The Future - Part 1 The - Part 1:Future Technological advances Based on the consistent and stellar evolution of our specialty over the last 30 years, it is virtually a certainty that there will be further dramatic break- throughs in Diagnostic Radiology.The bets are off, however, when trying to predict what these changes could be. Certain general trends are fairly clear, including refinements of existing technology leading to smaller, faster and friendlier machinery with more facilities. Less striking but highly prac- tical is the increasingly modular ap- proach to machine design, permitting easy upgrading of equipment. More attention is also being paid to func- tional and quantitative evaluation. Invasive devices and procedures are more dependable, with their appro- priateness in the clinical arena being clarified and formalised. S Beningfield MBChB(UCT), FFRad(D)SA Professor and Head.· Department of Radiology, University of Cape Town Medical informatics Most information technology ben- efits to Radiology ride on the back of commercial and consumer demand. Ultra-high speed wireless connections will make it possible to report from any location, at any time. The trans- fer of all but the largest images will be possible in the magical time of two seconds, the time it takes to extract a 6 SA JOURNAL OF RADIOLOGY· January 2000 film from its jacket and snap it up on the viewing box. The predicted de- mise of film, however, may take a lot longer than expected, and it may per- sist indefinitely in some hospitals. Electronic patient records with organised, intelligent, integrated and confidential medical data storage have been identified as a key growth node, with good reason. This area is subject to intense interest at present, although the complexity is highly challenging. A watertight universal patient identi- fier system will be critical. Computer-aided diagnosis will prob- ably take many years to achieve, and may then only serve as a support sys- tem, providing a cost-effective means of double-reading images. Images and reports (verbal or written) sent im- mediately to the referring clinician's desktop monitor will be the norm. Cost-cutting pressures could be firmly implemented with instant computer analysis and pre- authorisation. Closer integration of the various data standards is inevita- ble, with the combining of schedul- ing, clinical, imaging and financial in- formation. Medical science Genetic and molecular advances appear set to dominate medicine in the next century. Will atherosclerosis and cancer vanish? Can viral illness be uniformly overcome? Patient- centric pressure will feature strongly in the directions taken by future research. And what of the proposed ability to suspend aging by centromere in- tervention? Will families have to limit offspring to one person, in return for immortality? Will the usual diseases of the elderly manifest if aging is ar- rested at 30? to page 7 The Future - Part 1 frompage6 The modalities Are we running out of new meth- ods to view and guide our invasion of the interior of the human body? Al- though science appears to be approach- ing a more comprehensive understand- ing of atomic structure and physical phenomena, does this diminish the like- lihood of spectacular advances? It is in- teresting to remember that the princi- ples of CT and MRI were known for many years before they were applied to clinical imaging. What about the other parts of the electromagnetic spectrum, such as the infrared, ultraviolet, and microwave wavelengths? And laser, electrical con- ductivity or forms of sound other than ultrasound? Could we see images based on subatomic particles or quantum phe- nomena, with the arrival of "Quark To- mography" or "Boson Resonance Imaging"?- surely no less strange than Positron Emission Tomography: Direct digital acquisition, high acqui- sition speed, radiation dose reduction and real-time 3D post-processing are certain, as are many potential variations of functional and quantitative imaging. Viewing monitors and oper- ating consoles High-resolution, high-intensity, all-purpose workstations permitting re- porting of all modalities are largely the consequence of commercial 3-dimen- sional data display and manipulation. Viewer location will be immaterial, and multi-reading by a number of radiolo- gists may become the rule. These w~rkstations could be head-mounted devices (possiblytermed "headstations"], with low-power laser beams scanning highly detailed images directly onto the retina. The entire workstation could be a remotely connected wallet-sized unit. Vendor-specific viewing and op- erating consoles could make way for software-based systems running on off-the-shelf hardware, facilitating generic replacements and upgrades. The "front end" The detector/acquisition system may become the single proprietary component of imaging equipment manufacturers. Vendors may focus exclusively on acquisition modules, leaving the data processing and dis- play to standard computers run with customised software. The open stand- ards paradigm led by the DICOM 3 protocols will hopefully lead to simi- lar electromechanical standards, per- mitting compatibility for inter-vendor component and module interchange. For example, an integrated X -ray tube and generator in a shoebox-size unit could simply be clipped into position when replacement is required. X-rays Huge amounts of research and de- velopment finance have gone into at- tempting to design commercial direct digital systems. The problem in manu- facturing large area detectors or alter- nate systems appears more challeng- ing than initially thought. Some flat plate detectors exceed 15 kilograms, precluding their use as mobile receptors. For the time being, the in- termediate technology photo- stimulable phosphor computed radiography (CR) systems dominate this sector. Angiography Although digital subtraction angi- ography appears to be holding its own against the onslaught of Magnetic Resonance Angiography and Com- puted Tomographic Angiography 7 SA JOURNAL OF RADIOLOGY. January 2000 when intervention is planned, there appears to be little that is revolution- ary on the horizon. Computed Tomography (CT) Virtual colonoscopy, bronchoscopy and other 3-dimensional displays could become the standard if consumer-driven demand escalates. Combined multipur- pose fluoroscopic, angiographic and CT units should be possible when large flat panel detectors arrive. Cone Beam Computed Tomography (CBCT) using the full area of flat plate detectors for data acquisition in a CT gantry should allow almost instantaneous volumet- ric acquisitions. Ultrasound Three-dimensional ultrasound with volumetric display has yet to be widely used, but refinements of existing tech- nology promise ongoing development. Modular replaceable ultrasound units integrated into interventive fluoroscopic and CT units should be standard issue. Nuclear Medicine Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) imaging may merge further. Targeted imaging with monoclonal antibodies will be extended, paving the way for other organ-specific contrast agents. Magnetic Resonance Imaging Diffusion and perfusion imaging may be followed by the re-popularisation of metabolic imaging and spectroscopy. Ceramic MRI may resurface, but ma- jor developments could take a back seat to incremental improvements. Organ specific and targeted imaging topageB The Future - Part 1 from page 7 are beginning to appear commercially, and may set the scene for the future. Interventive Radiology Smaller, smarter, slicker will be the bywords here, but political pressure and the relationship with other mini- mally invasive procedures may be the pivotal aspects. The number of inva- sive procedures may well expand, de- spite the increased involvement of clinical colleagues. This may be partly as a result of the incorporation of pre- viously unguided procedures. The promise of routine remotely-performed procedures ap- pears a long way off, despite huge in- vestments in the technology, particu- larly feedback transducers. The specialty Turf wars, clinical re-alignments, and reimbursement issues may over- shadow technical advances. A major split of the specialty into the hands-on and remotely conducted components may occur, with central- ised or home reporting facilitated for the latter. Organ-specific teams will prob- ably emerge from the turf wars, be- coming the rule in the bigger centres. Medical training may adjust to this concept, with, for example, a career neuroradiologist or technique special- ist commencing training straight af- ter school, in the same way that den- tistry splits from general medicine. Could we witness a backlash against the sterile and remote digital environ- ment, with close personal attention and professional interaction becoming a selling point for some centres, rather than technical prowess? Conclusion Tissue-specificimaging remains our unreachable objective.Non-harmful in- tervention is the ideal. In the attempt, many promising new technologies will go the way of kymography, electron radiography and thermography, while others, at present unknown, may domi- nate. Gradual stepwise progress will hopefully be interspersed by exciting new developments, sending us all back to being students again. The Future - Part 2 The Future - Part 2: Training radiologists- past, present and future Peter Corr MBChB, FFRad(D)SA, FRCR, MMed(UCT) Professor and Head: Department of Radiology, University of Natal, Durban Radiology is one of the most popu- lar specialities in medicine. It is not dif- ficult to understand why. Few radiolo- gists regret making the decision: How- ever the future is not what it used to be: Radiology faces challenges both in South Africa and internationally a SA JOURNAL OF RADIOLOGY. January 2000 which will certainly affect the number and profile of future trainees enter- ing the speciality. Has the "golden age of radiology" truly gone? Doctors training in radiology in South Africa have followed a tradi- tional postgraduate programme as registrars in departments of radiology at the three English language medi- cal schools. They write the College of Medicine fellowship exam within four years of training. At the three Afrikaans language medical schools, registrars write the MMed exams within four years. The medical coun- cil requires four years of training in an academic department for special- ist registration. In many ways the cur- rent South African fellowship follows the UK fellowship exam structure in the late seventies and early eighties with essay type questions, film view- ing and long cases. Today 'the South African Qualifying Authority (SAQA) will effect the curriculum structure, entry and exit points and to page 10