the challenge of pediatric radiology in india
DESCRIPTION
My thoughts on the challenges in pediatric radiology in India today. I have discussed the current status and the future prospects and offered possible solutions as well. This was the Dr. Arcot Gajaraj oration that I delivered at the X Annual Conference of the Indian Society of Pediatric Radiology (ISPR) in Chandigarh on 29th September, 2012.TRANSCRIPT
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The Prof. Arcot Gajaraj Oration
Xth Annual Conference of the Indian Society of Pediatric
Radiology
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Because subspecialization is a basic necessity in radiology and all
subspecialty societies need to be nurtured and encouraged
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The Challenge of Pediatric Radiology in India
Bhavin Jankharia
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Children Are Not Young Adults
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14 years old boy with left hip pain 1 month later
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Idiopathic Chondrolysis
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The Current Situation
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2009 Survey
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2009 Survey
Is it necessary to have training in pediatric radiology?
•On a scale of 1-5•45% believed that it was not important to have
training (scores 1, 2)•23% were equivocal (score 3)•Only 32% believed that training was important
(scores 4, 5)
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2009 Survey
When asked whether radiologists were competent or not when handling children
•22% believed yes•30% believed no•48% were equivocal•Essentially only 30% believed that
radiologists were not competent
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2012 Survey
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The Initial Debate
• Does Pediatric Radiology as a specialty make sense
• A senior doctor put me on the defensive, by asking me a question, “are you for or against”
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2012 Survey
What is the role of a pediatric radiologist in a private practice group and a hospital?•The vast majority said that a pediatric radiologist is an asset in a hospital, but there is very little role in private practice
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Challenges and Reasons
• Economic issues– There may not be enough work to justify a
pediatric radiologist– Subspecialists may become “unemployable”
• Private v/s hospital– Pediatric radiology is not sustainable in private
practice and private hospitals– The concept exists only in large teaching hospitals
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Challenge
• Perhaps the biggest challenge is the mindset among radiologists that subspecialization makes you “unemployable”
• Hence a “neuroradiologist” will read perianal MRIs and a “chest radiologist” may still do obstetric ultrasound
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The Bigger Issue
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Why is Subspecialization So Important
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Subspecialization
• To answer the “why” of radiology• To answer the question asked by the
doctor
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Subspecialization
• Similary, a pediatric radiologist is required to answer the specific questions posed by a pediatrician
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The Bigger Issue
Radiologists in general are in danger of losing relevance because if we don’t
answer the questions that the referring doctors want answered who are more and more managing their imaging themselves
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The Bigger Issue
In fact, the only reason we are still relevant is that we control access to the imaging. If that access is re-distributed
or given away, our role is suspect
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Unless
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The Bigger Issue
We become integral parts of disease management teams, whether in private practice or in hospitals
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The Indian Problem in Subspecialization
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Too Few Radiologists
Currently, there is a shortage and so there isn’t really an incentive to
subspecialize
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Too Few Opportunities
Most hospitals and private practices do no encourage subspecialization and only
want generalists who can take care of the imaging workload reasonably well with a fast turn-around-time and few complaints
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Fear of Being “Unemployable”
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Given these problems with subspecialization per se, pediatric radiology comes much low
down in the list of priorities
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And hence, currently in India, the vast majority of pediatric imaging is done by
general radiologists or adult subspecialists
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The Pediatric Radiology Pyramid in India
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The issue though is that if getting pediatric radiologists is an issue, could perhaps part of
the problem be solved by having adult subspecialists refocusing as pediatric
subspecialists
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2012 Survey
Is it necessary for a pediatric neuroradiologist to have done pediatric radiology first or neuroradiology first or doesn’t matter?
•25 – doesn’t matter•10 - neuroradiology •20 – pediatric radiology•35 therefore believe that you don’t have to
be a pediatric radiologist to be a pediatric neuroradiologist
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Pediatric Subspecialty Issue
As long as the pediatric neuroradiologist knows how to handle children, it shouldn’t
matter how he/she got there – via pediatric radiology or via neuroradiology
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And just as we need subspecialists in adult radiology we also need subspecialists within
the subspecialty of pediatric radiology
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Belief I
A good number of radiologists still believe that it is not necessary to have specialized pediatric radiology training for themselves, even though they believe in general that pediatric radiologists play an important
role
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Belief II
The vast majority of radiologists believe that pediatric radiology is not sustainable
in private practice (including private hospitals), but works in tertiary care
teaching hospitals, when economics don’t play an important role and there is
significant patient flow
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Current Situation
Few, true pediatric radiologists, working in tertiary care institutes
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Current Situation
The rest who have an interest in pediatric radiology, are part-timers. They may be part-
time generalists or may be subspecialty radiologists in neuroradiology, etc. who handle both adult and pediatric cases
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Current Situation
The vast majority of radiologists, despite an abstract and theoretical understanding
that children are different, continue to handle pediatric radiology cases, without any understanding of the issues involved
and treat children as young adults
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The Pediatric Radiology Pyramid in India
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The Pediatric Radiology Pyramid in India
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The Near Future
Things are not likely to changeEconomics
Fear of subspecializationLack of opportunity
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The Near Future
However, there is a glimmer of hope with new pediatric hospitals being
setup by private players
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What to Do?
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What Do We Want?
Children should be handled well and that their conditions should be
diagnosed correctly, with as little harm as possible
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Aim
To inculcate in all general radiologists a basic understanding of pediatric
radiology
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Aim
Reduced harm (radiation, anesthesia etc.)
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There is no evidence that low-level radiation from medical imaging causes
harm
1. Amis Stephen. Radiology 2011: 261: 52. Position Statement of the Health Physics Society3. American Association of Physicists in Medicine – position statement. Dec 20114. Hendee William R. Radiology 2012: 264: 312
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Radiation Risk
Retrospective Study•180,000 patients underwent 280,000 CT scans below 22 years of age•The estimate is that one head CT scan performed in the first decade of life would produce one excess case of brain tumor and one excess case of leukemia per 10,000 patients who underwent CT scan, in the first decade after exposure
Pearce M et al. Lancet. Published online, June 7, 2012
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It is known that children are particularly more susceptible to radiation and there is no
question that the radiation dose used should be as low as possible. The risk however is
small and as long as the study is justified, not really relevant.
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Aim
Reduced trauma (radiation, anesthesia etc.)Understanding that children have different
pathologiesA basic knowledge of these pathologies
The confidence to refer to their subspecialty colleagues for opinions when stuck and the
knowledge of when to refer what kind of cases
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Way Forward
Education
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Way Forward
Teaching, teaching, teaching
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Way Forward
Dedicated CMEs, meetings, observerships, fellowships, Facebook
pages, online discussions, Google Groups, etc.
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Remember
Those who love pediatric radiology will find a way to do this. This will be a fraction of 1% of the radiologists
population
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Remember
For the rest, these leaders in pediatric radiology must do the best they can to inculcate a basic understanding of how
children are different in general radiologists so that OOPs issues don’t happen
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The Problem is Widespread even in the Clinical Communities
A 13-year old girl with soft tissue swelling in the thigh
Case Courtesy: Dinanath Mangeshikar Hospital, Pune
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T1W STIR STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune
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STIR
STIR
T1W
Case Courtesy: Dinanath Mangeshikar Hospital, Pune
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Case Courtesy: Dinanath Mangeshikar Hospital, Pune
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Case Courtesy: Dinanath Mangeshikar Hospital, Pune
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Summary & Solutions
Currently, pediatric radiology is not a major subspecialty in our country and many radiologists don’t believe in its
relevance
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Summary & Solutions
This is related toThe lack of a culture of subspecialization per se
The lack of clinical pediatric infrastructureThe lack of “glamour” and money
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Summary & Solutions
The subspecialty of pediatric radiology will grow if, as and when
The leaders as in the ISPR become more aggressive in educating the radiology community
The infrastructure improves
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Summary & Solutions
Adult subspecialists such as neuroradiologists and MSK radiologists should be encouraged to move into their respective pediatric specialties
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Thank You