special issue of the Journal of the American College of Radiology (JACR), published by Elsevier, challenges conventional wisdom across the imaging community. This collection of articles, the “Provocative Issue,” presents extreme opinions on pressing issues confronting radiologists with the deliberate aim of sparking positive dialog and debate that will lead to innovative solutions to improve patient care and imaging-related outcomes.

The issue is guest-edited by:

  • Caroline Chung, MD, MSc, director of advanced imaging—strategic initiative and director of imaging technology and innovation, department of radiation oncology and diagnostic imaging, The University of Texas MD Anderson Cancer Center in Houston, TX
  • Christoph I. Lee, MD, MS, director, Northwest Screening and Cancer Outcomes Research Enterprise, department of radiology, University of Washington School of Medicine in Seattle
  • Reed A. Omary, MD, MS, chairman, department of radiology and radiological sciences, Vanderbilt University Medical Center and School of Medicine, Nashville, Tenn.

“We expect this special issue will provoke strong reactions from our readers, ranging from shock, offense, and even disgust,” explain the co-guest editors. “The articles were deliberately selected to challenge the conventional wisdom across the imaging community.”

“We live in a divisive time of polarization on social, political, and scientific fronts. Yet, when oppositive or counter-intuitive points of view are brought forward, meaningful discussions can lead to new perspectives and novel solutions,” write the co-guest editors. “This special issue will challenge us to consider bold ideas that go against the grain. Our goal is to spark debate so that radiology can continue to evolve within our complex Darwinian healthcare ecosystem, leading to greater benefits for society.”

Articles in this special issue encompass the five content pillars of the JACR: health services research and policy; clinical practice management; data science; training and education; and leadership. Some of the provocative questions posed are the following:

  • Are prospective employer-initiated whole-body cancer screening programs a benefit and incentive for employees?
  • Matching imaging services to clinical context – can less be more?
  • Rethinking the approach to artificial intelligence (AI) for medical image analysis – is there a case for precision diagnosis?
  • Should we rethink patient consent in the era of AI and big data?
  • Can clinician-scientists survive in the modern era?
  • Is there a case for vertically integrating emergency radiology into emergency medicine?
  • Should there be duty hour limits for radiologists?
  • Are we over-supporting junior faculty and neglecting mid- and late-career faculty planning?

Of particular note are two featured articles that debate the paradox of scarcity and discuss potential solutions. The use of physician extenders, also known as nonphysician practitioners (NPPs), in medicine has increased over time within a multitude of specialties including radiology.

Radiologists are expensive to train and then spend too much time on low-complexity tasks and too little on high-complexity tasks, notes Saurabh Jha, MBBS, MS, associate professor of radiology at the Philadelphia-based Hospital of the University of Pennsylvania, who makes the point for training physician extenders to take on the less complex cases.

“Radiologists should train and supervise physician extenders to read portable chest radiographs, which should eventually be relinquished to them, so that we can focus on tasks exacting more skill and more befitting of our rigorous medical training,” says Jha. “Perhaps physician extenders reading serial radiographs can free radiologists to advise clinical teams on those serial radiographs.”

In a counterpoint article, Daniel A. Ortiz, MD, Summit Radiology Services, PC, Cartersville, Ga., and colleagues observe that although labor costs have been reduced and radiologists can focus more on complex imaging studies and interventional procedures, there are unintended consequences of NPPs in practice that could diminish physicians’ role as healthcare providers. They therefore encourage radiologists to consider an alternative to NPPs in diagnostic radiology: the incorporation of rapidly evolving AI algorithms into daily practice.

“Narrow AI algorithms can easily be integrated into existing workflow and amalgamated into a platform for use by radiologists,” the authors argue. “Many of the gains touted by proponents for the use of NPPs, such as efficiency, will likely be soon realized through AI to the effect of preserving the radiologist’s role, supplemented by AI. The ultimate goal for our community should not be relegating work to others but rather to work the complexities of developing a future in which we empower ourselves to remain at the helm of the imaging care to our patients’ benefit.”

The co-guest editors comment that the ever-increasing workload and the threat of radiologist workforce burnout will force us to consider how to keep up with imaging demands. Physician extenders and AI solutions are only two possibilities for practices to consider.

A final article provides an entertaining voyage into space and how the experience around radiation exposure within medicine can be applied to radiation exposure considerations in suborbital space tourism. “By exploring the provocative, we hope this special issue will serve as a catalyst to advance the field and expand the confines of radiology,” conclude the co-guest editors.