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Perspectives |
1 From the Schools of Medicine and Liberal Arts, Indiana University, 702 N Barnhill Dr, Rm 1053, Indianapolis, IN 46202. Received May 18, 2004; accepted June 1. Address correspondence to the author (e-mail: rbgunder@iupui.edu).
Radiology is the medical community’s paradigmatically visual discipline. It allows physicians to peer into the interior of the living human body without cutting it open and has revolutionized the way patients and physicians view health and disease. Many contemporary medical fields would be almost unrecognizable were radiologic imaging to become unavailable, and its benefits to life and health are difficult to overestimate. Yet, like every new way of visualizing things, radiology, in the course of revealing some things, tends to obscure others (1). By exploring how the lens of radiology has changed our medical vision, we can better understand what radiologic imaging reveals and avoid the mischief that might result from failing to recognize the blind spots of this technology.
The Long History of Observation
The central role of observation in Western medicine can be traced back to at least 5th century BCE Greece and the Hippocratic school. The authors of the Hippocratic corpus chided their medical contemporaries for failing to base their practice on systematic observations. In one Hippocratic work, "On Forecasting Diseases" (2), they elevated looking to a high art:
First of all the doctor should look at the patient’s face. If he looks his usual self this is a good sign. If not, however, the following are bad signs—sharp nose, hollow eyes, cold ears, dry skin and forehead, strange face color such as green, black, red, or lead colored. If the face is like this at the beginning of the illness, the doctor must ask the patient if he has lost sleep, or had diarrhea, or not eaten.
Although the followers of Hippocratic doctrines firmly established patient observation as a cornerstone of medicine, their observational practices differed from our own in important respects. First, the followers of Hippocrates depended on their unaided senses to collect information (3). They practiced without the tools that physicians today rely on to extend their observational reach, such as the microscope and stethoscope (4).
Second, they did not peer into the interior of the body. Dissection of human bodies was a cultural taboo, and surgery was practiced in a comparatively primitive fashion. As a result, their knowledge of internal anatomy was, by our standards, remarkably unsophisticated, and they thought of health in largely humoral rather than anatomic terms.
Third, they generally did not attempt to correlate symptoms and signs of disease with internal anatomic derangements. They regarded peering inside the human body as not only unseemly but also unnecessary. Physicians could discern what they needed to know by learning to observe how patients looked and lived, as well as by studying their bodily inputs and outputs.
Since the 16th century, medicine has taken a different approach to observation. To be sure, empiric physicians such as Thomas Sydenham continued to build on the ancient observational foundation (5). However, with the path-breaking anatomic studies of the Italian anatomist Andreas Vesalius, the focus of the physician’s attention began to change. Vesalius inaugurated a new era of hands-on direct inspection of human anatomy, revolutionizing our understanding of how the interior of the body is put together (6). Owing to the work of anatomic pathologists such as Giovanni Morgagni, physicians began to grasp that the external signs and symptoms of disease could be precisely correlated with internal lesions revealed at autopsy. This approach was perfected by the 19th century pathologist Rudolf Virchow. For example, one could link a patient’s progressively worsening angina pectoris and sudden death to such pathologic findings as an enlarged heart, coronary artery occlusion, and cardiac muscle infarction.
Investigators also expanded the ability to assess internal processes during life with such innovations as the Laënnec stethoscope. By observing the patient’s symptoms and carefully auscultating the lungs, physicians could determine whether conditions such as pneumonia and empyema were present even before autopsy. Thanks to the microscope, investigators such as Louis Pasteur and Robert Koch were able to link infectious diseases to the presence of microorganisms in tissues. Such innovations further shifted the observational focus in medicine from the exterior to the interior of the patient. Diagnostic and therapeutic decisions became more and more based on the physician’s ability to detect hidden events in the inner recesses of the body (7). This shift remains evident in our contemporary appellation for the largest branch of medicine, internal medicine.
A New Way of Seeing
Internal medicine took a giant leap forward in 1895 when the German physicist Wilhelm Roentgen discovered the x-ray (8). Within months of Roentgen’s announcement, his "invisible light" was enabling physicians to peer beneath the skin without a scalpel. They no longer needed to rely on their other senses to infer the presence of pathologic processes. Instead, they could see them directly in the form of x-ray shadows cast on photographic film. For example, nondisplaced skeletal fractures, which were formerly diagnosable only with use of external signs, such as point tenderness, swelling, and refusal to use the injured part, became accessible for visual inspection, as though one were looking at a pathologic specimen of the bone. Instead of diagnosing pneumonia by listening for changes in breath sounds or using percussion, the physician could see the focus of infection on a chest radiograph. Thus was born the radiologic aphorism, "One look is worth a thousand listens."
As imaging technology advanced, fluoroscopy, radiologic contrast agents, ultrasonography, nuclear medicine, computed tomography (CT), and magnetic resonance (MR) imaging provided additional "windows" through which to inspect internal anatomy. X-rays even played a crucial role in revealing submicroscopic anatomy. For example, x-ray crystallography made it possible to discern the normal three-dimensional structure of the hemoglobin molecule, as well as the distorted shape of this molecule in patients with the blood disorder sickle cell anemia. This procedure also made it possible to determine the double-helix structure of DNA (9).
Today, approximately 380 million radiologic examinations are performed in the United States each year (10), and the radiology department has become one of the principal resources to which physicians turn to help them diagnose their patients’ conditions. Even the scrupulously rational followers of Hippocrates might have suspected something divine in the medical community’s remarkable new ability to peer directly into the interior of the living human body without cutting it open.
Just as fish would be among the last creatures to notice water, we humans are inclined to overlook the most ubiquitous features of our daily experience. Physicians and patients rarely pause to reflect deeply on the philosophic importance of the tools of medicine. Heir to the long and shifting role of observation in medicine, radiology has deeply influenced how physicians and patients regard themselves and one another. Despite the fact that the practice of many medical specialties would be virtually unrecognizable in the absence of modern imaging techniques, the effect of radiology on our understanding of health and disease has received remarkably little attention (11).
The influence of radiology has been overwhelmingly salutary. Thanks to contemporary imaging technologies, physicians are able to detect or exclude diseases such as cancer, gauge the extent of such diseases, assess response to therapy, and reliably detect recurrences. For example, CT can depict lung cancer, guide the biopsy of lesions, help in assessing the spread of the disease elsewhere in the body, help determine response to chemotherapy, and aid in monitoring the patient for the return of disease. It has been estimated that CT enables physicians to avoid performing exploratory surgery in approximately 300 000 children in the United States each year and that the early detection of breast cancer through annual screening mammography can help to reduce disease-specific mortality by up to 70% (12,13). Yet, like every medical advancement, radiology is associated with risks as well as opportunities. Those who seek to understand the philosophic underpinnings of contemporary medicine need to explore not only the benefits but also the costs of the potentially Faustian pact that we have struck with imaging.
The Importance of Radiology
One aspect of disease that radiologic imaging has encouraged us to take more and more for granted is its hiddenness. Throughout the history of Western civilization, few people have thought of themselves as ill or even potentially ill until they actually developed symptoms of disease. Before the development of symptoms, they concluded that they were in good health because they felt well. Now, thanks in large part to the ability of diagnostic imaging to detect disease at an early presymptomatic stage, they think of health status more and more as a determination that should be made only by experts.
Although we may feel well, who knows what a chest radiograph or a CT scan might reveal? Perhaps our coronary arteries are filled with calcified atherosclerotic plaque, or perhaps we harbor a lung cancer that has already metastasized to other parts of the body. Whole-body cross-sectional imaging has received considerable attention recently as a means of screening for just these sorts of lesions. Of course, the same principle can be applied another way: We may sense that we are quite ill, but the test result may indicate otherwise. On the basis of a normal radiologic examination result, the physician may conclude that the problem is "all in your head."
On the one hand, radiology has given individuals greater insight into their health by providing new windows into the human interior. On the other hand, it has indirectly undermined individuals’ estimation of their ability to intuit their own health status by creating the presumption that to know if we are sick, we must undergo sophisticated and frequently costly imaging tests (14). As a result, our sense of personal autonomy and efficacy in health matters may be threatened. Amid an unprecedented abundance of health information, we may begin to feel more alienated from our biologic processes than ever before. Practically speaking, we may find ourselves running to the doctor at the onset of every twinge and failing to take simple, readily available steps to protect and improve our health.
Against this trend, the followers of Hippocrates would urge us to remain in touch—literally and figuratively—with our own health. Hippocratic physicians recognized that patients required their expertise, but they also sought to empower patients by urging them to monitor their own condition and by prescribing therapies such as diet that required patients to become active therapeutic allies. Physicians can provide valuable information and guidance, but there is also a benefit to knowing ourselves. Radiologists can contribute to this effort by taking opportunities to educate patients about the role of imaging in health care, particularly the contributions imaging makes to their care. If radiology personnel take the opportunity to show patients’ anatomy and physiologic features to them, patients will be likely to feel less alienated from their biologic processes.
Another potential pitfall of diagnostic imaging is its tendency to draw the physician’s attention away from the whole patient and focus it instead on the patient’s individual parts. The whole patient is rarely imaged in diagnostic imaging procedures. Instead, a chest radiograph, a CT scan of the head, or an MR image of the knee is obtained. Each examination not only reveals mere parts of the patient but also reveals only certain aspects of those parts—a necessarily incomplete picture (15). For example, a CT scan depicts only the physical density of the tissues through which x-rays pass. An MR image reveals only the magnetic properties of protons in different molecular environments. We usually cannot tell from a CT scan of the head whether a person is mentally healthy or mentally ill. We cannot determine from an abdominal MR imaging examination what kind of diet a person consumes, what prescription medicines he or she is taking, whether he or she takes an occasional drink, or how stressful the person finds his or her work or home life.
The physician who places all of his or her trust in medical images may think less and less of interacting with the whole patient whose internal structures the images depict. We may begin to forget the human aspect of health and disease (16). We may see our patients as that ruptured appendix or that patient with small cell lung cancer with the brain metastases (17). Against this trend, the followers of Hippocrates would remind us to beware the temptation to let imaging turn our patients into specimens. We must strive always to situate diagnostic imaging within the larger context of the whole patient. Anatomic lesions are vital ingredients in a recipe for understanding health and disease, but they are not by themselves a complete diet. Radiologists can enhance their long-term relevance to our medical colleagues and to the entire health care enterprise by remembering to situate diagnostic images in this larger context. It is vital that radiologists not merely obtain high-quality images and facilitate short report turnaround times but also seek opportunities to use our knowledge and skills to benefit human life.
As anatomic lesions supplanted Hippocratic physicians’ concern with humoral imbalances, the patient’s story became devalued as well. Michel Foucault observed that physicians who once asked their patients "How do you feel?" began by asking them "Where does it hurt?" (18). Medical students begin their studies wanting to get to know their patients, but by the time they complete their formal training, they conceptualize conversation with the patient as history taking—a means to a diagnostic end. The patient’s medical history and life may cease to be ends in themselves and become means by which to determine a diagnosis. Empirical studies demonstrate that physicians wait, on average, 18 seconds before interrupting their patients. This is a clear indication that listening to the patient’s story is not the priority it once was (19).
The patient is the background against which the disease is projected, and whenever we can focus our gaze on our true quarry—that is, the disease itself—we tend to do so with relish. Too often, we find ourselves putting up with the patient so that we can get at the disease. We take a history to find out what part of the body to image. We appraise medical competence not by how the patient does but rather by whether the physician ordered the right tests. In contrast, the author of the Hippocratic oath would remind us that respect and concern for the patient are the physician’s first responsibilities and that all other diagnostic and therapeutic maneuvers should revolve around that core.
A corollary of this evolution in medical observation is a progressive diminution of the role of other forms of perception. Vision reigns supreme. A blind person can practice psychiatry, but a blind radiologist is an oxymoron. It is widely admitted that as the power of diagnostic imaging has grown, physicians’ skills in medical history taking and physical examination have declined (20). When an abdominal CT scan can immediately reveal a patient’s internal anatomy in great detail, taking a full history and performing every relevant maneuver of a complete physical examination seem to be an inefficient use of the physician’s time. In many cases, patients are sent from the emergency room directly to radiology services for imaging examinations. When the radiologist calls to report the findings and asks for more clinical information about the patient, referring physicians respond that they have none because they have not yet seen the patient.
We radiologists sometimes find ourselves giving more credence to the images than to the patient, rendering the patient’s experience subordinate to the images on the monitor. What do such changes portend for the future ability of physicians to understand not only their patients’ diseases but also the patients themselves? What would the followers of Hippocrates say about physicians who know nothing of their patients’ day-to-day routines, who have never seen the physical conditions in which their patients live, and who have no idea how easy or difficult it might be for their patients to comply with their therapeutic recommendations?
In increasing our reliance on radiologic imaging, we run the risk of violating one of the primary directives of the Hippocratic school—namely, to know and care for the patient before the disease. Nothing better reminds us to put patients first than becoming patients ourselves. Assuming we are fortunate enough to avoid becoming ill ourselves, however, we need to make a conscious effort to recall what the sophisticated trappings of a radiology department look like from a patient’s point of view and to do what we can to make our environment as hospitable as possible.
Despite Hippocratic warnings to the contrary, radiology has taken on some trappings of a priestly role in medicine. The radiology department itself is generally a dark place and is often situated in the bowels of the hospital. It is kept dimly illuminated so that ambient light does not obscure the images. Each room has but one light source: the computer monitor or the transilluminated film through which the diagnostic signs are revealed. The radiologic oracles are divided into hierarchic groups according to the extent of their training and experience, with the novices relegated to the back and the most senior radiologists, the "high priests," perched at the altar, the computer monitor. The radiologic examinations themselves are highly ritualized: Patients are frequently required to eat specialized diets, purge themselves, undergo phlebotomy, remain motionless for long periods, and perform special maneuvers.
Because of the crucial role that diagnostic imaging plays in contemporary medicine, virtually all physicians who care for patients use diagnostic imaging services. They send patients to have their hidden interiors revealed; then, the physicians themselves visit the radiologic oracles to have the signs interpreted. Of course, ritual itself is not a bad thing. Yet the followers of Hippocrates would undoubtedly counsel professionals who are vested with such extraordinary powers to be especially on guard against arrogance.
We who wield the new radiologic armamentarium must never become so full of ourselves that we regard ourselves as more important than the colleagues and patients we serve. Amid increasing workloads, it is all too easy to begin regarding requests for face-to-face patient consultation as interruptions that impede workflow. When radiologists start to think in such terms, we cease to function as consultants and become part of an assembly line for radiology reports, and such an outcome bodes negatively for the future of the field. This is not to say that radiologists cannot or should not seek to make such consultations more efficient. However, it is the role of medical consultant—not that of resource-based relative value unit generator—that ultimately holds the key to radiology’s future prosperity as a medical discipline.
Conclusion
Radiology is the medical community’s paradigmatically visual discipline. Perhaps more than any other medical field except pathology, it has contributed to the objectification of patients and their diseases. There is no escaping the perceptual principle that we cannot see things well unless we step back from them, and the more visual medicine becomes, the greater the need for this distance. This primacy of seeing and the distance it implies have changed the way physicians see patients: These caregivers are tending to devalue touching and listening.
Touch creates an immediate human bond, conveying a warmth that is difficult to achieve any other way. Many patients, particularly those in the greatest distress, desperately need to be listened to. Radiologists must strive to retain and enhance their perspective as physicians—that is, as dedicated professionals who see not only medical images but also the patients in whom the images were obtained and who take seriously what those patients and the colleagues who care for them have to say. Radiologic procedures reveal the interior anatomy in the blink of an eye, but touching and listening require time, which for today’s physicians is a commodity in increasingly scarce supply.
Because physicians rely so much on diagnostic imaging, we run the risk of becoming too distant to connect with patients and too harried to make patients feel that their physicians care for them. I am not suggesting that we stop looking. We should, however, remind ourselves that we only see what we look for. Sometimes our expectations lead us to see things that are not there, and in other cases, we fail to look for what our patients most need us to see. In our zeal to use radiology to reveal the hidden, we must not forget to attend to those aspects of health, disease, and, above all, our patients that imaging cannot reveal.
REFERENCES
This article has been cited by other articles:
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  B Hofmann and K B Lysdahl Moral principles and medical practice: the role of patient autonomy in the extensive use of radiological services J. Med. Ethics, June 1, 2008; 34(6): 446 - 449. [Abstract] [Full Text] [PDF]
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 R. H. Gottlieb Imaging for Whom: Patient or Physician? Am. J. Roentgenol., December 1, 2005; 185(6): 1399 - 1403. [Abstract] [Full Text] [PDF]
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