Issue Three

Dr. Logan-Young, like the field of radiology itself, turns things inside out. A lover of light and the outdoors (she is an expert fly fisherman), she is hermetically sealed off from the broad spectrum of light as she descends into the murky depths of x-ray imagery to peer inside the tissue of her patients. The doctors’ workspace at her clinic is bright but devoid of windows. Looking all day for the potential fatal reality that lurks just beneath the surface, the radiologists’ only tool is just the opposite of bald observation. They deal in images, refractions, manipulated and bent particles of x-rays.

The practice of radiology presents a question that is at the core of the philosophy of medicine: Is the practice of medicine a science or an art? The either/or structure of the question sets up a false dichotomy, for every doctor in seeking healing must use both reason and imagination. Dr. Logan-Young considers herself and is considered by the world to be first and foremost a scientist. Logic, statistics, experimentation and technique guide her. As a researcher and a physician, she seeks predictability. Her dragon to slay is the chaos of this devastating disease that is the leading cause of death due to cancer among U.S. women aged 35-54. In New York State alone, 11,000 cases of breast cancer are detected and 3,700 of its residents die from breast cancer each year. With early detection, though, 95 percent of patients survive.

Still, there is something about Dr. Logan-Young that is artistic, creative, and intuitive. She works in a back-lit world of beautiful, haunting pictures. When I first asked her if mammography was a science or an art, she unequivocally pounced on the question: “It’s basically a science. There are some people who say that they are intuitive readers but they are not. It’s a science. It’s all pattern recognition and technique . . .” When asked, though, if there is a uniformity to breast imaging clinics, she says, just as emphatically: “Oh no. There’s an incredible variation in the ability of radiologists to interpret mammograms. It’s incredible, you just need to do it all day long to be good at it. There is a ‘feel’ aspect to it, like tennis or golf.”

 The philosopher Arthur I. Miller has pointed out that x-rays have excited our collective imagination ever since the German physicist, Wilhelm Roentgen, discovered them in 1895. Picasso’s investigations into the rearrangement of space and time were deeply influenced by the new world that Roentgen had discovered. As Roentgen said: “I have found rays that permit one to see the invisible, to see things inaccessible to the eyes.” At the turn of the century, the public considered the x-ray to be miraculous. After decades of arid, positivist empiricism in which scientists and philosophers held that we could only know what we could touch, see, hear, taste, or smell, Roentgen proved that there was a reality beyond appearances. Entire worlds of matter and energy, in fact, existed just beneath the surface of our lives and our bodies. As Miller has astutely observed, the very name “x-ray” is so generic and undescriptive that it implies that scientists never were quite sure what it was that they had discovered. The name reinforces the sense of mystery that attends the notion that we can look right through someone.

Dr. Logan-Young is not a mystic, though. She is a tough-minded and practical person who each day works in and wrestles with this radiological netherworld of cloudy, ghostly images. Her historic contribution to mammography and to the fight against breast cancer consists in applying common sense to the inefficient methodologies of breast cancer detection, recognizing and tempering the power of mammography. In the course of her research, Dr. Logan-Young amassed data to support the validity of techniques using reduced doses of radiation needed for clinically acceptable mammograms, thereby reinforcing the technique as a safe and accurate detection methodology. She also introduced the concept of direct patient-doctor communication, derived from internal medicine, enabling the radiologist to interact directly with the patient, reducing the time it took to communicate diagnostic results, and easing, to a certain extent, the patient’s anxiety as they awaited the results.

“My first entry,” Dr. Logan-Young begins to explain, “was as a member of the faculty of the University of Rochester. At that time [around 1970], maybe one percent of the women were getting screening mammograms and for five years I read the mammograms at the University of Rochester and the percentage went from maybe one to two percent. When Betty Ford and Happy Rockefeller both contracted breast cancer, the disease began to get national attention, as did the role of mammography in detecting breast cancer. By 1975, the number of women receiving mammograms had increased to five percent.”

Just as the use of mammography began to increase, some influential researchers began to advocate against its use. “At that point, John Bailor, at the National Cancer Institute, said that mammograms were causing cancer, the x-rays from the mammograms were causing cancer,” Dr. Logan-Young continues, “and Jane Brody from the New York Times and a number of very influential people began writing one article after another about the negative aspects of mammography. So I opened my office a half a year after that crisis started, after John Bailor published [his article]. It got worse and worse and worse. Two years later the number of people getting mammogram screening dropped almost to the level of 1970.”

Subsequently, recalls Dr. Logan-Young, some researchers began to experiment with reduced radiation levels. “Dupont, then Kodak, had developed mammography films with dose reduction to1/20th of the previous dose of x-rays. In fact I had two meetings at Roswell Park Cancer Institute, two international meetings where we had physicists and radiologists talk together about how to get the dose down and we edited two books out of that: Reduced Dose Mammography and Breast Cancer: The Radiologists’ Expanded Role.” As these books found their audience, around 1980, and established beyond doubt that x-ray dosage levels were not dangerous, public acceptance of mammography as a safe and effective breast cancer diagnostic technique increased, resulting in a dramatic rise in lifesaving early detections of the disease.

Dr. Logan-Young’s approach to breast cancer detection was formed by her early years as an internist. Her first stint out of the University of Buffalo Medical School internal medicine residency (where she was only one of three women), was as a physician in the United States Army. She realized then that she did not want to be an internist. “You have to be more like a missionary to do internal medicine. The main reason I left internal medicine was because I had four children by that time and internal medicine is too much like raising children. You are constantly buffering and moderating, and I wanted something more intellectual. So I did a residency in radiology at the University of Rochester.”

 Yet it was precisely this background in internal medicine that gave Dr. Logan-Young her basic insight into the field of mammography. “Well, first of all I had training in internal medicine so I knew what it was like to try to find a cancer by doing a breast examination. I knew it was an abysmal way to do it. And then I had the experience of being a radiologist. I could see the diagnosis of breast cancer from the perspective of the guy who’s in there in his office examining the patient and the perspective of doing it on the mammogram. The mammogram misses a lot of cancers that you can feel, and you can palpate a lot of cancers that the mammogram can’t find, but the mammogram actually finds more cancers, so it’s a complementary method. I felt that the radiologist was the best person to make the diagnosis because we had the mammograms and we could correlate the clinical examination with the mammogram and do special views to evaluate areas and nobody was doing that before, and I just felt that we would be in a better position to do that. Then ultrasound came along in 1975 and that revolutionized the evaluation of the breast because you could see a cyst; you could see a pocket of fluid that the mammogram couldn’t show.”

When Dr. Logan-Young’s suggestions to her clinical department head and members of the radiological community to deliver mammography, a clinical examination and ultrasound as a diagnostic package were received with skepticism, she decided to leave the University and form her own clinic.

Dr. Logan-Young became the first mammographer to give the results directly to the patient. “It was heresy,” she explains, resorting, as she sometimes does in conversation, to medieval, theological metaphors, “for the radiologist to come out and give the patients the results. The thinking behind it was that if the radiologist knew the patient as well as the referring physician, sure it was ok, but not if it was just a one time meeting and you’ve never seen the patient before; you don’t know what kind of person she is. My thinking was, I don’t care what kind of person she is. Why should she have to wait when she clearly wants to know the results of the exam?”

Instead of waiting days and sometimes weeks, the patient got the reading within minutes of the examination. With this simple turn, the Wende Logan-Young niche was established. “It was an innovation back then, but for me it was one plus one equals two. But, you see, I had this background in clinical medicine where I had been an internist for five years before I went into radiology. I could see it from the perspective of a referring physician and my feeling was that if we gave the results to the patient, the referring physician would be doubly blessed. First, the patient is happy, and second, it saves the physician the time of having to contact the patient and give them the results. The patient does not have to go through a third intermediary. Thirdly, the referring physicians do not really appreciate that we are much more intimately aware of the total extent of her disease. The referring physician can read the report but he or she cannot truly know the extent of the disease or whether or not the patient is eligible for a mastectomy or a lumpectomy. By giving the patient the results ourselves we felt that not only can we give her the results but we can help her out in deciding what to do if she has cancer. We can help the patients out in terms of counseling them about what is the best treatment. This thinking also was heresy back in 1975 but is more accepted now.”

The problem with this technique is that while one patient is receiving her results from the radiologist, all of the others are waiting their turn. In addition, each mammogram is read by two doctors to insure accuracy. Given these two factors, both of which add to the quality of care, patients can wait in the clinic at times for several hours. Still, women from all over the world flock to the clinic for their yearly mammograms. Dr. Logan-Young acknowledges the problem, but does not waver from the procedure or its underlying service philosophy supportive of the patient’s desire to obtain immediate access to information, evaluation and appropriate medical decision making, delivered in an environment where compassionate and common sense treatment are recognized as critical. “We have two doctors read every mammo. Because we do on-line work up of the patients, which the other clinics do not do, if the patient comes in the door and we see something on the screening mammo, . . . we evaluate that abnormality and if there is something there, we give them the results that day, or we do a biopsy the next day.” The busiest days can run long.

Dr. Logan-Young is often cited by younger women physicians as a feminist role model not only in science but also as a successful entrepreneur who has often stood up to a variety of male-dominated medical organizations and insurance companies. In the face of some competitors’ complaints that her clinic performed too many tests solely in the interest of generating revenue, she responded by publishing an article in the noted journal Cancer marshaling data which established that these tests actually saved health maintenance organizations significant financial resources by helping to avoid unnecessary surgeries. She knows that the best advertisement is a satisfied patient; she relies on this insight, for the most part, to rebut any criticisms.

Still, Dr. Logan-Young rejects the feminist mantle, explaining that her ability to establish a clinic was predicated precisely on the structure of the standard, patriarchal family. Since her husband assumed primary responsibility to earn money and support the family, she could afford to follow her vision, assume financial risks and lose money for a period of time. Dr. Logan-Young vehemently maintains that if she had been a man, she would never have had the flexibility to change careers as she did at the age of 40, when she walked away from her academic job to set up the clinic. She simply was not expected to function as a breadwinner for this period of time.

As she anticipates retirement, Dr. Logan-Young sees that the greatest challenge in the field of breast cancer is the training of new radiologists. Even with the advent of digital technologies and the promise of a blood test as a new detection device, patients will still need these scientist-interpreters to find the cancers. The number of fellowships in mammography has dropped from 95 to 55 over the past four years, due to the high costs of mammographic medical education. That fact, combined with the tough prevailing medical economic climate (in 1990 Medicare reimbursed the clinic $90 for a mammogram compared to $67 in 2000), has resulted in a drastic reduction in the number of board certified mammographers in the United States. The crisis in breast cancer detection, according to Dr. Logan-Young, is a human one, for it takes an exquisitely trained and talented eye to catch the gossamer killers that haunt the mammogram.

In the next few years, as soon as the resolution on the monitors is improved and Internet memories are expanded, technicians will probably be able to send mammograms over telephone lines anywhere in the world. A radiologist sitting in her cozy home in Western New York will be able to read the breast images of a woman in New Orleans. Some dream that this “teleradiology” technology will mitigate the need to train more mammographers. An investor in the new technology once told me that he envisioned a few superstar radiologists reading all of the mammograms in the country from their homes. Notwithstanding this vision of the future, Dr. Logan-Young will argue that mammographers will need more than a good eye. They will need to have “the touch” - a facility which develops out of a combination of talent and daily training. Who among medical practitioners will have the touch in the future and where will they come from? For once, Dr. Logan-Young is stymied. She does not have an answer to the dilemma of how to train more mammographers, which is why she keeps working to attract new medical talent to her clinic. This concern, though, has not diminished her zest for figuratively rollerblading through a daily routine of seeing patients, lecturing, traveling, fishing with her husband and visiting her children and grandchildren. She says, “We are here on this earth for one reason: to have fun. I keep telling everybody that. I told my kids the other day that the only thing you need is a good sense of humor.”