It is a fact that the health of a country is measured by the health of its children, as healthy children grow into healthy adults. Children under 14 constitute a significant one third of our population. Prevention and care of paediatric diseases therefore constitutes the cornerstone of our nation’s healthcare system.
Radiology, the science of medical imaging, has come a long way since the days of Roentgen. It is now realised that it is virtually impossible for a general radiologist to adequately address all clinical issues that may come to his or her attention. The tremendous advances in medical science have of necessity given rise to medical sub-specialisation. From the perspective of medical imaging, this has given rise to a number of radiologic sub-specialities, an important one of which is paediatric radiology.
A relevant aphorism states that ‘children are not merely small adults’. Paediatric diseases form a unique spectrum of pathology and require specialised understanding, including from the imaging perspective. The advances in paediatric imaging parallel the growth of the paediatric sub-specialities, such as paediatric surgery, cardiology, neurology, pulmonology, etc. A distinct set of clinical entities, congenital lesions – such as atresias (failures of certain anatomic structures to develop), genetic syndromes and dysplasias, etc, require specific and distinct management decisions and challenges, and in turn a completely different approach to imaging analysis than in the adult. Neonatal diseases in particular tend to be at the most challenging end of this spectrum. Issues such as paediatric trauma also require a different approach than trauma in the adult. Child abuse or non-accidental trauma is another issue of medico legal and public health significance which the specialised eye of a paediatric imager may be needed to detect, in order that steps may be taken to prevent further repetition of such trauma to the child by a caregiver.
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| Dr Arjun Kalyanpur |
Compounding the issues are the soft skill challenges related to obtaining history and conducting an examination or procedure on a young child, that require specialised training, expertise and sensitivity on the part of the imager.
Of particular importance, radiation dose and safety are issues that while not unique to the paediatric population, nonetheless have their greatest impact on children. This is because their cells and tissues are actively growing and developing and are therefore most sensitive to cumulative radiation damage resulting in potential mutation and carcinogenesis. Pediatric imaging therefore requires a much greater sensitivity on the part of the radiologist to the issue of radiation dose and safety. Programmes such as ‘Image Gently’ are initiatives of the Alliance for Radiation Safety in Pediatric Imaging whose mission is to minimise the diagnostic radiation dose to children to a level that is as low as reasonably achievable (ALARA). The Alliance is a coalition of healthcare organisations driven by, among others, the Society for Pediatric Radiology. Development of mindfulness of the importance of minimising radiation in the imaging of the child is an important part of paediatric radiology training and practice.
How is a paediatric radiologist made? The process begins with lectures and rotations during the postgraduate training of a radiologist. Recognising that paediatric imaging needs to be given a separate focus and training, the US has traditionally had dedicated paediatric radiology rotations as an integral part of their radiology residency training. When I did my residency and appeared for the American Board of Radiology examination in the late 90s, I spent several months rotating through the Children’s Hospital at Yale New Haven. Further, paediatric imaging was one of the ten sections that it was mandatory to pass in order to clear the boards, highlighting the importance of this sub-speciality. This is still the case. Further, the American Board of Radiology (ABR) website currently states that other sections/ modules such as musculoskeletal, cardiovascular etc. will also include items relevant to paediatric radiology, further highlighting its importance. Additionally paediatric radiology fellowships of 1-2 year duration that follow residency training have been well established for many years in the US, Canada and the UK, including sub-speciality board examinations and certifications. Given the number of specialised children’s hospitals that exist in that part of the world this seems a logical accompaniment.
In the past in India, paediatric radiology has traditionally been a self-taught speciality that has grown to support the departments of paediatrics and paediatric surgery. However, as the paediatric sub-specialities in India have evolved and modalities including sonography, CT and MRI have proliferated, further sub-speciality training in paediatric radiology in India has become necessary for those wishing to master the field. In India, such fellowship training programmes have only recently been instituted with fellowship training currently available at certain premier institutes such as the PGIMER Chandigarh and CMC Vellore. More such programmes are needed. At this time the relatively small number of sub-speciality fellowship trained paediatric radiologists in India have in several cases received their fellowship training overseas.
Why does India not train more paediatric radiologists? There is an acute radiologist shortage in India and from an employment perspective there are sufficient opportunities and more for general radiologists in the community. There is therefore no great incentive (and there is perhaps actually a disincentive) for a radiologist to go through an additional year or years of sub-speciality training in paediatric radiology, unless out of a genuine love and academic interest in the field, which is what characterises most sub-specialists. In fact there may actually be concern that sub-specialisation will lead to a reduced value in the job market, as stated in an editorial in the Indian Journal of Radiology and Imaging in 2010. Employment opportunities specifically for paediatric radiologists are also few, and paediatric radiologists, except at tertiary centres will tend to be drawn into spending some of their workday performing adult imaging. As a result the attraction for focussed training in paediatric radiology is currently lacking.
With reference to the quality of current training, Sidhu et al in an article on paediatric radiology state that in a survey conducted by them at a paediatric radiology education programme, of 86 respondents, 82 per cent indicated that their academic institutions did not place emphasis on dedicated paediatric radiology training, and 63 per cent indicated they received less than two weeks of dedicated training. Of the respondents, 77 per cent said their institutions practised paediatric radiology with inadequate standard of care. The authors conclude that education and training in paediatric radiology in India is currently inadequate.
There are however beacons of hope. Saxena et al in their article in the Journal of the International Medical Sciences Academy state that there are over 300 members of the Indian Society for Pediatric Radiology (ISPR), indicating a growing interest in the field among radiologists. The Society conducts conferences and midterm continuing medical education activities in paediatric imaging for postgraduates and practising radiologists. There is now even a Society for Pediatric Interventional Radiology. Such societies further and protect the cause of the speciality and create opportunities for training in this niche domain.
It is evident that the need of the hour for paediatric radiology in India is training, whether it be training of dedicated paediatric radiology sub-specialists or of general radiologists to increase their understanding and awareness of paediatric imaging issues. However, as in medical education in general, the challenges tend to be a) a shortage of educators b) constraints in physical access to training c) time constraints. In such a setting, technology innovations can be transformational. E-learning is a powerful means to spread learning in the field of paediatric imaging. In another paediatric sub-speciality, paediatric cardiology, an innovative online training curriculum has been developed and achieved significant success (http://heartstrings.linkstreetlearning.com/). A host of excellent teaching websites exist in paediatric imaging. The website www.wfpiweb.org is an excellent online resource for information on paediatric imaging. Online training portals such as www.radguru.net, supported by the Telerad Foundation also provide an opportunity for postgraduates to obtain training in paediatric (and other) sub-speciality imaging in a live interactive virtual classroom environment.
The use of technology offers an additional paradigm changing solution in the space of paediatric imaging. Teleradiology is a technology-enabled reporting process that has the potential to greatly increase the reach of sub-speciality imaging in India, and paediatric imaging is no exception. By using data networks to electronically transfer digital paediatric images from hospitals and imaging centres to sub-specialist paediatric radiologists, the quality of reporting and analysis can be enhanced. Access to sub-specialist paediatric radiologists from even remote and backward areas can be facilitated. Teleradiology can be used for reporting of paediatric examinations by sub-specialists, both in the emergency setting as well as in the elective or outpatient setting, and also to provide second opinions to general radiologists on their complex paediatric cases. Rapid turnaround time of reports can be achieved by the use of high-speed telecommunications and advanced teleradiology work-flow platforms, thus enhancing patient care in the paediatric age group. Further the use of teleradiology allows the paediatric radiologists time (a scarce resource to begin with) to be utilised more efficiently and productively, and permits them to focus more effectively on their sub-specialisation.
In summary, the imaging of children requires specialised training given the unique clinical challenges and radiation issues involved. Paediatric radiology is an established sub-speciality in Western countries, however India lags in this regard for a variety of reasons as discussed. There is a need to train more sub-specialist paediatric radiologists as well as to train general radiologists in paediatric imaging. Societies such as the Indian Society of Pediatric Radiology are making sincere efforts to this end with their CME activities. The use of innovative technologies such as teleradiology and e-learning have the potential to enhance paediatric radiology as well to facilitate the dissemination of knowledge in this critical space.
References:
Saxena et al JIMSA January-March 2013 Vol. 26 No. 1 77
Sidhu et al Pediatr Radiol. 2014 Jun;44(6):657-65.
Jankharia, B. Editorial, Indian J Radiol Imaging. 2010; 20(1): 1.
Indrajit, IK. Pediatric Imaging Web Review Indian J Radiol Imaging. 2009: 19(1) 89-90
http://heartstrings.linkstreetlearning.com/
www.wfpiweb.org
http://www.ispronline.com/
www.radguru.net
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