The announcement last week that every English hospital will soon store and transmit x-rays digitally, rather than print out (and lose) the traditional films, was met with some scepticism by radiologists. As one put it: "Our new system will be delivered by Lord Lucan riding on Shergar, and will no doubt die in mysterious circumstances."
The NHS has a chequered past when it comes to installing new IT programmes, so the omens for Pacs - Picture Archive and Communication Systems - are not great. There is also a certain irony in putting so much money into the presentation of x-rays when many units are still understaffed and using dangerously outdated equipment to take them. But if Pacs works as well as it has in the 25 pilot hospitals, will we miss our old x -rays?
For some doctors, there is an emotional attachment to a tangible film. As one radiologist observed: "It's nice to handle a proper, physical radiograph. And I prefer to magnify things by bringing them closer to my eyes rather than by computer enhancement."
Displaying an X-ray has an element of performance art; the satisfying clunk when you put it up on to the box, the brisk click of the switch and the sudden revelation to the semi-circle of eager medical students, all desperate to spot the abnormality. The effect is lessened when you realise it is the wrong x-ray, and the wrong way up, but it is a lot more fun than letting the computer do all the work.
As a student, I can remember running down to x-ray to pick up a film hot off the press with the same enthusiasm with which you would pick up your holiday snaps. Would you be the first to bring back news of the kidney stone to your boss and pick up three brownie points? You soon learned that NHS radiology departments don't quite have the same consumer culture as Photoquick. There is no guarantee that your film will be turned round in an hour. If you got past the receptionist, the film might already have been lost, or the radiographer was at an emergency or, if you were really unlucky, a bolshy consultant radiologist would give you a lecture on the inappropriateness of your request and the dangers of unnecessary x-ray exposure.
For patients, being able to see your innards up on the white screen has always had a huge cultural and placebo significance, but it is not always good medicine. Each year, we give a 1.5 million back-pain sufferers an X-ray of the spine, often for no better reason than the patient demands it or the doctor is at the end of his tether. On the plus side, patients take comfort from seeing their normal x-rays up on screen, but in only 1% does it alter the course of treatment. The dose used in a spinal x-ray is 120 times higher than a chest x-ray, and although the individual risk is low, unnecessary spine x-rays cause around nine deaths a year.
In one casualty department I worked in, the demand for unnecessary x-rays was so high we considered turning the machines off and making fake x-ray sounds behind the screen ("Zzzzzz" and "clunk"), then presenting patients with an entirely normal, pre-prepared set of x-rays for their obviously unbroken ankle, spine, or whatever. Sadly, it didn't get past the ethics committee. Whether the lack of a hard-copy x-ray to ponder over will reduce demand remains to be seen, but many patients are suspicious of computer-generated images. "Have my kidneys been doctored, Doctor?"
A more dubious advantage of hand-held x-rays, at least for doctors, is that they can be deliberately lost. This may be the cynical act of a desperately competitive junior doctor who "finds" the x-ray at the last minute to save the day and secure a good reference from his grateful boss. But usually, it is to cover your tracks. When I trained, the culture was very much "burn the notes, bury the x-rays, see you in court if you dare". With digital x-rays, any attempt to tamper or destroy should leave a trail of evidence.
This isn't to say that we should blame everyone for their mistakes - there is a huge difference between misinterpreting an emergency x-ray under pressure in a dank hospital cupboard at 3am and the leisurely but ruthless dissection of a computer image in court 10 years later. But a great advantage of Pacs is that not only will it not lose x-rays, but it shouldn't display them wrongly. A key failing in the tragic "wrong kidney" case was that the x-ray was placed the wrong way round in the operating theatre.
Perhaps the strongest case for ditching the old x-rays is the cost to the NHS of the ones that go missing. Operations, appointments and procedures are delayed and cancelled, and nurses and junior doctors are shouted at to the point of tears, until it emerges that the x-rays have slipped down the back of Mabel's nightie and are stuck to her buttocks with unnatural force.
As for the poor radiologists who have to dictate the reports, most spend 10 minutes looking at the x-rays and three hours sorting through big brown folders to fish out the relevant film which is always in the wrong order or envelope. All of this is done in the dark, which is why radiologists can be a sullen bunch with a high incidence of rickets and depression.
Contrast this with the happy consultants using the new Pacs system. "It's absolutely fabulous - the quality of the pictures is great, they are available instantaneously and they never go missing. To go back to the old films would be negligent," says one.
In new Labour's NHS, the dream is for staff to be able to access anyone's digitally encrypted notes and investigations from anywhere in the NHS, and patients to ponder their own from a home computer. You can also book outpatient appointments and log treatment preferences in their own personal "health space". If you haven't got a computer, a smart card will let you access all your health records from a cash-point machine. Plug in the wrong Pin number and who knows whose ovaries you could stumble across?
Back on earth, I suspect Pacs will be brought in on the cheap, and that the software and screens necessary to make it work will be confined largely to x-ray departments. Rolling it out into wards, theatres and outpatient departments, never mind GP surgeries and patients' homes, will cost substantially more than the NHS can afford. My guess is that the old films are here to stay for at least another 10 years, which means plenty of opportunity for getting them the wrong way round and losing them when things go pear-shaped. But at least there should be a master copy somewhere on a large computer hidden deep in the x-ray department - if you are brave enough to go and find it.
