CT

How Radiology is Pivotal for Healthcare Delivery

When a CT scanner in the past required six computer cabinets, today it runs on two standard PC towers

"The days when radiologists were confined to their 'dark-rooms' reading X-rays on view boxes, cut-off and separated from the rest of the medical community, are far-gone" - Dr Bhavin Jankharia Director Radiology Services Piramal Diagnostics

A person has a stroke. The first thing we do is a CT scan or an MRI to find out what the cause is. If the patient presents within three hours, then we can do additional studies to see if the patient is an ideal candidate for thrombolysis.

A 34-year-old man with a family history of coronary artery disease wants to know whether his coronary arteries are normal or not. A cardiac CT answers this question in a matter of five minutes.

Whether it's the evaluation of abdominal pain (ultrasound), or paraparesis (MRI) or tracking the progress of a foetus (ultrasound) or checking whether a patient is osteoporotic or not (DXA), there is some radiology investigation that is being used to answer the clinical question that has cropped up.

Radiology started in 1895 with X-rays. It immediately revolutionised the fields of chest and orthopedic medicine and surgery. When contrast media were discovered and invented, the use of barium and iodinated compounds opened up new vistas in the abdomen for surgeons. For the first time, they could see the bowel loops and the kidneys and ureters. Advances in X-ray based procedures continued till the 1970s, at which time, ultrasound and CT scan both made their presence felt.

Ultrasonography revolutionised the practice of gynaecology and obstetrics to start with and then other organ systems as well. CT scanning started with the brain. For the first time ever, we could actually visualise structures within the brain and look at normal anatomy and pathology. The fields of neurology and neurosurgery were changed forever.

Then came MRI, in the late 80s, which for the first time allowed us to see the spinal cord and vertebral discs and completely changed spinal medicine. Its exquisite soft tissue contrast also allowed further advances in neuromedicine and surgery. Orthopaedic surgeons found that they could see the ligaments in the joints for the first time, surgeons were able to evaluate the biliary tree without an invasive Endoscopic Retrograde Cholangio Pancreatography (ERCP), using a technique called MRCP and oral surgeons could see the temporomandibular joint disc for the first time and so on and so forth.

There have been other modalities as well that have impacted healthcare. Mammography is an integral part of breast-care in most first-world countries. Bone mineral density estimation by Dual X-ray Absorptiometry (DXA) allows us to look for osteoporosis. Ortho-Pantomo-Gram machines (OPG) allow dental surgeons to look at the jawbones and teeth on one single radiograph.

Over the years, as radiologists have become more involved in patient care, they have also started moving into invasive procedures. Though coronary catheter angiograms are today done by cardiologists, the first catheter coronary angiogram was performed by a radiologist. The first arterial stent was placed by a radiologist. Radiologists who specialise in a field called 'Interventional Radiology' essentially work like surgeons, intervening into various parts of the body, both for diagnosis and treatment. So, whether it is the performance of image-guided biopsies or radio-frequency ablations or

pain-alleviating injections, or angiographies and stent placements in various arteries of the body, or draining hydronephrotic sacs or performing percutaneous biliary drainage. these radiologists do them all. All of these advances have been helped by the amazing growth of computational power and information technology. When a CT scanner in the past required six computer cabinets, today it runs on two standard PC towers. Networking has allowed radiologists and centres to share images across multiple machines and imaging rooms, to have the images available to referring doctors on their personal workstations instantaneously and even to other radiologists or doctors across the world. This has fuelled the field of teleradiology where radiologists in other parts of the country or world, distant from the actual location of the scanner are able to report on the images and give their valuable opinions.

Whenever there is a significant advance in radiology and imaging techniques, it changes the associated clinical field as well. For example, today's cutting edge obstetric and infertility practices have been predominantly a result of ultrasound allowing us to actually visualise the foetus in utero. The role of the radiologist has changed as well. The days when radiologists were confined to their 'dark-rooms' reading X-rays on view boxes and performing fluoroscopy studies, often in basements, cut-off and separated from the rest of the medical community, are far-gone. Today's radiologists are part of the decision-making team, many of them sub-specialising in specific organ systems like the brain, chest, heart, etc and are an integral part of the clinical team that treats patients. For example, no bone tumour can be evaluated by any one person alone; the orthopedic oncologist, the radiologist and pathologist have to work as a team to provide the complete picture required for accurate management. From just reading radiographs, radiologists today question - 'Why am I performing this study?', 'Why is the patient with me?', 'What is the information that the referring doctors wants from this study?' This makes radiology an exciting discipline that impacts various organ systems throughout the body and allows radiologists to interact with a wide variety of physicians and surgeons. But with all these upsides, come downsides as well. The increasing use of imaging has led to a general 'hyposkillia' among clinicians. Reliance on the findings of scans as against the history and signs and symptoms, often leads to decision-making that may lead to unacceptable outcomes. Radiology is a capital-intensive practice. The machines cost a lot and they depreciate fast. To make up for this, it is necessary to generate patient volumes. This effectively means increasing the amount of imaging done on patients. This drives up patient costs and the overall cost of healthcare. It also leads to competition for patients, which may translate into unhealthy and unethical practices, like fee-splitting, incentivisation of referrers, etc. Vendors who sell equipment try to 'gift' decision-makers, whether they are radiologists, or administrators. As with industries across the world, these practices vary from place to place and country to country.

With a focus on adding functional information to the anatomic knowledge that we already have, the ability to diagnose and treat will only get better. PET/CT scanners have already revolutionised oncology and will continue to do so. Interventional techniques will get more and more refined and the combined impact will place radiologists and radiology in the forefront of patient management as well, moving away from just diagnosis as in the past to actual treatment using our radiology machines and minimally invasive methods!

bhavin@jankharia.com