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The Prof. Arcot Gajaraj Oration Xth Annual Conference of the Indian Society of Pediatric Radiology

The Challenge of Pediatric Radiology in India

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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.

Text of The Challenge of Pediatric Radiology in India

  • 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