A famous quote goes something like this “I am condemned to live in interesting times”. Well, that condemnation applies to all of us because the times certainly are interesting as they are characterized by uncertainty, perhaps even foreboding, too. I am sure when you read these words the uncertainty in the economy will still be persisting. I need not go into detail about that. Uncertainty in the political arena will also continue to bedevil us or excite us but it will definitely challenge us. We as a nation must confront compelling domestic issues and try to reestablish or redefine our place in the world. Our once secure position as the global hegemon has now been buffeted by events and by increasingly hostile attitudes towards us from Europe, Asia, Africa, and Latin America. We also must contend with uncertainty in the United States in the social arena. Our population is changing in its ethnic makeup. Immigration has continued to increase, both for people of limited education attainments and for professionals. Moreover, these trends have been accompanied by modification in our collective assumptions of value, in our consumption patterns and in our regard for the importance of preserving the environment. At the same time we are now undergoing profound reassessment in our most highly valued institutions, specifically, the profession of medicine, and precisely the specialty of Radiology.

The beginning of the twenty-first century stands out along with the end of the 19th, with respect to medicine. One was and the other will be disorienting eras. They can be considered together as bookends of disorder which temporally flank the relative stability of the twentieth century. Remember, the Flexner report was written before World War I. It did a lot to dispel the anarchy and lack of professionalism that had pervaded medical education back then. The public demanded more accountability and expertise from physicians, which led to the imposition of more vigorous standards in licensure, and further regulations in the 1920s, 1930s and 1940s, including the introduction of the specialty board certification. This was followed in the latter half of the century by the codification of requirements for medical education, then for graduate medical education and finally for continuing medical education. These rules, as well as board certification requirements, are now in flux. In fact, the regulations which have molded the reach and the obligations of medicine through the creation of a reliable superstructure of organizations were implemented and monitored according to the prerequisites of a guild. From their origin in medieval times, guilds have acted to maintain the aims and the processes of their carefully chosen constituents. A standard dictionary definition for a guild is an association of merchants or artisans, organized to maintain standards and to protect the interests of its members, to enable them to be recognized as a local, or today, a national governing body.

Yes, we, in medicine, are in fact a guild, with sub guilds superintending the various specialties. We function through such organizations to foster the members’ privileges and responsibilities. By so doing, sometimes we incur increased costs for the general population. Yet at the same time guilds profess standards to be pursued and met so that the public’s trust then can be repaid by good works under the rules imposed by the guild and by accepted notions of integrity which we deem to be the proper attitude of guild members.

Nonetheless, anarchy and uncertainty are seeping into the heart of our master guild, the American house of medicine in general, as well as infiltrating the parenchyma of its other viscera including the specialty of Radiology. Such physiologic dysfunctions threaten to disrupt the parameters and paradigms of guild structure operationally, tactically and even strategically. They are attacking the equanimity of the status quo from below, as a result of the aggressiveness of seemingly lesser occupations, from alongside us in turf wars among specialties and now, with the advent of telemedicine and medical tourism, from afar as well.