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Centennial sounding board |
1 Scottsdale Medical Imaging, Ltd., 3501 N. Scottsdale Rd., Scottsdale, AZ 85251.
Received May 12, 2000;
accepted after revision June 5, 2000.
Address correspondence to J. K. Crowe.
Introduction
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My father used to say that the most complex computer is the only one built with unskilled labor. This century will see increasing sophistication of artificial (silicone-based) intelligence and a rapid development of molecular, quantum, and perhaps DNA-based computing. However, it is not the computational skill but rather the imagination and excellence of our predecessors that made radiology what it is today. If we are to succeed in the future, we must increasingly provide value, quality, and even excellence.
To understand what value we can provide in any situation, we need to imagine improved quality and dream of the most excellent possible outcome. Unless computers can learn to imagine and to dream, my father's statement may still be true 100 years from now.
Our century has seen amazing progress in our quest for value, quality, and excellence. In cars, appliances, and other engineered tools of everyday living, quality has dramatically improved. Automotive construction methods evolving from worldwide competition and logic circuits for monitoring feedback and control have made our cars (not to mention our CT, sonographic, nuclear medicine, and MR scanners) excellent indeed. But what of the human side of the equation?
People are not machines. Our own internal computers make us interesting but harder to predict and to control. I often ask students, "If we can put men on the moon and bring them safely home, why can't we floss and brush after every meal?" Or, "Why has it been 60 years since baseball legend Ted Williams, batting without a helmet and facing the potential of serious brain damage with each pitch, batted.406?" Or, "Why do our modern sluggers, covered from head to toe with protective gear, rarely even come close to Ted's batting excellence?" The answer is in their computer—the one built with unskilled labor.
Building on the ideas of Deming and Juran [2], dramatic improvements in the quality of our equipment and processes have occurred. The machines and some of the people and work teams at Motorola or General Electric may imagine and even achieve goals of less than one error per one million operations. On our field of play, today's health delivery system, the error rate is much higher.
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By the time of the first American Roentgen Ray Society meeting in 1900, we had dreamed of and developed most of the ideas that sustained radiology for our first 75 years: tubes, generators, collimation, film, fluoroscopy, contrast agents, and so forth. These technical ideas were powerful and persistent. If reincarnated in 1970, early leaders of the ARRS such as Eugene Caldwell or Preston Hickey would have recognized virtually all that was going on in a radiology department.
The evolution of radiology also had a non-technical side. The imagination and creativity of many of our former ARRS presidents defined our specialty, improved its practice, taught it to others, and established the Board examination as an accepted standard of quality that has endured. Although we don't have baseball's precise statistics and despite technical improvements, an excellent differential diagnosis by Leo Rigler that hit home in 1930 would have connected solidly for Ben Felson in 1975. But neither radiologist would have become an honored aging slugger only by hitting a few homers at conferences. Like Ted Williams, they needed mastery of the fundamentals, imagination and creativity at the plate, and strength of personality to dedicate their lives to excellence on their playing field: practice, writing, and teaching.
In this important respect, and despite the rapid rate of technical invention and change, we can look back to gain understanding of our future. Despite various personal quirks and characteristics, most radiology Hall of Famers had unwavering dedication to excellence in their professional lives. This professionalism got us where we are today.
A young radiologist starting a career today is standing on third base possessing knowledge, relative security, medical credibility, and unlimited opportunity not because he or she had a triple the first time at bat. They are entering the base paths of our specialty as a result of the 100 years of hard work and mastery of the game's fundamentals by older team members who can no longer hit, pitch, or run as fast as they once did.
If you are wondering whose shoes you are filling as you enter the game, just read a team roster, the list of past presidents, Caldwell lecturers, and Gold Medalists of this society. Like Ted Williams, some of these folks could hit for an incredible average in any ballpark. All understood that the game requires multiple skills. Some were great organizers, teachers, researchers, editors, politicians, analysts, inventors, engineers, technologists, or military officers. Virtually all were superb radiologists in one area or more.
Aristotle said, "Quality is not an act, it is a habit" [3]. More than 2000 years later, Richard Marshak, probably the best known gastrointestinal radiologist of his day, was asked why he would refill and refluoroscope all patients undergoing barium enema examinations. Still practicing in his 60s with only one functioning eye, he answered, "I don't want anyone to say that they found something that Marshak missed" (personal communication). Therein lies a useful playing tip: it takes both pride and humility, as well as mastery of the fundamentals and everyday hard work, to be a great hitter, pitcher, or radiologist.
Increasingly, perceptive patients see radiologists and radiologic examinations as the core of the diagnostic process. Increasingly, it is critical that all of our constituents, but especially our patients, perceive that they receive great value and high quality when they come to us for help. Everyone should understand from the cleanliness of your work place; from the sincerity, kindness, and technical competence of each employee; and from your appropriate communication with your patient that you hope to move past quality service to your ultimate goal—excellence.
Radiologists must maintain the old and learn some new fundamentals if we are to be successful big league players at all levels of the game. We must increase public awareness of our value beginning with individual patients and medical students. Hitting a home run at the noon conference is not enough. We must participate actively in our hospital activities and also learn to play at local, state, and national levels of the game. We must be more visible. We must learn to communicate more effectively to doctors and our patients that solid technical abilities are only a small part of what we bring to the field of play. Others must learn that, as the game situation changes, we have the skills, the time, and the ability to step up to the plate in challenging situations. They should know that in a clutch situation we deliver improved quality and added value and consistently contribute to the patient's best interest.
Whether we use the technology of the first 75 years or the last 25 years of the century, we must still make the observation, interpret it, and give a diagnosis. Because we cannot possibly foresee the technology of the next 100 years, our focus must shift from simple mastery of technology to broader, more enduring skills of patient care, including patient education, communication, and appropriate use of our tools.
The Future of One Technology—A Foreseeable Example
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As surely as we have changed from wearing red goggles in the basement of a hospital, we must step off third base on each of our local ball fields as well as on the national game of the week. We take our lead into the global marketplace of the future. We can never forget that our future depends on what got us here: serious research and development; quality service that is available, responsive, and unexcelled; and involved enthusiastic education of those we need to be our fans—patients, other physicians, insurers, students, politicians, community leaders, and the general public.
Improving our performance and increasing our value is increasingly hard. It is ultimately our only route to future survival. We don't want to see our game rained out. In this respect, we have no more choice than Noah did when God came with the word that Noah had 2 weeks to build an ark.
Noah replied, "Nobody can build an ark in 2 weeks."
And God said, "Noah, how long can you tread water?"
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