Editorials Joel

E. Gray,





(or Bad)




this issue of Radiology, Suleiman et al (1) address an issue that is of critical importance today, the processing of medical imaging films. This article does indicate that the radiology practices are doing a betterjob of film processing than most nonradiologists and chiropractors. However, how can we prodaim to be the imaging professionals when about one-third of radiology facilities

Mammography Accreditation Program, the JCAHO does not provide the needed guidance and training for the radiologists, medical physicists, or tech-

are underprocessing their x-ray Why should we be concerned



underprocessing? al (1), “The

To quote


cessing are a higher (to both the patient degradation in film




of underpro-

radiation and staff) contrast.”

exposure and a

How can we, as imaging professionals, not be concerned about radiation exposure and contrast? What does this study tell us? As noted, about one-third of radiology faduities are underprocessing their film. On the other hand, only 7% of mammography facilities are underprocessing. Although 7% underprocessing is somewhat disappointing, this tells us that when our attention is focused on image quality and film processing, albeit by the



of Radiology

(ACR) Mammography Accreditation Program and requirements for Medicare reimbursement for screening mammography, we can improve our processing and, hence, image quality. There was an increase in underprocessing in hospitals from 1984 to 1987, a period during which the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) was requiring quality control programs. However, unlike the ACR



Radiations, personnel Radiology


exposure #{149} Screens


#{149} Quality

to patients and films


1992; 185:13-14





fives, although they get the job done, should not be needed in the imaging profession. This is especially true when we continue to tell our nonradiologist colleagues that we are the imaging spedalists and therefore should be responsible for all medical imaging. The oldest book about quality control of photographic processing on my shelf is dated 1960 (2), but there are other sources in the literature, going back to at least 1933 (3). More recently, the U.S. Food and Drug Administration recognized the problem and published two volumes on photographic processor quality control (4,5), but that was 15 years ago, and we still are not doing the job right! Where, then, is the problem? First, and foremost, we must become quality conscious. The 1-hour photo finishers are more quality conscious than the medical imaging community. If onethird of the photo finishers underprocessed their film, we would take our business elsewhere and they would go out of business. Fortunately (or unfortunately), our “customers” are not aware of the fact that we are using more radialion than necessary and producing medical images of less than optimal quality. But even if we all were quality conscious, there would still be a problem. The photographic manufacturers provide the 1-hour photo finishers with sensitometric


for testing

their processing systems-these provided by the manufacturers cal imaging products. At least

tographic From the Department of Diagnostic Radiology, Mayo Clinic and Foundation, 200 First St SW, Rochester, MN 55905. ReceivedJune 8, 1992; accepted June 16. Address reprint requests to the author. C RSNA, 1992 See also the article by Suleiman et al (pp 2528) in this issue. I

is the key to qua!-

this bode for the future? If we do not perform the imaging job properly, someone will tell us how to do it. Mandatory programs, or programs




ity imaging. What does


all of are not

of medione pho-


a ser-

over a modem and phone to analyze the results of the quality control sensitometric strips and advise the photo finishers on how to correct their processes. In addition, classes on quality control, its importance, and the impact on the customer are provided to vice, line,


all employees ishers. Many by the

of the 1-hour of the classes


photo finare provided


We must follow the lead of the 1-hour photo finishers. Our film manufacturers must provide us with calibrated sensitometers and the necessary information to determine if we are satisfactorily processing our film. (Unfortunately, preex-


sensitometric strips do not prothe sensitivity we need to evaluate our processors, since we process our ifims immediately after exposure [5,6j.) We must provide education to all of our vide


on the importance

of quality


trol and, most important, how to perform the necessary tests and evaluate the data. This education starts in our training programs but must be incorporated into continuing education programs to bring the knowledge to the thousands

of technologists


working in the field. It is the responsibility of the radiologists and medical physicists to reinforce the importance of these procedures to the technologists, especially since these tasks are often considered at the low end of the desirability scale, somewhere near mopping the floor. Our technologists, for the most part, do not see these tasks as an essential


of patient


In some

instances, they start a quality control program and after several months of not finding many problems, they discontinue it since they receive little or no support and encouragement from the radiologists




Most important, we must start considering photographic processing as an entire system and not something that is bought component by component on low bid. The film manufacturers cannot possibly be expected to evaluate their film in every possible condition under which it wifi be used. Variations in processing are due to the type and quality of developer and fixer, the quality of the photographic processor, the temperahire of the solutions, and the quality and volume of replenishment added to compensate for depletion and oxidation of the chemicals. Consequently, to produce quality medical images, we must use the chemicals, processor, processing temperature, and processing cycle time recommended

by the






facilities attempt to save a few by buying premixed chemicals. These chemicals are often mixed under less than ideal conditions and may be a “proprietary formulation.” Even if brand name chemistry is purchased in the premixed form, one cannot be sure that it has been diluted and mixed properly, or if it has been contaminated (it takes only a few milliliters of fixer in io L of developer to change [increase] the film density by 1.00 or greater). Developer and fixer solution accounts for about 5% of our film and chemistry budget. Why should we gamble with the quality of photographic developer and fixer when this last step in the imaging chain is the most critical, most likely to change, and least expensive? As medical imaging professionals, we must get our act together. We must support and encourage our technologists and provide the necessary education to dollars

that photographic processing control programs are in place in all of our medical imaging facilities. If we do not provide the leadership and guidance, the regulators, accreditors, and other nonradiology bodies will. It is time that we do the job right and ask the manufacturers of medical imaging films to provide us the same support they provide the 1-hour photo finishers. Otherwise, we may find an investigafive reporter outside our office on Monday morning, asking us if we subscribe to the “Processing Quality Watch” systern and looking for the picture of Bill Cosby’s smiling face endorsing the qua!ity of our processing. What a way to start the week! U


Suleiman OH, Conway BJ, Rueter FG, Slayton RJ. Automatic film processing: analysis of 9 years of observations. Radiology 1992;


Subcommittee of the Laboratory Practice Committee of the Society ofMotion Picture and Television Engineers. Control tech-



in film processing. Picture

Society of Motion Engineers, 1960.






Scarsdale, NY: and Television

Sensitometric control in the proof motion picture film in Hollywood. J Soc Motion Picture Engineers 1933; 21:5458. Gray JE. Photographic quality assurance in diagnostic radiology, nudear medicine, and radiation therapy. Vol 1, The basic principles of daily photographic quality assurance. Publication no. 76-8043. Rockville, Md: U.S. Department of Health, Education, and Welfare, 1976. Gray JE. Photographic quality assurance in diagnostic radiology, nudear medicine, and radiation therapy. Vol2, Photographic processing, quality assurance, and the evaluation of photographic materials. Publication No. 77-8018. Rockville, Md: U.S. Department of Health, Education, and Welfare, 1977. Poznanski AK, Smith LA. Practical problems in processing controL Radiology 1968; 90:135-138. cessing






assure quality

How good (or bad) is film processing?

Editorials Joel E. Gray, How I PhD Good (or Bad) I Film Processing’?’ this issue of Radiology, Suleiman et al (1) address an issue that is o...
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