New, improved radiology demands better analysis
any, many years ago, there was an emperor who was so terribly fond of beautiful new clothes that he spent all his money on attire . One day two swindlers came to town. They told everybody that they were weavers and that they could weave the most marvelous cloth. Not only were the colors and the patterns of their material extraordinarily beautiful, but the cloth had the strange quality of being invisible to anyone who was unfit for office, or unforgivably stupid.
“This is truly marvelous”, thought the emperor. His councilors and ministers persuaded him to let the swindlers cut and sew some clothes to wear in a procession at the next great celebration. When the day of the procession came, all the townspeople lining the streets, or looking down from the windows, said that the emperor’s clothes were beautiful. None of them were willing to admit that they hadn’t seen a thing. For if anyone did, then they were either stupid or unfit for the job he held.
Then, suddenly, a little child cried: “But he doesn’t have anything on!”
“Listen to the innocent one,” said the proud father as, at last, the crowd came to recognize that the emperor was naked.
"Is expensive high-technology equipment more new clothes for the emperor?"
Many, many years later, a hospital with a department of radiology was built in the same town. The hospital administrator and the head of radiology were terribly fond of beautiful new equipment. They had scanners and archiving systems for every possible application. Whenever a sales representative visited and described the machines on offer as “wonderful” or “marvelous”, the hospital heads would buy them. They had the latest ultrasound machines, digital x-ray equipment, digital mammography, multislice spiral CT scanners, 3-Tesla MRI, PET/CT hybrid scanners, PACS. And, of course, everything with the highest resolution, flat-screen monitors.
The hospital now possessed imaging equipment with superior resolution, unmatched and unprecedented volume acquisition, unsurpassed connectivity, unparalleled customer service. “Come ride with us. The magic continues”. The sales representatives had sold them freedom, breakthrough staggering possibilities, a universe of solutions, endless reality, informed decision-making, speed, the ultimate portable must-have radiology resources with advanced intelligent media and drives. The equipment output was clearly superior to anything else and strangely incomprehensible to anyone who was unfit for radiological office, or unforgivably stupid.
Life was gay and happy, and every day new patients arrived. They knew that all passenger aircraft of the kingdom were equipped with defibrillators so that no passenger or pilot would die of cardiac arrest during a flight – and they also knew that the latest radiology equipment and computer software would heal their Lyme disease and low back pain.
Patients entering the radiology department enjoyed extremely good care. On arrival, they were tagged with a special tracking device. In case they would be forgotten in a waiting or changing room, or on a patient table when the staff left for lunch, the device allowed a central computer to track and find them again – this helped reduce unproductive waiting times for the staff and prevented revenue loss.
The radiologists had access to the latest artificial intelligence computer software and could diagnose everything with information technology. They also could produce real time movies of the entire gastrointestinal tract from the esophagus through the stomach, continuing all the way through the duodenum, jejunum, ileum, colon, rectum, and out through the sphincter. All shown beautifully on the latest flat-screen monitors.
Bursting the bubble
One day, however, a radiologist from the neighboring country of Ruritania arrived. Ruritania happened to be backward in all matters related to high-tech medicine. They used machines that were six years old, or even older. This particular Ruritanian radiologist worked in a hospital with before turn-of-the century CT and MRI equipment. It even had an old fashioned library with books and journals – and, to be frank, with just one computer connected to MedLine.
When she saw the beautiful radiological department of the emperor’s country she thought:
“All these beautiful new machines: I could become envious – but I wonder whether they really can see more than I do. Do they get more information about the health of a patient? Do they know more than I do? Are their diagnoses superior and are their patients better served?
“Or am I the innocent bystander similar to the innocent child seeing that it is all a façade?“
The visiting radiologist acknowledged that imaging equipment could perhaps – or almost surely – remove of doctors’ imperfections and weaknesses in knowledge and skills.
“But what difference does it make if I have a screwdriver with built-in engine, if I cannot find the screw? These people seem to mistake information and information technology with knowledge. They lack the skill to interpret that knowledge, believing simply that radiological progress is accomplished with electronic gadgets.”
This is what the backward radiologist thought. We do not know how many of these thoughts she passed to her colleagues in the emperor’s country. However, she communicated and discussed her thoughts with her colleagues at home.
Answer is in outcome
The answers to her questions can be found from outcome studies.
In this context, it is worthwhile reading an article by Hunink and Krestin  working in Rotterdam and some of the papers they refer to. The authors propose ways of assessing new diagnostic imaging technologies and working out their value.
After an explosion of interest in outcome research and technical assessment some ten to fifteen years ago, this sort of work has been neglected. Many of the results of this research proved useless or they did not change inappropriate uses of imaging equipment.
In general, the effect of new technologies has been poorly quantified. Outcome research is not trendy or attractive. It requires a lot of time, and large quantities of information and material have to be collected. It is more work to milk a cow than watch it digesting.
In the mid-1980s MR outcome studies were performed in Germany, Australia, Switzerland, and a number of other countries. This happened at the beginning of the introduction if magnetic resonance imaging as a new diagnostic method. The studies were well intentioned, politically supported, but complex and onerous and, given the extremely rapid technological advances, prone to failure from the outset. One cannot evaluate the outcome of a brand-new technology immediately after its introduction. You have to wait at least ten years before contemplating to perform such an evaluation.
Hunink and Krestin do not suggest new procedures, but rather a different approach. They propose that a randomized, empirical trial design be used for the development, assessment, and implementation of new diagnostic imaging technologies. This design is to be based on a pragmatic study protocol interweaving research and clinical practice. Outcome measures should include factors related to clinical decision-making, costs, and patient health results. The key feature of their approach is to measure the trends in outcomes over time.
This approach appears easier to implement than well-meant, but rigidly bureaucratic previous efforts. Such studies still depend on funding, though.
“As Hunink and Krestin say near the end of their article, their proposal is not a panacea. It is, however, certainly a good start.” wrote Jeffrey G. Jarvik commenting the article in an editorial in the same issue of Radiology .
Let us see what will change. Will such outcome studies reveal that better use of established imaging techniques could benefit patients? What would happen to the 0.4-second 16-slice spiral CT scanners?
You and I know the answer: there will be 0.2-second 24-slice triple-spiral CTs, then 64-slice, then ...
However, I wonder whether apparently intelligent people can sell or buy equipment with the slogans the vendors use without thinking twice. If politicians praise computer technology as the greatest achievement after the invention of the electric egg cooker, I know with whom I deal.
1. Andersen HC. Favourite tales: The emperor's new clothes. London: Ladybird Books. 1993.
2. Hunink MGM and Krestin GP. Study design for concurrent development, assessment, and implementation of new diagnostic imaging technology. Radiology 2002; 222: 604-614.
3. Jarvik JG. Study design for the new millenium: changing how we perform research and practice medicine. Radiology 2002; 222: 593-594.