Image overload may be the single biggest challenge to effective, state-of-the-art practice in the delivery of consistent and well-planned radiological services in health care today. Although this appears to be a relatively recent phenomenon, resulting from the intersection of computing power and rapidly developing clinical modalities in the 1980 s and 1990 s, the problem is not entirely new. Those who see image management as a very recent difficulty err by more than a century. When Wilhelm Röntgen’s announcement of the “amazing new ray that could see through living human flesh” was sent out across Europe and North America in the first weeks of 1896, physicists, physicians, and even amateur photographers began experimenting with ways to capture the results on permanent images. More quickly than any new technique then or since, roentgenology (later radiology) would become an established part of health care. By 1898, many hospitals had fledgling x-ray departments, and specialized journals soon appeared to address topics of concern in the developing field. These included problems with referring physicians, expanding areas of focus within the body, new imaging techniques, and the difficulties of image management: the same topics that dominate today’s radiology literature. These problems today, however, will require very different, innovative interdisciplinary imaging informatics solutions.
Among the earliest and most serious problems with managing the new roentgenographic images were mass and volume. The thick glass plates on which images were developed were heavy, and their processing required a volatile mix of chemicals. Although the earliest images “spoke for themselves”—foreign bodies, fractures, and even novelty shots—more complex requests often required five or more “views.” X-ray departments and freestanding “x-ray clinics” soon found themselves overrun with requests from physicians who were fascinated by the new technology and its potential to answer longstanding questions and open new lines of inquiry in their disciplines. When every image required 10 or 15 minutes to develop and often as long to interpret, it is clear why the number-one complaint in many x-ray departments at the turn of the 20th century was too many images, too little time.
One answer to the problem was fluoroscopy—the original “real-time” imaging. It offered not only the opportunity to render diagnoses on the spot but also afforded radiologists and referring physicians the chance to “look around”—a new luxury in medicine. But this new way of “navigating” caused its own problems. Although fluoroscopy offered immediacy, referring physicians, surgeons preparing for procedures, and sometimes even patients themselves all wanted permanent images—in part because it was already clear that what one person “saw” on an x-ray image might not be what the next practitioner saw.
By the beginning of World War I and the advent of film to replace the cumbersome glass plates, all the elements of the present-day image overload challenges were in place and were openly discussed in the literature: how to solve variations in human perception, how to effectively and reliably process images, how to “navigate” through the data (with the human body as a master set of potential images), how to define quality, how to store the already massive accumulations of images and reports, how to disseminate this information to others both in and outside the hospital, how to integrate this data on an ongoing basis into patient care and research, and how to reconcile the finite human resources in the radiology department with a workload that seemed to be escalating exponentially.
Throughout the 20th century, radiologists wrestled with and met these challenges in creative ways. However, their tactics went almost exclusively into putting more personnel power and funds into film processing and interpretation. Only rarely were technological developments in radiological capabilities accompanied by innovations that provided even short-term solutions to the problems of growing numbers of images, procedures, and patients.
By the 1930 s, a host of new contrast studies and a rapidly expanding range of surgical procedures had become routine, even in rural hospitals. A new generation of radiologists found themselves fighting the insistence of many hospital administrators that the growing image overload could be dealt with simply by allowing nonphysicians or the referring specialists themselves to read the films. This invitation to cede all of the specialty’s turf was avoided by perhaps the most unexpected factor in radiology’s great success in the second half of the century: the effects of World War II.
Battlefield trauma and routine military care during the war demanded more imaging specialists than the United States could provide. Young physicians who had intended to specialize in internal medicine or pediatrics found themselves assigned to the Army’s short course in roentgenology. After the war, many were “grandfathered” into certification, and the ranks of practicing radiologists in the U.S. nearly doubled in the 1950 s. In effect, the requirements of mass and volume in image management were met with mass and volume in radiologists.
In the ensuing decades, new factors would be added to the difficult balance between volume of studies and available personnel. New modalities, including ultrasound, computed tomography, and nuclear medicine would change the meaning of “training” in the field of medical imaging. The modalities themselves changed rapidly, and each required specific sets of interpretive skills. To some extent, the difficulties caused by this growing diversity of ways to look at the human body were resolved by specialization. Ultrasound specialists did not interpret thyroid scans; nuclear medicine specialists did not interpret mammograms, and so on.
The advent of the microchip—both in imaging and information processing technologies—changed the landscape of medical imaging forever. The problems of mass and volume skyrocketed, with new technologies that could provide hundreds of views as easily as one. Today new computer-enabled technologies that can image anatomy and function down to the cellular level have blurred the boundaries among imaging disciplines and between radiology and other image-intensive fields such as cellular biology, biochemistry, and pathology.