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RSNA 2017: Telling radiology’s unique tale offers keys to unlock its future

Knowing that disruption and reinvention of our practices is necessary, we must embrace disruption rather than have it imposed on us by others.

Richard L. Ehman, MD
President, RSNA
November 26, 2017

In his president’s address at the annual RSNA meeting in Chicago, Richard L. Ehman, MD, posed the following rhetorical question: “Is it time to reinvent radiology?” The 103rd president of the RSNA left no doubt that he believes the time is now, and he urged, cajoled, and implored radiologists to roll up their sleeves and engage in the transformation of the specialty.

“This morning I’d like to reflect on your story, the unique origins of the tools that support your essential role in delivering excellent patient care, and the wonderful opportunities that lie ahead as we explore, reinvent, and transform our profession,” he began.

Ehman time-traveled back to an emergency room in 1970. A bad car accident had caused a patient to briefly lose consciousness, and although radiography showed no skull fracture, the patient experienced increasing drowsiness, headache, and nausea.

While a significant epidural bleed was not probable, it was possible. It was, he said, a diagnostic dilemma.

The main diagnostic option, the gold standard, would have been Burr holes, drilling though the skull in various places to check for pools of blood, basically “the same primitive invasive procedure that we know was done 8,000 years ago in Neolithic times,” he noted. “The advent of computed tomography addressed this problem elegantly, and we now take for granted that a quick imaging exam can resolve this uncertainty.”

The role of invention

Many of the most important innovations in medical imaging have been inventions, and the way forward, Ehman suggested, will be paved with the methods of the past—invention, the creation of multidisciplinary teams, and the rapid translation of research into clinical applications.

Ticking off a list of inventions since Roentgen’s discovery that have revolutionized medicine—x-ray tubes using tungsten filaments, barium as a safe GI contrast agent, angiography, expandable stents, CT, MRI—Ehman reminded radiologists that as early adopters of technology, they themselves have played a key role in the development of those inventions.

Most people would say that it was Hounsfield, Cormack, Lauterbur, and the late Mansfield who invented MRI and CT, but Ehman maintained: “In a very real sense, these remarkable diagnostic inventions as practiced today were invented by their users, the radiology community.

“When the technologies were first introduced, few understood how to interpret the images, and pioneers in radiology conducted early clinical studies that gradually deciphered this information. They were true explorers.”

Four unique traits of radiology research

Ehman identified the following four traits that uniquely characterize the field of research in medical imaging:

1.     Medical imaging advances have almost always been the product of teamwork involving not just biomedical science but physics, mathematics, and engineering. Roentgen’s invention, fast Fourier transport, a breakthrough digital processing technique.

2.     Advances and innovations are often rapidly translated, and this is not often the case,  In the US for instance, it takes an average of 12 years for a new drug to make it into the medical cabinet. Radiography was in use within months of Roentgen’s invention, and just four years passed between Hounsfield’s proof-of-concept CT and the commercial availability of the technology for patient care. In MRI, aspirating echo imaging, MR angiography, and parallel imaging also quickly moved from the lab into clinical practice. “Radiologists are fierce early adopters of new technology when they believe it can improve the care of their patients.”

3.     Radiology’s scientific strategy has often been “use-inspired,” unlike the broader medical community, where academic research has been driven largely by basic science. Ehman referenced Stokes’ Pasteur’s Quadrant in giving high marks to radiology’s ability to solve practical problems with research.

4.     Research in medical imaging science often yields an extraordinary return on investment. The founding of NIBIB was an important milestone in changing the perception of the importance of medical imaging science. The NIH supports about $30 billion of medical research that it distributes between about 30 institutes. The productivity of these institutes in yielding new inventions and patents varies widely. The average is 5.5 inventions per $100 million in research, but NIBIB produced more than three times that number.

Reinventing radiology

Ehman suggested that radiology will achieve the transformation that is necessary to tap the full potential of radiology by taking the following four steps.

Recognize and capitalize on the unique aspects of our science. These include use-inspired research rapidly translated for high impact on patient care and multidisciplinary research.

Continue to innovate. Some have wondered if we are reached a plateau when it comes to invention but if you look at exploding content research in journals you will know that this is not the case.

Innovate around value. Perhaps the most urgent need is to innovate practice to optimize value.

Embrace disruption. If radiology doesn’t do this, it will become a victim of disruptive innovation. Innovators enter a market and may not have full functionality of established companies but make their product or service available at a lower price and is more accessible, he explained. Over time, the innovators overtake the mature industry.

“It is now time for radiology to be proactive in adopting innovations that enhance value even if they disrupt the current model of fee for service,” Ehman said.

Fertile areas to explore include machine learning, highly focused protocols, and value-focused re-engineering that will allow radiologists to use their diagnostic tools more proactively and effectively for the benefits of patients in the new world of population-based care.

“Isn’t it possible that we will look back at this time, and it will seem quaint and misguided that we didn’t make better use of our technologies?” Ehman asked. “Knowing that disruption and reinvention of our practices is necessary, we must embrace disruption rather than have it imposed on us by others.”

—Cheryl Proval