IMPROVING RADIOLOGICAL SERVICES IN INDIA ALONG THE LINES, OBSERVATIONS AND SUGGESTIONS PROPOSED BY EUROPEAN RADIOLOGICAL ASSOCIATION STANDARDS 2003:
Dr Himadri S. Das
At the introductory meeting held at IAEA headquarters in Vienna in March 2003 on Thematic Planning for Diagnostic Radiology, representatives of the IAEA indicated that the Agency wished to take a more holistic approach to the improvement of global radiological services by helping to develop adequate standards for the 135 Member States, and by developing partnerships with other organizations with similar interests. Within IAEA there are already four programs in the health area covered by the Division of Human Health namely Nuclear Medicine, Radio Biology, Dosimetry/Physics & Nutrition. The focus is on identifying a role for nuclear sciences and technology in addressing human health problems particularly in developing countries, rather than duplication of activities already covered by other agencies, i.e. a complementary and co-coordinating role with a focus on patient radiological services, rather than strictly regulatory aspects. Specific concerns expressed during the meeting included the absence of access to Radiology services for two thirds of the world’s population, and the predicted growth in malignant disease in both developed and developing countries over the next decade requiring significant Investment in trained staff and equipment.
Access to health care should be a basic human right. Diagnostic Radiology is fundamental to the proper assessment and monitoring of many diseases processes, and is required in around 25% of medical Interventions. The challenge is to maximise the utilisation of diagnostic equipment in a timely fashion to expedite diagnosis and initiate appropriate treatment. Emergency Radiology services are now required on a 24 hour / 7 day week basis. Screening for early diagnosis of disease e.g. breast and lung cancer and vascular disease, provides an organizational, financial and ethical challenge. Research into the next developments in imaging is required. Many of these stem from the genomics project, and the requirement for molecular imaging and cellular imaging, in order to promptly identify disease processes and follow response to therapy.
It is appropriate that the worst cases are prioritized, i.e. third world and highly populated countries like India, or those affected by recent conflicts, are supported in the provision of, at least, basic radiology services. The development of pilot centres of excellence as already in effect in the WHO initiative would be a good starting point. These could be hospital and/or community based and should offer the possibility of providing a “critical mass” of trained Radiologists and Radiographers and support staff drawn from the indigenous population, with practical support and encouragement from outside gencies and national governments.
These could provide the framework for the development of training programmes and benchmarks for staff development, and are more likely to have basic infrastructure, e.g. a reliable electrical supply, required to underpin an ongoing radiological service, and the pump priming of sustained academic development.
Basic X-ray equipment, which is robust and easy to maintain, should be provided. Image processing using film based systems may require a lower initial investment, but Computed Radiography (CR) systems offer lower revenue expenditure in the long term and the possibility of image transmission (tele-radiology) or reporting/second opinion, if the local telecommunications system is capable of supporting this technology. Basic Ultrasound equipment has become cheaper and more sophisticated and small portable units have now got quite sophisticated capability including colour Doppler imaging. These are invaluable in obstetric assessment, as well as general abdominal and small parts: thyroid, testis, breast, etc. evaluation, and also for vascular evaluation and paediatric cerebral examination. With good tuition, those with basic anatomy and pathology training can master the operational skills without too much difficulty. Training programmes could be provided on a “fellowship” basis. The capital cost of CT scanners has relatively declined in recent years. Regular planned maintenance is essential. Modern X-Ray tubes are relatively resilient. A properly planned CT examination is a flexible and powerful diagnostic tool and should be available in any “core” hospital department. Targeted contrast agents and the development of new MRI sequences leading to functional imaging are of particular importance, especially in Neuro-Radiology. Collaborative multi centre studies are required and could be supported.
Radiology services require teamwork and the involvement of trained Radiographers, Clerical/Administrative staff and Medical Physicists. Nowadays IT Staff are essential to support Radiology Information Systems (RIS), Picture Archiving and Communications Systems (PACS) and integration with Hospital Information Systems (HIS). These arrangements support the provision of comprehensive Radiology services and are usually based in hospitals or clinics.
Lack of comprehensive training leads to emphasis on one modality, sometimes undertaken by physicians with no formal Radiological training. Similarly, absence of reliable up-to-date equipment also limits the quality and range of diagnostic & therapeutic options. In the worst scenario, as indicated above, there is a complete absence of Radiological services, often compounded by other fundamental problems: starvation, lack of clean water, electricity and telecommunications, and the presence of endemic diseases – AIDS, malaria, hepatitis, Tuberculosis etc.
In Europe, postgraduate training in Radiology lasts for five years, following medical qualification and experience. Modalities used are: X-ray Fluoroscopy, Ultrasound, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Recently, Positron Emission Tomography (PET) has been added to the diagnostic armamentarium – often in conjunction with CT (e.g. CTPET).
The situation in India is after basic medical qualification (MBBS degree) and general medical experience, postgraduate training in Radiology (MD) lasts for three years. Diploma courses (DMRD) are offered in few places. Some Radiologists sub-specialise, usually on the basis of Interest in one or other organ systems, but most Radiologists conduct a Radiological practice utilizing Radiographic Images derived from X ray, USG & doppler with CT, MRI etc being available in few Governmental Hospitals, nursing homes, general purpose diagnostic centres and the likes. New entrants are corporate hospitals with ultramodern equipments but these lack the experience of properly trained Radiologists WITH the experience of using such machines.
The Government, Radiological Associations and regulatory bodies could help to:
1. Co-operate in the provision of training and educational standards
2. Inspect and advise on training centres
3. Encourage the development of national legislative requirements in Radiation protection. Provide quality and benchmarking guidelines for Radiology Department management.
4. Upgrading Guidelines on Pregraduate and Postgraduate training in Radiology and in Continuing Medical Education. Referral Guidelines for physicians setting out an appropriate radio diagnostic approaches.
5. Encourage Radiologists to provide leadership in the provision of high standards in radiological services.
Significant funding is required if we are to compete with our international colleagues who have been successful in attracting huge government funding to new national radiological research institutes. The world of Diagnostic Radiology is a referral specialty of medicine providing services in medical imaging and image guided Interventional techniques to the patients of Medicine and allied practitioners, surgeons, oncologists and other medical specialists.