Opinion: The rise of the Clinical Radiologist

by Nitin P. Ghonge (drnitinpghonge@gmail.com )

The marriage of computers and Radiology in mid-twentieth century accelerated the growth of Radiology and initiated the rise of Radiologist. Rapid advancements in imaging technology and digital medical images have revolutionized the work-flow systems in modern hospitals. Radiology is one of the most dynamic branches where new concepts are being converted to clinical applications in an endless manner. “The only thing constant in Radiology is CHANGE”. Change for the betterment of healthcare and change for the betterment of society.

Clinical Radiologists: Evolving roles and responsibilities
The traditional role of radiologist as a physician who only generates and interprets diagnostic images is outdated. Radiologist’s roles have expanded to political advocacy for policy decisions, health delivery for population screening, safety officer for radiation risks and contrast concerns, continuous quality improvement and a collaborator for clinical research across disciplines. Radiologists now add value to healthcare through these diverse roles [1].

From Gatekeeper to Steward of Medical Imaging
Radiologist has evolved from ‘gatekeeper’ to ‘steward’ of medical imaging infrastructure to ensure efficiency and quality of imaging services [2]. Radiologists need to review and decide the imaging appropriateness and intervene, based on the risk-benefit analysis. As a ‘steward’ of imaging facility, Radiologist is expected to assume greater responsibility including the imaging appropriateness, quality, patient safety and the emergency services.

Mcdonaldization of Medicine
‘McDonaldization’ is a part of the wider phenomenon of Globalization, whereby global brands follow the same principles and practices [3]. The key components of efficiency, calculability, predictability, standardization, and control are being applied to other sectors to enhance monetary profits. In a ‘McDonaldized society’ there is however, no scope for any creativity or value for human skills. Mindless application of these principles in healthcare would have devastating effects, due to sundry presentation of diseases, wide variations in human anatomy and physiology and its varied response to same set of treatment. MacDonald’s fast food model or Ford’s assembly line production of Cars, which involves small repetitive tasks for an individual, cannot be applied to healthcare. Doctor-patient interaction and imaging-based diagnosis need much more individual attention and cannot be automated. Medicine’s most cherished and defining values of personalized care for individual patients will be threatened.

Artificial Intelligence in Radiology
In recent times, there is global hype about the role of AI in Radiology practice and AI has become a latest buzzword [4]. The overenthusiastic claims about the initial success of AI and implications in Radiology apparently seem to be another attempt to augment Mcdonaldization of Medicine. AI tools have demonstrated success at automated recognition of patterns in imaging data. This however, does not validate their role in imaging diagnosis and does not raise concerns about replacing the Radiologists. The nuances involved in clinically-relevant diagnosis and Radiologist’s work profile goes much beyond the image interpretation. AI algorithms are likely to enhance Radiologist’s efficiency and their role will expand as a comprehensive service-provider with primary care triaging, clinical decision-making and knowledge experts across the clinical disciplines. I have doubts whether AI will ever be able to replace Radiologists, but I am sure that “AI-enabled Radiologist” will replace Radiologist of the past.

Over-specialization in Medicine
The specialist-driven healthcare is now a standard and at times raises concerns about over-specialization in Medicine [5]. High referral rates to specialists are often due to defensive practice related to fears of litigation. Easy availability of specialist doctors is an important reason in regions like urban India. Apart from increase in the cost, this seems to cause significant treatment delays, mismanagement and at times confusion for the patients. With too many specialists involved in patient care, inpatient care in modern hospitals seems like a relay race for physicians and patients as batons [6]. Specialization is necessary to delve deep into the vast sea of medical knowledge, but a working knowledge of wide specialty of Medicine cannot be understated. These fields of specializations are our own making. Nature does not discriminate and split itself off into different disciplines. Specialist knowledge should not hinder our ability to diagnose a disease which does not actually require specialist knowledge. It is not uncommon to see a patient presenting to an incorrect specialist. Patient’s symptoms often do not follow the dividing lines of medical specialities. Patients with multi-system involvement presents to one or the other specialist, who has limited knowledge outside his area of expertise and often delays diagnosis. In close approach to a tree, one should not loose view of the forest.

Though, system-based specialization has also penetrated Radiology, Radiologist in general are good at image interpretation across systems. Patient is a complex anatomical and functional entity with integration of organ systems and always needs multi-specialty approach. In present healthcare scenario, Clinical Radiologists are therefore in best position to perform primary care triaging and clinical decision-making. They can connect all the confusing dots to solve the enigma of a complex multi-system disorder. Clinical Radiologists who specialize in not specializing may emerge as keys to the future of Medicine.

Medical Ethics in Today’s Clinical practice
With advent of corporate sector, global healthcare has entered a new era. Medicine is now treated as business, with profit margins as the highest priority [7]. Corporate entities apply the same principles of Mcdonaldization and promote culture where patient is simply a number. Dr Richard Reece, an internal Medicine specialist aptly described the state of affairs. “Once upon a time there was a profession called Medicine. Now there is an industry called Health Care”. As expected in an industry, performances are calculated in numbers and end-point shifts from patient’s wellbeing to monetary gains. The practice of commissions for patient referrals is deeply rooted in several healthcare spaces. The practice of performing unnecessary surgical or invasive procedure is a worrying cause of concern [8,9]. It doesn’t take much to realize that these unethical practices in the modern healthcare have a common connect with the commerce.

Clinical Radiologist is in a unique position to serve as the ‘ethical watchdog’ for the medical community which includes appropriate specialist referral and emphasis on optimal treatment. Radiology consultations should always provide insights into prognosis and treatment. Due emphasis on conservative treatment in appropriate clinical & radiological settings will avoid any attempts for aggressive treatment and would serve the patient’s interest and well-being.

Evidence-based practices and the era of Personalized Medicine
Healthcare is moving towards ‘personalized’ approach using the molecular medicine therapies and techniques. Radiology is likely to play crucial role by virtue of early disease detection, monitoring and image-guided targeted therapies with use of anatomical, functional and molecular imaging [10]. Evidence-based Practices [EBP] in radiology will further optimize patient care. Radiologists who use the tool of EBP will be most influential advocates of Radiology in future [11]. There is gradual shift in Radiology from traditional ‘volume-based’ role to ‘value-based’ services in the interest of the patient [12]. As also emphasized by ACR white paper [13], direct consultation between Radiologist and Patients is vital to establish the value of Clinical Radiologists. This will elevate the status of Radiologist from only Doctor’s Doctor to Patient’s Doctor.

The rise of the Clinical Radiologist
By virtue of knowledge in cross-sectional anatomy, understanding of disease patho-physiology and expertise in imaging techniques, Clinical Radiologists are well-positioned as comprehensive healthcare service provider. This will include gate-keeping during diagnostic work-up, providing directions for specialist referral during primary care triaging, assisting clinical decisions during the treatment, providing roadmaps for surgical planning, acting as ethical watchdog and advising patients about the surveillance/follow-up. ‘Patient-centric approach’ & ‘problem-solving attitude’ are essential traits of a Clinical Radiologist to ensure these evolving roles [14].

‘The rise of the Clinical Radiologist’ as a comprehensive service provider is the need of present times, when rising costs, concerns of over-specialization and ethical issues are haunting the healthcare. With advent of artificial intelligence, this positive change in the healthcare is just round the corner.