Beware of fads, fashions, and market-speak
ecently I talked to a fellow-radiologist from an Eastern European country. He told me that many of his colleagues share the opinion that radiology in the Western Europe, in the United States, and in Japan is a luxury discipline that is governed by money rather than end result for patients. As a high-tech branch of medicine radiology depends on marketing and fashion, with techniques changing for no reason based in medicine, he added. For example, where is the evidence that new techniques such as spiral CT add anything to the diagnostic or positive therapeutic outcome for a patient?
"Radiology in the Western Europe, in the United States, and in Japan is a luxury discipline that is governed by money rather than end result for patients."
Radiology's place in the consumer-driven rat race is summed up in a pair of cynical quotations, attributed to two successful computer industry executives:
"Don't worry about what anybody else is going to do ... The best way to predict the future is to invent it. Really smart people with reasonable funding can do just about anything that doesn't violate too many of Newton's Laws!" said Alan Kay in 1971. He is the former director of research for Apple Computers and inventor of “Smalltalk” which was the inspiration and technical basis for the Macintosh computer and subsequent window-based systems.
“We don’t sell people what they need. We sell them what they want,” commented Michael Dell, founder of Dell Computers.
Does this mean that industry should develop products people do not really need and then create an artificial demand for them so that people will want to buy them?
Fashion in clothing, cars, furniture, ideology, sports, and in nearly everything else change from year to year.
Eating and drinking habits alter, too, as do diet fads. Some years ago, butter was thought to be bad for you and margarine was good, but nowadays consumers are told that some types of margarine will kill them and butter might help save them from certain death.
Similarly, medical practice depends on fashion as well. It was once common to remove appendices and tonsils whenever suspicion arose that symptoms could be caused by them. Surgeons and ENT physicians are a bit more selective today about using their scalpels.
Radiology is not exempt from this kind of irrational behavior. While a few years ago in some institutes xeroradiography was the non-plus-ultra in x-ray breast imaging, the method is hardly used now.
"Examinations and therapies are not always based on scientific evidence."
You and I would like to think that we are immune from outside pressures and we cannot be influenced easily. We are intelligent, we know what we want, and we have all the background information necessary to make appropriate decisions.
But we also suspect that certain radiologists and administrators who are buying new equipment for a hospital department – or, for that matter, their own private practice – make decisions based on trends rather than trusting their own knowledge.
Consider the market for MR equipment. First it was low field, then it had to be high field; then the low/mid-field market exploded when patients demanded easy-access systems. Now the trend is toward ultrahigh machines.
Salespeople always find arguments. They are enthusiastic about their products, persuasive in their sales pitch, and they speak the language of the customer. They predict success with their products: happy patients, happy relatives, happy doctors, happy administrators, happy local politicians.
And everybody wants to be part of a success story. In striving to meet the high expectations of radiological customers, salespeople understand they cannot sell an average product. They have been instructed to promise heaven on earth (or at least some fringe benefits) to clinch the deal.
The Holy Grail?
Radiologists been sold countless products and innovations during the last thirty years. Of course, many products were necessary and they benefited patients, but the quest for diagnostic heaven (the replacement of histopathological diagnosis) demands closer examination.
Nuclear medicine. When powerful new computers, at least for that time, and new radiopharmaceuticals became available in the 1970s, physicians looked forward to detecting and grading tumors all over the body. Despite optimism from companies and doctors, the promise of histopathological diagnosis through the eye of the gamma camera did not materialize.
Computed tomography. In 1979, Cormack and Hounsfield received the Nobel Prize for Medicine and Physiology for their discovery. No doubt, this was a big step forward in diagnostics. The promises – though not made by Cormack and Hounsfield – were the same as for nuclear medicine – the results were also the same.
MR imaging and spectroscopy. The big diagnostic leap forward. We were given (or gave ourselves) the same promises – only to suffer yet another disappointment.
Advanced ultrasound equipment and contrast agents. You will find these even in the smallest village. A number of recent publications on ultrasound read like a re-write of the nuclear medicine/ CT/ magnetic resonance articles of the last twenty years: identical promises and, most likely, identical disappointments.
Molecular imaging. Although these imaging approaches look very promising, let us wait ten more years before evaluating the outcome.
Unfortunately there is usually no proper evaluation of new techniques. When one has been introduced and sold to the enthusiastically waiting public, the next one steps out of the wings and is welcomed by flag waving and flower throwing like the newly-married queen arriving in town.
Many radiological products are doubtless better tested and more useful than goods in the supermarket or in the average consumer electronics shop. Most sales representatives of radiological products are likely to be better trained and perhaps even more honest than the average telephone salesman.
We should also remember that the companies are not the sole culprits in the radiological fashion industry. They are also subject to fashion dictates and in many cases they are simply following the radiologists’ own fads to keep their market share.
Radiology manufacturers do dictate fashions, though, by persuading customers to buy equipment for which there is no proven need. Such equipment usually disappears as soon as radiologists realize it offers no advantages. It is bought, however, at very high cost, and may not benefit patient management. In addition, often unnecessary but expensive gadgets are added to machines. As one radiologist with whom I discussed this topic put it: “Why can’t I get a Volks-Ultrasound which does what I want and need to do and nothing else? Why do I have to buy machines with all these add-ons which are so costly and not useful in routine?”
Technology assessment that distinguishes between necessary and optional features – nice to have but not needed for a reliable diagnosis – would be the best solution. Radiological technology is changing rapidly, though, and this may invalidate efficacy research done early during the evolution of a new technique. Some degree of stability is needed to encourage investment in such research. Sound and scientifically rigorous evaluation of new technologies is needed to ensure quality of care and cost-effective use of resources.
Radiologists, a highly individualistic group, on the one hand, and their commercial partners, on the other hand, are unlikely to agree unanimously and voluntarily on such an evaluation. Sooner or later they will be overpowered by dictates from politicians and reimbursement agencies. While only solid health outcome data can effectively combat such dictates in the long run, many physician groups – radiologists as well as clinicians – have joined manufacturers in their resistance to written guidelines. Or guidelines have been written in their pure self-interest.
The last century has been a period of permanent, intensive development. One hundred years of radiology have brought an enormous benefit to mankind, but as radiologists we have to remain flexible and self-critical.
We are as fallible as anybody, in particular our fellow physicians, and we follow the market leaders and opinion makers because this is the easy way. Sometimes we even cave in to other physicians or patients who determine what and how we should deliver our diagnoses.
About the only certainty in radiology – and in all human affairs for that matter – is that it is never in a steady state. The pendulum of popular attitude is always swinging one way or the other, and a permanent state of change ensures that a final conclusion is never reached.
There is a fashionable market for certain examinations and therapies, and although some of these fashions are “scientifically based”, any book on the history of medicine shows that the truth of one age is the absurdity of the next. And the most painful absurdity is not to be prepared for change. This is a lesson easily learnt from history.