the ultrasound equipment, and an approximate estimate gestational age can be made after each examination.
of
Reference 1.
Gardner
MJ, Altman
MJ, Altman and
Tonse
statistical
guidelines.
N. K. Raju,
Department
Estimating with confidence. In: Gardner with confidence: confidence intervals
London:
BMJ,
1989;
3-19.
MD
was
of Pediatrics,
Chicago,
University
of illinois
at Chicago
IL 60612
The
U
DC.
DG, eds. Statistics
Nature
of Science
and
Discovery
From: Leon Kaufman, PhD Radiologic Imaging Laboratory, University 400 Grandview Drive, South San Francisco,
of California CA 94080
Editor: The historical perspective by Walden in the December 1991 issue of Radiology (1), while of excellent scholarship, raises important issues as to the nature of science and discovery. These issues
do
not
involve
the
author’s
quality
of historical
research
or his style; rather, they involve macroand microissues. The macroissue revolves around the interpretation of what is and is not a discovery. One view on the subject can be found in Boorstin’s “The Discoverers,” in which, when referring to the discovery of America, the author writes, “The Vikings were probably the first European settlers in America, this is far from saying that they discovered America. . . . What they did in America did not change their own or anybody else’s view of the world. Was there ever before so long a voyage . . . that made so little difference? . . . What is remarkable is not that the Vikings actually reached America, but that they reached America and even settled there for a while, without discovering America. Their experience in America was not an encounter. . . . The word ‘encounter’ (Latin in, in; contra, opposite, against) means coming up
against,
a meeting
that
conflicts
with
the
familiar
or the
al-
ready known.” Everything that can be discovered or known is already in existence or embodied in the laws of the universe. Without such a view, there is no science, no physics. The discoverer recognizes the appearance of the unfamiliar as such and opens the way to its explanation and to an expansion of human knowledge
of the
Contrast nings,
what
to the
universe
was
work
around
merely
us.
a curiosity
of Roentgen.
to Goodspeed
Roentgen
had
and
been
Jen-
using
the
Crookes tube to study its emissions. Systematic experiments were being performed. When he observed fluorescence of a far screen, Roentgen quickly recognized that this phenomenon could not be produced by cathode rays (which were known to be emitted by the tube) and that he was in the presence of an unknown, penetrating radiation. He quickly intuited that this radiation
had
characteristics
closer
than of cathode rays. He studied when he understood their nature, had learned with the accompaniment supporting his world. Goodspeed
Roentgen, momentous To me, Goodspeed
claims.
ment. There
Roentgen and Jennings
of ultraviolet
changed our view of the would not have, without they may have been witnesses
photograph exposed plate, which is not to assess the reproducibility
It is not even clear whether was no timely documentation
184
Number
#{149}
2
available. of the
no
science,
no
discovery,
no
sense
of science,
and
no
sense
of discovery. All we have-and the author has done an admirable job of scholarship in their documentation-are personal recollections, some secondand thirdhand. Some references are circular. A major reference is a 30-year after-the-fact lay press report. Those of us unfortunate enough to have dealt with the lay press, or who know the facts behind some reporting, are well aware of the press’s propensity for distorting and dramatizing even current events so as to make them salable (ie, attractive to the masses). I doubt that the press of 1927 were any more reliable than they are today or whether they were driven by any loftier goals than selling newspapers. As for Figure 4, commercial companies are not a veritable source of unbiased information,
especially
in precedence
cases.
We
also
know
from
recent
events in the scientific community how easy it is to confuse data or interpret an experiment while we are in the midst of it. What reliability can be placed on even the most honest of reporters (and I am not, for a minute, suggesting any dishonesty on the part of Goodspeed and Jennings) when they report on an experiment for which the answer is known 5 years later? It is thus that I object to the interpretation provided by the author of the events of 1890. I object also because this interpretation is provided without a critical analysis of the events and their sources, with no other interpretation being considered. I object even more strongly to the judgmental value of the article, embodied best by the use of the word “unfortunate” when referring to the event. Unfortunate for whom? If he is referring to Goodspeed and Jennings, what did they lose that they deserved? Certainly this event was not unfortunate for Roentgen. Or do they mean unfortunate for all of us because the discovery was delayed 5 more years? In this case, all edge are unfortunate, but in a “what if” world,
losses
of knowl-
we could go much further back to find events that could have happened and that could have led to the discovery of x rays but did not. The second microissue involves an all too well known melody: We rush far too quickly to the use of the words “first,” “novel,” “unique,” and “new,” to the point that they have lost any value. As the undocumented title of this article shows, we even enshrine the current rush to mark the tree by retrospective history. I note that, by the standards of the article, it is impossible criteria,
to call
any
photograph
how do we know x-ray photograph? Although not intended service
to the
cheapens ence.
memory
that this
the
“first.”
there
was
way,
of Roentgen
the concept
of what
After
the article and
all,
with
not a forgotten
his
represents contribution,
is a discovery
and
what
these
earlier a disand
Reference 1.
Walden account 635-639.
TL Jr. The of the x-ray
first radiation photograph
accident in America: a centennial made in 1890. Radiology 1991; 181:
to a
There experi-
Dr Walden I appreciate my
article.
responds: Dr
Kaufman’s
However,
compliment I find
his
on
comments
the on
scholarship whether
of a discov-
there was one coin or two. of the work except for the do not match the size of any
ery had been made to be “true and irrelevant.” Goodspeed, Jennings, or the article did not maintain or suggest that a discovery was, in fact, made. Dr Kaufman doubts the description of the events surround-
larger
ing
shadow
was
caused
it
is sci-
light
on asserting that x rays in 1890 and that of an x ray. The “discovery”
lost plate. The round shadows coins in use at that time. If the
Volume
to those
these x rays for 7 weeks, and, he disseminated what he of photographs and data
ever realized that discovery. there are also two microissues and Jennings discovered
Figure 3 is the “first” is based on a single was no duplication
tube spot size, there should be a noticeable penumbra. There are other similar-intensity but irregular blotches in the photograph, clearly not the result of x-ray exposure. They may be the result of handling of the film, maybe pressure from holding it. Could the coin shadow be the result of physical contact, of their pressing the cardboard on the film and possibly affecting the photographic plate? We will never know because there was no follow-up, no exploration, no scientific work. There
by
the
production
of the
radiograph
by
maintaining,
Radiology
in one
581
#{149}
fell swoop, that journalists, commercial companies, and sdentists themselves are incapable of an unbiased reporting of empirical events. Indeed, if this were true, we would be in a sad state of affairs, doomed to a condition where it would be impossible to learn from our own history. Dr Kaufman objects to the characterization of the Goodspeed and Jennings radiograph as the “first” x-ray photograph and suggests that there may be another undiscovered radiograph made at a still earlier date. I agree that many firsts are both uninteresting and unimportant. However, in my article the word first is used in its chronological sense. Dr Kaufman’s objections are inconsistent because he does not object to the article’s description of the first photograph of lightning or the first aerial photograph of Philadelphia. It appears that Dr Kaufman’s comments serve some agenda that is related only tangentially to the content of my article. Thomas L. Walden, Washington, DC
ing medication to patients during interventional procedures, with or performing procedures, and providing postprocedure care and follow-up. Her more extensive understanding of disease, patient care, and procedures makes her the perfect person to classify and schedule cases. We have had no problems or feelings of “loss of patient control.” There has been no obvious detriment to resident or fellow education; in fact, the physician’s assistant helps the staff in many practical areas of resident and fellow training. Despite the successful use of physician’s assistants in other medical specialties, these professionals are still greatly underutilized in radiology. In vascular and interventional radiology, physician’s assistants can complement a dedicated patient treatment team and offer an excellent way to increase efficiency, better utilize valuable physician time, and improve the quality of patient care. assisting
References
Jr. PhD
1.
Ellis B!. Physician’s assistants in radiology: has the time come? Radiology 1991; 180:880-881. Barth KH, Matsumoto AH. Patient care in interventional radiology: a perspective. Radiology 1991; 178:11-17. Land M, Carver D. The role of the nurse in interventional radiology. In: Kadir 5, ed. Current practice of interventional radiology. Philadelphia: Decker, 1991; 18-21. Adams P. The physician’s assistant in interventional radiology. In: Kadir 5, ed. Current practice of interventional radiology. Philadelphia: Decker, 1991; 21-23. White RIJr, Denny DF, Osterman FA, Greenwood LH, Wilkinson LA. Logistics of a university interventional radiology practice. Radiology 1989; 170:951-954.
2.
Physician’s
U
Assistants
Interventional
in Vascular
3.
and
Radiology 4.
From: Timothy C. McCowan, MD, Timothy C. Goertzen, MD, FRCPC, Robert P. Lieberman, MD, Robert F. LeVeen, MD, and Victoria A. Martin, PAC Department of Radiology, University of Nebraska Medical Center 600 South 42nd Street, Omaha, NE 68i98-i045 Editor: In the September 1991 issue of Radiology, Ellis regarding the role of the physician’s assistant tremendous
growth
of vascular
and
(1) wrote a letter in radiology. The
interventional
radiology
5.
Radiologists,
U
Clinicians,
and
Patient
Care
From:
has mandated increased participation in direct patient care and treatment by the radiologist (2). This has put a strain on the already busy interventional radiologist. Most radiology technologists do not have the training to as-
Pamela K. Woodard, MD Department of Radiology, Duke Box 3808, Durham, NC 27710
sist
Editor: Having recently finished a clinical internship, I am writing this letter 6 months or so into my radiology residency with the belief that my experience on “both sides of the fence” can provide some added insight regarding the relationship between radiologists and clinicians.
the
interventional
radiologist
with
in-depth
patient
treat-
ment. The increased role of nurses in vascular and interventional radiology has certainly improved the problem but has not entirely alleviated it (3). However, another health care professional is available to help in this area-the physician’s assistant (4,5). Physician’s assistants can be an important and productive part of a team approach to vascular and interventional radiology.
In the
physician’s assistant program at the University of NeMedical Center, 2 years of undergraduate study with a focus on the sciences are required. Once accepted into the program, the student undergoes 2 more years of education. The 1st year in the program is didactic and includes courses in anatomy, biochemistry, immunology, pharmacology, and internal medicine. The 2nd year is composed of 13 months of cmical training with an emphasis on family practice. Physician’s assistants are licensed by the state of Nebraska to
braska
work with a primary
supervising
physician
and,
as needed,
with other “backup” physicians. With proper certification, physician’s assistants can perform some specific duties (eg, perform biopsies, suturing, and arterial punctures, and order medication) under supervision of a physician but without the necessity of the physician being actually present. Training, licensing, and acceptable activities of physician’s assistants may vary from state to state and should be investigated by any institution or group wishing to employ a physician’s assistant. Our department has employed a physician’s assistant for 3 years. During that time, she has worked exclusively with the section of vascular and interventional radiology. Because of her level of training and her ability to act autonomously, she helps in patient treatment, including such diverse activities as explaining procedures to patients and obtaining consent, contributing to preoperative assessment, monitoring and administer-
582
Radiology
#{149}
As
radiologists,
we
are
University
physicians,
and,
Medical
rightly,
Center
we
are
both-
ered when some imply that we are merely sophisticated technicians. We resist the “us” and “them” mentality, yet, perhaps subtly, we promote it. Some of these feelings may arise because we are in different specialties. Surgeons have more exposure to other surgeons, and radiologists, likewise, work with other radiologists. We have all experienced the colleagueship or bonding among individuals who work together. The key phrase, however, is work together, and it sometimes appears that neither radiologists
nor
clinicians
realize
that
the
ultimate
objective
working together with the common goal of patient ologists can do several things to foster both a good with the clinician and good patient care. 1. Examine
the
an emergency gists
do
not
patient.
room visit
the
Although
setting, floor
radiologists
often
it is my experience or
the
intensive
care
that unit
is
care. Radirelationship do this radiolo-
in
often
enough. Periodically examining the patient whose images you read every day not only provides the radiologist with additional clinical information, but also fosters relationships with clinicians. As an intern in medicine, I was impressed with radiologists who made this effort, and as a radiologist, I have been met with nothing but appreciation for doing the same. Besides showing that radiologists own stethoscopes, time spent on the floor or in the unit gives the radiologist an opportunity to discuss patient care with the ward team and to provide guidance to the young clinician who may be overwhelmed by the myriad of available radiologic studies.
August
1992
of
Reference 1.
Gardner
MJ, Altman
MJ, Altman and
Tonse
statistical
guidelines.
N. K. Raju,
Department
Estimating with confidence. In: Gardner with confidence: confidence intervals
London:
BMJ,
1989;
3-19.
MD
was
of Pediatrics,
Chicago,
University
of illinois
at Chicago
IL 60612
The
U
DC.
DG, eds. Statistics
Nature
of Science
and
Discovery
From: Leon Kaufman, PhD Radiologic Imaging Laboratory, University 400 Grandview Drive, South San Francisco,
of California CA 94080
Editor: The historical perspective by Walden in the December 1991 issue of Radiology (1), while of excellent scholarship, raises important issues as to the nature of science and discovery. These issues
do
not
involve
the
author’s
quality
of historical
research
or his style; rather, they involve macroand microissues. The macroissue revolves around the interpretation of what is and is not a discovery. One view on the subject can be found in Boorstin’s “The Discoverers,” in which, when referring to the discovery of America, the author writes, “The Vikings were probably the first European settlers in America, this is far from saying that they discovered America. . . . What they did in America did not change their own or anybody else’s view of the world. Was there ever before so long a voyage . . . that made so little difference? . . . What is remarkable is not that the Vikings actually reached America, but that they reached America and even settled there for a while, without discovering America. Their experience in America was not an encounter. . . . The word ‘encounter’ (Latin in, in; contra, opposite, against) means coming up
against,
a meeting
that
conflicts
with
the
familiar
or the
al-
ready known.” Everything that can be discovered or known is already in existence or embodied in the laws of the universe. Without such a view, there is no science, no physics. The discoverer recognizes the appearance of the unfamiliar as such and opens the way to its explanation and to an expansion of human knowledge
of the
Contrast nings,
what
to the
universe
was
work
around
merely
us.
a curiosity
of Roentgen.
to Goodspeed
Roentgen
had
and
been
Jen-
using
the
Crookes tube to study its emissions. Systematic experiments were being performed. When he observed fluorescence of a far screen, Roentgen quickly recognized that this phenomenon could not be produced by cathode rays (which were known to be emitted by the tube) and that he was in the presence of an unknown, penetrating radiation. He quickly intuited that this radiation
had
characteristics
closer
than of cathode rays. He studied when he understood their nature, had learned with the accompaniment supporting his world. Goodspeed
Roentgen, momentous To me, Goodspeed
claims.
ment. There
Roentgen and Jennings
of ultraviolet
changed our view of the would not have, without they may have been witnesses
photograph exposed plate, which is not to assess the reproducibility
It is not even clear whether was no timely documentation
184
Number
#{149}
2
available. of the
no
science,
no
discovery,
no
sense
of science,
and
no
sense
of discovery. All we have-and the author has done an admirable job of scholarship in their documentation-are personal recollections, some secondand thirdhand. Some references are circular. A major reference is a 30-year after-the-fact lay press report. Those of us unfortunate enough to have dealt with the lay press, or who know the facts behind some reporting, are well aware of the press’s propensity for distorting and dramatizing even current events so as to make them salable (ie, attractive to the masses). I doubt that the press of 1927 were any more reliable than they are today or whether they were driven by any loftier goals than selling newspapers. As for Figure 4, commercial companies are not a veritable source of unbiased information,
especially
in precedence
cases.
We
also
know
from
recent
events in the scientific community how easy it is to confuse data or interpret an experiment while we are in the midst of it. What reliability can be placed on even the most honest of reporters (and I am not, for a minute, suggesting any dishonesty on the part of Goodspeed and Jennings) when they report on an experiment for which the answer is known 5 years later? It is thus that I object to the interpretation provided by the author of the events of 1890. I object also because this interpretation is provided without a critical analysis of the events and their sources, with no other interpretation being considered. I object even more strongly to the judgmental value of the article, embodied best by the use of the word “unfortunate” when referring to the event. Unfortunate for whom? If he is referring to Goodspeed and Jennings, what did they lose that they deserved? Certainly this event was not unfortunate for Roentgen. Or do they mean unfortunate for all of us because the discovery was delayed 5 more years? In this case, all edge are unfortunate, but in a “what if” world,
losses
of knowl-
we could go much further back to find events that could have happened and that could have led to the discovery of x rays but did not. The second microissue involves an all too well known melody: We rush far too quickly to the use of the words “first,” “novel,” “unique,” and “new,” to the point that they have lost any value. As the undocumented title of this article shows, we even enshrine the current rush to mark the tree by retrospective history. I note that, by the standards of the article, it is impossible criteria,
to call
any
photograph
how do we know x-ray photograph? Although not intended service
to the
cheapens ence.
memory
that this
the
“first.”
there
was
way,
of Roentgen
the concept
of what
After
the article and
all,
with
not a forgotten
his
represents contribution,
is a discovery
and
what
these
earlier a disand
Reference 1.
Walden account 635-639.
TL Jr. The of the x-ray
first radiation photograph
accident in America: a centennial made in 1890. Radiology 1991; 181:
to a
There experi-
Dr Walden I appreciate my
article.
responds: Dr
Kaufman’s
However,
compliment I find
his
on
comments
the on
scholarship whether
of a discov-
there was one coin or two. of the work except for the do not match the size of any
ery had been made to be “true and irrelevant.” Goodspeed, Jennings, or the article did not maintain or suggest that a discovery was, in fact, made. Dr Kaufman doubts the description of the events surround-
larger
ing
shadow
was
caused
it
is sci-
light
on asserting that x rays in 1890 and that of an x ray. The “discovery”
lost plate. The round shadows coins in use at that time. If the
Volume
to those
these x rays for 7 weeks, and, he disseminated what he of photographs and data
ever realized that discovery. there are also two microissues and Jennings discovered
Figure 3 is the “first” is based on a single was no duplication
tube spot size, there should be a noticeable penumbra. There are other similar-intensity but irregular blotches in the photograph, clearly not the result of x-ray exposure. They may be the result of handling of the film, maybe pressure from holding it. Could the coin shadow be the result of physical contact, of their pressing the cardboard on the film and possibly affecting the photographic plate? We will never know because there was no follow-up, no exploration, no scientific work. There
by
the
production
of the
radiograph
by
maintaining,
Radiology
in one
581
#{149}
fell swoop, that journalists, commercial companies, and sdentists themselves are incapable of an unbiased reporting of empirical events. Indeed, if this were true, we would be in a sad state of affairs, doomed to a condition where it would be impossible to learn from our own history. Dr Kaufman objects to the characterization of the Goodspeed and Jennings radiograph as the “first” x-ray photograph and suggests that there may be another undiscovered radiograph made at a still earlier date. I agree that many firsts are both uninteresting and unimportant. However, in my article the word first is used in its chronological sense. Dr Kaufman’s objections are inconsistent because he does not object to the article’s description of the first photograph of lightning or the first aerial photograph of Philadelphia. It appears that Dr Kaufman’s comments serve some agenda that is related only tangentially to the content of my article. Thomas L. Walden, Washington, DC
ing medication to patients during interventional procedures, with or performing procedures, and providing postprocedure care and follow-up. Her more extensive understanding of disease, patient care, and procedures makes her the perfect person to classify and schedule cases. We have had no problems or feelings of “loss of patient control.” There has been no obvious detriment to resident or fellow education; in fact, the physician’s assistant helps the staff in many practical areas of resident and fellow training. Despite the successful use of physician’s assistants in other medical specialties, these professionals are still greatly underutilized in radiology. In vascular and interventional radiology, physician’s assistants can complement a dedicated patient treatment team and offer an excellent way to increase efficiency, better utilize valuable physician time, and improve the quality of patient care. assisting
References
Jr. PhD
1.
Ellis B!. Physician’s assistants in radiology: has the time come? Radiology 1991; 180:880-881. Barth KH, Matsumoto AH. Patient care in interventional radiology: a perspective. Radiology 1991; 178:11-17. Land M, Carver D. The role of the nurse in interventional radiology. In: Kadir 5, ed. Current practice of interventional radiology. Philadelphia: Decker, 1991; 18-21. Adams P. The physician’s assistant in interventional radiology. In: Kadir 5, ed. Current practice of interventional radiology. Philadelphia: Decker, 1991; 21-23. White RIJr, Denny DF, Osterman FA, Greenwood LH, Wilkinson LA. Logistics of a university interventional radiology practice. Radiology 1989; 170:951-954.
2.
Physician’s
U
Assistants
Interventional
in Vascular
3.
and
Radiology 4.
From: Timothy C. McCowan, MD, Timothy C. Goertzen, MD, FRCPC, Robert P. Lieberman, MD, Robert F. LeVeen, MD, and Victoria A. Martin, PAC Department of Radiology, University of Nebraska Medical Center 600 South 42nd Street, Omaha, NE 68i98-i045 Editor: In the September 1991 issue of Radiology, Ellis regarding the role of the physician’s assistant tremendous
growth
of vascular
and
(1) wrote a letter in radiology. The
interventional
radiology
5.
Radiologists,
U
Clinicians,
and
Patient
Care
From:
has mandated increased participation in direct patient care and treatment by the radiologist (2). This has put a strain on the already busy interventional radiologist. Most radiology technologists do not have the training to as-
Pamela K. Woodard, MD Department of Radiology, Duke Box 3808, Durham, NC 27710
sist
Editor: Having recently finished a clinical internship, I am writing this letter 6 months or so into my radiology residency with the belief that my experience on “both sides of the fence” can provide some added insight regarding the relationship between radiologists and clinicians.
the
interventional
radiologist
with
in-depth
patient
treat-
ment. The increased role of nurses in vascular and interventional radiology has certainly improved the problem but has not entirely alleviated it (3). However, another health care professional is available to help in this area-the physician’s assistant (4,5). Physician’s assistants can be an important and productive part of a team approach to vascular and interventional radiology.
In the
physician’s assistant program at the University of NeMedical Center, 2 years of undergraduate study with a focus on the sciences are required. Once accepted into the program, the student undergoes 2 more years of education. The 1st year in the program is didactic and includes courses in anatomy, biochemistry, immunology, pharmacology, and internal medicine. The 2nd year is composed of 13 months of cmical training with an emphasis on family practice. Physician’s assistants are licensed by the state of Nebraska to
braska
work with a primary
supervising
physician
and,
as needed,
with other “backup” physicians. With proper certification, physician’s assistants can perform some specific duties (eg, perform biopsies, suturing, and arterial punctures, and order medication) under supervision of a physician but without the necessity of the physician being actually present. Training, licensing, and acceptable activities of physician’s assistants may vary from state to state and should be investigated by any institution or group wishing to employ a physician’s assistant. Our department has employed a physician’s assistant for 3 years. During that time, she has worked exclusively with the section of vascular and interventional radiology. Because of her level of training and her ability to act autonomously, she helps in patient treatment, including such diverse activities as explaining procedures to patients and obtaining consent, contributing to preoperative assessment, monitoring and administer-
582
Radiology
#{149}
As
radiologists,
we
are
University
physicians,
and,
Medical
rightly,
Center
we
are
both-
ered when some imply that we are merely sophisticated technicians. We resist the “us” and “them” mentality, yet, perhaps subtly, we promote it. Some of these feelings may arise because we are in different specialties. Surgeons have more exposure to other surgeons, and radiologists, likewise, work with other radiologists. We have all experienced the colleagueship or bonding among individuals who work together. The key phrase, however, is work together, and it sometimes appears that neither radiologists
nor
clinicians
realize
that
the
ultimate
objective
working together with the common goal of patient ologists can do several things to foster both a good with the clinician and good patient care. 1. Examine
the
an emergency gists
do
not
patient.
room visit
the
Although
setting, floor
radiologists
often
it is my experience or
the
intensive
care
that unit
is
care. Radirelationship do this radiolo-
in
often
enough. Periodically examining the patient whose images you read every day not only provides the radiologist with additional clinical information, but also fosters relationships with clinicians. As an intern in medicine, I was impressed with radiologists who made this effort, and as a radiologist, I have been met with nothing but appreciation for doing the same. Besides showing that radiologists own stethoscopes, time spent on the floor or in the unit gives the radiologist an opportunity to discuss patient care with the ward team and to provide guidance to the young clinician who may be overwhelmed by the myriad of available radiologic studies.
August
1992
