The Challenge of Pediatric Radiology in India

The Prof. Arcot Gajaraj Oration

Xth Annual Conference of the Indian Society of Pediatric

Radiology

Because subspecialization is a basic necessity in radiology and all

subspecialty societies need to be nurtured and encouraged

The Challenge of Pediatric Radiology in India

Bhavin Jankharia

Children Are Not Young Adults

14 years old boy with left hip pain 1 month later

Idiopathic Chondrolysis

The Current Situation

2009 Survey

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)

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

2012 Survey

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”

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

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

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

The Bigger Issue

Why is Subspecialization So Important

Subspecialization

• To answer the “why” of radiology• To answer the question asked by the

doctor

Subspecialization

• Similary, a pediatric radiologist is required to answer the specific questions posed by a pediatrician

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

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

Unless

The Bigger Issue

We become integral parts of disease management teams, whether in private practice or in hospitals

The Indian Problem in Subspecialization

Too Few Radiologists

Currently, there is a shortage and so there isn’t really an incentive to

subspecialize

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

Fear of Being “Unemployable”

Given these problems with subspecialization per se, pediatric radiology comes much low

down in the list of priorities

And hence, currently in India, the vast majority of pediatric imaging is done by

general radiologists or adult subspecialists

The Pediatric Radiology Pyramid in India

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

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

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

And just as we need subspecialists in adult radiology we also need subspecialists within

the subspecialty of pediatric radiology

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

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

Current Situation

Few, true pediatric radiologists, working in tertiary care institutes

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

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

The Pediatric Radiology Pyramid in India

The Pediatric Radiology Pyramid in India

The Near Future

Things are not likely to changeEconomics

Fear of subspecializationLack of opportunity

The Near Future

However, there is a glimmer of hope with new pediatric hospitals being

setup by private players

What to Do?

What Do We Want?

Children should be handled well and that their conditions should be

diagnosed correctly, with as little harm as possible

Aim

To inculcate in all general radiologists a basic understanding of pediatric

radiology

Aim

Reduced harm (radiation, anesthesia etc.)

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

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

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.

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

Way Forward

Education

Way Forward

Teaching, teaching, teaching

Way Forward

Dedicated CMEs, meetings, observerships, fellowships, Facebook

pages, online discussions, Google Groups, etc.

Remember

Those who love pediatric radiology will find a way to do this. This will be a fraction of 1% of the radiologists

population

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

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

T1W STIR STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune

STIR

STIR

T1W

Case Courtesy: Dinanath Mangeshikar Hospital, Pune

Case Courtesy: Dinanath Mangeshikar Hospital, Pune

Case Courtesy: Dinanath Mangeshikar Hospital, Pune

Summary & Solutions

Currently, pediatric radiology is not a major subspecialty in our country and many radiologists don’t believe in its

relevance

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

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

Summary & Solutions

Adult subspecialists such as neuroradiologists and MSK radiologists should be encouraged to move into their respective pediatric specialties

Thank You