What has really happened in radiology since 1985?

These days, the 20th anniversary of a journal is something special. Most journals die younger, particularly those that are not taken seriously by serious readers.

Many people read this magazine, with pleasure and for information they do not get elsewhere. They read it superficially perhaps, as many things are covered and have to be treated superficially. Diagnostic Imaging Europe might not be unique, but it's good. Above all, it is honest, in spite of the highly competitive commercial environment, and it reflects the trends in radiological thinking. Furthermore, it's a European platform reflecting European approaches to medical imaging.

"We live in a global village" is a stupid phrase happily repeated by politicians and the like. However, even such a marginal occupation as ours varies in some respects from one country to another. French radiology is different from German radiology, although the pictures are also produced in black and white. DI Europe allows readers a glimpse across borders, which other journals do not necessarily offer.

To celebrate the anniversary, the editor has asked me to contribute something fitting, perhaps slightly personal. Of course, I rejected this offer. Why talk about myself?

I decided to become a radiologist in the mid-1970s, when I was still at medical school. A major reason for entering the field was my collection of several hundred crime novels. Radiology involved a touch of detection. At that time, radiology was about x-rays, not computing. Years later, most of my crime novels were destroyed in a mudslide, and the rest were lost some weeks later when a hot water pipe in the ceiling of the storage room exploded. But I still liked the "sleuth touch" of radiology.

In the hot summer of 1975, I tried to get my first radiological bearings in a small Swiss hospital. I read a book by Zdansky called Roentgen Diagnosis of the Heart, which was probably not the best introduction to radiology but was one of the best books on cardiac imaging.^1,2 It was very difficult to understand how the shape of the shadow of the heart on a chest x-ray changed according to various acute or chronic diseases. I blamed my limited knowledge of medicine. Only later did I realize that there is no exactness in medicine, and that in radiology sometimes you see what you believe.

This remains true today. If you can take pictures of something and show them to people, they'll believe that what they see in these pictures is important, one of the leading examples being a CT scan of the heart. The question is whether the information obtained has any influence on possible therapy and the health outcome of a patient.

Let's skip some years, countries, and inclinations during my circuitous career in radiology and return to the main topic: What has changed in radiology between 1985 and 2005?

The common answer is nearly everything. The days of plain x-rays have passed for most of us in Europe. Everything is computed, and new modalities have moved in and on. A radiologist with the knowledge that was current in 1985 would not be able to practice in Europe today, whereas a radiologist from 1960 would have had no major problem performing examinations and reading images in 1980.

Breast imaging is the outstanding example of how radiological techniques have changed. Plain x-ray mammography has been the gold standard for decades, although it has improved on a regular basis. In between, we saw xeroradiography and thermography come and go. Xeroradiography seemed to be a promising and more efficient method, but it lacked spatial resolution. Thermography was even worse, and it was unreliable in detecting early carcinoma. Today, conventional x-ray mammography coexists side by side with digital mammography, and MR mammography waits in the wings.

The human body and its diseases and ailments are still the same. Therefore, the medical subspecialties are still the same. Several modalities and techniques are different, however, as the imaging indications have been adapted to new modalities, and the referring physicians ask novel diagnostic questions.

During the last 20 years, ultrasound and MR have been the major new advances in medical imaging, ultrasound dating some years further back than MR. Ultrasound has become a valuable addition to the stethoscope for many physicians, and MR imaging is a clean and elegant modality for answering diagnostic questions in formerly inaccessible parts of the body.

Other developments, among them PACS and spiral CT, are only accessories in the application of computers in medicine, rather than new technologies themselves. Praised as innovations, they are not scientifically innovative.

In many instances, there is little critical analysis. Thinking spoils illusions and is not good for sales.

The German radiologist, Gunter W. Kauffmann, stated in a long and well-founded 1999 article defending radiology, "It is the declared intention of radiologists and their learned societies to intensively stimulate the development and utilization of alternative examination methods without ionizing radiation to minimize the radiation exposition of the population according to the patient guidelines of the European Union."³

Today we see an explosion of powerful CT equipment. It can be argued, however, that multislice CT is a step back into invasiveness. A technology that potentially does bodily harm to the patient should be avoided at all costs,⁴ unless there is proof of its superiority. But there is no proof. The last 20 years have seen the rise of outcome studies and their decline. Outcome studies are strenuous and bad for business. Perhaps science, combined with ethics, will overcome developments that are not called for. On the other hand, science should be open and, within ethical rules, unrestricted.

The last 20 years were also characterized by the growth of the diagnostic business. Increasing commercialization and competition for patients have turned many a radiologist into a businessperson. The boundaries between being a medical doctor and a merchant often blur in the same way that boundaries between medical tools and toys merge.

Checking the contents of radiological journals from the last 20 years reveals that few learned papers seem to have survived or to be relevant today. This is how science is supposed to work. Ideas come and go, but only the fittest ideas survive. Unfortunately "fit" does not automatically mean useful for the patient.

This is nothing new, as Moliere demonstrated in his play A Doctor Despite Himself 350 years ago:

Geronte: It seems to me that you are locating them wrongly: the heart is on the left and the liver is on the right.

Sganarelle: Yes, in the old days that was so, but we have changed all that, and we now practise medicine by a completely new method.⁵

For more than 20 years, the Nobel Prize Committee did not consider radiology to be a major innovative performer in medicine "for the benefit of mankind." Allan M. Cormack and Godfrey N. Hounsfield received the Nobel Prize in Medicine or Physiology for the development of CT in 1979. In 2003, the medical Nobel Prize went to Paul C. Lauterbur and Peter Mansfield for their pioneering research in MRI. Interestingly, among those people involved in their research and invited to the presentation in Stockholm there was, to my knowledge, only one radiologist.

It seems that radiologists are not the source of technological progress in radiology. Of course, this claim is not completely true, but it keeps readers agitated and they will read this entire article.

What happened to radiologists during the last two decades? Not many of them can perform a small bowel enema, an enteroclysis, any more. When did you perform your last lumbar puncture? Everybody, however, knows anatomic structures that radiologists were unaware of 20 years ago. The style of work has changed. Classical x-ray radiology was a craft, often dealing hands-on with the patient. This has been replaced by interventional therapeutic radiology, which also has evolved enormously during this period.

Most of diagnostic medical imaging today is a sedentary occupation that involves pushing buttons and watching pictures on a screen. The techniques have become more intellectually challenging, although interpretation of the hundreds of images created per patient can be more like reading coffee grounds than interpreting a chest x-ray.

I recently gave my archive of early issues of DI Europe to the editorial office. I donated to a library more than 20 years of scientific journals, weighing nearly 1.5 tons. The journals spanned from the very beginning of clinical MRI until the turn of the millennium. Among all those copies of Magnetic Resonance in Medicine, Radiology, European Radiology, I found the 30th anniversary issue of Playboy, dating from 1984.

It has a black cover, like European Radiology, and contained interesting articles. I kept it.

I am looking forward to the 30th anniversary issue of DI Europe-for its color pictures, of course.

PROF. DR. RINCK is a visiting professor at the University of Mons-Hainaut in Mons, Belgium. He can be reached at peter.rinck@umh.ac.be.

References

1. Zdansky E. Rontgendiagnostik des Herzens und der grobetaen Gefabetae. Vienna, 1949.

2. Zdansky E, Boyd LJ. Roentgen diagnosis of the heart and great vessels. New York, 1965.

3. Kauffmann G. Zur Situation der Diagnostischen Radiologie in der Bundesrepublik Deutschland (mit besonderer Berucksichtigung der MRT). [The status of diagnostic radiology in Germany (with special reference to MRI)]. Rofo 1999;170:M7481.

4. Imanishi Y, et al. Radiation-induced temporary hair loss as a radiation damage only occurring in patients who had the combination of MDCT and DSA. Eur Radiol 2005;15:4146.

5. Moliere: Le medecin malgre lui. 1667: scene IV.