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.

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  • dear bhavin,

    orthopaedic peadiatric radiology is by and large ignored branch esp basic xrays and trauma.the radiological config of fractures plays a huge role in mgt but r routinely reported as just fracture so and so. i think the majority of radiologist have more interest in ct and mri ,the cream in radiology. pure ped rad is financially not viable but is sometimes the need of the moment
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The Challenge of Pediatric Radiology in India

  1. 1. The Prof. Arcot Gajaraj OrationXth Annual Conference of the Indian Society of Pediatric Radiology
  2. 2. Because subspecialization is a basic necessity in radiology and all subspecialty societies need to be nurtured and encouraged
  3. 3. The Challenge of Pediatric Radiology in India Bhavin Jankharia
  4. 4. Children Are Not Young Adults
  5. 5. 14 years old boy with left hip pain 1 month later
  6. 6. Idiopathic Chondrolysis
  7. 7. The Current Situation
  8. 8. 2009 Survey
  9. 9. 2009 SurveyIs 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)
  10. 10. 2009 SurveyWhen 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
  11. 11. 2012 Survey
  12. 12. 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”
  13. 13. 2012 SurveyWhat 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
  14. 14. 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
  15. 15. 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
  16. 16. The Bigger Issue
  17. 17. Why is Subspecialization So Important
  18. 18. Subspecialization• To answer the “why” of radiology• To answer the question asked by the doctor
  19. 19. Subspecialization• Similary, a pediatric radiologist is required to answer the specific questions posed by a pediatrician
  20. 20. The Bigger Issue Radiologists in general are in danger of losing relevance because if we don’t answer the questions that the referringdoctors want answered who are more andmore managing their imaging themselves
  21. 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. 22. Unless
  23. 23. The Bigger Issue e become integral parts of disease management teams, whether in private practice or in hospitals
  24. 24. The Indian Problem in Subspecialization
  25. 25. Too Few RadiologistsCurrently, there is a shortage and so there isn’t really an incentive to subspecialize
  26. 26. Too Few OpportunitiesMost hospitals and private practices do no encourage subspecialization and onlywant generalists who can take care of the imaging workload reasonably well with afast turn-around-time and few complaints
  27. 27. Fear of Being “Unemployable”
  28. 28. Given these problems with subspecializationper se, pediatric radiology comes much low down in the list of priorities
  29. 29. And hence, currently in India, the vast majority of pediatric imaging is done bygeneral radiologists or adult subspecialists
  30. 30. The Pediatric Radiology Pyramid in India
  31. 31. The issue though is that if getting pediatricradiologists is an issue, could perhaps part of the problem be solved by having adult subspecialists refocusing as pediatric subspecialists
  32. 32. 2012 SurveyIs 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
  33. 33. Pediatric Subspecialty Issue As long as the pediatric neuroradiologistknows how to handle children, it shouldn’tmatter how he/she got there – via pediatric radiology or via neuroradiology
  34. 34. And just as we need subspecialists in adultradiology we also need subspecialists within the subspecialty of pediatric radiology
  35. 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. 36. Belief II The vast majority of radiologists believe that pediatric radiology is not sustainable in private practice (including private hospitals), but works in tertiary careteaching hospitals, when economics don’t play an important role and there is significant patient flow
  37. 37. Current SituationFew, true pediatric radiologists,working in tertiary care institutes
  38. 38. Current Situation The rest who have an interest in pediatric radiology, are part-timers. They may bepart-time generalists or may be subspecialty radiologists in neuroradiology, etc. who handle both adult and pediatric cases
  39. 39. Current SituationThe vast majority of radiologists, despitean abstract and theoretical understanding that children are different, continue tohandle pediatric radiology cases, withoutany understanding of the issues involved and treat children as young adults
  40. 40. The Pediatric Radiology Pyramid in India
  41. 41. The Pediatric Radiology Pyramid in India
  42. 42. The Near FutureThings are not likely to change Economics Fear of subspecialization Lack of opportunity
  43. 43. The Near FutureHowever, there is a glimmer of hope with new pediatric hospitals being setup by private players
  44. 44. What to Do?
  45. 45. What Do We Want? Children should be handled well and that their conditions should bediagnosed correctly, with as little harm as possible
  46. 46. AimTo inculcate in all general radiologists a basic understanding of pediatric radiology
  47. 47. AimReduced harm (radiation, anesthesia etc.)
  48. 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. 49. Radiation RiskRetrospective 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
  50. 50. It is known that children are particularly more susceptible to radiation and there is noquestion that the radiation dose used should be as low as possible. The risk however issmall and as long as the study is justified, not really relevant.
  51. 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. 52. Way Forward Education
  53. 53. Way ForwardTeaching, teaching, teaching
  54. 54. Way Forward Dedicated CMEs, meetings,observerships, fellowships, Facebook pages, online discussions, Google Groups, etc.
  55. 55. RememberThose who love pediatric radiology will find a way to do this. This will be a fraction of 1% of the radiologists population
  56. 56. Remember For the rest, these leaders in pediatric radiology must do the best they can to inculcate a basic understanding of howchildren are different in general radiologists so that OOPs issues don’t happen
  57. 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. 58. STIR T1W STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune
  59. 59. T1W STIR STIRCase Courtesy: Dinanath Mangeshikar Hospital, Pune
  60. 60. Case Courtesy: Dinanath Mangeshikar Hospital, Pune
  61. 61. Case Courtesy: Dinanath Mangeshikar Hospital, Pune
  62. 62. Summary & SolutionsCurrently, pediatric radiology is not amajor subspecialty in our country andmany radiologists don’t believe in its relevance
  63. 63. Summary & Solutions This is related toThe lack of a culture of subspecialization per se The lack of clinical pediatric infrastructure The lack of “glamour” and money
  64. 64. Summary & SolutionsThe subspecialty of pediatric radiology will grow if, as and when The leaders as in the ISPR become moreaggressive in educating the radiology community The infrastructure improves
  65. 65. Summary & Solutions Adult subspecialists such as neuroradiologistsand MSK radiologists should be encouraged tomove into their respective pediatric specialties
  66. 66. Thank You

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