WG 1 — Final Report Part 3 — Medical Changes

Part 3: The Impact Of Changes In Medicine On Medical Imaging

• Health Care Reform
• Human Resources
• Medicine and Molecular Biology
• The Evidence-Based Medicine Movement

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Medicine at the beginning of the 21st century is in transition. One commentator has observed that the care of the sick will change more in the next 20 years than in the preceding 2000 ¹⁷. This perception relates both to changes intrinsic to medicine and biology, but also as much to the societal context in which medicine is practised, and health care delivered to the population.

Health Care Reform

Improving Care — Rising Costs: In the recent past, medical developments have come to influence significantly the course of many diseases and modify their outcomes. Costs of care have risen in proportion. This is so despite gains from preventive strategies such as the replacement of "iron lungs" to care for poliomyelitis victims by a vaccine for prevention. Aging populations have served to increase demands upon a system stretched to meet its goals. At the same time, many countries including Canada, having been in deficit spending, are now being forced to re-examine their social and fiscal priorities. In particular, the need for deficit reduction and enhanced spending on education, for example, by countries concerned with global competitiveness has necessarily impacted on the amounts of money available for health care.

For most political jurisdictions in Western society, resources in health care are at a premium. In Canada, long waiting lists, crowded emergency rooms, aging physical plant, limited capital renewal and referrals of patients to the U.S. for care have become the daily substance of news reports ¹⁸.

Reduced Capital Reinvestment: In Canada, these fiscal pressures have resulted in very low levels of capital reinvestment in the health care system. Hospitals in particular have suffered since, in many, the capital inventory was already aging and inadequate. Compounding this situation, hospitals had been slow to invest in modern information technology, the acquisition of which has become increasingly important as health care reform unfolds. Canada remains among the top half-dozen countries in terms of spending on health as a fraction of gross domestic product. And yet, by all existing measures the nation has the poorest record of investment in technology, certainly among the developed nations and even in a wider sense ^{19, 20}. It is tempting to conclude that this paradox is due, at least in some measure, to a failure to realize the efficiencies that might result from the judicious use of technology.

Evolving Technology: In parallel with those changes intrinsic to the "health care system", the emergence of powerful diagnostic tools (CT, MRI, PET to name only a few) and therapeutic agents and techniques (antibiotics, antiviral agents, psychotropic drugs, minimally invasive surgery, again to name only a few) has been matched by a change in the relationship between doctors and individuals. While medicine remains, according to numerous polls, a well-respected profession, patients (often called clients in this new context) now expect to have much more say in their care ²¹. The public use of the Internet, with all its limitations as a source of health information, is also empowering patients as never before.

In the face of these massive social forces it has become almost a ritual to blame the escalating costs of health care on technology — expensive machines and their use are an obvious potential scapegoat for such escalation. Imaging devices, such as CT and MRI machines each costing several million dollars are, perhaps, the most visible sources of expense. And yet radiology accounts for less than 3 percent of health care costs in the U.S. It may be difficult to sustain the argument attributing increasing costs to technology, while the concept that technology may be a source of cost efficiencies, already advanced above, deserves more study ^{22, 23}.

Silo-Funding in a System with Archaic Accounting: The fiscal climate in which medicine is practised in Canada in 2000 inhibits change, innovation, and the application of cost-effective technology. The imposition of rigid income caps within a fixed specialty structure makes it difficult to innovate in one specialty, even if the results were to realize a net savings, since that service might have to be funded from an inflexible global budget at cost to another specialty. The result is that physicians have been forced, in a protectionist sense, to resist technological innovation since they will end up paying for its introduction out of their own pockets. If this situation and the rigid perpetuation of specialty boundaries persists, medicine, and the public, will suffer as innovation is stifled and cost-effective change is inhibited.

In precisely the era in which radiological methods are evolving to help solve the new fiscal environment of health care reform, global budgeting and "silo" financing have undermined progress. Interventional radiology, for example, has resulted in procedures, hitherto requiring admissions and operating-room time, potentially being done in the radiology department on out-patients. The savings, despite high capital costs, are real but difficult to realize without a "system perspective". Any view of the future of imaging technology must consider this trend likely to continue. However, innovation is difficult. For example, vast sums are now spent on the treatment of the neuroses and psychoses. Such treatment is almost always on a "suck-it-and-see" basis. If functional imaging methods can fulfill their potential to create a classification of psychiatric disease such that specific remedies might be matched to specific disorders, the savings in medical and social costs would be prodigious. But how will the capacity for such powerful methods be developed, still less delivered? The archaic funding of health care and medical technology thus needs to be revisited to ensure a flexible future different from that of the immediate past.

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Human Resources

The uncertainties of the last decade led to a reduction in the numbers of radiologists educated (as of all physicians). In retrospect, the cuts in the number of training positions were misguided. A recent study by the Canadian Association of Radiologists reveals a severe and escalating national shortage of radiologists. Depending upon the variables used in a sensitivity analysis, this shortage amounts to some 100 radiologists nationwide ²⁴. It is worthwhile reflecting that this number is not based on any ideological view of ratios of radiologists to population, etc., but on the reality of demand by hospitals and communities seeking to recruit radiologists. The situation is, moreover, compounded by a small but consistent level of emigration by physicians and radiologists. In this context, the depleted and decaying technology inventory in Canada does not help. Canadian graduates trained to work with sophisticated machines often fail to find suitable employment opportunities in their own country.

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Medicine and Molecular Biology

Functional Imaging: Röntgen’s first images (of his wife’s hand) were concerned with the anatomy of the human skeleton. In their time, these images were remarkable enough, revealing structures not hitherto accessible in life. In the 100 years since, imaging technologies have greatly refined the study of structure. Imaging methods have also been directed to studies of tissue and organ function beginning with nuclear medicine methods including single photon emission computed tomography (SPECT) and positron emission tomography (PET), but expanding into functional magnetic resonance imaging (fMRI) and magnetic resonance spectroscopy (MRS). The in vivo monitoring of gene therapy, anti-sense imaging and other initiatives will constitute a further imperative to the greater development of functional imaging, while it is now apparent that PET cost-effectively out-performs other imaging methods in, for example, staging many cancers ²⁵.

Image-Guided Minimally Invasive Procedures: The development of imaging methods has resonated with another trend impelled by health care reform. With increasing pressures on hospital length-of-stay and the need to reduce the time spent in the operating room on exploratory surgery, there has resulted a burgeoning of minimally-invasive surgery (e.g., laparoscopic cholecystectomy) and minimally-invasive image-guided procedures such as percutaneous biopsies, drainages and angioplasty. These procedures are very cost effective ^{26, 27, 28} apart from being of obvious benefit to the patient. There are yet other examples of strategic imaging techniques that in fact reduce system costs due to reducing the length of admissions and use of conventional operating rooms.

Pharmacotherapeutic Imaging: Traditionally, new drugs have been tested in large and expensive studies of outcome measure. Radiological methods are now being examined for their potential to study new drugs in vivo. More importantly, as medications become more expensive, there will be increasing pressure to determine their efficacy early in the natural history of disease. Cancer chemotherapy, for example, is extremely expensive. At present, techniques to measure individual tumour responsiveness are cheap but insensitive; for example, measuring the potential shrinkage of a tumour from a chest radiograph eight or twelve weeks into therapy. In terms of global savings, it might be better to use more sensitive functional tests of tumour response earlier in the natural history of the disease ^{12, 29}.

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The Evidence-Based Medicine Movement

Historically, medicine has been mostly learned by an apprenticeship. The recent rise of a movement to critically appraise both diagnostic procedures and therapies has gone some way to remedy the use of redundant or irrelevant parts of medicine. Indeed, the need for critical thought has only emerged in the recent past because, until less than a century ago, there were no more than a handful of effective tools available to a physician. While the evidence-based medicine movement has led to reductions in the use of some procedures and elimination of unnecessary duplication, its impact on radiological innovation will not be entirely negative ³⁰. Use of computer-based guidelines and decision support will be technology-intensive but will further rationalize practice. Indeed, in the longer view, computer-based records with on-line data about the impacts of interventions on treatment and outcomes will result in on-line real-time interactive applications of evidence to the way medical care is delivered and medicine practised ³¹.