Cyberspace and internet technology's impact on radiology practice

Radiology and Cyberspace

The creation of 'cyberspace,' or the sharing of information through email, on the Internet and on websites, has had a profound impact on nearly every field of human endeavor. Medical science, and particularly Radiology, has been particularly affected and enhanced by new technology. Radiology, by its very nature, has always been a leader in the use of emerging technology in the medical field. Now, new technology developed during the growth and expansion of the Internet is giving Radiology the opportunity to expand as never before.

What is Radiology

Radiology is the branch of medical science devoted to the use of a variety of energy sources in the diagnosis and treatment of disease, including x-ray, ultrasound, magnetic resonance, and nuclear energy. Diagnostic imaging allows practitioners to create images of internal body structures, including bones, tissues and organs. This usually necessitates a balance between using the correct amount of energy needed to produce an image with the optimum diagnostic information for the physician and maintaining minimal risk to the patient. Thus, Radiology provides a non-invasive method of viewing internal body structures and allowing diagnosis without the need for exploratory surgery.

Radiology Professionals

The Radiologist and the Radiology Technologist are the two main professionals in Radiology. The Radiologist is a diagnostic physician who works either as a consultant to primary physicians, or, depending on the type of disease present, Radiologists may act as primary physicians themselves. Radiologists read and interpret diagnostic images, advise on the best diagnostic tests to perform, supervise radiographic examinations and perform radiographic treatments.

In the early days of Radiology, physicians were often considered 'general radiologists,' both performing radiographic examinations and providing therapy. Since the 1970s the field of Radiology has grown so dramatically that the Radiologist cannot remain active in the entire field. Initially, Radiologists began to specialize in either diagnostic or therapeutic radiology. With the continued expansion of the field however, Radiologists now specialize in areas such as neuroaudiology, interventional radiology, ultrasound, MRI and CT specialists, mammography, etc., as well as radionuclide and nuclear medicine specialists.

In many cases, the actual diagnostic images are taken by Radiology Technologists for later interpretation by Radiologists. Radiology Technicians must deal directly with the patients to ensure that images provide sufficient diagnostic information, but must also guard the patient from overexposure to radiation.

History of Radiology

Wilhelm Conrad Roentgen, a professor at Wuerzburg University in Germany, first discovered x-rays in 1985. Roentgen was experimenting with fluorescent light using a cathode-ray tube when he noticed, when high voltages of electricity were applied, that a green glow was coming from nearby objects. After much investigation, Roentgen was able to use this method to produce an image of the bones in his wife's hand. In 1901 Roentgen was awarded the Nobel prize for physics for a discovery that changed the course of medical science (Eisenberg and Powell 1992).

Roentgren's initial machine for creating x-rays was easily reproduced, but was later modified by Sir William Crookes (Thomas, par 2). Creating x-rays using this machine was widely demonstrated to both scientific and lay audiences. This phenomenon caused considerable astonishment in both sectors of society and considerable demonstration was required before its validity was widely accepted and believed. Its application to medical science was quickly understood, however, and, as technological advancements improved the initial mechanism, hospitals and clinics began to use it as standard practice. This expansion of technology was limited, however, by the lack of availability of electricity in hospital buildings.

Other early difficulties in the use of x-ray technology included inadequate shielding for both patients and technicians, and the use of high levels of radiation when producing images. Radiation burns and dermatitis were common in the early days of x-ray technology. Because the results of high levels of radiation exposure often developed slowly, the cause of the problem was often not known. While x-ray imaging of hands and feet caused few problems, early attempts to create images of denser body areas produced disastrous results and even deaths.

Peripheral radiography was not a problem where the body part was thin. Radiography of the trunk was to prove technically more demanding and the shadows produced were much more difficult to interpret. Harnack had three assistants, Reginald Blackall, Ernest Wilson and Harold Suggars. Ernest Wilson joined in 1898 to help with the X-ray work and to perform clinical photography and developed signs of injury within a few months. By 1903 they all had radiation injuries. Wilson died of his injuries in 1911 and took a series of photographs of his hands showing progressive bony damage leading to malignancy. Harnack ultimately had both hands amputated. Suggars and Blackall worked for longer and helped to establish the College of Radiographers (Thomas, par 7).

After a great number of these early tragedies occurred, safeguards and procedures were finally developed that allowed the safe use of x-ray technology.

Early diagnostic images using x-rays were initially created using glass plates. The development of photographic film enhanced the use of x-rays making them both easier to read and easier to store (Goodwin, Quimby and Morgan, 1970).

During the initial phase of diagnostic imaging, radiologists and radiological technicians were recruited from general medical staff. Images were difficult to read and no training was available. Physicians were often left to wonder what the shadowy images represented. Gradually, medical personnel began to specialize in this branch of medicine and training courses were set up, with the eventual creation, in 1920, of the Society of Radiographers (NDT Resource Center).

Karl Dussik first used ultrasound, which had been developed during the first and second World Wars with the use of submarines, as a tool of medical diagnostics in the 1930s. Ultrasound was first used to destroy tumors. Later, John Wild developed the hand held ultrasound device that became popularly used in the 1950s. Ian Donald began using ultrasound in 1955 to diagnose tumors and breast lesions, which brought ultrasound into popular use in radiology (NDT Resource Center).

In 1952 the Nobel Prize in physics went to Felix Bloch and Edward Purcell for their independent discoveries in Magnetic Resonance Imaging. Raymond Damadian continued this work until he produced the first full body MRI scanner in 1977. David Kuhl first developed emission reconstruction tomography in 1962, which resulted in the imaging techniques called PET and SPECT (Thomas).

Imaging of Today

Today's Radiology, while still concerned with producing an internal image of the human body using minimally invasive techniques, has grown and diversified by using the more advanced technology available today. Modern images provide higher quality while keeping patient exposure to harmful energy levels low.

Film quality has advanced greatly with the development of automated processing, eliminating the risk of human error in manual processing. Most radiology departments now possess an automatic processor which greatly enhances the time to development and diagnosis.

Digital imaging using computers and other electronic devices provide the availability of 'filmless' processing, lowering costs. Computer generated images can be enhanced and captured online, and transferred over the Internet to other computers for consultation with Radiologists in other parts of the world. These images are also easier to store and do not deteriorate in the same way as images processed on film.

Equipment in Radiology has also advanced. Modern x-ray and other imaging machinery is smaller and more easily transported, while producing superior images. Modern technology makes it possible to take such equipment to the patient, for greater access to healthcare in rural areas and instantaneous delivery of images from ambulances, allowing physicians to be apprised of patient condition even before arrival at the hospital (Willis, par 1).

Modern methods of imaging are also more advanced. Transmission imaging, used in x-rays, CT scans and others produce beams high-energy photon beams, which are passed through the body. The increased focusing and concentration of these beams in modern technology allows higher quality images to be generated. Reflection imaging, including ultrasound, has also increased in quality. Rather than passing through body structures, reflection imaging uses waves that bounce off of body structures at different speeds. Computer analysis of these reflected waves provide clear and concise images of the body.

The Future of Radiology

As Radiology continues to advance, the use of computers in imaging becomes of greater importance. Increased use of 'filmless' imaging allows Radiologists to share consultations with others anywhere in the world. Images can also be shared with customers online. This is particularly useful with images such as those produced with ultrasound where images are moving.

Another area in which emerging technology will affect Radiology is in computer enhanced evaluation of images. Changes in tissue and body structures too small or elusive for even the trained eye to see may be uncovered with the aid of computer programs. Computers will also likely scan images for abnormalities that will then be flagged for more intense review by the physician.

Increasing use of color in diagnostic imaging, particularly in ultrasound imaging, shows signs of enhancing visual identification of internal structures. Color in the ultrasound imaging of fetuses already provides a much clearer picture of infant features. This makes reading images easier and more reliable.

Computer aided design will likely become an important tool in the education and training of both the radiologist and radiology technician of the future (Giger and Vyborny, par 3). Computer simulations of bodies with injury or disease will increasingly be developed as a training tool. These simulations will allow students to take medical history, ascertain symptoms, prescribe and perform diagnostic tests and design treatment online, using case histories. These technologies can simulate real world situations under life-like conditions.

In addition, new technologies are making new treatment and therapy available. Increasingly, chemotherapy is being used in conjunction with radiation therapy, as it has been found that they each have the tendency to improve the effects of the other. Interoperative irradiation is being used during surgery to directly target radiation therapy on a tumor or other mass. This decreases the area and amount of tissue to receive radiation and lowers patient exposure to high levels of energy during treatment for cancer, where the patient may already be weak. Stereotactic irradiation is also used, particularly for brain cancer treatment. Modern technology allows the use of very narrow, very precise beams of radiation at high levels.

Other new forms of therapy include particle radiation therapy and three dimensional conformal radiation therapy which allows the precise definition of the borders of cancerous tissue or tumors which enhances radiation therapy and makes surgery easier.

Conclusion

While the field of Radiology has always been at the forefront, by its very nature, of the development and use of new technology, the development of computers and Internet technology has caused an explosion in the field. New methods of diagnostic imaging and therapy are introduced almost daily, and, as technology grows, more uses can be visualized. Computers are playing a leading role in the production of enhanced, moving images in real time. Long waits for plate and film development, and longer waits while images are sent through the post to be read are a thing of the past. Real-time online consultations between physicians at opposite ends of the country are now possible while the images are being scanned. Images can be taken in rural areas and read by radiologists almost instantly. Ambulances can scan and send images while patients are being transported to the hospital. Computer images can be enhanced to show features too small to see in normal images and the addition of color makes reading images faster and easier. All of these elements make the diagnosis and treatment of patients more rapid and more reliable. 'Cyberspace' is providing an arena for great strides in Radiography.

Until the 1980s the techniques needed to store reports and films had changed little since the 1920s. Modern technology is transforming departments with the introduction of computer management systems and digital image storage. This last technique will dramatically alter the use of images with studies being transferred via links between different institutions and offices. The last 100 years have produced many changes and the next 100 will be even more dramatic (Thomas, par 24).