PACS and the Grim Reaper

No, it's not what you think, so don't bring out your dead. You'll get the joke later on.

I've maintained this blog for over 12 years, believe it or not. Despite my years of whining about PACS, I still love the concept, and to varying degrees, many of the products out there. Some I can praise, some I complain bitterly about, and some I have left alone because of the more and more complex nature of the hats I'm wearing in my old age.

It is no exaggeration to say that PACS has changed everything about what we do in Radiology. My First Law of PACS distills this to its essence:

I.  PACS IS the Radiology Department

This concept is so simple and fundamental, it is often ignored, but becomes quite obvious if you have downtime, as we did just recently. For four hours, the only way to read things was directly off the modality consoles. Apparently someone forgot to renew a domain. This is not good patient care, trust me. But even when it works, the changes PACS brings could be a mixed blessing. Is that the fault of the system, or is PBKAC?

With a hat-tip to RadRounds, I present this excerpt from Robert Wachter’s “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (excerpted on the KQED website with permission from McGraw-Hill. Copyright 2015...I'm going to present some clips from the excerpts, and hope I'm covered under the same permissions...)

Dr. Wachter is apparently an old fart like me, and remembers well the days before PACS, when we used yucky old film. Blecch. While I don't think he was all that much in love with the medium itself,  he does bemoan the loss of human contact once necessitated by celluloid:

At Penn in the 1980s, everybody — and I mean everybody, from the lowliest student to the loftiest transplant surgeon — brought films for deciphering to the late Wallace Miller, Sr., a crusty but endearing professor of radiology and one of the best teachers I’ve ever known. For students like me, time spent with him was at once exhilarating and terrifying. “What’s this opacity?” he asked me once, the memory burned into my hippocampus by that cognitive curing process known as overwhelming anxiety. “A … a pneumonia?” I stammered.

“Mooiaaa,” retorted The Oracle, an unforgettable signature sound uttered as Miller smartly turned his head away in mock disgust. I loved it. We all did.

Today, many of my internal medicine trainees barely know where the radiology department is. Just as your record player and LPs are now long gone, in your local hospital today, the films, the analog X-ray machines, and even those charming film conveyor belts have left the building.

Personally, I don't miss film or any of the accouterments associated with it. PACS has quite a few advantages, you know, and Dr. Wachter agrees:

While the main catalyst for PACS was economic, the quality of the images and the ability to manipulate them were also important. Unlike regular films, CT scans need to be viewed at various contrast levels: One setting is best to look at bones, another to look at lungs, and still another to look at soft tissue like muscle.

PACS allowed radiologists to toggle through these views, in the same way that Instagram lets you play with your photos. You can also use a nifty magnifying glass to zoom in on a part of the image. An unexpected benefit was “stacking”: rather than looking at 100 images arrayed in a 10 × 10 grid on a one-dimensional page, the images could be digitally stacked, one on top of another, allowing the radiologist to scroll through them swiftly by rolling a mouse ball. Moreover, computerization let the radiologist look at the images from home, enabling senior experts to weigh in on subtle findings that trainees might flub. And while the images were fuzzy at first, today they’re as crisp as high-definition television.

Perhaps most important, PACS obviated the need for maddening searches for prior X-rays. Twenty years ago, when a chest X-ray revealed a lung nodule, the first commandment on the radiologist’s report was to “obtain old films". . . But searching for old films was often an exercise in frustration: They were lost, or locked up, or at another institution, or in a filing cabinet in the thoracic surgeon’s garage, behind the golf clubs. . .

When I give talks to medical students and other PACS neophytes, I state it more simply. With the information in digital form, it becomes separated from the storage medium. Decoupled from the piece of celluloid, the data can be viewed in the same room, or on the moon (eventually). The concept is simple, the execution less so. But PACS can be a double-edged sword:

The advantages of PACS are so vast that few would want to turn back the clock. Yet the effects on those of us who order X-rays and the radiologists who read them have been profound, and they’re not all positive. The fact that we can now review our images without trekking down to radiology means that we rarely do make the trip.

And those same images can be sent to a night-hawk service anywhere in the world...which opens the door to day-time predators. But that's for another time.

PACS brings other mixed blessings:

On top of this, there are even greater threats to radiologists’ livelihoods and happiness. One of them flows from the growing pressure on health care systems to slash their costs. Currently, virtually every X-ray performed at a U.S. hospital is sent for a formal reading by a radiologist, who is paid a fee by an insurance company. In today’s cost-cutting environment, it’s probably only a matter of time before some health care systems permit their frontline specialists to officially read certain films, reserving radiologist “overreads” for those images that the clinicians have questions about or the ones with super-high malpractice risk if they are misread. Radiologists can be counted on to fight such a move by frantically waving the banner of quality, but they will need to demonstrate that the value of having them review every film is worth the considerable expense.

Moreover, a major theme of Obama-era health reform is a shift from our historical fee-for-service, piecework payment model to one that dispenses a single payment to a hospital and doctors to manage all the care for a group of patients (“accountable care organizations,” ACOs for short) or a given episode of disease (“bundled payments”). Under such systems, the risk for the cost of care shifts from the insurer to the providers, and it’s up to the latter to decide how to divvy up the cash. Ron Arenson, chairman of the department of radiology at the University of California, San Francisco, sees this as the greatest threat to his field.

“If the world moves to bundled payments, we won’t do well,” he said. “We’re not very high in the pecking order.”

And so comes the specter of "Value" which is simply another way of separating us from our earned revenue, as I've stated elsewhere.

And of course we cannot say anything about Radiology in this day and age without mentioning Artificial Intelligence...

Finally, there is the ultimate threat: replacement by the machine. Of course, this issue is marbled throughout health care as we enter the digital age. To date, most claims that “this technology will replace doctors” (in areas ranging from diagnostic reasoning to robotic surgery) have proven to be hype.

However, in fields that are primarily about visual pattern recognition, the promise (or, if you’re a radiologist, the threat) is much more real. Studies have shown that computers can detect significant numbers of breast cancers and pulmonary emboli missed by radiologists, although nobody has yet taken the bold step of having the computers completely supplant the humans, partly because there are armadas of malpractice attorneys waiting to pounce, and partly because, at least for now, the combination of human and machine seems to perform better than either alone.

I'm still not writing Radiology's obituary quite yet.

All this being said, the greatest source of Dr. Wachter's angst is the loss of collegiality (and congeniality) that PACS engenders. Since we now just sit in front of computers, we don't talk to humans anymore. Or so it seems:

A few years ago, when I asked my interns and students to visit the radiology department to review the key films, they looked at me as if I had grown a second head. After my team humored me by accompanying me to the radiology department, I conducted a little sociology experiment. Standing outside my hospital’s chest reading room, I delivered a brief speech:

“Watch what happens when we enter. Does anybody turn around and welcome us, ask, ‘How can I help you?’ and seem genuinely enthusiastic? When they go over the X-ray, do they delve a layer deeper than what they said in the formal report? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?”

I did this because I am deeply concerned that mine is the last generation to have learned the habit of going to the radiology department. Nostalgic for my interactions with Wally Miller and his like, it saddens me that our current trainees will never know how much they can learn from a great radiology teacher, and how much their patients’ care can be improved by actually talking to a real live radiologist. Yet I know that even if I bring my young horses to water, whether they visit the radiology department after I am no longer their wrangler will be determined by the quality of their experience.

We entered the chest reading room and were greeted by a wall of radiologists’ backs, their faces trained like lasers on the computer screens in front of them. Not a single head—located atop the shoulders of about eight different radiologists—turned to greet us.

After a couple of awkward minutes of crescendo throat-clearing, one of the radiologists grudgingly swiveled around to face my team and me. “Oh, do you need something?” he asked.

“Sure; can you help us look at a few films?”

He did, kind of, but offered his help in a whisper animated mostly by passive aggressiveness.

I thought it couldn’t get any worse, but it did.

“What do you think of this area?” I asked him, pointing to a confusing patch of whiteness on one patient’s chest CT scan.

“Did you look at the official report?” he hissed. (In other words: “Perhaps you don’t know how to turn on your computer?”)

The unspoken message was clear: Get out of my space; I’m busy.

Is this simply a power-play? Are the rads in question getting our revenge for having our prestige taken away?

Radiologists’ alienation runs deeper than the lack of collegial exchange and the inability to find out what’s really going on with the patients. It’s also about power, status, and expertise. The fact that the traditional film lived only in the radiology reading room gave radiologists a monopoly over their entire ecosystem. PACS, observes Tillack, created a new normal in which “the ‘right’ to see [the image] is no longer mediated by radiologists, as it was in the reading room,” and has thus “eroded radiologists’ claims for authoritative knowledge over the interpretation of medical images.”

Once the radiology department no longer housed the films, the impact was immediate and dramatic. Without any changes in policy or very much forethought, the mid-1990s transition to filmless operations at the Baltimore VA hospital led to an 82 percent decrease in in-person consultation rates for general radiology studies. Today, many clinicians—particularly specialists like neurologists, pulmonologists, and surgeons—look at images themselves and act on their own interpretations; Many don’t even bother to read the radiologist’s formal report (which usually takes several hours, sometimes even a day, to reach the chart) unless they have unanswered questions or judge the study to be particularly challenging.

And so it can be. However, my particular practice is a little less progressive than what Dr. Wachter describes, and that is a good thing. Still, I seem to be one of a very few who will get up out of the seat and go back to the clinical areas when a finding justifies the trip. In fact, the docs at one clinic actually cringe when they see me coming: it's never good news. I have thought of wearing a Grim Reaper costume for such excursions, but the patients would probably not appreciate that very much.

This situation could be panic-inducing, were I not at the end of my career. As a short-timer, I'll simply practice in the only way I know, and watch and wait. Some will succumb to Imaging X.X, wherein we are supposed to run naked in the halls wearing only a stethoscope to be sure the patients know we are indeed doctors:

Slowly, radiologists are waking up to their peril. Rather than isolating themselves from clinical care, some are now relocating their reading stations in clinical areas, such as the ER and the ICU, to be in the line of sight of their clinician colleagues. Others are resurrecting interdisciplinary conferences and training their staff in customer service. Technological solutions that allow radiologists and frontline clinicians to communicate through PACS and the electronic health record are springing up (through programs that create a mash-up of a Skype-like communication tool and a John Madden–style telestrator).

Said Paul Chang, the University of Chicago radiologist whose advocacy of PACS so upset his father, “We have to go beyond isolating ourselves and concentrating on messages in a bottle, where we just write a report and are done with it, but instead fostering collaboration.”

Or we could just wear Grim Reaper outfits when discussing cases. Works for me.