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Helene Pavlov, M.D.

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The Ethical Imperative to Invest in Medical Technology

Posted: 06/02/10 11:35 AM ET

Technology is fascinating, and can be quite addictive. We want our tools to be bigger, faster, with more Apps, more color, more depth and, of course, more cost. How does this idea relate to medicine?

Focusing on radiology and imaging technology, MR, CT and Ultrasound, for instance, there is a constant push for the development of new coils, protocols, transducers and more. These development goals are all aimed at capturing an image faster and with improved sensitivity and specificity. The ultimate goal is to diagnosis conditions as early as possible and to see smaller abnormalities with more clarity than was previously the case.

Even more exciting is that we are now investigating the ability to see what is not yet obvious to the eye. That means, we can now see non-invasively inside a joint (a knee, a shoulder). We are able to see intracellularly without surgery and without a needle stick. We can see cartilage deterioration and breakdown or tendon healing and vascularity before it is evident to the naked eye or on a routine MR, CT or Ultrasound examination. Imagine the possibility of seeing more detail than if one opened the knee surgically or probed the joint arthroscopically. How can this be? What is being investigated today in various clinical trials and in animal models is the future of imaging technology, "quantitative imaging."

This is an exciting time in imaging. Investigations are ongoing regarding predicting diseases and conditions while signs and symptoms are still in the preclinical state. This type of work will require years of investigation and validation. Even more challenging is what to do with the information the imaging provides. Will the information mean earlier surgery, more physical therapy, longer post surgery/trauma recovery time? Can "failure" be predicated so that appropriate prevention protocols can cheat failure?

Many years ago, long before the era of MR, I gave my very first presentation at a major national Radiology meeting and described a method for accurate radiologic diagnosis of ACL injuries. A very prominent radiologist in the audience stood up and stated: "Your technique and presentation were impressive but since they cannot fix the ACL, who cares?" I was just at the beginning of my career and he was very established. I thought for a minute and said "You should." The surgeons will in time figure out how to fix the ligament. Our job is to know how to provide an accurate diagnosis.

While the future of imaging could not be more exciting, there is the unfortunate burden of the cost associated with technological development and advancement. Obviously the research of injury and disease prevention has a price. There are hardware, software, equipment and personnel costs associated with these investigations. As younger and younger athletes are pushed to be faster and to pursue more challenging venues, is it fair to have these athletic expectations without having the diagnostic tools for prevention and repair? Research takes time. Technological diagnostic enhancements may help enable less invasive surgery or even prevent unnecessary surgery. Early diagnosis may help permit appropriately timed drug intervention to prevent the development and the irreversible destruction of joints secondary to arthritis.

Healthcare costs are escalating and are in the news daily. Imaging is being attacked as a major cause for the rise in healthcare costs. We must be careful not to throw the baby out with the bath water. Appropriate utilization of imaging must be encouraged while the ordering and self-referral of unnecessary imaging must be controlled. Radiologists, patients and referring physicians must be knowledgeable and responsible. Radiologists and their physician colleagues must collaborate and listen to their patients in order to drive the technological development in the appropriate direction -- to explore new technological advancements that answer clinical questions through research. Policy makers and politicians must also be responsible and weigh the value of imaging and research against the cost.

Can we afford the cost to pursue new imaging tools? How much will this research cost? The effectiveness and eventual cost reduction and potential improvement in quality of life provided by these types of clinical investigations will not be evident in the short term. Can we afford the research? The real question to be asked is, can we afford not to keep moving the potential of imaging technology forward? If we do not pay now, if we do not cover these costs today, who will ultimately pay tomorrow? What cost do we place on the value of a longer and better quality of life?

HSS