nearby

objects

isting

requires

distance

by to both

The

is +2.0

to +2.5

eyes,

m. This situation tions for radiologists, 0.4-1.2

a positive

correction. does

not who

correction correction,

D for

close

correspond examine

Each

In

at 0.2-0.5

viewing that

radiologist

should

radiologists bifocals,

D added Viewing day,

more

some

than

different

tions

condiare about

one

trifocals. about 1.0

be

worn

the

on

the

radiology

should

metal

inadvertently

interest the

case

objects

it is relatively

simple

plastic or glass, at a cost Laboratories (Cleveland) supplied

by

to coat

eyeglass

frame), with

lenses,

of about $25. North will coat uncoated

opticians.

Hoya

Optical

Company

pany

(South

Bridge,

who

do not

may

try

Mass)

understand

to sell

provide

the

principle

services.

or tinted

Com-

Opticians

of multilayer

ultraviolet-absorbing

coatings

lenses

instead.

These have no value for routine radiology. A controlled experiment on the effects of using bifocals reading errors has not, to my knowledge, been done and would be difficult to do. It is reasonable to expect, though, that will in

use of single-vision, optimize reading

multilayer-coated conditions and

viewing therefore

on

ologists.

Radiology

U Radiology Radiology

From:

eyeglass

1979;

Richard

G. Stiles,

Organization

TN

aid

School

at CT examination

organize a deradiology mesiof the Mallinck-

rodt

David

of Radiology, Jefferson

companied tively

This

Dr Salvador’s

specific

radiology. radiology

St Louis,

University

plan

for

inquiry.

is already

afoot,

to address

will

simply

a particular

and

area

that

Dr

Levin

has

the

to by

gan-system radiology.

Volume

Dr

subspecialization,

174

#{149} Number

Levin

occurred

particularly

2

that

own

radiology-muscuboskeletal different institutions.

referred

a reba-

their

general diagnostic have been at three chaos

outlined a department

In none for

have

would

be

me-

a particular or abdomen,

probmuscu-

extensive

tailor-

and

to the

of the

chest

anatomic

and

part.

abdomen

are very

different.

of anatomic

parts,

necessitate

angling

of the

to subtle details of muscuboskeletal of how to perform multiplanar

reconstructions. such attention

gantry,

anatomy, and three-di-

No other organ-system to detail. MR imaging

has

subspecialmany

of

the same problems. I do not believe that it is logistically impossible to have organ-system-subspecialized radiologists involved in all modalities. Perhaps if the organ-system-subspecialized radiologist is too lazy to leave his or her seat and walk to the CT scanner or the magnetic resonance (MR) imaging area, there might be a problem. However, with sufficient energy and commitment, one can be involved with all imaging modalities without adversely affecting throughput. It has been my experience that orthopedic surgeons and are

that

disappointed

in

they get from madiobogists, In two of the three universities

particularly

theme

were

generaily

the

been

established

in

all

modalities.

In

there

was

when

After

the

radiobogic general

where muscuboskebetal

have

involved

there

not

no established

ma-

I have sections

other,

I started

musculoskele-

a muitimodality, radiology section

be

I wish into

of or-

musculoskeletal

knowing

is actually

true.

I has

to whom

Essentially,

organ-systemhad been built,

else

for turn consultation.

in the

and

it

the

more

with

severe

problem

recommended

radiologists

retire.

surgeons neurologists,

who

would

choose

them to plain-radiograph to ask their residents

take

a position

that

they

ing.

In

in general

would other

how

never departments

called

general

sisted

of members

whom

diagnostic of the

they the

and

academic

diagnostic be actively which

the

is when their studrheumatolamthmo-

work

radiology

section who

as

madiobo-

if it limited

I challenge would be

radiology

department

often. orga-

young

position

I have

most

to fill positions

bright

involved

reading the

departmental

is how few

interpretation. many of them

in

mheuwho

were in a centralized and consultation with with

of very an

and

of radiology,

by Dr Levin I know

con-

imaging

consultation, orthopedic sumto the orthopedic or muscuboThey generally do not

department

radiologist

even

nization

Quite

they tend not to know to whom to turn to go from modality to modality to find found subspeciabists in orthopedics and happy when their standard madiogmaphs,

muscuboskeletal

gists

to turn.

all muscuboskeletal

are ordered by orthopedic Just like neumosurgeons

anyone

An

radiology. of them

as a result

do they

that

head

do

orthopedic

They

system

positioning

grams, CT scans, and MR studies area, available for their viewing in

subspein other

imaging. lumped

nor

necessitate

history

the

muscuboskeletal

only time they have ies. I have ogy most

of

it will

If we do not subspecialists

generally

CT scan, for

been sub-

sections through of oral and inexaminations of the

know

(3), ac-

I believe

to do

Levin

that subspeciabization organ-system lines.

of radiology. lines, then prefer

Salvador

Philadelphia,

within

Unlike Dr Levin, I believe will require divisions along

movement

Dr

Dr Levin

organization

necessary for the survival cialize along organ-system disciplines

and

Hospital,

who

in-

tomographic

disease

often

turn to the neuroradiobogist geons and rheumatologists skeletab radiologist for

In the September 1989 issue of Radiology, Dr of Barcelona, Spain, wrote to ask how best to pamtment of radiology and how best to train dents (1). Replies fmom Dr Ronald Evens (2), Institute

those

of the

if

if one simply obtains transverse contiguous the chest and abdomen after the administration travenous contrast material. However, CT

examinations matobogists.

Editor:

of Thomas

except

In two

it is that

examination of the

fails

rarely

trary

of

37232-2675

Rafael

the

the

was readily apparent that rheumatologists and orthopedists were much happier about the service they received. Dr Levin refers to studies being dispersed to different parts of the department for reading and to referring physicians in need of

and

University

that

have little, examina-

radiology what

from

clinical

consuitation

Vanderbilt

anyone

muscuboskeletal

tal radiobogy section. oriented musculoskeletal

to radi-

MD

of Radiology,

Nashville,

a viewing

to gain

particular

to the

worked,

131:793-794.

Department Education

Department Medicine

lenses:

found

computed

to learn

ing

working Low-reflectance

worked,

CT examinations

service diobogists.

Reference CS.

by

radiology.

loskeletal

that

Revak

I have

muscuboskeletal

about

rheumatologists

glasses reduce errors

radiology.

1.

is trying

mensional ty requires

(Torrance,

similar

in

close attention and a knowbedge

either

prescription. Optical

I have

motivation

knowlege

unusual

American Coating lenses that are

Cabif) grinds and coats lenses from the user’s Bausch & Lomb (Rochester, NY) and American

the

One

way

department

modality

quimed to best design a CT lem. Unlike CT examinations

about

vs plastic the

have

surgeon this

be in some

any

in which

not

department

frame leave

with

specialty

and

institutions,

in musculoskeletab

one

wrong glasses. A further improvement can be realized by reducing annoying reflections from the surfaces of the lenses (1). Multibayem coatings on the lenses can reduce reflections from 9% to 1%. All mediumto high-quality camera lenses have such coatand

obtained

at the

in

in defining

They

(eg,

value

The alternative D added above

in

away.

bifocals not

best

three

(CT) scans obtained for orthopedic reasons have largely ignored or done poorly. This is because people without

the

ings,

at these

subspecialize

correction radiolo-

If possible, a view box.

inconvenience

meters

does

a viewing for general the

examination. directly

minor

a few from

so that

can

with useful

determine

wear with

below. glasses

with

working

orthopedic surgeons and rheumatologists simply any, tolerance for interpretation of muscuboskeletal

stitutions

of the ophthalmologic observe madiogmaphs

Some is viewing

all

reading

exequal-

m away.

time should

2.0

to the

applied

to the radiogmaphs

Single-vision prescription glasses of +1.0 to +1 .25 D are particularly gy.

added

usual

everyone willing to

if they in CT worked,

has were

knew

or MR the

imagso-

largely

con-

close

to retire-

Radiology

#{149} 579

ment.

These

are

very

important

members

of the

department,

and

and they provide an incredible service. Our specialty has done very poorly in attracting people to fill the shoes of these pmactitioners. By the same token, I do not think it reasonable to ask bright

young

radiologists

to limit

themselves

to the

standard

radiographic modalities. Furthermore, most of the residents were attracted to radiology because of CT, MR imaging, and interventional radiology. A much better option is to train organsystem multimodality imagers as much as possible. Otherwise, we will find ourselves in the 21st century with MR imagers and CT imagers and no one to read chest radiographs, arthmograms, and skeletal madiogmaphs. This sort of situation will provide more impetus for clinical specialists to do their own radiologic examinations. I would not have chosen to subspecialize in musculoskeletal radiology had I not believed that I would be able to pursue a career that would allow me to cross multimodality lines. By that I mean not just crossing with consultation but

rather

crossing

with

Dr Levin states could master the and interventional might

apply

to their

of anatomy

clinical

own

organ

system

believe the that radiologists and

of interest.”

more can

in all

Again,

of the

organ

sys-

tems that they image with a given modality. Furthermore, I believe that clinicians will be chronically dissatisfied if they are not provided with imagers who can speak their subspeciabized language. As a muscuboskeletal radiologist, I have been involved in imaging this system with standard radiography, standard arthrogmaphy, standard tomography, CT, CT arthrography, CT-guided and fluoroscopically guided bone and muscle biopsies, MR imaging, and three-dimensional meconstruction

of digital

data.

I think

that

young

radiologists

would

be

attracted to this type of work. I think one’s chances of recruiting a young radiologist out of residency with the prospect of limiting his or hem practice to chest and bone radiography are almost nonexistent. In summary, I feel strongly about organ-system subspecialization,

and

as a result,

I agree

more

with

Dr

Evens’

response

(2)

than I do with Dr Levin’s response (3). It is obvious from the foregoing that I also feel very strongly about the subspecialty of musculoskeletal radiology. Furthermore, I believe that the survival of radiology as a specialty will require organ-system subspeciaiization.

Levin’s dude

I could

reply

when

with

support

not

I read for

make

sense

out

the conclusion.

of the

body

He seems

subspecialization.

Will

his

of Dr

to conso-called

general diagnostic radiology be a subspecialty? I agree that we must work toward subspecialization now. However, I do not believe it to be acceptable for musculoskeletal radiologists to be relegated to the role of plain-radiograph readers. I also believe that

subspecialists

in gastrointestinal

and

ing

will not accept such banishment It seems to me odd that Dr Levin ogy should be the only subspecialty timodality

work

approach

in that

tem-omiented

neurologists refer their radiograph

to imaging

subspeciabty, subspecialties.

would patients doctors

an

then

genitouminary

either. believes allowed organ

I doubt

that

imag-

that neuromadiolto pursue a mulsystem.

can work

it

If it can

in other neurosurgeons

and

wish to return to a system whereby to CT doctors and MR doctors and rather than to neuromadiologists.

they plain-

Salvador

R.

education.

Radiology

2.

Evens ment.

RG. Reply: Radiology

3.

Levin

DC.

Dr

580

Reply:

tured?

how

1990s.

Radiology

Levin

Dr Stiles gan-system

department

Radiology

should

1989; the 1989; how

organization 172:609-611. should

of a modern radiology be

organized?

technologically

oriented

ap-

opportunities

for

joint

consultation

by Dr Stiles, phy but also

wherein he MR imaging

on

and our

performs and CT,

in fact already

faculty

with

and

possible, and rapid radiology

not only standard would certainly

does.

primary

We have

interests

in

reading

as long as flow of advocated madiograwork in my

two the

madiobo-

muscuboskel-

etal system. One has broad experience in MR imaging as well and works in both the general diagnostic and MR imaging divisions. He reads most of the muscuboskeletal MR imaging studies and supervises the protocols used for such studies. The other radiologist has more of an interest in standard madiographic studies and arthrography but is also now familiarizing himself with musculoskeletal MR imaging. Both activeby consult

on

muscuboskeletal

do not routinely ed our system Dr

Stiles

CT

supervise these. to their particular

points

out

that

his

examinations,

although

Thus, we interests.

have

musculoskeletal

they

accommodatwork

includes

standard radiography, arthmography, tomography, CT (irtcluding three-dimensional reconstruction), and MR imaging. However, these areas do not represent the sum total of muscuboskeletal radiology. What happens when a patient with osteosarcoma of the distal femur needs an intraarterial chemotherapy

infusion

this procedure, gists? Who does

ment-Dr read the

in

his

department?

or is it done by the madionuclide

Does the

Stiles or the nuclear medicine plain radiographs of pediatric

dysplasias, tient with

or do the peripheral

pediatric soft-tissue

Dr

interventional bone scans

Stiles in

perform

madiobohis depart-

physicians? patients with

Does bone

he

radiologists read them? If a patrauma needs an ultrasound do it, or is it done in his ultra-

examination, does Dr Stiles sound division? Unless he is doing all these studies himself, he is not as subspecialized as he claims to be. My viewpoint on departmental organization is largely ternpered by my experiences as a chairman. For a department of radiology first

(academic

requirements

or otherwise) is rapid

and

to be efficient

successful, service

one

of the

to patients

and

referring physicians. Dr Stiles acknowledges that theme might be a logistical problem “if the organ-system-subspeciabized radiologist is too lazy to leave his or hem seat and walk to the CT scanner or the MR imaging area.” More likely, the pmobbern is not one of laziness but rather one of being too busy. What does Dr Stiles do when he has three patients sirnultaundergoing

hopes that personally least

two

arthmography,

CT,

and

MR

imaging?

One

all three do not have to wait until he gets around to perform their studies. If they do, he will have unhappy

patients,

and

their

referring

at

physicians

will no doubt hear about it. One of the main reasons for my more technologically oriented approach is the need to provide a “private office” type of service, and that means maximizing efficiency and the rate of patient throughput.

radiology

radiology

residencies

more

depart-

for

Thomas

Jefferson

University

Hospital

be struc-

proposals

David C. Levin, MD Department of Radiology,

the

11th

and

Walnut

Streets,

Philadelphia,

PA 19107

172:611-614.

responds: makes a strong lines (especially

Radiology

#{149}

and

172:609.

departments

1989;

organization

somewhat

of studies should be provided whenever these do not interfere with an orderly work.” The approach to musculoskeletal

neously

organ-sys-

References 1.

stimulation,

gists

realistic situation is master all of the subtle-

pathophysiology

my

department,

responsibility.

that “it is unlikely that most radiologists technobogic intricacies, imaging subtleties, techniques of all the modalities as they

quite the contrary-I that it is unlikely ties

full

criticizes

proach. However, he seems to have ignored an important point that was strongly emphasized in my article-that flexibility is necessary. Specifically, I stated that “I do not advocate rigid separation of activities or responsibilities along divisional lines. Theme will be frequent overlap of interests between divisions, and these should be encouraged rather than discouraged. For example, radiologists in the general diagnostic division will often wish to participate in CT or MR imaging studies of the chest, gastrointestinal or genitouminary tracts, or muscuboskebetal system . . . To promote greater intellectual

case

for subspecialization in musculoskeletal

along radiology)

or-

February

1990