REVIEWS AND COMMENTARY • EDITORIAL
Radiology 2040
James A. Brink, MD • Hedvig Hricak, MD, PhD
Nothing is permanent except change.
—Heraclitus, around 500 BCE
H istorically, radiology has been a specialty of innovation.
Radiology has embraced new technologies and recog-
nized their potential well before their clinical value has been
widely accepted. We have been fearless in change and adap-
tation. Over the past 4 decades alone, we have repeatedly
expanded and reshaped our field to accommodate revolu-
tionary technological advances. We adopted cross-sectional
anatomic imaging with CT and MRI, which required ad-
aptation to much greater levels of detail in image interpreta-
tion. We introduced various forms of functional and mo-
lecular imaging, which required us to incorporate biology
into our knowledge and image interpretation. We facilitated
tremendous growth in applications of interventional radi-
ology, incorporating clinics and clinicians with admitting
privileges into many of our departments. Finally, most re-
cently, we introduced marked advances in radiotheranostics,
which combines targeted molecular imaging with radionu-
clide therapies.
Today, we are in some ways the victims of our own suc-
cess, as the demand for imaging, especially in oncology,
keeps increasing. We now face large volumes of examina-
tions, exponential increases in the number of images gener-
ated by each examination, and the demand for 24/7 cover-
age. In an era of widespread physician burnout, our specialty
is among the most affected.
The present is not sustainable, and yet again, radiology
is at a crossroads. The next several decades are sure to bring
seismic organizational and operational changes that will af-
fect all medical specialties, including radiology. Artificial in-
telligence (AI) is emerging as an extremely powerful force
in medicine and particularly in radiology—one that could
help streamline our workflow and reduce our workload
while also posing challenges to our relevance. Moreover,
the pace of technological change is constantly accelerating.
Many operational and technological developments that will
affect radiology are being driven by external forces beyond
our control. Imaging will still play a critical role in diagno-
sis and minimally invasive intervention. But, as radiologists,
our focus must be laser-sharp on ways in which we can add
value to the health care continuum, especially given the rise
of non–image-based precision diagnostics and minimally
invasive interventional techniques certain to occur in other
specialties. Radiologists whose activities are limited to image
From the Department of Radiology, Massachusetts General Hospital, Brigham and Women’s Hospital, Boston, Mass (J.A.B.); and Department of Radiology, Memorial
Sloan Kettering Cancer Center, 1275 York Ave, Ste H-704, New York, NY 10065 (H.H.). Received October 10, 2022; revision requested October 14; revision received
October 20; accepted October 25. Address correspondence to H.H. (email: hricakh@mskcc.org).
A translation of this article in Spanish is available in the supplement.
Una traducción de este artículo en español está disponible en el suplemento.
Conflicts of interest are listed at the end of this article.
Radiology 2023; 306:69–72 • https://doi.org/10.1148/radiol.222594
This copy is for personal use only. To order printed copies, contact reprints@rsna.org
interpretation will not only become a commodity but, even-
tually, may become obsolete. It is time to actively search out
and demonstrate new means through which we can contrib-
ute beyond image interpretation. If we approach this chal-
lenge in the right way, then the specialty will continue to
prosper. But the specialty will have to change considerably.
At the most basic level, radiologists’ ability to remain
clinically relevant will depend on our becoming and staying
part of the clinical team. The ability to offer therapy will also
be essential for strengthening our clinical impact. Thus, we
will need to cultivate interventional radiology and radiother-
anostics extensively. Furthermore, it will be critical for us to
partner with other disciplines—in medicine, data science,
engineering, and other areas—to perform clinically relevant
research and carve out paths of innovation and expertise
unique to our specialty. This editorial describes a variety of
anticipated changes in the science and practice of radiology
(Table), some of which will appear almost inevitably and
some of which the imaging community will only be able to
achieve through vision and intense determination.
Radiology Workflow and Teleradiology
Increasingly, computation and data analytics will support
imaging and other diagnostics, as well as connectedness and
telehealth (1). Current workflows are largely driven by pa-
tient location. Worklists are organized according to whether
patients are inpatients, outpatients, or admitted to the emer-
gency department. But we will see the distinction between
these three patient locations blurred as more and more medi-
cal care is delivered at home. Home hospital programs are on
the rise. If inpatient care can be delivered at home, it is likely
that we will see more urgent and acute care being delivered
at home as well. Thus, our workflows will need to be driven
by disease focus rather than patient location.
Just as other medical care will be delivered at home,
imaging technologies will increasingly be brought to the
patient for self-examination. AI-powered autonomous or
semiautonomous US using low-cost transducers driven
by smartphone technology will enable patients to perform
simple US data acquisition on their own, with images being
reconstructed automatically (2). In the future, other exami-
nations may be performed locally, including with portable
equipment for radiography, CT (motionless), and MRI (low
field strength) (3,4).
Home reading and teleradiology will continue to rise due
to the growing demand for worker flexibility and the need
• Content codes: • © RSNA, 2023
Radiology 2040
for continuous coverage as well as outreach beyond urban centers.
However, radiologists of the future will need to think hard about
how to balance remote and on-site readings for the benefit of pa-
tients, education, and cross-fertilization of knowledge. It will be
important for radiologists to maintain a strong presence within
their health care institutions so that they continue to be recognized
as key partners in patient care and research.
Artificial Intelligence
AI will not replace radiology, but it will profoundly affect our rel-
evance and our workflow. The greatest risk to our specialty is that
other medical specialties, and potentially patients themselves, may
leverage AI for independent image interpretation. Given that re-
ferring physicians have clinical information at their fingertips, they
will be able to put imaging findings in a clinically relevant context
to a much greater degree than traditional radiologists.
The globalization of consultative work combined with AI au-
tomation will increasingly threaten many white-collar disciplines.
These include medicine and law (5). Our pathology colleagues
have seen evolution in practice. For example, the Papanicolaou
test no longer requires human interpretation routinely (6). Ma-
chine-based interpretations, potentially in distant locations, have
become the norm. The only exceptions are in unusual conditions
that prevent automatic reading and require human intervention.
Certain radiology examinations will undergo a similar evolution.
AI algorithms will provide comprehensive and autonomous inter-
pretation. At present, most AI algorithms are narrowly focused,
targeting a specific imaging feature or function. Over the next
several years, algorithm development will broaden substantially
to include a comprehensive evaluation of all possible features that
may be present in certain imaging examinations.
Algorithm development will become increasingly federated,
with the training of distributed algorithms on local data rather
than moving data beyond secure firewalls. This will increase the
diversity of training data and minimize training bias, thereby
promoting health equity and algorithm robustness. Once an al-
gorithm is trained, its quality will be maintained with continu-
ous learning. Temporal degradation owing to changes in local data
environments will be minimal (7,8). Radiologists must remain the
keepers of such algorithms and oversee their use unequivocally.
Just as AI will permeate all facets of daily living, it will affect
all aspects of radiology practice. These will range from examina-
tion triage and planning to lesion detection, characterization, and
measurement (9). AI will also enable greater assessment of disease
likelihood and potential treatment outcomes by seamless integra-
tion of imaging findings with other clinical indicators. Radiolo-
gists’ role in this continuum is not assured. We must see to it that
we are adding value at every step.
The “lifelong learning” of AI algorithms, including their ability
to adapt to improved or new technologies (eg, novel MRI pulse
sequences, novel radiotracers) will influence the training of the
next generation of radiologists. The integration of AI into training
will continuously evolve. Radiologists will, at least in the short-
and mid-term, still be required to supervise and, if necessary, over-
rule AI, thereby providing feedback and improving model per-
formance. While training supported by AI will surely be a great
learning opportunity, especially when visualization tools such as
70radiology.rsna.org
What to Know to Ensure Radiology Is Thriving in 2040
1. Radiologists must add value to the health care continuum,
especially given the rise of non–image-based precision diag-
nostics and minimally invasive interventional techniques
2. Radiologists whose activities are limited to image interpreta-
tion will not only become a commodity but, eventually, may
become obsolete
3. The ability to offer therapy is essential for strengthening
our clinical impact. We will need to cultivate interventional
radiology and radiotheranostics extensively
4. Our workflows will be driven by disease focus rather than
patient location
5. Radiologists need to maintain a strong presence within their
institutions and continue to be recognized as key partners in
patient care and research
6. Radiologists must recognize that artificial intelligence (AI)
will enable us to function at a higher level, just as did the
advent of digital imaging and electronic image display
7. Radiologists must remain the keepers of AI algorithms and
oversee their use unequivocally
8. Non–image-based precision diagnostics (ie, “liquid biop-
sies”) will continue to rise, and radiology’s place in the value
equation will need to evolve commensurately. Radiology
will be responsible for phenotyping with imaging markers
that are prognostic and predictive of treatment response on
a large scale
9. Subspecialized training will remain extremely important,
as radiologists’ clinical relevance can only be assured by
radiologists being as knowledgeable as our subspecialized
referring physicians
10. The carbon footprint of medical imaging will be at the
forefront among environmental sustainability efforts
11. We must remain vigilant to do our part in bringing the
power of medical imaging to the most underserved popula-
tions across the globe
12. Imaging technologies will become increasingly multiscale,
multimodal, and multiomic
13. Due to advances in imaging, devices, techniques, and
robotics, the array of minimally invasive interventions will
continue to grow
14. Radiotheranostic growth will expand clinicians’ ability to
first “see with precision” and then “treat with targeting.”
Radiology and nuclear medicine will take leading roles in
cancer diagnosis and treatment
gradient-weighted class activation mapping, or Grad-CAM, are
applied, we need to ensure that trainees acquire sufficient knowl-
edge and do not unquestioningly trust the results produced by an
algorithm (10). For this, trainees need at least a basic understand-
ing of AI algorithm design and training strategies to understand AI
algorithms’ performance levels and limitations.
Over time, AI algorithms will enable the integration of ra-
diomic features and metabolic or functional information with
genomic and other phenotypic information for disease detection
and characterization. These capabilities will likely exceed what is
■ Radiology: Volume 306: Number 1—January 2023

achievable by humans alone (11). As radiologists, we must wel-
come the assistance that AI will provide to our practices, recogniz-
ing that it will enable us to function at a higher level, just as did
the advent of digital imaging and electronic image display. To truly
harness this AI-enhanced, integrated diagnostic approach, cross-
training with other specialties such as pathology will be vital for
the next generation of radiology trainees. This may be achieved
by electives during residency, short-term fellowships, or at an even
earlier point during medical school in the form of integrated MD-
PhD programs.
Value-based Care
Non–image-based precision diagnostics (ie, “liquid biopsies”) will
continue to rise, and radiology’s place in the value equation will
need to evolve commensurately. We must strive to be the primary
purveyors of imaging examinations in every respect, from their
most appropriate uses to timely, accurate, and precise reporting
of the information they contain. Imaging centers will evolve be-
yond diagnostic centers to treatment planning and prediction cen-
ters. Radiology will be responsible for phenotyping with imaging
markers that are prognostic and predictive of treatment response
on a large scale.
The drive toward subspecialization for maximal value creation
will continue. But AI may enable radiologists to achieve highly
subspecialized excellence (as so-called centaur radiologists—a
combination of human plus computer) (12). While it is tempting
to imagine that this scenario may enable AI-powered generalists to
deliver the value typically seen with subspecialists, subspecialized
training will remain extremely important, as radiologists’ clinical
relevance can only be assured by radiologists being as knowledge-
able as our subspecialized referring physicians.
Imaging examinations will give rise to AI-derived three-di-
mensional data sets of imaging findings. Radiologists will need to
ensure the accuracy of salient findings. More importantly, radiolo-
gists must ensure the integration of these findings with relevant
clinical scenarios to produce meaningful and impactful diagnoses.
Imaging interpretations will be converted to lay language instantly
and in a variety of media, including static and motion content
with automatic, cinematically rendered images (13). Patients and
their providers will have instant and full access to their images and
interpretations in real time, potentially for the application of in-
dividual or personal AI algorithms on features of interest. Recom-
mended follow-up imaging or other diagnostic testing will be com-
municated, confirmed, and, if warranted, arranged automatically
through robust care coordination systems (14). These changes will
further marginalize radiologists and threaten our relevance unless
we integrate ourselves in the care continuum and add value be-
yond machine-generated interpretations and recommendations.
Environmental, Social, and Governance Concerns
The carbon footprint of medical imaging will be at the forefront of
environmental sustainability efforts. Thus, technical advances that
substantially reduce our energy consumption will be embraced
uniformly. These include imaging devices and viewing equipment
with reduced power requirements. Renewable sources for con-
sumables in diagnostic and interventional radiology will become
mainstream.
Radiology: Volume 306: Number 1—January 2023 ■ radiology.rsna.org
Brink and Hricak
Radiology’s role in ensuring that health care is delivered equi-
tably across all demographic groups of our society is not assured.
Economic pressures will continue to favor the greatest care deliv-
ery to those who can most afford it. We must remain vigilant to
do our part in bringing the power of medical imaging to the most
underserved populations across the globe (9).
Similarly, diversity among our leadership and within our gov-
ernance structures is not assured. We must continually strive for
parity for women and members of other underrepresented groups,
or the axiom “if you’re not at the table, you’re on the menu” will be
as apt in 2040 as it is today.
Evolution of Imaging Technologies
Imaging technologies will become increasingly multiscale, multi-
modal, and multiomic. They will incorporate relevant metabolic,
proteomic, and genomic information. “Smart” contrast agents
will increase exponentially, leveraging in vivo biochemistry, im-
munohistochemistry, reporter genes (genes that produce receptors
that bind imaging probes), and nanoparticles. Bioengineering will
advance rapidly, showing explosive potential to alter the practice
of medicine, with an outsized impact on medical imaging. Pheno-
typic data generated by the physical interaction of an external en-
ergy source with biologic tissue will enter multiomic databases that
cross multiple levels of biologic regulation, potentially bypassing
the need for image formation (ie, fingerprinting). Images will be
reconstructed in select cases where human understanding is best
achieved by visual means, such as for surgical or interventional
radiology treatment planning.
Therapy: An Expanding Role of Radiology
Precision Imaging and Image-guided Intervention
Due to advances in imaging, devices, techniques, and robotics, the
array of minimally invasive interventions will continue to grow
(1). Percutaneous endoscopic imaging will enable interventional
radiologists to perform minimally invasive interventions in do-
mains previously reserved for other specialties. When combined
with multispectral optical imaging, in vivo virtual histologic ex-
amination may be possible for certain pathologic conditions, po-
tentially obviating the need for a needle biopsy (15).
Interventional procedures will become increasingly automated,
powered by AI. This will enable less-trained personnel to carry out
some less complicated image-guided procedures, potentially at
home and other locations beyond the purview of standard health
care facilities (16). AI-powered robotics may follow for more com-
plex procedures.
Radiotheranostics
Molecular imaging will continue to expand through basic science
research and clinical practice via the rapid rise in theranostics.
Theranostics combines diagnostic imaging with targeted therapy
to noninvasively determine tumor phenotype and evaluate func-
tional and molecular responses to therapy.
Radiotheranostics will continue to expand exponentially, com-
bining molecular imaging—currently with PET and SPECT—
with radionuclide therapy, leveraging small drugs, peptides, and
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Radiology 2040
antibodies to carry therapeutic radionuclides (alpha-, beta-, or
auger-emitters). Radiotheranostic growth will expand clinicians’
ability to first “see with precision” and then “treat with targeting.”
While oncologic radiotheranostics already includes numerous
contemporary applications, it has enormous untapped poten-
tial for treating a huge range of cancers, given its capacity to be
adapted to different targets and maximize tumor killing while
minimizing side effects (17).
Real-time feedback from imaging allows clinicians to improve
patient selection for therapy, provide earlier and more precise
treatment response assessment, and expedite drug development.
Whereas patients are typically selected for cancer therapies based
on clinical (and secondarily histopathologic or molecular) param-
eters, pairing radiation therapy with a companion diagnostic (eg,
technetium 99m, fluorine 18, or gallium 68) allows clinicians to
visualize in vivo the expression of the therapeutic target, confirm
the presence of the therapeutic agent, and visualize tumor burden.
In the field of oncology, drug development currently fails about
90% of the time. Radionuclide therapies, however, provide in-
sights regarding the biodistribution of both intended targets and
radioligands that allow researchers to quickly halt, adapt, or ac-
celerate their experiments. This increases the success rates of these
therapies over those of conventional cancer therapies.
The development and implementation of radiotheranostics
will clearly represent a tremendous opportunity for radiology and
nuclear medicine to take leading roles in cancer diagnosis and
treatment. Furthermore, while radionuclide probes for the selec-
tive and targeted diagnosis and treatment of specific cells hold im-
mense promise for cancer, they also will have potential for appli-
cation to other patient-specific diseases, including inflammatory
and autoimmune conditions. Realizing the full potential of radio-
theranostics for advancing clinical care will require more extensive
cross-training of radiologists, and likely other clinicians, in nuclear
medicine (18).
Conclusion
The next 2 decades will bring astonishing changes to health care
that are yet to be imagined. With the expected growth of AI, ra-
diologists will need to offer added value beyond image interpreta-
tion. We have been tremendously innovative over time, and we
must remain at the leading edge of innovation in both diagnostic
imaging and image-guided therapy (eg, interventional radiology
and radiotheranostics) to ensure that our technical advances and
expertise continue to provide value in the years ahead. We are con-
fident that with flexibility and agility, we will sustain our relevance
to the full continuum of clinical care. However, we must continue
to embrace changes that are best for patients, and decisions made
with patients at their center will always serve us well. Radiologists
will carry on shaping our own destiny just as we have for the past
72radiology.rsna.org
100 years, since the first innovations of our specialty were set to
print in Radiology.
Acknowledgments: The authors thank Jason Lewis, PhD; Marius Mayerhoefer, MD,
PhD; and Ralph Weissleder, MD, PhD, for their valuable input and Ada Muellner, MS,
for editing the manuscript.
Disclosures of conflicts of interest: J.A.B. Member of the board of directors for Ac-
cumen and president of the International Society for Strategic Studies in Radiology.
H.H. Grants from the National Cancer Institute (principal investigator or co-leader);
member of the external advisory board of the Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins, the international advisory board of the University of Vienna,
the Scientific Committee of the DKFZ (German Cancer Research Center), the board of
trustees of the DKFZ, and the board of directors of Paige; paid member of the board of
directors of Ion Beam Applications.
References
1. Weissleder R. Leveraging technology to address current and future world issues.
Sci Transl Med 2022;14(666):eabq0606.
2. Akkus Z, Cai J, Boonrod A, et al. A survey of deep-learning applications in
ultrasound: artificial intelligence-powered ultrasound for improving clinical
workflow. J Am Coll Radiol 2019;16(9 Pt B):1318–1328.
3. Cooley CZ, Stockmann JP, Armstrong BD, et al. Two-dimensional imaging
in a lightweight portable MRI scanner without gradient coils. Magn Reson
Med 2015;73(2):872–883.
4. Cramer A, Hecla J, Wu D, et al. Stationary computed tomography for space
and other resource-constrained environments. Sci Rep 2018;8(1):14195.
5. Baldwin R. The Globotics Upheaval: Globalization, Robotics, and the Future
of Work. New York, NY: Oxford University Press, 2019.
6. Karasu Benyes Y, Welch EC, Singhal A, Ou J, Tripathi A. A comparative
analysis of deep learning models for automated cross-preparation diagnosis of
multi-cell liquid Pap smear images. Diagnostics (Basel) 2022;12(8):1838.
7. Hosny A, Parmar C, Quackenbush J, Schwartz LH, Aerts HJWL. Artificial
intelligence in radiology. Nat Rev Cancer 2018;18(8):500–510.
8. Pianykh OS, Langs G, Dewey M, et al. Continuous learning AI in radiology:
implementation principles and early applications. Radiology 2020;297(1):6–14.
9. Hricak H, Abdel-Wahab M, Atun R, et al. Medical imaging and nuclear medi-
cine: a Lancet Oncology Commission. Lancet Oncol 2021;22(4):e136–e172.
10. Oya M, Sugimoto S, Sasai K, Yokoyama K. Investigation of clinical target
volume segmentation for whole breast irradiation using three-dimensional
convolutional neural networks with gradient-weighted class activation mapping.
Radiol Phys Technol 2021;14(3):238–247.
11. Thrall JH, Li X, Li Q, et al. Artificial intelligence and machine learning in
radiology: opportunities, challenges, pitfalls, and criteria for success. J Am Coll
Radiol 2018;15(3 Pt B):504–508.
12. Dreyer KJ, Geis JR. When machines think: radiology’s next frontier. Radiology
2017;285(3):713–718.
13. Recht MP, Westerhoff M, Doshi AM, et al. Video radiology reports: a
valuable tool to improve patient-centered radiology. AJR Am J Roentgenol
2022;219(3):509–519.
14. Lacson R, Gujrathi I, Healey M, et al. Closing the loop on unscheduled diag-
nostic imaging orders: a systems-based approach. J Am Coll Radiol 2021;18(1
Pt A):60–67.
15. Weissleder R, Nahrendorf M. Advancing biomedical imaging. Proc Natl Acad
Sci U S A 2015;112(47):14424–14428.
16. Brattain LJ, Pierce TT, Gjesteby LA, et al. AI-enabled, ultrasound-guided
handheld robotic device for femoral vascular access. Biosensors (Basel)
2021;11(12):522.
17. Bodei L, Herrmann K, Schöder H, Scott AM, Lewis JS. Radiotheranostics in
oncology: current challenges and emerging opportunities. Nat Rev Clin Oncol
2022;19(8):534–550.
18. Hricak H. 2016 New Horizons Lecture: beyond imaging—radiology of
tomorrow. Radiology 2018;286(3):764–775.
■ Radiology: Volume 306: Number 1—January 2023