400 Degrees, 20 Minutes

About the only things I cook in the kitchen are steaks and

fish. I cook everything at 400 degrees for 20 minutes, and things have always seemed to me to turn out quite well.

The fish is moist and tender, and the steaks are cooked enough so that they no longer move under their own

power and are never burnt. It seems like a good formula

to me. Once in awhile I get fancy and add, as a flourish,

1 minute of broiling at the end, but that's just showing

off. That came to mind the other day when I was looking

at some marvelous three-dimensional images of the upper

thorax that showed the subclavian artery trapped between

the clavicle and the first rib. The image could be turned

any which way, and on one view I could even see down

the vertebral canal. Spectacular stuff. All it takes is a spi- ral computed tomographic scanner, a properly planned

image acquisition protocol, and adequate reconstruction

time.

Our physicist tells me that the day will come when all

of our diagnostic studies will be portrayed on a television

monitor rather than on film, and I believe him. He also

tells me that the day will come when everything we see will be in three dimensions and be utterly manipulable.

Two-dimensional images will be passr, and plain radio-

gral~hs will be historical curiosities. Since most of the ex-

aminations now performed in our department are these soon-to-be historical curiosities, the prospect of the New

Order gives me pause. Now that our radiology course has become a required

clerkship, I get to go to the monthly meetings of the

clerkship directors. There we discuss problems and de-

sign solutions, and we spend quite a lot of our time talk-

ing about the creation of a new curriculum. The old one

is to be discarded in favor of a curriculum characterized

by small class groups, few lectures, lots of interaction, and problem-based learning, from year 1 on. The design-

ers of the new plan assure us that the day is long gone

when faculty time can be conserved by lecturing to large

groups, and the sciences basic to medicine will be learned

at the same time as patient care. The anatomy course I re-

member (from 1951) lasted many hours a day for a full

academic year. It is now but a faint shadow of its former

self--an 8-week course that necessarily leaves out a lot. No one has figured out a way to accurately measure

the quality of the product we produce in medical school,

so we are unlikely to be able to show much in the way of

difference between the physicians we produced under the

old curriculum and those we manufacture under the new

one. But modern times require modern approaches, and if

all that results is happier students, perhaps we should be

satisfied. The fact that the new curriculum will require

immeasurably more faculty time for no real promise of

improved results is largely ignored.

Progress is a good thing, but it is not synonymous with

change. In the case of radiologic imaging, progress may

be defined as steps in the direction of improving diagnos- tic accuracy such that patient care is improved. We can

count as progress of a lesser degree those steps that do

not change things for the patient but make them cheaper.

In the case of curricular reform, progress should be de-

fined as those changes that improve the outcome, that is,

produce a better physician. Failing that, we can count as

lesser progress those changes that do not cause deteriora-

tion of the product and at the same time make everyone

happier. We can cook steaks on the outdoor grill, microwave

them, or even bury them in the earth wrapped in banana

tree leaves and surrounded by hot coals. And fish can be

eaten raw, marinated and never cooked, or cooked in a

variety of ways. If the result is better looking, better tast-

ing, or better for you and costs no more in time, trouble,

and money than 400 degrees at 20 minutes, we should

surely do it. Some of the time we do it just for the sake of variety, and I think that is a potent element of our interest

in new imaging methods and curricula. But if we cannot

demonstrate that we have gotten something demonstrably worthwhile for our extra effort and expense, we might

want to hang on to tried-and-true methods a little bit

longer. Melvyn H. Schreiber, MD

University of Texas Medical Branch Galveston, Tex

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