“Embrace the digital evolution of radiology” was the charge from RSNA President Nick Bryan, M.D., Ph.D., in Sunday morning’s opening address. This is a fairly benign challenge, since most radiologists have been actively pursuing digital transformation for the past few years — witness the explosion in the PACS market that continues unabated. If you were to remove the PACS companies from the Exhibit Halls at RSNA, there would be a moonscape between the remaining exhibitors. Scary thought, eh?

I’m not quite so enthusiastic about the follow-on projection from Dr. Bryan, as he predicts that continuing digital evolution will usher in a shift in radiology practice from small, relatively inefficient local operations to larger, automated medical enterprises. The assumption is that the larger groups will better incorporate the patient into the “process.” This is debatable, as most contentious predictions are these days. My view? Technology will enable smaller operations to improve their work and achieve efficiencies that enable them to stay local and connected to the patients and physicians whom they service. Bigger operations are not proven to be better — they are just larger and definitely more bureaucratic. Ever get placed on hold by a big, brand name company? I’ve had my fill of apologetic customer service agents, and prefer local suppliers (if any are still left out there). Radiology remains a service, specialized in screening for disease, diagnostic imaging and now guidance of interventions. Service to the local referring physicians was the primary goal 20 years ago (in the pre-digital era), and even though patients today are very actively involved in their own care, service to referring physicians remains the cornerstone of radiology. So, I’m not in the camp of radiology being revolutionized by the digital era. I’m still firmly on the side of radiology using digital tools to improve their work. And digital technology brings the price of these advanced imaging tools to the point where small local operations can afford to use them. For example, check the latest prices of entry-level MRI and CT scanners to see how much imaging technology your budget can buy these days.

CT Screening
The RSNA session on CT Screening was a bust — no shouting or screaming, just dispassionate dialogue and suggestions for further research. Hmmm. I think this was a missed opportunity to lay out the case for corralling the current direct-to-consumer anxiety campaign. OK, Americans appear to demand self-referred screening services — which seems to always coincide with a major advertising campaign in the local market. And this screening comes at a price and radiation dose that no individual is prepared to rationally evaluate. Owners of these clinics do find disease among these “patients,” but in small numbers, but they also find a large need for additional studies driven by incidental findings. Why does this sound like my auto mechanic? Meanwhile, the status quo of investing in these sites continues, with the hospitals and radiologists piling onto this bandwagon. I expected to hear a clear statement that these exams should only be done on a referral basis — I may be waiting awhile for this to happen.

Brain Disease
Work in this area presented at RSNA was fascinating, diagnosing the far-too-common disorders of the brain, particularly using functional imaging tools (as contrasted with traditional anatomical imaging tools). Perfusion imaging, diffusion imaging, and fMRI are actively focused on stroke, tumors and diseases of the mind (Alzheimer’s, schizophrenia, depression, ADHD, etc.). Many of the most interesting scientific presentations involved fMRI, which may still take another five years to become clinically relevant in brain disorders, but which is already actively used in pre-surgical planning for brain surgery. The presentation by Zerrin Yutkin, M.D. (University of Texas, Southwestern Medical Center, Dallas, Texas) on brain re-organization after a traumatic injury was notable for uncovering the brain’s ability to adapt and continue functioning, even after an injury. Functional MRI demonstrated brain activity in language and memory tests in different zones for the brain trauma patients vs. the normal patients, shedding more light on the nature of this organ’s ability to adapt.

“Mammography Not Perfect
… but it’s the best we have now,” noted Valerie P. Jackson, M.D., in the Annual Oration in Diagnostic Radiology speech. Reviewing the scientific literature, popular press and scientific press, Dr. Jackson noted the call for improved performance in detecting breast cancer, but mammography remains the only gold standard screening tool that is widely available. There is a body of development work underway, both research and clinically based, in new and improved imaging tools that include ultrasound, digital mammography, computer-aided detection and MRI. I would expect that next year’s RSNA will demonstrate significantly more clarity on where we are headed with this disease, in screening and diagnostic and interventional procedures. The focus has to remain on improving the early detection of cancer, while guiding patients and physicians with confidence in the outcomes.

While the final attendance figures were up substantially from the 2001 meeting and slightly below the high-water mark of 2000, the enthusiasm of attendees at this year’s meeting was noted everywhere — this is a dynamic market achieving tremendous results that benefit patients on a routine daily basis. The reason that radiology capital budgets remain intact (and even expand a little) is imaging supports every medical specialty and guides almost every patient diagnosis. Stay focused for 2003, and next year’s meeting will be even better!

Doug Orr, president of J&M Group (Ridgefield, Conn.), consults with medical device companies in strategy and business development for emerging growth markets, notably radiology and cardiology. Comments and suggestions can be sent to dforr@aol.com.