An RSNA 'Christmas Carol'

For years, the PACSman Awards were an annual tradition in's coverage of the RSNA conference. With the PACSman hanging up his typewriter last year, the baton has now passed to the Dalai Lama of PACS, radiologist and blogger Dr. Sam Friedman, who shares his unique RSNA experience.

CHICAGO - The PACSman was gone, and radiology wasn't looking too good either, no doubt about it. The somber, funereal atmosphere in McCormick Place at the RSNA conference was pervasive, even palpable.

Radiologists wandered the halls, heads bowed, hoping to learn something that might make them a better hospitalist, or pathologist, or whatever the Affordable Care Act might actually support. But there were still some bright spots here and there. A new scanner, a novel technique. A shred of hope for some disruptive technology.

I entered the Technical Exhibit Hall, hoping more for some free candy to quiet my rumbling stomach than any particular revelation. I was immediately swarmed by salesmen in ill-fitting Men's Wearhouse suits.

"A happy RSNA to you, Dalai, would you be so kind as to have a look at our wares?"

"Bah, humbug!" I replied, looking for something to scrounge, or even some swag to take back to my family -- a key chain, a little flashlight, anything to justify my trip to this drab, cold place.

"But Dalai, this is the most incredible of all radiology meetings!" they said. "Surely you have found something amazing here!"

I shook my head and kept walking. There was nothing wonderful here. Why did I choose imaging anyway? Because I loved the field? Ah, the foolishness of youth.

Finding no solace, I turned on my heel and returned along the Grand Concourse to the North Building. In a small basement classroom, I found the session I was seeking, an uplifting little talk titled "Tales of Alleged Radiology Fraud and Abuse."

I settled into the chair and pulled out my iPhone, hoping to find a pleasant email from home. Instead, there were three angry emails from my PACS administrators, all expressing escalating desire to serve up my partners as Christmas dinner for the local wildlife.

As the speaker droned on about the loopholes in Stark II, I found myself becoming drowsy, and to my embarrassment, my head nodded, my chin hit my chest, and I shuddered, startled back awake once again ...

But ... something was wrong, very wrong. I looked about. The harsh lines of the plain McCormick Place classroom were gone. Rather, as I looked around, the room was plush and even gilded. The chairs were comfortable. A man with a bushy mustache at the podium was wearing a suit with narrow lapels and an even narrower tie, and he was speaking about the "revolutionary EMI Mark I." There was a heavily pixelated image on the screen that seemed to be a brain, but it was not very well defined. I blinked. On the podium, emblazoned in gold, was the inscription "the Palmer House Hotel."

Wait! The Palmer House? EMI Mark I? How was this possible? The Mark I was introduced at the RSNA annual meeting in ... 1972! Could it be?

"You bet your ass, goombah!"

I turned to the source of the booming voice next to me.

"PACSman!" I cried out in surprise. "How did you get here? How did I get here?"

It was then I noticed that while he was there beside me, he wasn't quite all there; I could see through him to the gentleman seated two chairs away. He was bound in Cat-5e cable, with broken hard drives lashed to his feet. Strangely, no heads turned in annoyance over our conversation.

"Dalai, buddy, you ate some bad shrimp last night," the PACSman continued. "I told you not to go to any parties put on by the big companies, but does anyone ever listen to me? Oh well, it's nothing but a thing anyway."

"But PACSman, I thought you were gone!" I exclaimed. "Why are we at an RSNA from 40 years ago?"

"One thing at a time, bubbie," he said. "Yes, I've departed your world for one I think will be better. Live and learn, or maybe die and learn, heh? As for the why, look up, friend. You've been brought here to RSNA Past so you can remember the joy and love you once had for medical imaging. Can't you feel the electricity in the air? This was the day when CT became king! Cross-sectional imaging, baby! It all started here!"

Indeed, I could feel the excitement creeping up on me. It was none other than Dr. Sir Godfrey Hounsfield himself speaking to the enraptured crowd at the Palmer House ballroom. What I wouldn't give to have been there -- I mean here -- I mean, whatever.

I listened for a few more moments, but again, my head started to nod, and once more I awoke with a start. I was back in the modern McCormick Place, but instead of re-emerging in the small classroom, I was seated in the cavernous Arie Crown Theater, front row and center. And the gaseous apparition of my friend the PACSman was seated next to me. Clearly, my strange journey wasn't over.

"Hey, Dalai! Pay attention," he admonished. "The president of the American Medical Association is schooling you guys about how much trouble you're in. Something about triple jeopardy and not getting paid. Sounds like a triple whammy to me."

And he was right about that. I couldn't take any more of this. I got up and walked out, magically disturbing no one, the PACSman trailing behind, broken hard drives clanking at his feet.

We wound our way over the bridge to the Grand Concourse, then wandered aimlessly to the Technical Exhibit Hall in the South Building. Before long, we encountered a booth that easily covered the area of a football field. There were hundreds of black-suited, brown-badged gents milling about, looking for anyone wearing the coveted blue-rimmed name tag. I had one on, of course, but I was now accustomed to my invisible status, and I expected to remain unaccosted. The shiny new scanners, lights blinking, spun their tubes in futile pursuit of customers.

"PACSman, what are we to see here?" I asked.

"Isn't it obvious?" he asked. "Here's the deal. No one knows where healthcare is going, so we're all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we'll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no 'free' meals. As a bonus, system prices will drop 30% because vendors won't have to pay for RSNA. It's sheer brilliance, I tell ya!"

I sat down on a PET/CT gantry and bowed my head. The room spun, and when I looked up again, we were seated on a bench beside Lake Michigan. It was a blustery day, with winds one only sees in Chicago in the winter. Strangely, I felt no chill, as I watched leaves blowing through the PACSman's shadowy figure.

I looked behind me and gasped. The once-stately Lakeside Center was in ruins, shattered black pillars and glass everywhere.

"PACSman! What happened here?"

"Oy, Dalai, you need to lay off the Kung Pao, OK? Welcome to RSNA 2045," he said. "Or, well, it would have been if there still was an RSNA. Which there isn't."

"But why?"

"What did you expect?" he said. "Between the UnAffordable Care Act, the doctors' 'fix' that fixed you guys good, and all of your good friends, the clinicians, you radiologists didn't stand a chance."

"But who reads imaging studies now?" I asked.

"Geez, Dalai, why do you even care? OK, OK," he said. "You've come this far. Look, imaging reached the point where it didn't pay squat, right? So no one wanted to do it anymore. Even physicians' assistants and nurse practitioners wouldn't touch it. Imaging got so cheap that people got their scans at Walmart and everybody's data were stored in the cloud or on some vulture -- I mean, vendor-neutral -- archive. Got that? So many images were crammed into all these interconnecting networks that ... badda bing, badda boom, they grew self-aware. So, the damn computers are doing the diagnosing themselves. Whaddya think of that? End of the line for radiology."

"No, PACSman!" I exclaimed. "It cannot be! This is an honorable profession, and it cannot end this way!"

I sat back down on the bench, staring at the frigid breakers on Lake Michigan, the wind whipping through my spectral presence by the ruins. I slowly drifted off to the crashing of the waves.

"Dammit, Dalai, watch what you're doing!"

I looked up quickly. The PACSman was standing next to me, very much alive and quite solid, nursing his foot, which I had apparently stepped upon in my delirium. We were in the Technical Exhibit Hall once more. Again, something was different. The booths were lit more brightly than ever before, the scanners positively glowed, and the salesmen were all grinning and patting each other on the back. The customers with blue badges were smiling too, several making excited cellphone calls, clearly happy with a deal they had just made.

"What ... what's going on?" I mumbled, totally disoriented by this, the final shift back to reality. But it was a different, better reality than the one I had left but a moment ago.

"Gawd, Dalai, you really need a cup of coffee or something," PACSman said. "They just announced record sales for this RSNA. All the big boys have sold more scanners in the past three days than they had in the past five years! It's a damn miracle!"

"Yes, PACSman, yes!" I exclaimed. "It had to happen! So many of us love radiology. What a relief! How were we rescued?"

"Probably something to do with that first Tuesday in November, goombah," he said. "Hey, I'd like to stand around and shoot the breeze, but I have to get back to my new home away from home. I'm in a good place now ... good company, good people, good product, and all that jazz."

As he walked away, he turned, smiled at me, and said, "Hey Dalai, guess who gets the Flashdance Award?"

I laughed, thankful that some things never change ...

I ambled my way to the glass portal of the Grand Concourse. The sun was shining brightly, and the traffic cops had shed their slickers in the warm afternoon.

I went outside and walked down by the Hyatt for a ways, then looked back at the sparkling edifice of McCormick Place. I couldn't help but notice the huge banner: "Welcome to RSNA, 2012."

In addition to regular posts in the PACS Digital Community Forums, Dr. Friedman also maintains a blog at His observations and opinions are entirely his own.

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