Beyond the basics:
Is knowledge power?
hilosopher Francis Bacon once said, “Knowledge is power”. The topic came up in a conversation during a board meeting of the European Magnetic Resonance Forum. The forum, which has organized magnetic resonance teaching courses in Europe since 1982, discussed the necessity and contents of basic teaching in magnetic resonance imaging.
Two main opinions were voiced: On the one hand, radiologists as users of MR equipment did not feel the need to acquire the physical, chemical, or mathematical basics in order to read and interpret MR images. On the other hand, physicists and chemists underlined the necessity of knowing the background of nuclear magnetic resonance and its applications.
“If radiologists do not understand the basics, they will be passive users of MR machines. They won’t be different from a technician – and then, who should teach technicians?” they said.
One of them presented the following analogy:
“You can compare MR imaging with photography. Good touristic pictures can be produced without any other knowledge than to push the button, but a good photographer understands how a camera works, how to set the right shutter speed, how to choose a film with the appropriate sensitivity, and what influences the contrast of a picture.”
Not too long ago, a well-known British radiologist, Ivan Moseley, wrote in a book review:
“How much does the practicing neuroscientist need to know of the technical aspects of magnetic resonance imaging and spectroscopy? One can argue either way: the basic theory is relatively simple, and the phenomena it describes determine the appearances of the images, so it behooves the clinician to be familiar with them; or, beyond the simplest level, the people would be well advised to leave technical details to their specialist colleagues.
“I incline to the latter view, not through arrogance, but because I regard these complex details as entirely analogous to the electronics of spectral analysis of the EEG, the methodology of S100 staining of the identification of CSF proteins: merely technical …”
Moseley was not alone in his opinion. A large number of radiologists shy away from having to learn the detailed basics of new techniques, in particular such complex and challenging techniques as MR imaging.
This is easily understandable because development is faster than the average physician (the author included) can handle within the short time available daily that can be devoted to continuing education. This does not only include technical basics but also medical basics, such as the interpretation of flow phenomena in MR angiography, the changing contrast behavior of hemorrhage, or the signal alterations in the brain during functional imaging. So one often leaves the understanding to natural scientists, and the operation of equipment is left in the hands of technicians.
"Development is faster than the average physician can handle within the short time available daily that can be devoted to continuing education."
A good example is the use of MR contrast agents. For many radiologists it has been difficult to understand that these contrast agents are different from x-ray contrast agents; they behave differently and their indications are, to a certain extent, different. But many radiologists use MR contrast agents as they would use x-ray contrast agents in computed tomography (CT), because they have not explored the details of MR contrast agent behavior.
The rapid increase of scientific knowledge in MR imaging has had a far-reaching effect on the radiological community. Radiology is no longer a field for the gifted amateur as it was 50 years ago.
Radiologists must spend many years in training. In the old times, a good x-ray institute could be recognized by the quality of x-rays as much as by the quality of examinations and reports.
Basically, this has not changed, but no radiologist today is able to cover the whole range of medical imaging; one cannot be excellent in conventional x-ray diagnostics, in x-ray CT, angiography and interventional radiology, ultrasound, MR imaging, and nuclear medicine.
Radiological sub-disciplines have become more and more specialized. Even within these specialties, such as MR imaging, the radiologist may find it difficult to keep up with the literature that reports advances in the field. Still, for obvious reasons, the sub-specialist is expected to deliver proper and good work, even if it has changed from universal radiological craftsmanship to specialized high-technology imaging.
In light of the above considerations, it appears that as technology advances, the meaning of knowledge changes. By the same token, what “power” implies in this context is something that can be said to be “in the eyes of the beholder”.
Let us first consider knowledge.
Radiology, as medicine in general, is not a steady accumulation of knowledge. New theories, new methods and new applications are proposed, used, – and abandoned, and the existing knowledge at any period is only provisional, never final and irrefutable. It's similar to science. The philosopher Karl Popper takes the view that it is never possible to prove anything in science with absolute finality, since there is always the possibility that an exception will be found to every scientific law.
MR imaging, as an evolving technology, has presented some classical examples for this statement. Some years ago physicists declared that it would be impossible to compete with the rapid imaging times of CT because of the physical and chemical restrictions given by the relaxation times T1 and T2; it would also be impossible to image the human body at fields higher than 0.3 Tesla. As we know today, both statements were wrong.
The knowledge we are talking about, then, is not only specialized knowledge, but also knowledge whose main purpose is to allow the creation of new, more advanced knowledge by means of discussions, questioning, and discovery.
In terms of power, one would feel compelled to begin by asking: “Power for what?” Several answers jump to mind: the power to contribute to, and perhaps even guide, the advancement of this area; the power to judge the benefit and utility of developments and decide on their use and application; or even the power to ensure that those who (should) ultimately benefit from one’s work – the patients – are getting the best one can give. In general terms, these will all benefit medicine and mankind.
But knowledge and power can also take the wrong direction. Italian writer Giovanni Guareschi, creator of the two famous figures of Don Camillo and Peppone, wrote about this problem, which is a general problem of our time:
“It is too much knowledge which leads to ignorance, because ... from a certain moment on people only see the calculable part of things. And the harmony of numbers becomes their god ... Progress makes the world increasingly smaller for people. And one day when people will be able to fly one hundred miles a minute, the world will appear to them microscopically small, and they will feel like a sparrow on the top of the highest mast of a ship, and they will bend over to infinity... And they will hate the machines which have turned the world into a handful of digits and destroy them with their own hands.”
"It is too much knowledge which leads to ignorance, because ... from a certain moment on people only see the calculable part of things. And the harmony of numbers becomes their god ... ."
Is such a development foreseeable in diagnostic imaging? Will people finally realize that the development of more and more numbers is not what medicine stands for? Will radiologists turn away from digital imaging, because they may drown in the “datarrhea” thrown up by computers, and because the techniques have become too complicated and they no longer consider this to be medicine?
In other words, could it be that the measure of all things in medicine will become the human being again? The question is whether this development can continue and whether it is fulfilling for both physicians and patients.
If the development of radiology means that the radiologist has more time for the patient, it would be a step forward in medicine, because patients need their physicians more on a human level than on a digitized level.
What are the implications of all this in regard to our original question and Moseley’s argument?
One possible scenario is that Moseley’s opinion will crystallize to become the opinion of the majority of practicing radiologists. They would concentrate on acquiring sufficient knowledge to have the power to give their patients what they judge to be best, while leaving all technical details to other specialists. The radiologist would become a recipient and user of technical development.
A second scenario is an exaggeration of the previous: radiologists would completely leave all technical knowledge to others and focus only on its medical exploitation, taking the “product” and interpreting it without concern for how it was produced.
One imaginable result – even if far fetched – is that high-technology medicine would be taken over by natural or computer scientists and technicians, who would become the medicine men of the 21st century. Like medicine men of the past, they would have a certain knowledge of illnesses and, in addition, could cast spells with their frightening machines. One could imagine that radiologists would disappear. They would no longer be necessary. Diagnoses could be delivered by technicians, and physicians would go back to interactive, patient-devoted medicine. Image-making would be included in therapeutic medicine.
A third – and more desirable scenario to the author – is that radiologists turn to selective knowledge, as physicians have always done. They would know some of the background, process it intellectually for the benefit of their patients, and give it a more human touch than it has today.
They can also communicate back to the technical specialists on desirable applications, problems found, and perhaps even new ideas for development. This would require the existence of a middle ground, where developers and practitioners would meet to cooperate and communicate without being hung up on their own particular specialties. The most likely consequence of this aggregation of knowledge would be collective power – and responsibility – for the advancement of science.
1. Guareschi G. Mondo piccolo, Don Camillo. Milan: Rizzoli 1948. The little world of Don Camillo. New York: Pellegrini and Cudahy, 1950.