What are the greatest opportunities and challenges for radiology during the coming twenty-five years?

INTRODUCTION TO THE FUTURE Niels Bohr once said, ‘‘It’s difficult to make predictions, especially about the future.’’ The line has been repeated so often it has become a cliché, but that makes it no less true. Given the rapid rate of discovery in medical imaging and the changing health care environment, accurately forecasting the next five years would be a challenge. The next twenty-five years are a tabula rasa. Almost anything could happen. So let me start with the only thing I am sure of—the future success of radiology will depend in large part on whether there is continuing important innovation in imaging that makes its way into practice. You can write it down. Future success depends upon more of the same extraordinary development of new technologies that has underpinned radiology’s current ‘‘Golden Age.’’ According to Elias Zerhouni, radiologist and former director of the National Institutes of Health, the future practice paradigm will be P4 medicine: Predictive—New tests will probe for genetic and environmental influences affecting our predispositions to disease, allowing more targeted, less costly surveillance than current methods. Personalized—Treatment will target specific disease and patient characteristics unique to the individual and will be more effective and have fewer side effects. Preemptive—It is an axiom of medical care that finding disease earlier in its course is better than discovering disease after it has become established or widespread. Participatory—Patients have increasing access to health-related information. Patient expectations of participating in medical decision-making will only increase in the future. The direction of imaging research is both being dragged along by the transition to molecular-based P4 medicine and, in some cases, leading the way. What is now developing in the realm of molecular imaging portends an acceleration of innovation that might one day overshadow imaging’s remarkable past. Consider the following metaphor for how molecular imaging discovery could ideally satisfy the demands of P4 medicine. The year is 2036. An outwardly healthy-appearing young woman lies fully conscious in a sophisticated advanced imaging device called the Omniscient, awaiting her first annual whole-body screening examination. The Omniscient employs a completely safe radiant energy, discovered during testing of experimental weaponry. A technologist administers a safe, odorless gas—a molecular contrast agent—then conducts a scan that broadly assesses genomic risk for a number of serious diseases. In this case, the agent attaches to specific cellular receptors, identifying a genetic lesion that predisposes Lucinda to the highly aggressive lung cancer #236R (by this time, there are 335 known genetic variants of cancers arising from the lungs). A second gaseous agent specifically seeks out any evidence of active #236R, detecting a sub-millimeter lesion in the left upper lobe. A software program highlights the abnormality and sets off a beeping sound as reinforcement. The scan finds no other hot spots, showing with exceedingly high reliability that there are no metastases. Finally, the technologist directs the Omniscient to transmit a new and unique set of energy pulses precisely focused on the abnormality. The pulses cleave the contrast agent’s molecules attached to the cancer cells, transforming the agent into a highly effective therapeutic molecule. The molecule triggers tumor cell apoptosis but leaves the surrounding normal lung tissue unharmed. Lucinda is cured of a condition that formerly was nearly uniformly fatal. She drives herself home immediately following the procedure. Insurers happily pay for annual