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(Radiology. 2000;214:15-23.)
© RSNA, 2000

Opinions

Radiology at the Turn of the Millennium1

Alexander R. Margulis, MD and Jonathan H. Sunshine, PhD

1 From University Advancement and Planning, University of California at San Francisco, 3333 California St, Laurel Heights, Suite 16, San Francisco, CA 94118 (A.R.M.), and the American College of Radiology, Reston, VA (J.H.S.). Received January 22, 1999; revision requested March 5; revision received July 19; accepted September 20. Address reprint requests to A.R.M.

Abstract

Herein, the authors (a) review the status of the specialty; (b) report and analyze the various areas in which progress has occurred, namely, conventional radiology and picture archiving and communication systems (or PACS), ultrasonography, computed tomography, magnetic resonance imaging, interventional radiology, and nuclear medicine; and (c) discuss the problems radiology faces as it enters the new millennium. The problems are those facing medicine as a whole, as well as those threatening the future of radiology. These include the following: Will there be a need for radiologists in the future? Will radiology be too costly to be affordable? How can turf wars and fragmentation be solved? Possible remedies are suggested. Positive aspects are discussed in the light of the challenge to demonstrate value. Medical imaging is entering the new millennium with a solid record of recent advances in digital, cross-sectional, and interventional radiology. These advances have made the specialty indispensable in the treatment of patients. Careful statesmanship will be needed to solve the many problems that face medicine as a whole and radiology in particular.

Index terms: Economics, medical • Opinions • Radiology and radiologists, history • Radiology and radiologists, research

Radiology's advance has not stopped in the 100+ years since Roentgen's momentous discovery at the end of 1895. Radiology has achieved importance as one of the most powerful diagnostic approaches in clinical medicine. The contributions of radiology have increased in the past 25 years with the advent of cross-sectional imaging and the flowering of interventional radiology and nuclear medicine imaging. In 1995 (latest data available), 34% of radiologic imaging procedures and 73% of the relative value units involved in radiologic imaging were in fields that had not existed or were only embryonic a generation earlier; namely, computed tomography (CT), magnetic resonance (MR) imaging, ultrasonography (US), interventional radiology, or nuclear medicine (data are from tabulations of Part B Medicare Annual Data Procedure Files for 1995 using Medicare's resource-based relative value scale). For the foreseeable future, the promise of further progress in radiology is equally dramatic. Medical imaging is becoming more precise, increasing in sensitivity and in specificity; it is acquiring and displaying data in three dimensions; and it is capable of providing virtual presentations. Functional and metabolic imaging are becoming a reality, and one can expect that genetic and molecular marker imaging is going to be a reality in the foreseeable future. New, more biologically specific contrast media for all medical imaging modalities and especially for MR imaging are in various stages of testing. New techniques are also resulting in rapid throughput of patients, which makes even examinations performed on very expensive instruments more affordable as high volume produces reduced costs. Of course, we do not know for sure how many of these potential advances will prove worthwhile in everyday clinical practice, but the possibilities are enormous.

Progress in recent decades is due among other factors to advances in electronics and computing. For the past 15 years, computer power has been doubling every 18 months (Moore's law) (1) (Fig 1). Multiple billions of calculations per second are already possible, and neural network computers offer the promise that they can be trained to recognize normal anatomic features and deviations from the learned normal appearance (2). Miniaturization of equipment, improvements in detectors, and the revolution in image acquisition, resolution, transmission, and manipulation have further contributed to the vertiginous advances in medical imaging in the past 2 decades.



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  		Figure 1a. (a) Graph illustrates the increase in computer function power, with its doubling according to Moore's law. (Graph used with permission from Intel, Santa Clara, Calif.) (b) Graph depicts the decline in relative computer price at constant computer power. (Graph used with permission from R2 Technology, Los Altos, Calif.)

 


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  		Figure 1b. (a) Graph illustrates the increase in computer function power, with its doubling according to Moore's law. (Graph used with permission from Intel, Santa Clara, Calif.) (b) Graph depicts the decline in relative computer price at constant computer power. (Graph used with permission from R2 Technology, Los Altos, Calif.)

 
Some of the research that has made these computational advances possible has been supported by defense and space programs funding and by exploration for energy and mineral resources conducted from satellites. Government grants (eg, National Institutes of Health, National Science Foundation, the U.S. Department of Energy, the Max Planck Institutes in Germany, etc) have indirectly contributed to funding the research that has led to progress in medical imaging. The medical imaging industry has heavily invested in this research, dwarfing the contributions from universities. In the past decade, venture capitalists expecting rich returns from innovations in medical imaging equipment or new contrast media have provided an additional source of funding. Whether these sources will continue to provide the necessary supply of funds in the next decade is at present unpredictable.

SPECIFIC ADVANCES INTO THE NEXT MILLENNIUM

Future developments promise to make the progress of radiology in the 1st decades of the next millennium as dramatic, exciting, and expansive as it has been in the past 25 years. The most promising of these likely advances in each field are described in the following sections.

Each, however, faces three hurdles. First, will an advance that now seems probable actually prove capable of reliably producing diagnostically accurate images (or, in interventional radiology, therapeutically reliable results)? Second, will advances that are successful technically turn out to be of substantial value in ordinary, day-to-day practice? Third, will the health care dollars be there to pay for the use of new clinically valuable advances?

Conventional Radiology and Picture Archiving and Communication Systems
In the future, there is likely to be an even greater separation between the most developed countries of the industrial world, which will be continuing to advance in medical imaging with technologic breakthroughs, and the rest of the world, which will be lagging behind, continuously playing catch-up, and much constrained by severe financial limitations. In the industrial world, radiology will become increasingly filmless and digital with streamlined, lower cost, and physician-friendly workstations. With the advances in flat-surface digital detectors, even bedside radiography will become directly digital and all of it will feed into user-friendly and cost-effective picture archiving and communication systems (PACS). High-power workstations in radiology departments will, in addition to permitting the viewing of images from present and recent studies, also provide immediate preprogrammed retrieval and access to all studies digitally archived on a particular patient and make it possible to reformat and even handle the data in displays of virtual reality. Less versatile monitors for the display of imaging studies can be incorporated into a network that includes hospital floors and outpatient and referring physicians' offices. Gastrointestinal studies with digital fluoroscopy and radiography will need no repeat exposures, as adjustments can be made for optimal image quality and excellent spot radiographs are obtainable with reduced radiation exposure (Fig 2).



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  		Figure 2. Lateral digital spot image, from images obtained at a rate of three per second, demonstrates hypertrophy of the cricopharyngeal muscle (the upper esophageal sphincter) (arrow). With digital fluoroscopy providing good morphologic detail, demonstration of transient events is easily reproducible.

 
With the cost of data transmission decreasing as fast as the cost of computing power, practical opportunities for global teleradiology are rapidly opening. Teleradiology has distinct advantages. It can provide subspecialty expertise in the form of second readings, radiology services to remote communities without a radiologist, as well as a 24-hour radiology reading presence through networks at an affordable cost. These pluses, however, come with disadvantages. There is loss of direct patient contact, and thus no possibility of seeing the patient to ask for more history details or to perform a physical examination. Although direct patient contact by radiologists is not the routine in the United States, the opportunity for direct contact with the patient is available and is taken advantage of in departments where a radiologist conducts and monitors the study. Furthermore, with teleradiology, there is no opportunity for face-to-face contact with referring physicians. These encounters generally provide invaluable information about patients. Telephone contact is possible, but typically somewhat less informative and often time-consuming. Exchanges of information with referring physicians in the reading room are also valuable for teaching. It would be a great loss to the profession if radiologists were to be identified by other physicians and patients only as image readers sitting exclusively in front of workstation screens and ceasing to be clinicians. It is also important to discuss the cases in conference with other colleagues and have an input in the selection of treatment.

The perceived threat of teleradiology made the subspecialty of interventional radiology very attractive to radiology residents fearful of the possibility of a shrinking diagnostic radiology job market. There was a great increase in the number of applications for interventional fellowships in 1996 and 1997 and a general, but temporary, decrease in applications for diagnostic radiology (3–73–7; authors' unpublished data, 1999).

The savings that PACS, digital radiology, and particularly teleradiology can offer are potentially enormous. In a financially constrained world, the clinical losses associated with generalized use of teleradiology, which we have just described, may be accepted as a means of saving dollars.

Ultrasonography
US has achieved the status of the most popular cross-sectional modality in most of the world. Indeed, in the nonindustrial world, it is often the only cross-sectional approach available. Its popularity is due partly to lower cost and partly to the possibility of obtaining real-time, highly informative images. Great advances have been achieved in the resolution and noise reduction of modern US machines. With the introduction of contrast media and improvements in Doppler techniques, US will continue to be the predominant imaging modality in much of the world, with the exception being Western Europe, the United States, Canada, and Japan. High-quality fetal US, whether endovaginal or transabdominal, has made intrapregnancy fetal surgery possible (8) (Fig 3). Endoluminal US will continue to increase in use, and as transducers diminish in size, US intravascular imaging and US-guided interventions will become common procedures. US will also continue to be the most commonly used technique in guiding biopsies and the drainage of abscesses. The only drawback in this optimistic picture is the steady rise in the price of the improved instruments, resulting in a continuous increase in the cost of US procedures. Advanced, sophisticated US machines today have the same price tag as lower echelon CT scanners, and if streamlined MR examinations are performed with fast and disease-focused sequences even MR imaging can become price competitive with high-technologic US. We may therefore see a proliferation of acceptable-quality special-purpose US instruments that can be much lower priced.



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  		Figure 3. Intrauterine sagittal US image of a fetal head and neck demonstrates the good detail obtainable with state-of-the-art US equipment.

 
Computed Tomography
In the United States, CT has increasingly become the initial approach for evaluation or detection of acute abdominal conditions, lung metastasis and primary lung neoplasm, airway obstructive disease, stroke, fractures, renal disease, and others. With the advent of helical and electron-beam CT, the usefulness of CT has further increased and will undoubtedly continue to do so for the foreseeable future (Fig 4). In addition to much faster throughput, three-dimensional reformatting, and rotation of images, these techniques are becoming automatic, making them into everyday procedures of great help to other clinicians, particularly to plastic surgeons, vascular surgeons, and neurosurgeons. Reformatting and three-dimensional acquisition of angiographic images is introducing CT as a serious competitor to conventional and even MR angiography. The use of electron-beam CT for the detection of coronary calcifications, which when correlated to age, distribution, intensity, and amount can give an assessment of the presence and severity of most types of coronary atherosclerotic disease, is gaining acceptance (9,10) (Fig 5). In addition, for the first time the less-invasive thin-section CT coronary angiographic approach is almost clinical (11–16). Advances in CT computer programs are also making virtual endoscopic examinations a noninvasive, diagnostic approach applicable to screening, which will become very important as identification of genetic susceptibility to various diseases becomes a reality (17). Conventional endoscopy will then be restricted only to biopsies and therapeutic procedures. CT and MR colonography, CT bronchography, gastrography, cystography, and others are currently being evaluated in multiple research centers (18–24) (Fig 6). Multicenter studies that will establish the sensitivity, specificity, and accuracy of CT colonography, as well as help devise standardized approaches, are being conducted. Large-bore CT scanners with in-room television screens are being adapted for interventional radiology and image-guided surgery. The reduction of the risk of radiation overexposure for patients and operators is currently being seriously addressed by the imaging industry. CT fluoroscopy is currently being introduced by several large imaging companies.



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  		Figure 4. Helical transverse CT image of the abdomen very clearly shows gas bubbles (arrow) in the small-bowel wall and gas in small mesenteric veins (arrowhead) draining into the portal vein.

 


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  		Figure 5. Electron-beam CT scan obtained in an asymptomatic patient shows calcifications in the left coronary artery (arrow).

 


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  		Figure 6a. (a) CT colonographic image shows carcinoma (arrow) of the sigmoid colon. This image was obtained after CO2 insufflation with automated navigation (Acuimage, Millbrae, Calif) fly-through on an electron-beam CT scanner. (b) Conventional colonoscopic image of the same carcinoma.

 


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  		Figure 6b. (a) CT colonographic image shows carcinoma (arrow) of the sigmoid colon. This image was obtained after CO2 insufflation with automated navigation (Acuimage, Millbrae, Calif) fly-through on an electron-beam CT scanner. (b) Conventional colonoscopic image of the same carcinoma.

 
MR Imaging
MR imaging is fulfilling the promise of becoming the ultimate imaging technique. The modality is steadily diversifying and advancing with increases in imaging speed without sacrificing spatial resolution, with three-dimensional acquisition, high-quality angiography, functional imaging, spectroscopic imaging, new contrast media, and magnetic source imaging to name only the most important advances. MR cholangiopancreatography promises to become a clinical examination greatly reducing the invasiveness, morbidity, and cost of endoscopic retrograde cholangiopancreatography (ERCP) (25–28). It is used clinically in Europe and in the United States and appears to be equally as accurate as conventional ERCP (28). The latter will probably become only a therapeutic procedure. Functional MR imaging, presently applied primarily to the brain where, in a noninvasive manner, it can reveal new information that could not be obtained as part of a total imaging evaluation with any other method (29,30), undoubtedly is going to be feasible in other organ systems as well. MR imaging also promises to become an essential part of the operating theater of the next decade. To achieve this goal, administrative and technical issues will need to be addressed. Modern radiation therapy of tumors will soon also depend on accurate MR treatment planning (31–36). MR compatible instruments are either already available or being developed. Proton MR spectroscopic imaging with voxels of 1.0–2.5 mm is already being used clinically in the assessment of spread of carcinoma of the prostate (37,38) and recurrence of brain tumors after irradiation (39–41) and is going to be applied to the study of many more diseases in the future (Fig 7). MR angiography is already being used clinically and with the use of contrast media is most likely going to limit conventional angiography to guiding interventions (42,43). It is, however, facing competition from rapidly advancing helical and electron-beam CT angiography.



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  		Figure 7a. Transverse MR images obtained with an endorectal coil, and postprocessing program compensating for proximity to surface coil brightness, show the use of proton spectroscopic imaging in following the success or failure of prostate cancer therapy. (a) Left: Choline-citrate ratio greater than 1; area representing cancer is depicted in red and superimposed over the MR image before cryosurgery. Right: Following successful cryosurgery, the same area shows no increase in the choline-citrate ratio. (b) Unsuccessful cryosurgery, cancer area (in red) is smaller but persists.

 


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  		Figure 7b. Transverse MR images obtained with an endorectal coil, and postprocessing program compensating for proximity to surface coil brightness, show the use of proton spectroscopic imaging in following the success or failure of prostate cancer therapy. (a) Left: Choline-citrate ratio greater than 1; area representing cancer is depicted in red and superimposed over the MR image before cryosurgery. Right: Following successful cryosurgery, the same area shows no increase in the choline-citrate ratio. (b) Unsuccessful cryosurgery, cancer area (in red) is smaller but persists.

 
Interventional Radiology
With the addition of applications of other imaging modalities (eg, US, CT, and MR imaging) to digital fluoroscopy (44) for the guidance of procedures, interventional radiology has acquired renewed vigor. New ancillary instruments adaptable to the different imaging modalities and interventions are continuously evolving, and the demand for these has created imaginative, fast-expanding, multimillion dollar companies to bring to market surgical microinstruments, balloons, guide wires, stents, catheters, coils, glues, patches, and so forth (Fig 8). Interventional radiologists are advancing the quality of patient care and reducing health care costs by replacing open surgical procedures with image-guided interventions such as abscess drainage, ablation of liver metastases, and introduction of stents through obstructing lesions or through abdominal aortic aneurysms (45–47). Neurointerventional radiologists are performing life-saving procedures such as occluding cerebral aneurysms or arteriovenous malformations and even introducing stents (48–50) into vessels generally inaccessible to neurosurgeons, such as the basilar artery. Interventional radiologists often facilitate the work of neurosurgeons by, for example, preoperatively partially occluding giant arteriovenous malformations (50,51). As the field is expanding, the differentiation between surgeons who perform videoscopically guided interventions and interventional radiologists is becoming less distinct, and, ideally, interventional radiologists should have joint appointments in respective surgical departments and have admitting privileges.



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  		Figure 8a. (a) Right anterior oblique angiogram shows a large aneurysm (arrow) of the basilar artery. (b) Right anterior oblique angiogram obtained after the transarterial introduction of a stent (which is keeping the arterial lumen open) and packing of the sac with microcoils shows that the aneurysm is occluded.

 


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  		Figure 8b. (a) Right anterior oblique angiogram shows a large aneurysm (arrow) of the basilar artery. (b) Right anterior oblique angiogram obtained after the transarterial introduction of a stent (which is keeping the arterial lumen open) and packing of the sac with microcoils shows that the aneurysm is occluded.

 
Nuclear Medicine
While research into new radiopharmaceuticals and equipment developments such as whole-body imaging and imaging methods for specific organ systems are continuously advancing the field of positron emission tomography (PET), the cost and personnel investments for PET generally have limited the installation of these instruments to only large medical and university centers. New whole-body PET systems, however, now do not cost much more than some gamma camera systems, making it possible for more widespread applications of this technology (52,53) (Fig 9). The most promising developments in nuclear medicine appear to be in pharmaceuticals and equipment innovations in the field of single-photon imaging. Peptides and other receptor agents are already producing high-quality images based on receptor uptake. Single-photon emission CT (SPECT)–CT combined and PET-CT combined camera systems are starting to incorporate advantageous but simplified features of SPECT and PET imagers at more affordable prices. While research in the use of monoclonal antibodies continues, and some advances are made in specific areas such as imaging of cancer of the prostate with use of an indium 111–labeled monoclonal antibody, the general clinical utility of these agents still has not met expectations (54). Modern and future nuclear medicine workstations will network and allow incorporation into PACS with not only simultaneous viewing of US, CT, and MR images but also with the option of image fusion.



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  		Figure 9. Coronal PET images of a patient with metastases from a poorly differentiated adenocarcinoma of the left lung. The patient underwent chemotherapy, and an attempt at resection was made. Metastases (areas of uptake) in lymph nodes are clearly demonstrated following administration of 2-[fluorine 18] fluoro-2-deoxy-D-glucose.

 
DIFFICULTIES FACED BY RADIOLOGY

Problems Faced by Medicine as a Whole
Medicine as depicted by Norman Rockwell in his timeless painting of the compassionate physician sitting at the bedside of a very sick child and holding his hand does not pertain to the present. Its message is unfortunately not timely today on two counts: For one, today the physician can offer much more to a fever-stricken child than profound sympathy and, second, whether in solo practice, group practice, or employed by an HMO, the physician should but would not have the time to spend holding hands. Furthermore, the computer doing the billing probably does not have a procedure code for sympathy and today's payers would be unwilling to pay the cost of longer visits.

The public's perception of physicians, at least in the industrial world and particularly in the United States, has changed from profound respect to physicians being seen more as just another kind of businessman. Newspaper publications of average incomes for specialists and even for general practitioners do not soften that image (55–58). The general perception of governments and the public that there is a plethora of practicing physicians is the subject of debate and controversy. (Per thousand population: Italy 3.8, Belgium 3.4, Germany 3.1, Switzerland and Sweden 2.9, France 2.7, United States 2.3, Japan 1.6 and UK 1.4 [59]). When viewed in the light of over $1 trillion in health expenditures in the United States consuming approximately 13.5% (60) of its gross domestic product, or GDP, and the professional practitioner portion of this enormous sum holding steady at close to 20% (60), it is not surprising that there is a trend of diminishing affection by the public for the medical profession as a whole. Yet in the United States lately, there has been a change in patients' perception of the care they receive. A recent poll has shown that patients are even more satisfied with their care than physicians realize (61,62).

The United States consistently ranks in the bottom half of developed nations in male and female life expectancy and in infant mortality (63). In contrast, our health care spending, at 13.5% of gross domestic product (60), is well above that of any other nation and far above the developed-nation average; almost no country spends above 10% of gross domestic product on health (63). Thus, critics who study health care systems say we are by far outspending the rest of the industrial world, but getting less for our money. Moreover, public attitudes parallel this criticism by experts. Surveys of citizens of several countries indicate that only 10% of Americans thought only minor changes are needed in their health care system, compared with 56% of Canadians, 41% of Germans, 32% of Swedes, and 27% of British (64,65). Only Italians showed as low a level of satisfaction as Americans.

Radiology's share of total personal health care spending in the United States was only approximately 3.5% in 1990 (66), so it is not appropriate to blame much of the country's health cost problem on radiology. (Although newer information on this percentage is not available, it is unlikely that it has changed much.) However, dramatic new radiologic technologies involving costly equipment, such as MR imaging, have captured the public's imagination, drawing more attention to high-technologic radiology in the context of escalating costs than its modest share in the expense total would merit. Moreover, it is true that new technology, which doing more for patients, has been the primary cause of the steep increase in health care spending that the United States has seen over the past 3 decades as health spending grew from 5% of gross domestic product in 1960 to 13.7% by the mid-1990s (60). Also, high-technologic imaging has had one of the highest expenditure growth rates of any type of health care in recent years (67,68).

Threats to Advances in Imaging and Possible Remedies
Will there be a need for radiologists in the future? With the new modalities, images are clear and it is often fairly easy for a knowledgeable clinician specialist to read his or her clinical diagnosis into the images and very often that diagnosis will be correct. It is therefore easy to foresee that clinician specialists may come to believe that radiologists do not contribute sufficiently to the care of patients to justify their presence. To prove their clinical value, radiologists in specialized situations must be organ system oriented and knowledgeable in all the aspects of physiology, pathology, and up-to-date therapies applicable to the respective organ system, as well as be experts in the multiple imaging modalities applicable to the clinical problem addressed. A multicenter study (69) assessed the contributions of a second reading by radiology subspecialists of cross-sectional images in patients with cancer of the abdomen; the results indicated that a substantial number of findings affecting therapy decisions were not detected by the primary readers.

Another type of radiologist, however, is also needed for survival in the era of prevalent managed care. The primary care physician, whether a general internist, general pediatrician, or family practitioner, will need help (at least until computers with artificial intelligence are capable of guiding them) from a general radiologist as to what imaging procedure will most likely provide the diagnosis without having to go through the escalating sequence of imaging tests. To be able to render these consultative services, the general radiologist will need to keep abreast with the key new developments in most subspecialties. The general radiologist will also be very much needed for the ever-expanding outpatient practice. In radiology, as with our nonradiologist physician colleagues, the effective and efficient interfacing of generalist and specialist will be a hurdle that needs overcoming.

Cost Containment
In the Western world, there are no miraculous approaches available for slowing the increases in costs of medicine, given the fact that the profession and the media keep the public informed about modern medical advances. Because of the high cost of some examinations such as MR imaging, these examinations are sometimes delayed and often difficult to obtain in the managed care atmosphere prevalent in the United States. Yet a precise, accurate diagnosis results in appropriate and effective therapy, in contrast, a progression of imaging tests from the least expensive to the more costly sometimes results in higher costs and a waste of time (70). The appropriate higher cost imaging study leading to the precise diagnosis if performed first is generally cost saving (71). Interventional radiology procedures are usually more cost-effective than open surgery. Many articles attest to this (72,73). The advantages of interventional radiology over open surgical procedures also result in a shorter hospital stay, decreased morbidity, and shorter recovery time. Managed care has slowed the rise in health expenditures mostly (a) by using less inpatient care and (b) by contracting for lower prices. It will be most important to train radiologists to conduct well-planned cost-effectiveness and outcome studies and to educate physicians, administrators, third party payers, and the public about the results and about other information regarding the value of modern imaging in providing accurate diagnoses that affect therapeutic decisions (74,75). To combat inappropriate restrictions on imaging imposed by managed care companies putting their finances ahead of patient welfare, it probably will be important to conduct public information campaigns. This will produce patient demand for the optimal imaging procedure to support physician recommendations and overcome these inappropriate restrictions.

Turf Wars
Managed care, global fees, and discrepancy in reimbursement between primary care and procedures have intensified turf wars world wide. Although radiologists believe that procedures that they have started (eg, coronary angiography, prostate endorectal and Doppler US, and many others) have been taken away by other specialists, vascular surgeons, general and liver surgeons, gynecologists, urologists, and other specialists believe that radiology is invading their territory. Turf wars have been particularly bitter in US, angiography, and nuclear medicine. Some fields that radiologists consider their own have been invaded by other specialists. As an example, the US market in the United States in 1998 amounted to $890 million, of that the radiology portion amounted to $269 million and the nonradiology portion to $621 million (data are from the National Electrical Manufacturers Association and can be accessed on the Internet through any electrical company; authors accessed through General Electric). Although in normal obstetric situations general obstetricians perform equally to radiologists, in high-risk obstetric US, subspecialists outperform general obstetricians (76). Yet even these subspecialists, whether radiologists or other physicians, are often bypassed. The continuing use of diagnostic ERCP instead of MR cholangiopancreatography, although not a high-volume procedure, is just another example of endoscopists performing more invasive procedures. MR cholangiopancreatography is noninvasive, free of complications, and apparently equally accurate in diagnosis as ERCP (28). A more frightening phenomenon is the sporadic return of exploratory surgery. To serve patients better, turf wars should be avoided. This can be achieved by having teams of radiologic subspecialists and specialists practice together, supporting each other and having radiologists working together with educated primary care physicians. This is being achieved in many centers in the United States.

However, radiologists must expect that some amount of turf warring will remain, and we must become more effective in these disputes. It is not enough for radiologists to proclaim that they are better at imaging than clinician colleagues. They must demonstrate this in methodologically sound research and in credentialing processes, and then energetically disseminate the results to decision makers as well as clinical colleagues. Radiologists must also strengthen the service orientation of practice that makes success in claiming a particular line of work feasible. For instance, preventing incursions by emergency physicians will require better after-hours coverage by radiologists than has been traditional.

Fragmentation of Radiology
The reasons for fragmentation are understandable. Subspecialized radiologists often believe that joining departments with colleagues with whom they relate conveys security, avoids participation in ugly turf wars, and often leads to better remuneration. Fragmentation is particularly noticeable in nuclear medicine. In the United States, nuclear medicine is sometimes affiliated with internal medicine; in Europe, it is often a totally separate department. In Western Europe, particularly in Germany and Switzerland, neuroradiology is increasingly trying to separate itself from departments of diagnostic radiology. Fragmentation has a negative effect in that it separates radiologists from advances in the general field, removes them from cooperation with other radiologists and basic scientists in imaging, and usually makes them too one-sided and less valuable to patients. Research laboratories in radiology departments foster unity, but such laboratories cannot be maintained unless there is a department of "viable size" supporting them. While joint appointments in other departments (eg, neuroradiologists in neurosurgery, genitourinary radiologists in radiation oncology) are valuable, maintaining the main affiliation in radiology helps in keeping up with the technologic advances in the field and is generally also appreciated by other unrelated departments.

Government Regulation
With various government agencies supplying about 46% of the cost of medical care in the United States (77), he who "pays the piper" is increasingly trying "to call the tune." The government is attempting to control costs largely by administrative bureaucracy. The general tendency is to attempt to squeeze the physician's and hospital's reimbursement. Overregulation at all levels also tends to wrestle control of what procedures are to be performed out of the hands of physicians and radiologists, transferring the decisions to government and insurance administrators. The only way to avoid cuts that will interfere with the well-being of patients is to educate the public as well as government officials through well-conducted and well-controlled cost-benefit studies about the value of various imaging diagnostic and interventional procedures. Understanding how the various government agencies function will also help solve problems.

Positive Aspects Worldwide
Radiology, however, is still advancing, helping, and participating in the steady progress of modern medicine. It is still attracting the best and the brightest students, and it continues to be a most important diagnostic clinical approach. In the industrial world, it is still generally affordable and it is making dramatic advances in the emerging world. It is to be expected that with advances in technology, computers, and collaboration with molecular and evidence-based medicine, radiology will remain dominant in clinical diagnosis. The technologic advances of radiology in developing and perfecting new modalities, ancillary instruments, and contrast media are achieved by basic scientists and engineers working in industrial or university laboratories generally with technique-oriented and organ-system subspecialized radiologists. The approach is fairly simple: Radiologists know what is needed to improve their diagnostic sensitivity and specificity; the whole team achieves the innovations.

Challenge of Demonstrating Value
Improving imaging technology, however, is not our only task. In the past, new imaging techniques have often been adopted because they produce striking images of the hidden interior of the body, images almost as detailed and clear as views previously only available through surgery. However, payers are increasingly adopting a "show me" attitude and demanding a more scientific demonstration of the value of the new types of images. Therefore, radiologists face the challenge of better research. This challenge starts with familiar concepts like receiver operating characteristic curves, sensitivity, specificity, and positive and negative predictive values, which will need to be demonstrated in high-quality, multicenter trials. But the challenge goes further. It calls for showing the value of imaging in the overall diagnostic process or for showing how the imaging makes a difference in what the treating physician does for the patient. There may even be a call, especially in the screening of asymptomatic patients, to show an effect on the patient's health status. Demonstrating these outcomes is likely to be as important a challenge for radiology in the new millennium as is developing new imaging techniques.

Footnotes

Abbreviations: ERCP = endoscopic retrograde cholangiopancreatography PACS = picture archiving and communication system

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