This essay is another in a series of challenges to Radiology as a specialty, specifically as a challenge to the prospective employment characteristics of American radiologists. I think that because of a conjunction of compelling if seemingly disparate events, the moment is now so unique with engaging prospects but also with foreboding, that I need to comment about it in a summative way. But I will assume the role of Cassandra in this forum (for the last time, at least for awhile) before once again paying attention to more pleasant radiology-related matters.

But, as I said, I must acquaint you with some inferences about the near future, as if you did not know about some of these trends already. A long record of success in any venture (or should I say adventure) can inure us from inherent risks that exist for sure but are submerged below our consciousness. A protracted skein of good results is the pre-requisite for overconfidence and under preparedness for when things turn negative. Unlike all other specialists who are engaged in the care of individual patients (with the exception of Pathologists) we do not have face time with them, save for interventional procedures and breast imaging. By and large, the subjects we provide expertise for are not patients that we “own” in a caregiving sense. Instead, our connection with them is mediated by the technology we employ, not the trust and camaraderie we engender. In essence, our currency is embedded in the machines over which we have gained dominion. Thus, as the record of the past 40 years has shown, the more and the better image creating devices under our purview, the better we do. Moreover by dint of our specialized training and also by the long history of effective politics pursued by the organizations that represents us, we have become for many conditions the arbiter of diagnosis and, in an increasing array of illnesses, the conveyor of therapy. We have been riding the growth curve for a long time. Mostly it has been a smooth ride. But all growth lines reach a terminus eventually and we are almost there now. It is folly to assume that the journey would be never ending. Here are some golden rules we should acknowledge and obey as we come to the end of the ascendency pathway and seek to make our way under an array of restraints.