Radiology has been a distinct medical specialty with unique technical challenges from its inception. The origins of specialisation can be traced back to the technical nature of X-ray image capture and perhaps more significantly the difficulty of exposing, transporting and developing images on fragile glass plates for subsequent interpretation. Despite pressure in the early 1900s to define radiology as a technical service, radiographic image interpretation and reporting required medically trained specialists. Therefore, radiologists have been clinical specialists, who have been obliged to also become experts in image capture technology, broad-based advances in engineering and, more recently, applications of information technology for healthcare, which continue to drive and be driven by radiology.
Radiology is now the key diagnostic tool for many diseases and has an important role in monitoring treatment and predicting outcome. It has a number of imaging modalities in its armamentarium which have differing physical principles of varying complexity. The anatomical detail and sensitivity of these techniques is now of a high order and the use of imaging for ultrastructural diagnostics, nanotechnology, functional and quantitative diagnostics and molecular medicine is steadily increasing. Technological advances in digital imaging have also enabled the images produced to be post-processed, manipulated and also transmitted rapidly all over the world to be viewed simultaneously with the transmitting centre.
Radiologists have been strongly involved in these technological developments and have been responsible for much of the evaluation of the strengths and weaknesses of different investigations. Radiologists have developed the knowledge of the appropriate integrated imaging algorithms to maximise clinical effectiveness. They have also been responsible for the implementation of these developments into the clinical setting and for ensuring the best use of assets and healthcare resources.
The improved image clarity and tissue differentiation in a number of situations has dramatically increased the range of diagnostic information and in many cases the demonstration of pathology without the requirement of invasive tissue sampling (histology). This increased information also requires careful interpretation without preconception to avoid prejudging the findings. The use of imaging for functional evaluation and cellular activity has created a new challenge for radiologists whose training has predominantly been based on the anatomical and pathological model with limited experience in physiology and cell function. It has therefore been the case that in some super specialist areas of work, clinician specialists may believe that radiologists have not contributed sufficiently to the care of patients [1]. It is therefore incumbent on radiologists to mobilise their skills to utilise these new approaches to evaluate clinical questions in the most effective way. For this reason the radiological training programme for Europe is now mainly system- and disease-focussed to ensure that radiologists can respond to the multiple interactions of patient care.
Although the training programmes are repositioning radiology in this way, these developments are now occurring and are affecting all radiologists who in general, at present, are satisfied with their overall position within the respective health care system in most European countries. Radiologists have no difficulties in finding professionally fulfilling and well-paid employment. Indeed the rapid rise in workload and complexity of examinations have resulted in a shortage of radiologists in most countries which may reduce the opportunity or desire to move and up-date sufficiently with these advances. The availability of high-speed internet transfer of images may affect the requirement and role of local radiologists by transferring images to major centres for rapid specialist interpretation. Thus the rapidly developing and expanding field of imaging becomes a challenge to our specialty, especially as it has also become so attractive to others. We should therefore be concerned to ensure the future of radiology as a medical specialty and take into consideration the forces and the dynamics surrounding our profession by meeting them with foresight and flexibility.
Although as a specialty we must embrace the opportunities that these developments create, the requirements to embrace all aspects of the speciality are now considered unattainable for any individual, especially in an environment where the clinicians themselves are focussed on specific anatomical or disease-related areas as specialists. Therefore the dilemma for radiology and radiologists is how to achieve the objectives of the specialty and still provide a comprehensive service within the confines of a radiology department where so many of the tasks previously undertaken by clinicians are now the province of radiology.
The need for change
Numerous facilities in clinical services are collectively used by different specialties: operating rooms are not owned by surgeons anymore, ICUs have become independent of departments of cardiology, internal medicine, or neurology, while emergency rooms are not part of traumatology departments. Hospital beds are no longer dedicated to individual specialists or specialties and are available for radiologists for one or two nights following interventional procedures in some hospitals. At present the radiology department remains predominantly the domain of the radiologist, but this is changing and there is no specific reason why imaging facilities should not be used by other clinical specialists trained in imaging, and images produced in these departments may also be reported remotely.
New knowledge in imaging is being developed at an increasingly rapid rate. The field of radiology has expanded dramatically. The range of radiology covers diseases from the foetus through to the multi-morbid aging population, from prostate to the pituitary gland and from pancreatic neoplasia to bone dysplasia. No single person can master all the available knowledge. However, the referring physicians need a clinical interface with the imaging specialist. In order to create added value for the referring clinician, the radiologist must fully understand the clinical problem. The radiologist is expected to be able to do this at a different level and for all medical specialties. Therefore clinical experience is required before embarking training in imaging, and appropriate training in specific clinical specialties may also be needed. If not, imaging may increasingly be regarded as a sub-entity within the clinical specialty and in that setting each specialty will take care of its own specialised imaging and training, and the influence of the radiological expertise would diminish.
Public recognition of the clinical role of radiology is essential and is very much dependent on contact with the patients [2]. However, over the past years radiologists reading more and more complex examinations have become less and less visible for patients and the public. Moreover, in some health care systems the emphasis of radiology work is placed on the in-patient referrals to major general (secondary) and university (tertiary) hospitals where the role of the radiologist as part of the team is less obvious to the patient. There has been less focus on the provision of radiology services to primary care (including general practitioners and office based specialists), where the requirements are different, with a need for a more general service but still involving a range of imaging services, and where the individual role of the radiologist is more obvious to the patient.
In some countries clinical specialists may be the primary providers and interpreters of imaging in their offices. This has potential disadvantages for the patients. The self-reporting clinician may focus on the images to confirm or refute a preconceived clinical diagnosis whereas the interface of a radiologist, reporting the images, provides an independent opinion. It is also suboptimal for funding healthcare, as self-referral has been shown to increase numbers of radiological procedures and consequently costs. Moreover, radiologists will ensure the appropriate use of equipment and quality control, and apply radiation protection principles which are particularly pertinent with the massive increase in the use of multi-detector CT [3].
Radiology has prospered by staying ahead of the wave of progress. But radiologists will have to change many of their attitudes and rethink their professional training to accommodate to the dramatic revolution and evolution of radiology [4]. Radiologists need to adapt to the changes in technology in order for the profession to deliver the service that patients expect and medical progress requires.