Editorial
Radiologists: Threatened by a Veritable Identity Crisis?
Werner Golder*
Department of Nuclear Medicine, Medical Imaging, France
*Corresponding author: Werner Golder, Department of Nuclear Medicine, Medical Imaging, France
Published: 20 Feb, 2017
Cite this article as: Golder W. Radiologists: Threatened by
a Veritable Identity Crisis?. Clin Oncol. 2017; 2: 1212.
Editorial
Radiologists have always found it harder than representatives of other disciplines to ensure
that their patients perceive and recognize them as true physicians rather than medical technicians.
They are too strongly and too unilaterally associated with the machines they operate and with their
products; in many cases, they are also too far removed from the pain and anxiety that prompted
the patients to see a physician. Many radiologists have come to terms with this situation, accepting
their role as representatives of a paramedical science more or less uncomplainingly and trying to
make the best of things. No radiologist likes to be described as an academic photographer, but this
unflattering epithet cannot be rejected entirely. The interpretation of conventional radiographs is
an art and deserves to be recognized as such, but radiologists cannot claim to be the sole diagnostic
agency and must share the prerogative of interpretation with others. Prime examples are specialtyspecific
diagnostic imaging – e.g., for orthopedic specialists - and the undisputed authority of
other disciplines, such as dentistry, in adapting the imaging material to the case and treatment.
The radiologist`s status is inferior to the clinician`s - in individual cases considerably so – and
radiologists do not diminish this inferiority when they ask their referrring colleague what the latter
expects to find from their report. Physicians who request examinations can supply most of the
answers themselves, based on their specialist training and several years of practical experience in
their discipline. The surgical specialities also have the advantage that they can compare the images
directly with the site. No consultative discussion or clinical-radiological meeting can compensate
for this privilege.
Diagnostic illustration freely available everywhere
In the long era of analogue imaging, radiologists subservient role was confined to the
interpretation of images. With the digital revolution, however, they are also suffering the same
fate as their production, namely with data acquisition. Unlike the conventional radiograph, the
digital radiograph is no longer a definitive, unique document, this product can no longer claim
unrestricted copyright. Although radiologists obtain the dataset, they have no influence over what
is done with it and what is made of it. The radiographic representation they have chosen is only
one of many alternative ways of presenting the dataset optically. This limitation applies both to
projectional radiography and diagnostic cross-sectional imaging. Whoever receives the raw data
of an examination with the data pack can use the integrated program to post process the image
impression on the computer and thus alter the content information at will. The computerized
analyses and syntheses - Computer Assisted Diagnosis (CAD) included - do not just make the
images potentially more presentable; they also make them more meaningful, easier, and more
reliable to interpret. In assessing CT and MR images, knowledge of the subtleties of classical
radiologic anatomy, has become dispensable. Two-dimensional, 3D and 4D reconstructions give
the raw dataset an impressively sculpture-like quality; the computer-assisted evaluation at least
partially anticipates the radiologist`s diagnostic judgement, making it an alternative or competitor.
The digital revolution has indivualized and boundlessly liberated data manipulation in diagnostic
radiology. Anybody can be their own medical photographer, processing the dataset they have been
given at will and emphasizing or toning down individual findings. Diagnostic illustration is thus
gaining the potential to be as freely and ubiquitously available as photography has long since been
in everyday life.
New digital techniques for non-radiologists
Compared with the technical options, such as those that can be used in reconstructing the
dataset of CT colonography, the skill that radiologists have to demonstrate when they perform a
conventional double-contrast examination of the large bowel seems like a poor craftsman`s relic.
Meanwhile, the image of the staff who show the dataset recipients how to configure the presentation
and documentation has been enhanced. Therefore, the digital revolution has considerably boosted
the prestige of the medical technical assistants, both in terms of patients and referring doctors.
So far, teleradiology has had no such effect on the standing of the
diagnostician. On the contrary, teleradiology is a further technical step
on the way for radiologists to make themselves medically dispensable
and to lose their prerogative of interpretation, even in emergency
medicine. For telecommunication in radiology does not only mean
medical activity remote from the patient; through the limitless
dissemination of the image material, it also makes it possible for those
who are not radiologists to be commissioned with the interpretation
and/or to obtain a second or third opinion at the same time. Even in
interventional radiology, the apparently new domain of the specialty
of radiology, there has been a similarly critical development. In
diagnostic radiology, at least non-specialists only post process the
datasets obtained, but the new digital techniques give non-radiologists
the opportunity to make their own recordings within the framework
of interventions. The hybrid operating room makes this possible.
Its array of equipment - angiography, CT, interventional MRI –
practically invites the surgeons themselves to work in a minimally
invasive fashion. During the preparation, operation, and control of
image-guided interventions, they gain the necessary knowledge and
skills to perform the interventions themselves later, more or less
independently, and to integrate the data at the appropriate moment
into open surgery. The digital imaging revolution has given a new
dimension, both qualitative and quantitative, to competition in
angiology, and also to other sectors in which minimally invasive work
is done by both radiologists and the doctors giving clinical treatment
who have the potential to refer. If this development continues at the
same rate and to the extent outlined, the radiologist will soon become
obsolete as the person responsible for configuring images, and he
or she will be only one of many people who process the imaging
datasets. Radiologists will have to come to terms with the fact that it
will increasingly be possible for radiological assessments – unlike, say,
reports from a pathologist or laboratory consultant – to be checked
autonomously on the basis of the original data from the people who
commissioned them, the patients and their relatives, and for them to
be questioned and corrected thanks to post processing. Radiologists
will have to accept that their chosen configuration of the images will
therefore be only a provisional result in some cases and that this will
devalue their craftsmanship. And they will finally have to endure the
fact that minimally invasive diagnosis and therapy are increasingly
becoming an interdisciplinary specialty.
Still the final authority in borderline cases
This will not make diagnostic and interventional radiology a
scientifically obsolescent model. Radiologists will still be the final
authority in borderline cases, at least formally. Multidisciplinary
statements and the unrivalled classification of variants at the
borderline between normal and pathological will continue to earn
them respect, and intelligent differential diagnosis will still be valued.
But radiologists must learn to live with the paradox that although
the digital imaging revolution and its immense configurative options
are enlarging their methodological arsenal, this has not strengthened
their authority. On the contrary, it is increasingly weakening it.