What's old is new again, and the world rolls on

April 29, 2010
Bradley M. Tipler, MD

Diagnostic Imaging, Diagnostic Imaging Vol 32 No 4, Volume 32, Issue 4

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists.

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists. The future of radiology is subspecialization, they like to say. “They,” coincidentally, are always subspecialists.

I'm reminded of a line from The Graduate. “I want to say one word to you. Just one word: plastics.” The screenwriter hit the nail pretty squarely on the head. We use ever increasing amounts of plastic in our lives.

I bought a new Mazda, which is 99% plastic. Great for gas mileage, but turned out to be not so The car is when my wife hit a curb at 5 mph and destroyed the front end. Like plastic, subspecialization is ubiquitous in medicine. But also like plastic, it is not synonymous with quality.

There are definite advantages to subspecialization, which subspecialists love to point out. By limiting your field of expertise, you can concentrate your study and CME on that area. This is particularly helpful if you lack the will or capacity to stay abreast of radiology in general. Zing.

The corresponding clinical subspecialists find rapport with you more easily because you all speak the same language. Of course, if either you or they encounter a problem outside your narrow field, you would want to consult the appropriate subspecialists in that field and let them communicate precisely with one another. When that third problem arises you will need a committee meeting.

Or-here is a novel idea-why not have someone who talks all these languages and integrate the problems, a super subspecialist? Patients have a funny way of showing up with more than one problem, or one problem that affects several organ systems at once. We could call this new guy the multi–organ-system subspecialist, or MOSS for short.

The creation of MOSS radiologists has some other, less obvious, advantages. Academic departments could establish new subsections, thereby creating new job opportunities for younger radiologists. Whole new avenues for getting journal articles published, which is so important to many subspecialists and clearly makes you a better doctor, would be available.

Other radiology subspecialists would be able to communicate with MOSS radiologists without fear of stigmatizing themselves by associating with inferior beings. This new field, by combining a broad knowledge of radiology with the ability to integrate the total clinical picture and the total imaging spectrum, would be adding a unique value to the patient's care. This is especially important because value added has always been one of the best ways to assess the practice of medicine.

As we move closer to the corporate model in medicine, I foresee large healthcare organizations employing MOSS radiologists as chairs and central coordinators of imaging departments. Patients admitted to hospitals might have their imaging optimized and initial exams done by a MOSS radiologist, and, when necessary, additional studies could be preformed or interpreted by other subspecialists.

Large outpatient and emergency centers might use MOSS radiologists, comfortable as they are with the myriad of patient presentations, to initially read exams and then determine the course of subsequent imaging and appropriate subspecialty referral. MOSS radiologists would be a central, critical part of the radiology spectrum.

I have been a general radiologist for 25 years. The entire time subspecialty radiologists from various fields have been predicting and promoting my demise. In that same 25-year span I have never heard a single general radiologist call for the end of subspecialization within radiology. Why is that? Sure, you see my mistakes, but I see yours. Part of the problem may be you see more of mine than you see of your own, because you are not second reading your own work. Every general radiologist I know, myself included, has always seen a role for subspecialists in radiology and values their contribution. The difference between us may be an ego thing, like those two plastic surgeons on TV. Do some subspecialists consider themselves the rock stars of radiology?

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