterical thinking, Dubbins! Surely, teleradiology is a power for good.

A host of arguments attest to the value of teleradiology: improved workflow, quicker turnaround times, provision of services in remote communities, image sharing for teaching, improved availability of expert opinion-day or night, improved service coverage during leave or sickness, better strategies for coping with fluctuations in demand, and the ability to work at home.

I know there are examples where teleradiology does work in these ways. Radiology services are enhanced and workflow improved.

So why do I feel uneasy? Technology controlled by experts can bring great benefits. The problem is that the potential advantages of teleradiology are at risk of being subsumed into two objectives: improved turnaround time and cost containment. Major healthcare providers are enthusiastically signing up to outsource at least some of their reporting, if not all. Independent teleradiology providers are hawking their wares, seducing radiologists with promises of additional earnings and the flexibility of homeworking. Faster reporting means higher income. You get paid for what you do. This is the power of the marketplace. Nothing wrong with that, is there?

Review the working week of a radiologist, and you find a multifaceted and multitalented professional. Duties may include discussing imaging strategies with colleagues and individual patients; managing complex departments; teaching, training, and supervising junior colleagues and students; performing minimally invasive imageguided procedures; developing new techniques and validating existing methods-treatment via drainage, embolization, stenting, ablation . . . .

Perhaps teleradiology is just a tool, one of many that puts the radiologist at the center of healthcare delivery.

All tools in the wrong hands have the potential for harm, though. If, as in Gremlins, evil forces are at work, then what is the future for radiologists? Will we be condemned to a life in the dark, barred from human contact, treated as reporting machines, discarded when our reporting speed falls below one standard deviation of the mean?

I suppose there is always the sequel!