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Centennial Sounding Board |
1 Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-0030.
Received April 5, 2000;
accepted after revision April 20, 2000.
Address correspondence to N. R. Dunnick.
Introduction
 Top Introduction |
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As a child, I remember that when a member of our family became ill, he or she was seen by our family physician, Dr. Branion. He was a kindly gentleman who expressed great concern and empathy, occasionally wrote a prescription, but rarely used ancillary testing. Most often, he dispensed advice, an attitude of caring, and an expression of concern. The natural history of the illness was little altered by medical care. At that time, the physician's ability to diagnose and effectively treat many diseases was limited.
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Since entering radiology, I have witnessed a tremendous increase in the use of diagnostic imaging, which now plays a central role in the evaluation of a patient's medical condition. For example, patients arriving at our emergency department after severe abdominal trauma are no longer required to undergo exploratory laparotomy to identify the source of the problem—CT routinely reveals not only the extent of injury but also the source of bleeding. Diagnostic peritoneal lavage has given way to emergency CT examination (and occasionally sonography) of the abdomen. High-quality imaging studies give clinicians the confidence to observe patients who might otherwise have been taken immediately to the operating room.
Nonacute surgical procedures are markedly affected by imaging studies. Patients with biochemically proven tumors of the adrenal gland can expect to be cured by surgical removal of the tumor. Before effective imaging studies were available, surgery on these patients was performed using an anterior approach to examine both adrenal glands and to identify the gland containing the tumor. With effective localization, a more direct flank incision with simple removal of the ipsilateral adrenal gland is feasible. As a result, surgical morbidity and mortality have been reduced significantly.
The field of laparoscopic surgery depends on accurate imaging studies. Instead of exploratory surgery, abdominal CT is done. Instead of surgical palpation to distinguish a normal from an abnormal organ, imaging is used to direct the surgeon to the pertinent abnormality. Radiologic imaging, especially CT, is essential to exclude disease in other locations and to allow the surgeon to concentrate on the one area of abnormality seen through a laparoscope.
Advances in interventional radiology have been equally dramatic. Percutaneous techniques are now standard treatment for removing stones, draining abscesses, creating access tracks, and removing foreign bodies. Augmentation of regional blood flow is accomplished by percutaneous transluminal angioplasty and placement of a variety of intravascular stents. Filters are deployed to capture venous thrombi and prevent pulmonary emboli. A variety of techniques are available to stop arterial bleeding, obliterate arteriovenous malformations, ablate tumors, and redirect toxic chemotherapeutic agents. Interventional radiologists are now accepted as members of the surgical team when noninvasive treatment is insufficient.
To improve our patient care, we recently established a cross-sectional (CT or sonographic) imaging-guided interventional service to perform percutaneous biopsies and aspirate or drain a variety of fluid collections. Although we provided these services previously, the establishment of an officially designated service allows us to schedule a time to perform the procedures rather than trying to carve time out of a day already filled with diagnostic examinations. The number of these interventional procedures has increased by 63%, year to date, from the previous year. Interestingly, there has been a utilization shift from CT to sonography, which I suspect reflects the growing confidence of the radiologists. We now realize that it is not necessary to precisely define the entire abdominal anatomy before placing a needle into a lesion. And, yes, assigning a physician assistant to the service to triage, coordinate, schedule, and communicate is an enormous help.
Along with advances in imaging technology have come advances in information technology. There is a new level of knowledge and awareness on the part of our patients. Discussions of the use, accuracy, and even risks of imaging studies are pervasive. The level of patient sophistication has reached the point that patients themselves may now specify the diagnostic examination they desire and need. Patients expect sonography when pregnant, CT when disease or injury of the abdomen is suspected, and MR imaging to reveal back or central nervous system problems. An exceptionally knowledgeable patient, who has an inherited disease in which I am particularly interested, calls me each time a member of her family undergoes a radiologic examination. We discuss not only the findings but also the choice of technique and the particular parameters of the examination.
We have educated the public about the need for preventive medicine—immunizations, a healthy lifestyle, and screening examinations such as mammography. I find that we are a victim of our own success as we struggle to increase our capacity to meet the increasing demand for breast imaging.
Discussions of medical topics are not limited to filling television's lower cost daytime hours. Medical programs, especially those involving emergency departments, are some of our most popular television shows. Newspapers, magazines, and television and radio talk shows regularly include medical topics, and imaging tests are frequently included. An enormous amount of information is available on the Internet. Radiologic examinations are often mentioned during news reports about political leaders or prominent personalities. Color commentators at professional football games report that a player is going to the side-lines for an MR examination. Will they be specifying the protocol next?
Radiology has directly affected the daily practice of our clinical colleagues. Physicians who come to the department to review an examination with a radiologist often comment that they are too busy to do a physical examination and want to see what the CT shows first. Consultants ask for the results of imaging tests before they consent to accept a patient being referred to them. The information contained in these imaging studies is deemed so valuable that surgical residents sequester the films to make sure they are available for an operation planned the next day.
Although we will undoubtedly witness further advances in these and other technologies, the issue in the current frontier is the need to disseminate diagnostic information to practitioners dispersed in time and space. Digital imaging could not have come at a better time. Outpatients having an imaging examination at one of our off-site locations have the images sent electronically to the radiology department in the hospital, where the images are then triaged to the appropriate subspecialty section for interpretation. Teleradiology systems are commonly used to send images to physicians' homes for consulation at night. In the future, radiology reports will likely consist of a pertinent image, possibly annotated, and a relatively brief written interpretation. If a picture is worth a thousand words, imagine how brief our reports could be.
For the past several days, I have been having some nagging flank pain. I think I will ask my primary care physician for a referral for an unenhanced multidetector CT examination from the top of my kidneys to the symphysis pubis with 2.5-mm collimation, retros of the true pelvis at 1.25-mm collimation, volume rendered reconstructions, and have the images networked to B1G503. (Just kidding!)
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