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.
- 1. The Prof. Arcot Gajaraj OrationXth Annual Conference of the
Indian Society of Pediatric Radiology
2. Because subspecialization is a basic necessity in radiology
and all subspecialty societies need to benurtured and encouraged 3.
The Challenge of PediatricRadiology in IndiaBhavin Jankharia 4.
Children Are Not Young Adults 5. 14 years old boy with left hip
pain 1 month later 6. Idiopathic Chondrolysis 7. The Current
Situation 8. 2009 Survey 9. 2009 SurveyIs it necessary to have
training in pediatricradiology? On a scale of 1-5 45% believed that
it was not important to havetraining (scores 1, 2) 23% were
equivocal (score 3) Only 32% believed that training was
important(scores 4, 5) 10. 2009 SurveyWhen asked whether
radiologists werecompetent or not when handling children 22%
believed yes 30% believed no 48% were equivocal Essentially only
30% believed thatradiologists were not competent 11. 2012 Survey
12. The Initial Debate Does Pediatric Radiology as a specialtymake
sense A senior doctor put me on the defensive,by asking me a
question, are you for oragainst 13. 2012 SurveyWhat is the role of
a pediatric radiologist in aprivate practice group and a hospital?
The vast majority said that a pediatricradiologist is an asset in a
hospital, butthere is very little role in private practice 14.
Challenges and Reasons Economic issues There may not be enough work
to justify apediatric radiologist Subspecialists may become
unemployable Private v/s hospital Pediatric radiology is not
sustainable in privatepractice and private hospitals The concept
exists only in large teaching hospitals 15. Challenge Perhaps the
biggest challenge is themindset among radiologists
thatsubspecialization makes youunemployable Hence a
neuroradiologist will read perianalMRIs and a chest radiologist may
still doobstetric ultrasound 16. The Bigger Issue 17. Why is
Subspecialization SoImportant 18. Subspecialization To answer the
why of radiology To answer the question asked by thedoctor 19.
Subspecialization Similary, a pediatric radiologist is requiredto
answer the specific questions posed bya pediatrician 20. The Bigger
Issue Radiologists in general are in danger oflosing relevance
because if we dont answer the questions that the referringdoctors
want answered who are more andmore managing their imaging
themselves 21. The Bigger Issue In fact, the only reason we are
stillrelevant is that we control access to the imaging. If that
access is re-distributed or given away, our role is suspect 22.
Unless 23. The Bigger Issuee become integral partsof disease
managementteams, whether inprivate practice or inhospitals 24. The
Indian Problem inSubspecialization 25. Too Few
RadiologistsCurrently, there is a shortage and sothere isnt really
an incentive tosubspecialize 26. Too Few OpportunitiesMost
hospitals and private practices do noencourage subspecialization
and onlywant generalists who can take care of the imaging workload
reasonably well with afast turn-around-time and few complaints 27.
Fear of Being Unemployable 28. Given these problems with
subspecializationper se, pediatric radiology comes much low down in
the list of priorities 29. And hence, currently in India, the vast
majority of pediatric imaging is done bygeneral radiologists or
adult subspecialists 30. The Pediatric Radiology Pyramid in India
31. The issue though is that if getting pediatricradiologists is an
issue, could perhaps part ofthe problem be solved by having adult
subspecialists refocusing as pediatric subspecialists 32. 2012
SurveyIs it necessary for a pediatric neuroradiologistto have done
pediatric radiology first orneuroradiology first or doesnt matter?
25 doesnt matter 10 - neuroradiology 20 pediatric radiology 35
therefore believe that you dont have tobe a pediatric radiologist
to be a pediatricneuroradiologist 33. Pediatric Subspecialty Issue
As long as the pediatric neuroradiologistknows how to handle
children, it shouldntmatter how he/she got there via
pediatricradiology or via neuroradiology 34. And just as we need
subspecialists in adultradiology we also need subspecialists within
the subspecialty of pediatric radiology 35. Belief I A good number
of radiologists still believethat it is not necessary to have
specializedpediatric radiology training for themselves,even though
they believe in general that pediatric radiologists play an
important role 36. Belief IIThe vast majority of radiologists
believe that pediatric radiology is not sustainablein private
practice (including privatehospitals), but works in tertiary
careteaching hospitals, when economics dont play an important role
and there issignificant patient flow 37. Current SituationFew, true
pediatric radiologists,working in tertiary care institutes 38.
Current Situation The rest who have an interest in
pediatricradiology, are part-timers. They may bepart-time
generalists or may be subspecialtyradiologists in neuroradiology,
etc. who handle both adult and pediatric cases 39. Current
SituationThe vast majority of radiologists, despitean abstract and
theoretical understandingthat children are different, continue
tohandle pediatric radiology cases, withoutany understanding of the
issues involvedand treat children as young adults 40. The Pediatric
Radiology Pyramid in India 41. The Pediatric Radiology Pyramid in
India 42. The Near FutureThings are not likely to change
EconomicsFear of subspecialization Lack of opportunity 43. The Near
FutureHowever, there is a glimmer of hope with new pediatric
hospitals beingsetup by private players 44. What to Do? 45. What Do
We Want? Children should be handled well andthat their conditions
should bediagnosed correctly, with as little harm as possible 46.
AimTo inculcate in all general radiologists a basic understanding
of pediatric radiology 47. AimReduced harm (radiation, anesthesia
etc.) 48. There is no evidence that low-levelradiation from medical
imaging causes harm1. 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 49. Radiation
RiskRetrospective Study180,000 patients underwent 280,000 CT scans
below 22 years of ageThe 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 exposurePearce M
et al. Lancet. Published online, June 7, 2012 50. It is known that
children are particularly more susceptible to radiation and there
is noquestion that the radiation dose used shouldbe as low as
possible. The risk however issmall and as long as the study is
justified, not really relevant. 51. Aim Reduced trauma (radiation,
anesthesia etc.)Understanding that children have different
pathologies A basic knowledge of these pathologies The confidence
to refer to their subspecialty colleagues for opinions when stuck
and theknowledge of when to refer what kind of cases 52. Way
ForwardEducation 53. Way ForwardTeaching, teaching, teaching 54.
Way ForwardDedicated CMEs, meetings,observerships, fellowships,
Facebook pages, online discussions, GoogleGroups, etc. 55.
RememberThose who love pediatric radiology willfind a way to do
this. This will be afraction of 1% of the radiologistspopulation
56. Remember For the rest, these leaders in pediatric radiology
must do the best they can toinculcate a basic understanding of
howchildren are different in general radiologists so that OOPs
issues dont happen 57. The Problem is Widespreadeven in the
Clinical Communities A 13-year old girl with soft tissue swelling
in the thigh Case Courtesy: Dinanath Mangeshikar Hospital, Pune 58.
STIR T1W STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune 59.
T1W STIR STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune 60.
Case Courtesy: Dinanath Mangeshikar Hospital, Pune 61. Case
Courtesy: Dinanath Mangeshikar Hospital, Pune 62. Summary &
SolutionsCurrently, pediatric radiology is not amajor subspecialty
in our country andmany radiologists dont believe in its relevance
63. Summary & SolutionsThis is related toThe lack of a culture
of subspecialization per seThe lack of clinical pediatric
infrastructure The lack of glamour and money 64. Summary &
SolutionsThe subspecialty of pediatric radiology will grow if, as
and whenThe leaders as in the ISPR become moreaggressive in
educating the radiology community The infrastructure improves 65.
Summary & Solutions Adult subspecialists such as
neuroradiologistsand MSK radiologists should be encouraged tomove
into their respective pediatric specialties 66. Thank You