Radiology's basic mission to identify and diagnose illness and injury is universal, but its methods are not. Two-thirds of the world lacks access to basic medical imaging, and leading-edge technology is available to only a small fraction of the rest. Just steps away from exhibit halls filled with the most advanced imaging equipment, Diagnostic Imaging gathered radiologists from around the world at the 2003 RSNA meeting to discuss access to care and training, and the technology that serves as both bridge and barrier between wealthy nations and the developing world.
On the panel were Dr. Bhavin Jankharia, a private-practice radiologist and educator from Mumbai, India; Dr. Peter Corr, chief radiologist at the University of Natal in Durban, South Africa; Dr. Holger Pettersson, a professor of radiology at University Hospital in Lund, Sweden, and chair of the International Commission of Radiologic Education of the International Society of Radiology; Dr. Stephen Davies, a radiologist from Cardiff, Wales; Dr. Valentin Sinitsyn, senior radiologist at the Cardiology Research Center in Moscow; Dr. Ricardo Garcia Monaco, an interventional radiologist from Buenos Aires and secretary of the Interamerican College of Radiology; Millan Alvarez-Miranda, director of health imaging global operations for Eastman Kodak; and Dr. Pablo Ros, vice chair of radiology at Brigham and Women's Hospital in Boston.
Diagnostic Imaging: Where do you and your colleagues at home put the emphasis in radiology? Is it research, education, or basic services? In your home country or region, what's important in radiology right now?
Dr. Stephen Davies: One of the main problems in the U.K. is human resource staffing issues. Many radiology establishments are running at 50%. As a consequence, we've had to examine the way that we practice radiology. We've trained technologists to take on some of the traditional radiologists' skills. And we've taken on digital imaging to try and improve the efficiency and quality of our reporting.
The challenges for a lot of radiologists are to maintain their knowledge base, given the explosion in the variety of imaging and the expectations for more accurate reporting, particularly in oncology.
Dr. V.E. Sinitsyn: In Moscow, we have enough radiologists. It seems like the most important problem is that we need to change the system of professional education and renewal. It's still basically the same as it was 20 or 30 years ago, despite all the technology and major changes. When the hospital gets new high-tech equipment, suddenly they recognize that they haven't trained people to use this equipment.
Dr. Ricardo Garcia Monaco: In Argentina, we have maybe too many radiologists. The problem is that most of them are in the big cities, and there are no radiologists at all in the small cities or rural areas. High technology is not in every city and region of the country, but just in big cities. So you have two or three completely different levels of radiology inside the country.
Dr. Bhavin Jankharia: I think we have a similar issue in India. We have adequate radiologist staffing in all the public hospitals, but we have a shortage of radiologists who would go into private practice in the smaller towns and would then be able to drive the momentum for better radiology. In the big cities, we are overloaded with radiologists. Everybody wants to practice, and we're beginning to export them to England, the U.S., and whoever has a shortage.
Dr. Peter Corr: In South Africa, we have about 500 radiologists for 40 million people. And I would estimate that there are probably only about 700 radiologists in sub-Saharan Africa. For us, training and retaining people is the issue. We have reasonably modern imaging equipment, but we cannot keep people.
Dr. Holger Pettersson: For Scandinavia and Europe as a whole, we are slowly getting squeezed between what we can do and what we can afford to do. New technology is expensive, as are exams, and the population is aging and requires more imaging. Before some years ago, it would have been impossible to even discuss who should do what between the technicians and doctors and paramedics. But now it's obvious that there are jobs enough for all of us. We have to prioritize what we can do and what we would like to do.
MIGRATION
DI: Several of you mentioned the relative shortage or abundance of radiologists. It seems like there's a growing flow between countries. What is the experience of radiologists who are looking to work abroad out of India, Argentina, and so on? In terms of educational standards, are you able to transfer skills and training?
Garcia Monaco: Many radiologists in Argentina are going abroad, especially to Spain because the standards are more or less the same. And also to the U.S., where they can work inside the universities, especially in the southern U.S. If you are a part of a country with agreements with Europe or with the United Kingdom, there's no problem. You just have to take an examination. If you go to the U.S. and you work in a university that needs you, they might help you get a license. There are also many agreements with university faculties in Spain. So those are the biggest emigrations of Argentinean doctors. It's much less common to have Argentinean doctors going to Switzerland or Germany.
Jankharia: Most Indians go to the English-speaking countries. That's the U.S., Canada, the U.K., Australia, and New Zealand. Getting into the U.S. can be pretty difficult because you may never get a visa to travel out of India. And if you do, then there are a lot of variables in terms of getting a job, doing the residencies, and so on.
With four or five years of experience working in the country, people have been invited directly as fellows, given the license, become faculty, and then given the board exam. When a foreign department wants somebody, they pick them up. But for somebody to go on his or her own is not very easy. Australia, New Zealand, and Canada are open for immigration. You just go there and hope to get a bed, and you're going to stay there for the rest of your life.
Sinitsyn: Not that many radiologists leave Russia, mostly due to language problems and the problem of certification. But we have some radiologists from India and Pakistan who get training in radiology in Russia. Then they go in droves to other countries. The situation will improve once Russia revises its standards for education to better match other European countries.
Corr: About 80% of the people I've trained leave Africa. Obviously, that's depressing if you're looking toward the future climate of healthcare. I think it's a phenomenon of globalization. I think the world will change, and I hope in the future our country will be more attractive for these people to return to.
Davies: What we're going to see certainly within the European Community is not so much personnel movement but skill movement or image interpretation movement. I know in the States, for example, teleradiology and networks are quite developed and the opportunities for exporting image interpretation exists. One or two hospitals in the U.K. are beginning to develop initiatives on their own to export some work. So they don't need to import the radiologists, but they can export the work. This is in its infancy. It's not actually established at any site yet, because legal and practical questions need to be addressed.
Pettersson: Officially, within the European Union there is free migration of labor, but it is astonishing how small the actual movement of labor is between these countries. I don't know why, really. There is a language barrier between many countries, and there has always been a slow migration to and from the U.S. You'll get there for a few years and you'll go back again, and so on, in between Europe and the U.S. But in between the European countries it could be much more of a migration. It may come. I saw an interview with an Australian doctor in Sweden. He said you would earn 10 times as much in Sweden as in Lithuania. So there are many things that make the migration not so free at all.
Jankharia: I think the most important reason for migration-at least one that we see in India-is based on lifestyle and salaries. If an average radiologist would earn in the range of about $2000 a month in India-which would be about $12,000 to $15,000 in Europe-if that person can come to the U.S. and earn a quarter of a million in private practice within four years, I think that's the driving force.
Millan Alvarez-Miranda: There are two different migrating movements. One is within the E.C., which is built to facilitate movement of people and merchandise. And the other is the bigger migration from developing countries to the other countries. What is more surprising is that European movement is not happening. Hospitals are still closely allied with governments, whereas corporations may be acquired or moved around and stimulate migration. In the U.S., integrating hospitals across the country is creating more movement, and that may happen in Europe eventually.
SETTING STANDARDS
DI: Underneath all that, the issue of education has come up. Does anyone have thoughts about setting international standards for radiology education to facilitate movement?
Pettersson: We do find standards in Europe, for instance, that indicate when someone is a qualified radiologist, and the standards are about the same in the States. This would work also for the economically and technically developed parts of the world. But then you will find a totally different reality for big parts of the globe.
Two-thirds of the world population has very little or no access to adequate equipment or trained personnel. That baseline of education is totally different from what we are talking about for radiology in the U.S. or Western Europe. Before we can set baseline standards, we need baseline education. We must realize that the gap between this goal and reality is enormous.
Garcia Monaco: It's much easier in a place like Europe that has the same educational, security, and economic levels. It's very difficult to do a global standardization because there is no standard of education, security, economics, income. What we are doing in some developing countries is first trying to standardize our own country and then see if we could go outside. But it's very difficult to globalize or to be international if the local situation has not been standardized.
Sinitsyn: The situation in Russia is more or less similar. We are trying to adapt EAR standards, but we cannot make an instant transition, for example, to five-year education in radiology. So we are making it a three-year training using EAR standards, maybe in some shorter way with an intention to move further. This is the first step of our program of teaching in radiology.
GLOBAL TELERADIOLOGY
Dr. Pablo R. Ros: I would like to challenge some of you around the table. Globalization is here to stay. The average size of a radiology group in the U.S. 10 years ago was 20 radiologists. Now there are a couple of groups of over 1000 people. These groups are truly countrywide. They may practice in every state. It is not unusual for a radiologist in the U.S. to have 10 state licenses or more. In the state of Massachusetts alone, over 100 hospitals use international reading services from Australia or India.
The same way that large multinational companies have absolute reach over the entire world-the same is going to happen to radiology. These major industrial giants operate in maybe 100 countries, from the most developed to the most undeveloped. This trend is not going to reverse because the financial interest in multinational industry is tremendous.
The same is true in radiology. Financial interests are what will motivate the credentialing, standardization, and education. If there is a guy in India who is satisfied reading cases for $1000 a month, and the same service can be obtained in the U.S. for $20,000 a month, there's no question that the jobs will migrate, and standards will migrate with them.
In industry, the "high-end" of manufacturing still occurs in certain advanced countries in the world, but the basic manufacturing of clothing or other goods is in less specialized countries. The same is going to happen in radiology. I can foresee departments where very specialized people do unique interpretations for which you need a $20,000 radiologist. The basic chest x-ray, the basic portable film that's no money even here, is going to be read elsewhere. Globalization is coming, and I bet that in five years, it's going to touch the life of everybody in radiology. Still, radiology has two components: interpretation and procedural. The procedural will have to be done locally, but the interpretation is truly going to change.
Garcia-Monaco: All this globalization or reading and study from abroad can benefit developed countries, but patients in the countries where the baseline reading is done still won't have access to that level of care. It will be years before that occurs.
Ros: No question about it. A sports shoe is manufactured in Central America or Southeast Asia. Obviously, that sports shoe is going to be sold in Europe or Japan or North America. The people in Honduras or Malaysia will not have a chance in their wildest dreams to buy that shoe, but the shoe is manufactured there because the price of producing it in Europe or North America would be 10 times higher. People have crossed the legal barriers for trade because the financial incentives are tremendous. And I'm just telling you that this is so logical that it's going to happen in radiology. Maybe our role as educators will be to make sure that things are done better rather than worse.
Davies: This provides for radiology in developed countries with high costs and provides employment opportunities in countries like India, but it doesn't actually solve the problem at all in those countries that are providing the services. And this is really the challenge, isn't it, for radiology? Yes, we can globalize the reading services, the education, and the standards. But it doesn't actually help the people in rural communities in these countries who have very poor access to services. And that really is the challenge for global radiology.
Jankharia: The difference between making shoes and radiology is the huge difference in the entry barriers. The entry barrier to starting a shoe factory in Bangladesh is a question of getting through red tape. But the U.S., for example, has high entry barriers for radiology. There's one individual who's board-certified in Bangalore, who hires 10 other radiologists who are non-board-certified to read cases from the U.S. He reports, and he oversees their training. How many board-certified radiologists from India are willing to come back to India to practice? If he's making a quarter-million dollars in the U.S., there is no way he's going to make that doing even teleradiology in India. And why should he therefore migrate?
These issues are going to need to be solved. If tomorrow the U.S. says that yes, if you've got X amount of training we don't care if you're certified or licensed, that's when the entry barrier goes down. Then we'll say, yes, we can provide you services. Believe me, all of us will start doing reports for $80 or $90. That's not a big deal. But I don't think that will happen. Not unless the entry barriers go down-but those barriers were developed to maintain standards. It wasn't a question of just manufacturing. It was because the U.S. said, we need a certain standard. If the barriers don't go down, how do we actually truly get globalization? And the same would work for the U.K., Canada, Australia, New Zealand, everywhere where there are such tremendous barriers to entry either way.
On the other hand, I get spam e-mails every three weeks from nighthawk people in the U.S. telling me, "We'll give you $1 an x-ray, $2 a CT, $3 an MR. Can you do preliminary reporting? We can supply you with 1000 exams a day. You could make $3000." That's morning for me. That's prime-time reporting work for me. Do you really expect that I'm going to do this?
CHALLENGES FOR THE DEVELOPING WORLD
Pettersson: Yes, of course globalization will go on. But what we're talking about now is shuffling images to and fro around the globe for those who already have services. It will take much longer before this Internet sharing of images is available to benefit people all over the world. Moreover, radiology is not just evaluation. Radiology requires an examination. If you don't have equipment, if you don't have personnel trained enough to make a proper examination, then you can evaluate as much as you want and send out images around the world, but it's worth nothing.
So when we talk about education and what we could do on the global level, it's first to look at equipment, second to look at very basic education for doing the examination and for the first basic evaluation of these images. And then the final evaluation can be done in very different ways.
Ros: I agree. There is no question that the discrepancies are going to not only exist but increase, and there should be efforts to raise the basic quality of radiology available worldwide. The angle that I am bringing in here is that the Internet and teleradiology have already changed the way we practice and are going to keep on changing the way we practice. And if this is arranged appropriately, we have a unique opportunity. No other specialty can send its work anywhere in the world. In telemedicine, we're sending electrocardiograms, and pathological slides, and derma pictures, and endoscopy pictures. It exists for other specialties to a small extent, but for us who are 10 years ahead of the curve, it is a little bit our responsibility to somehow foster what is happening. Maybe you won't take the $3 MRI prereading, but I bet there is somebody somewhere who will take it. We could have centers of reference across the world. Industry and business will find a way around all of these entry barriers that we were talking about. But we should be clever enough to foster it in a more productive way.
Jankharia: It's globalization on a totally different level from what I was talking about. One doesn't exclude the other. We should be aware that this is still a thing for a small upper slice of the world, and in the long run it could give good things to the rest of the population. But we should be aware that we shouldn't just give everything to one and neglect the other at the same time.
Corr: I think that in the developing countries, radiologists should sort of promote radiology and its potential to politicians so that they are aware of what we can do. Hospitals are not well-maintained. Politicians are just not aware of what radiology can do for patients.
Davies: You have to ask yourself whether it's appropriate to export an MRI read to an area that hasn't got a chest x-ray machine that works or has an ultrasound machine that's 12 years old and no prospect of MR for 10 years. It's not a particularly relevant form of training. If we're going to have these $3 overseas reads, we also have an obligation to start training people or to provide funding for equipment at those sorts of levels.
USING TECHNOLOGY WELL
Jankharia: The other issue is industry. They do provide training avenues, but they are profit-driven, and any kind of initiative is always a little suspect. For example, in India CT and MR are glamorized by the companies. Every time there's a new machine, you have a nice show, to our detriment. In a country like ours, if ultrasound can do the job, it's better for everybody. A simple example is acute pancreatitis. CT is the gold standard for staging, but if you have a refurbished, conventional, nonspiral scanner with a 320 matrix versus a reasonably new ultrasound machine, ultrasound is better in that setting than CT would be.
We need the good radiologists, with reasonable equipment, to serve the small towns. We've got 5000 radiologists for a billion people, and most of the radiologists are in large cities. Maybe what would work is teleradiology from rural areas to our places where we could charge $1 for an x-ray than doing dollar-read reporting from the U.S. But that requires so much initiative, which is political and economic, as the doctor from Argentina said.
Alvarez-Miranda: We are talking about two different things. One is how to link the business of radiology across countries such as the U.S. and India. And the other thing is how to provide basic services to the rural areas. The first one is positive in the sense that you can provide revenues to India to invest in other things, but it has nothing to do with supplying radiology services in India. It can mean that you have more industries that can provide more GDP for India and be reinvested in medicine or infrastructure. It's about how to develop the economy in India and other countries so that services like radiology can be built out to the countryside.
Jankharia: But the two things do get linked. Teleradiology does not raise the GDP of the country. Even if all the 5000 radiologists in India start doing teleradiology in India for the developed world, it's just personal income to a certain level, maybe four or five times what people are earning. The companies in between are the ones making the profit, unless you are board-certified and can demand money. If I am not board-certified, then I will get paid body-shop charges. It is the company in between that arranges it that makes all the profit. I may get $20 for an MR, but the guy in between is still making his $200 as the commission. And if I were board-certified, why would I come to India? I would live in the U.S. and make the kind of money that I wanted to.
Corr: I'd like to comment on what Pablo just said about the Internet as a form of education in radiology. I really do believe that will be the future. I'm amazed at the small places in Africa. You may not have a proper road, but you'll see an Internet cafe.
Davies: There's an initiative in the U.K. to set up radiology academies, which are extensions of existing radiology training schemes. For a significant percentage of time, radiologists will sit in an electronic classroom and access electronically stored cases. And they will be taught in these electronic classrooms, so that the amount of time they actually need to spend in the clinical environment can be shared over a large number of trainees, thereby increasing the number of people going through the system. If it is successful, you could see an extension beyond the U.K. boundaries.
Sinitsyn: I'd like to go back to what Holger said. The Internet and teleradiology are very nice, but one of our challenges is how to price access to imaging services to patients in countries with a limited amount of radiological equipment. First of all, you need to do an examination. Somebody can consult and help you with interpretation, but if the patient hasn't any access to any imaging it won't help, right? Of course, the technological answer is quite clear. Please buy more imaging equipment and the problem will be solved. But of course the question is global, economical, and political. A topic we have to discuss is how to use more rationally those limited resources that these countries have.
NONRADIOLOGISTS AS IMAGERS
DI: An issue came out in the course of our research: In much of the world, radiology is not done by radiologists. It's done by primary-care physicians, by technologists. Is there potential in the underserved two-thirds of the world to train the nonradiologists at a local level?
Pettersson: The Global Steering Group is trying to create centers of excellence that would be the nuclei for very basic indications in different areas. We have worked with Nairobi, Kenya, as a base for central and southern Africa. Radiologists or general physicians come and get the very basic education.
Another part of the world just starting up is the South Pacific. It's a quarter of the world, but there are thousands of islands and people living on these islands, and they need healthcare. There are almost no doctors-there are radiologists on some of the big islands and, of course, New Zealand and Australia, and Hawaii on the U.S. side. But the reality is people break their bones. So we have started up a program for nurses that gives basic training in taking images and making the first evaluations. We hope for the future that they could send the image somewhere for evaluation, but we need to have this basic work done. This situation applies also for rural areas inside Asia or in lower India and South America.
And then we come to the next step, when we can try to at least train people who do radiology most of the time. Then we have some sort of radiologists. And then we come to the level where you can talk about what we think are educated radiologists.
Ros: A certain consensus is building. We are indeed talking about two different areas. One is the basic service of radiology, the other one is globalization. I also think that everybody agrees that, more or less, both issues are intertwined. Everybody agrees that the Internet is a key element for transfer of imaging and also transfer of information.
But I have news for you. In the next five to 10 years, the projection in the U.S. is for a 218% increase in imaging. This is 10 times more than any other specialty in medicine. The appetite for imaging is absolutely insatiable. In the U.S., many rural hospitals would have to close because there are no radiologists. Companies like the one I mentioned that has 1000 radiologists are the saviors for rural hospitals because they can provide backup for reading.
The need for imaging is such that we're going to have more and more nonradiologists working in radiology. You could have nurses doing angiograms or supertechs who would prescreen mammograms or CT scans into normal and abnormal. We need more and more people who are able to perform the procedures and interpret the results. So we have plenty of work. The bad news is that we have to organize ourselves better.
Alvarez-Miranda: I agree that education is very important. I agree that it would be very important to have a basic standard of equipment everywhere. But I think it's also interesting to see how the technology is so vital and how in some cases it's even surpassing those basic standards in healthcare, just as it's doing in other sectors. We see the digital penetration faster than we expected in some of the developing countries.
Sinitsyn: In the not-so-distant future, industry will make a digital box that takes care of the information, makes the image, stores it, and you can read it. You will put these boxes on the other side of the patient instead of down the hall and get rid of all the darkrooms. Some of the big companies realize that if they can do this cheaply, it's a huge market for basic radiology around the world. So it seems that if we have the digital image locally, then we can get the evaluation somewhere else. Then we can lead these two roads together.
