Inside Out

Advances in radiology – including uses for magnetic resonance imaging (MRI), computed tomography (CT) scans, angiography, and ultrasonography – give doctors a window into the body that shows objective evidence of disease and may decrease their reliance on a patient’s subjective complaints and physical examination.

Arun Dhand, M.D., a physician at Ormond Beach-based Gastroenterology Consultants, has been a gastroenterologist for 24 years. He says that imaging technologies have enhanced his ability to identify disease and made diagnoses more accurate.

“A patient may present with abdominal pain and weight loss, with normal physical exam, and if I suspect serious intra-abdominal disease, a CAT scan of the abdomen may find a tumor that I can’t feel,” Dhand says. “What the human hand can’t feel, the CAT scan or MRI can feel for you.”

CT scans combine computer and x-ray technologies to provide detailed images of inside a patient’s body. MRIs generate images using magnetism and radio waves, and can differentiate between types of body tissue. Doctors have dozens of other radiologic tools at their disposal. Positron emission tomography (PET) scanners, nuclear imaging, ultrasound, fluoroscopy, and mammography are just a few. Ultimately, they all allow doctors to see inside our bodies without piercing the skin.

Harry Black, assistant medical director for surgery for Florida Health Care Plans, says that while imaging technologies are an integral part of medicine, they have not superceded the patient’s own voice.

“You’re not going to do the test unless the patient complains,” says Black. “[The scan] helps define the complaint in a more complete way. The patient interaction is very important, because it helps the doctor hone in on what tests can be useful in making the diagnosis.”

At this point, patients still expect their doctors to physically examine them. This could, theoretically, change in the future. Imagine a time when a patient would receive scans in a radiology department based on a physical complaint, such as pelvic pain. A gynecologist would view the images in her own office, confer electronically with the radiologist, and then prescribe drug treatment without ever meeting the patient. So far, this does not happen.

“Certain things are time honored. You still have to be able to sit down with your patient, talk to your patient, examine your patient,” says Dhand. “The question is whether the new technology will change the patient/doctor relationship.”

It is true that some doctors may now order a scan before seeing a patient. One medical professional describes a time when a spouse suffered from headaches and called for an appointment with a neurologist. The neurologist suggested that the patient get a CT scan before the office appointment.

Black says that such a situation is atypical, and we are not on the cusp of eliminating the doctor or patient. He uses radiological results to aid in his decision-making process, but that the technology is nowhere near being self-sustaining – the machines aren’t thinking yet.

“It helps clarify for me something that I may have operated on [routinely] ten or fifteen years ago,” says Black. “Now on the basis of the scan, I figure out now if I need to operate. It doesn’t take the physician out of the decision-loop and it doesn’t take the patient out, either.”

New digital capabilities do take the film out of images, though. In the past, radiology departments had darkrooms that developed each film and produced a physical image. These had to be manually carried from place to place, and stored for years. Lost films are not uncommon. The transition from film to digital storage makes using the images easier, cheaper, faster, and more efficient.

Dhand states that it may only take a few minutes to scan a patient’s head or abdomen. After that, the radiologist and treating physician can view a digital image almost immediately.

“If a patient had a CAT scan at 10:00 a.m., at Memorial Hospital, I can look at it at 10:05,” Dhand says. “I generally look at the films before I make my rounds, so I can correlate a patient’s clinical picture with the scans.”

Dan Miles, a radiologist at Radiology Associates, explains how not only the prevalence, but also the capabilities of radiology have increased, partially as a result of the transition from film to digital imaging.

“The technology of the CT scanner, for example, has improved so we can take thinner and clearer images than we could before,” Miles says.

While some of these imaging capabilities have been around for years, recent advances and an aging population are fueling the demand for them. According to a study by The Freedonia Group Inc., a research firm based in Cleveland, the U.S. market for imaging equipment will increase 7.6% per year through 2008 to $9.5 billion. Digital radiography equipment and PET scanners will experience the highest increase in demand, with traditional x-ray equipment seeing the slowest growth.

“Radiology and imaging has become an integral part of the diagnosis of disease in a patient’s work up,” says Miles. “There is no question that as the technology has improved, there’s been a significant increase in the use of imaging.”

Radiology Associates recently purchased a new stand-up MRI machine. Miles describes this machine as like “a small room,” and a boon for patients who suffer from claustrophobia. In a typical MRI machine, the patient lies on his back and slides inside the machine. Miles estimates that perhaps 20% of patients get an MRI because they suffer from pain of unknown origin. Their complaints are not specific enough for the physician to identify the problem. A patient may feel pain when bending over, but not when laying flat.

“With this particular scanner, if they have pain when they bend over, you have them bend over,” Miles says.

Use of medical imaging technology has risen sharply over the past several years as a result of the benefit in diagnosis and even treatment of ailments. Financial motivation may also be a factor in its use. While insurance companies and medical guidelines that regularly deny claims may discourage some excessive scanning, the expensive machines needed for these services make money only when they are in use.

Other questions may arise in the near future as the government addresses electronic medical records in general. Who and what entities may gain access to the hundreds of thousands of electronic scans being performed each year in the U.S.? Film could be stored in a doctor’s office or hospital, and reproduced only at great expense. An electronic image can be reproduced an infinite number of times at little to no cost. Could insurance companies require that physicians provide them with electronic imaging files, and if so, could they be evaluated and used to exclude coverage for health or life insurance?

The time when doctors had only their five senses and the patient’s own observations to diagnose ailments has long gone. The stethoscope, which remains a symbol of authority, hangs on a doctor’s neck now more than it is pressed to a patient’s chest. With technologies that allow a view of the human body from the inside out, images provide the doctor with more information than the patient himself.

Nevertheless, Black says that despite incredible advances in medical imaging, real people are still necessary for the doctor/patient relationship to work.

“Sometimes there’s kind of a Zen aura to radiology, but most of the time it’s not that. It involves the patient, clinician and radiologist. It’s very much a symbiotic relationship,” Black says.