Author + information
- Alfred A. Bove, MD, PhD, FACC, ACC President*
- ↵*Address correspondence to:
Alfred A. Bove, MD, PhD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
Prior to the 15th century, books were handwritten by monks in scriptoria. Taking on a project like transcribing the Greek philosophers or other classical writings was a lifetime job, and the books that were produced, one at a time over many years, were consigned to the libraries of the monasteries of Europe or to university libraries that could afford to purchase one of these rare works. While monks and university scholars had access to these writings, the ordinary public could only gain access through a monastery or library. In a monastery, the librarian or an assistant would accompany the reader to the library, open the book on a reading table, and stand by while the reader gleaned the needed knowledge from the book. Of course, the librarian or abbey would want to have some idea of why a person wanted to read the book, and after carefully inspecting the reader's request for access, might have looked over the reader's shoulder to be sure that he (never she) was not planning some sort of heresy based on the knowledge he had read. When the allotted time elapsed, the reader was politely asked to complete his reading and depart, and there might have been some negotiation for a return visit for more reading. This method obviously allowed the monastery total control over the flow of information to the public. It also required the reader to go to the library any time he wanted to gain information.
Around 1436 in Germany, a goldsmith named Johannes Gutenberg developed an idea that he could print many pages at one time with a press that would ink a plate of characters and transcribe them to paper. Gutenberg found a few businessmen to bankroll his invention, and in a few years, printed books were coming off the press in several places in Europe. The large number of books produced by these presses far surpassed the ability of monks to transcribe individual volumes, and very rapidly, the low-cost books were disseminated to the public. Best of all, a person could purchase a book, take it home to read, and not have to travel to a library, obtain permission, and examine a book for only a few hours a day. The entire process of knowledge acquisition changed to the point where everyone had information at their fingertips. The democratization of knowledge changed civilization and eventually put the monks out of the business of transcribing books by hand. Acquiring knowledge locally was clearly an advance, and we quickly became accustomed to this behavior.
If we fast forward to the 19th century, we can credit Wilhelm Röntgen for discovering X-rays and the observation that we could look inside the body at bones and other structures not evident in the world of visible light. It soon became apparent, however, that this higher energy radiation had problems: it was biologically active and could cause direct harm to tissue and induce cancer, and the high-energy equipment, if not properly designed and maintained, could cause serious harm or destruction due to technical failures. The routine use of X-ray technology in medicine required a new dimension in engineering to generate and manage the very high energy (i.e., 100 kV) needed to produce reliable X-rays for medical use. A cadre of high-voltage engineers and physicists evolved, and a number of companies began building these large and somewhat dangerous machines, while some physicians developed specific skills in managing the high-energy machines, creating the film images, and applying proper safety precautions. These machines were installed in medical centers that could afford the costs and maintain an in-house staff of needed engineers and physicists. When patients needed an X-ray study, they traveled to the X-ray machine, where their images were obtained and archived. When the physician needed the information, he or she also traveled to the X-ray department where the archivist would retrieve the films, and wait to get them back after the clinicians examined them for their clinical decision-making. For a long time we behaved just like the ancient monastery librarians. Medical imaging needed democratization.
Fortunately, the digital revolution has allowed the images to be archived electronically and distributed well beyond the film room of the past so that the images can be examined at work stations throughout the hospital, but rarely in a physician's office. The digital revolution, however, did not mitigate the need for the patient to travel to the machine to be examined with the imaging tools. This need for the patient to travel to the imaging machine, have an examination, and have the images read and reported delayed care, and it became obvious as imaging technology improved that the tools, like the printed books of the 16th century, could be brought to the patient to improve efficiency for both patient and physician. This democratization of imaging is part of human behavior, yet some among us want to cast it in a negative light, and call it “self referral.” I call it “better, more efficient, timely health care.” Even now, I see patients who are “assigned” to an imaging center somewhere in our city and who are not allowed to have a point-of-care image study. Almost without fail, the study is done weeks later, and the resulting information is lost in a sea of different record systems. The data thus reside in one health system while the care is provided by another health system, and the 2 systems do not communicate with each other. This is the nightmare 14th century health care delivery that insurance administrators have designed, not for good patient care, but for a better bottom line. Those who work in the imaging centers have a very strong self interest in preserving this ancient system, even though it does not serve our patients well. They campaign to preserve this system by describing our efforts at better and more efficient patient care as self referral. But forcing imaging services into an imaging center is also self referral that is clearly not in the interest of better patient care. Democratization, they say, may be good for our society, but not for health care.
In more recent times, the need for trained engineers and physicists has diminished because of better design of X-ray machines and better isotope handling, and we now have several forms of imaging that do not have the risk of injury inherent in high-energy radiation. Ultrasound imaging has become a mainstay of imaging of many parts of the body. Radiology adopted this methodology as an imaging tool, not because of risk or danger, but because it created new forms of images of the body. However, these images should not be the exclusive domain of a department of imaging. If so, then acoustic “images” obtained with a stethoscope should be generated in a department of auscultology and read by auscultologists with the formal report arriving on my desk a week or 2 later. This week, I had the opportunity to see one of the new smartphone-sized portable echocardiography machines. I believe that ultimately we will have a combined stethoscope and echocardiography imaging tool in our side pocket when on rounds and in the clinic. This may play havoc with echocardiography reimbursement, but for patient convenience, it is ideal. Immediate bedside information is available, quick decisions can be made, and treatment plans can be laid out and instituted without the need to wait for a formal study and report. Outcome-based (vs. procedure-based) reimbursement would support this type of bedside diagnosis.
In addition, technology has moved forward with single-photon emission computed tomography (CT) imaging so that an in-office single-photon emission CT machine is safe, affordable, and convenient for patient care, and I expect that we will have completely different magnetic resonance imaging and CT machines in the future that will not need the intense technical support currently required for safety. Advances in quantum physics will change how we create images in the future. New discoveries in particle physics will come from the supercollider that recently began operating in Europe (we turned it down in the U.S.), and some of these new concepts will clearly change how we create images in the future.
Let us not return to the 14th century in the name of self referral. If there is abuse or overuse we need to manage it, and we are learning how to do that. Advances in health care will come from better understanding of pre-disease and will depend, among other things, on advanced imaging done at the point of care. We have the best health care in the world. This is evident in a striking reduction in cardiovascular mortality over the past 10 years, at the same time that we saw an increase in cardiovascular imaging. This is not a coincidence. These imaging methods have allowed us to improve accuracy of diagnosis and intervene earlier in care of heart disease patients. We need to control costs, and we need to get these technologies to every patient. Let us not go back 600 years in the name of cost control and preservation of an old methodology. After all, it is the patient we are sworn to help, not ourselves.
- American College of Cardiology Foundation