Diagnostics - Seeing the Whole Elephant

Dr Basri Johan Jeet Adbullah, University of Malaya

Key Points - Boundaries between related speciality fields have become increasingly blurred. - There are many ‘turf battles’ for ownership of imaging technology and processes. - A new approach to medicine must be adopted in light of the ‘imaging revolution’.

Dr Basri Johan Jeet Abdullah of the University of Malaya believes the imaging technology is in place to drastically improve patient care.What is sometimes lacking is the political and institutional will to use this technology effectively.

From the humble beginning of imaging following the discovery of X-rays in 1896, imaging evolved rapidly. As early as 1897 – only a year after the discovery of X-rays by Wilhelm Roentgen, radioactivity by Henri Becquerel and radium by Marie and Pierre Curie – it was concluded that X-rays could also be used for therapeutic purposes.

Imaging Develops

The role of imaging has expanded with the development of newer and more accurate imaging modalities and has become an essential component in the practice of medicine. Imaging has permeated every discipline of medicine from screening (using mammography) to diagnosis and staging of a multitude of diseases (such as coronary disease, colorectal carcinoma, lymphomas and Lyme disease). It plays a vital role in diagnosis and in determining appropriate therapy; essential not only in evaluating the response to therapy and follow-up, but increasingly to instituting the very therapy itself. With the rise of molecular imaging, the ability to image cellular processes at the genomic or proteomic level is already here.

Even death has not been spared, with the advent of the virtual autopsy, even for those who died thousands of years ago. The discovery of the X-ray and its spin-offs has had ramifications beyond medical practice, which extended into the realm of art, fashion and the very way that we look at ourselves.

What is even more fascinating is that the entire paradigm of managing a disease in discrete stages (from diagnosis to staging, to treatment, to follow-up) may no longer apply as we are increasingly looking at blurring these discrete steps into a continuum where diagnosis,therapy and response are just different aspects of the same imaging technique – so-called theragnostics.

As a speciality, radiology has never looked back and has been enjoying a never-ending series of successes in all the different imaging modalities, with leading for a short period of time before being overtaken by another – for example, MRI followed by spiral and MDCT followed by PET/CT.

Systemic Problems

Despite all these successes, the imaging community seems to be facing what appear, on the surface, to be insurmountable problems – increased costs, increased need for specialised staff,newer technologies (the advent of image fusion has added both to the complexity and capability of imaging), expensive therapies, and a rapidly rising clinical load with lacking or static manpower. This is taking place in an environment of continuous turf battles on many fronts about the definition of imaging and imageguided therapies and who ‘owns’ them. The boundaries between related speciality fields have become increasingly blurred,with numerous approved specialities and even more operating outside the system of certification, with numerous territorial claims. This is especially so with the greater commercialisation of medicine,where ‘loss of territory’ hurts the pocket.

Marketing of outpatient diagnostic imaging services is being increasingly pursued due to demographics,competition, non-radiologist expansion,self-protective practice and evolving technologies. There is a greater desire for self-referrals among those who own imaging equipment and those who have to refer to an imaging specialist. The increased role of minimally invasive image-guided therapy, with its lower invasiveness, faster recovery and good long-term outcomes, has encroached into every area of medicine, replacing traditional surgical procedures completely in many instances. This has further complicated the scene.

A Need for Clarity

Even though specialisation is presently seen as a necessity, with the increasing complexity of medical knowledge and the demand for administrative rationality, patients are finding it increasingly difficult to decide which physician(s) should be responsible for their care. This has cost implications for the community. There is an urgent need to define who is responsible for the coordination of patient care, the boundaries of specialisations and the owner of the health system in which physicians practice.

As a consequence of this new imaging revolution, a new approach to wellness, disease prevention and treatment needs to be implemented, especially in the world’s less developed countries. The potential contributions of biomedical imaging, bioengineering and bioinformatics are of prime importance to emerging research areas, such as:

  • • Functional genomics
  • • Proteomics
  • • Molecular biomechanics and drug delivery systems
  • • Tissue and cell engineering
  • • Quantitative biology and computer modelling
  • • Molecular and computational imaging
  • • Computer-aided diagnosis
  • • Metabolic imaging
  • • Ultra-fast and integrated imaging systems

Governments, medical organisations,researchers, vendors and providers are finding it hard to cope with these challenges alone. Partnerships are a critical mechanism for facing the initiation of any new concept.

Leadership Required

There are no easy answers to these issues, as the cultural, social and political environments surrounding medicine increase the complexity of applications across nations and societies. However just like the blind men and the elephant there must also be an opportunity for these differencing viewpoints to be shared, explored and brought together. Eventually, we as a responsible community, which has the welfare of the patient at its heart, must allow the fruits of our success to be enjoyed throughout the wider community. This can only happen if we have leaders who can champion this cause. One has to recognise that there are many approaches to prepare, select and support leaders in difficult times and that strong leaders do not necessarily have to possess a uniform background, but do need integrity, courage, vision and expertise in communication, dedication to improvement, business acumen and experience, as well as being role models. With all these requirements, it is a miracle that there still are a few great leaders in the field.

When we feel uncomfortable about changes occurring in our environment,we should resist the temptation to withdraw into our comfort zones, but rather explore these new possibilities, which may herald the dawn of a better era for patients and community. With the increasingly blurred borders between the various ‘traditionally’ defined disciplines, this discomfort is easily appreciated. It is imperative that we work towards establishing relationships that share the risk of adopting new technological innovation,programmes, services and processes designed to improve overall patient care, and access to cost-effective healthcare. The current, unsatisfactory situation will continue unless we all get involved in this discussion and see the whole elephant!

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