The Promise Ahead for Radiology

We know where imaging has been.

We think it’s going to a better place. But exactly when it will get there and what it will look like when it arrives are tough to say. We think the new imaging is going to make radiologists very relevant. It’s going to make medicine more efficient. And it’s going to make patient care better. 

This future will come when imaging “puts the patient first,” as the RSNA says. It will be part of what people are calling “value medicine,” a term that is difficult to define exactly. And it may be easier to define than achieve.

Simply put, value medicine is the practice of medicine that delivers a better outcome for patients as it pushes costs down. It’s efficient. It’s effective. And it’s what everybody wants to hear.

Like world peace, it’s hard to find anybody against it. And, also like world peace, it is a long way from where we now are.

Rule Out Medicine

Modern medicine is all about ruling out what’s not wrong. Doctors who hear hoofsteps may think horses before zebras — but there are a lot of different types of horses. The “if, then” decision-making can be a lot like the game of Mousetrap before — finally — the cage comes down on the truth.

A couple years ago, I walked into my doctor’s office strongly suspecting a torn rotator cuff in my right shoulder. The nurse told me I’d be going first to radiography, which — lucky for me — was just down the hall. I said no. My doctor, who knows me well, told the nurse I would balk. And, really, my position was unassailable.

My symptoms clearly indicated soft tissue damage, something radiography would not show. I needed an MRI, I said. And, in the end, I got one … but not until being X-rayed.

In the end, the insurance company paid more than was needed and I got unnecessary radiation. The radiographs showed great looking bones; the MRI torn muscles. And, a few months after surgery, my arm was moving like it had before.

A Sea Of Giant Question Marks

And yet, I wondered, in cases similar to mine, does radiography ever do the trick? Does it find fractures and eliminate the need for an MRI? Or are MRIs ordered anyway, if for no other reason than to rule out soft tissue damage? Could there be a fracture — and torn muscles? Would it have made more sense to begin with MRI, which — without using ionizing radiation — can pick up even subtle signs of a stress fracture, as well as soft tissue damage? 

They are giant question marks adrift in a sea of many others. Will value medicine replace them with periods? Even exclamation points?

Maybe. If the right questions are asked. And there’s money to dive deep into data. And clinical researchers are willing to take on the questions. And practitioners are willing to change protocol, if one is indicated.

This last consideration may be the toughest of all.

Recently the Center for Medicare and Medicaid (CMS) informed American providers that its payments for film and computed radiography (CR) exams will soon be reduced in favor of those done with digital flat panels. If X-ray demand goes down, providers depending on increased demand to gain a reasonable return on their investments in digital radiography are going to be disappointed.

And what of ultrasound? And echo; angio and cardiac cath; scintigraphy and SPECT, both of which have something to offer; PET/CT and plain old CT — and spectral CT; and, of course, MRI?

Where will all these fit?

It’s going to be a sticky wicket, to be sure. The adoption of value medicine is shaping up to be a promising — but long — slog.

The first battles will be picked for their likelihood to demonstrate real gains. Those gains will be thoroughly documented; implemented; and, after follow-up has demonstrated beyond a shadow of a doubt what everyone expected would be the case, they will be pressed as examples of why value medicine makes sense. And why it should be further pursued. And the slog will continue.

Slowly, the gears of medical practice will be swapped out. Years of virtually imperceptible change will pass and, then, if all goes according to plan, medical practice will change. Will medicine be more efficient and effective? Will imaging have fomented this change? Maybe.

And, maybe, MRI will be the go-to exam for patients suspected of rotator cuff injury.

If I’m lucky, it will happen before I need my other shoulder done. Unfortunately … I’m beginning to feel a bit of a twinge.

Editor's note: This is the second blog in a four-part series on State-of-the-art Radiology. The first blog, "When Will the Greatest Trend in Radiology Happen?" can be found here.