Radiology slowly rebuilds in Balkan countries

July 14, 2003

The radiology department at Opca bolnica Sveti Duh, or General Hospital Holy Ghost, was bustling on a cloudy March day. Technologists positioned patients for CT scans, and an anesthesiologist carefully sedated a pediatric patient for an MR study.

The radiology department at Opca bolnica Sveti Duh, or General Hospital Holy Ghost, was bustling on a cloudy March day. Technologists positioned patients for CT scans, and an anesthesiologist carefully sedated a pediatric patient for an MR study. Radiologists called each other to a light board to consult on a CT scan that showed an esophageal mass. Nothing suggested that a nationwide physician's strike was under way.

Every hospital and clinic in Zagreb, Croatia's capital, was just as busy. Over the course of a hectic day, I visited most of them, then headed southeast to Sarajevo, Bosnia-Herzegovina. In both countries, I wanted to see how radiologists practiced and to find out more about the state of healthcare in the years following the breakup of the former Yugoslavia.

The strike in Croatia, which had started Jan. 15, was largely symbolic. The government guarantees access to top-quality healthcare for all citizens, according to Prof. Miljenko Marotti, director of radiology at Klinicka bolnica Sestre milosrdnice, Sisters of Mercy Hospital. But in practice, the nation's economy is relatively small, and medical providers struggle to maintain standards on tight budgets. The public blames the doctors, Marotti said, and the doctors called a strike in protest. In reality, few if any turned away patients, and not many could risk walking away. Physician salaries average US $12,000 per year, but prices-in the capital at least-aren't far from those in Western Europe. By spring, the government had responded with a pay increase for physicians.

Standards for physicians are high. To be certain that the state receives a number of years of service in exchange for medical education, prospective radiologists cannot be older than 30 when they enter training. Four years of specialty training and oral and practical boards are required to earn a license. The Ministry of Health and the Society of Radiology, are considering adding a fifth year for subspecialty training. Neighboring Slovenia, which is petitioning to join the EU in 2004, requires five years already, and Croatian radiologists anticipate that they'll have to follow suit when their own country joins the EU. Once qualified, radiologists must complete continuing education requirements in multiple subspecialty areas, and they are expected to publish, present research, or teach.

About 330 radiologists practice in the country today, at 64 hospitals and multiple private clinics. Improved training will make it easier for some to leave and work in the West for better pay. Dr. Zoran Rumboldt is completing his radiology training in Croatia but plans to take a neuroradiology fellowship in the U.S. that will launch an academic career, taking advantage of a different trend in this country.

"Not many U.S. residents want to pursue academic positions, so departments there need to attract faculty from overseas," he said. "The rules of protocol also are different there. It's easier to establish a name earlier in one's career."

Most Croatian radiologists will spend their careers in their homeland, and they can expect to see change. Dr. Dalibor Krpan, head of Opca bolnica Sveti-Duh, calls his hospital a combination of the 19th and 21st centuries, but he could be referring to nearly any medical center in the country. Most equipment used today has at least 15 years of service behind it.

Little money has been available to bring multidetector CT, high-field MR, or PACS into the country, but the basic medical infrastructure is slowly being renewed, thanks to internal and international resources.

X-ray and ultrasound account for the majority of radiology work, and radiography may be peformed on anything from brand-new equipment in a gleaming suite to worn, wood-table units in rooms with peeling paint and chipped floors. Each district hospital has at least one CT unit, mostly early models, and several hospitals in the capital have more than one. That turns out to be a necessity more than a convenience, as it's only on a good day that more than one is working at a given center. Fourteen MR units, mostly 1T or lower field, dot the country, but Zagreb's Poliklinica Neuron, the Croatian neurology institute, boasts a 2T model used for a combination of research and private practice.

Opca bolnica is charged with some ambitious goals: to computerize all service, to integrate clinical departments that now operate autonomously and organize them instead around care pathways, and to launch a public-private hybrid polyclinic with foreign investment. This last project would involve bringing in dialysis, women's health, outpatient surgery, and possibly genetic and metabolic bone disease specialists. Using those services to generate income from private-pay patients would help modernize services for the rest of the hospital and increase its independence from state-run insurance. It's a new idea for the country, but it offers the hope of catching up sooner rather than later with the technology and capabilities colleagues have in nearby countries.

"Everything is changing in Croatian hospitals," Krpan said. "We know what we want to do, what we want to change, and what equipment we want to buy. The difficult thing is to change minds."

CITY OF CEMETERIES

A few hundred miles to the southeast, radiologists in Sarajevo are equally focused on the future. The recent past is a little harder to ignore, however. Sarajevo's mix of Ottoman, Austro-Hungarian, and Communist-era buildings remain badly scarred by years of ethnic violence, including a three-year siege conducted from the forested hills that ring the city. For a city its size, it has a disproportionate number of cemeteries. Today, though, the city is peaceful and quiet, with sidewalk cafes and markets creating a lively downtown. Mosques, synagogues, and churches coexist side by side as they have for centuries.

On a hillside above the center of town, the Sarajevo University's hospital campus bears holes from 298 artillery shells that bombarded the grounds between 1992 and 1996. A plaque near one commemorates 49 employees who died during the siege.

The hospital operated continuously during the war, with long stretches of no electricity, heat, or food-in a mountainous region that sees cold nights and snowfall well into spring. With no film and no spare parts, radiography was impossible. A mobile CT unit, purchased shortly before the hostilities began, was set up in a bunker and run off a generator, providing images of embedded shrapnel and other wounds.

With 590 physicians and more than 1800 beds, the hospital is the centerpiece of medical care in Bosnia-Herzegovina. Regional centers in Tuzla, Mostar, and Banja Luka train students and conduct research, but nearly all radiologists spend their residency in Sarajevo. Some divisions from the war persist: Within the country, the Serbian-majority Republika Srpska essentially has its own government. Medical students from that region train in Belgrade, while most of the faculty in Sarajevo is Muslim or Croatian Catholic.

Thirty radiologists work at the university hospital, with a dozen or so residents. In addition to a full complement of x-ray and ultrasound, the center offers mammography, densitometry, angiography, 1T MR, and three CT units, two of them spiral. The facility performed more than 10,000 CT scans alone last year. In a separate department, five nuclear medicine specialists offer thyroid scans, cardiac SPECT, and other studies on four gamma cameras, including one dual-head. Among the war's lasting effects are an increased incidence of melanoma thought to be related to depleted-uranium shells, and an abundance of patients living with shrapnel that makes MR imaging a challenge.

Much of the equipment is relatively recent, acquired after the war, but radiology director Dr. Faruk Dalagija and colleagues have their eye on a 1.5T or even 3T MR unit and multidetector CT. Dr. Vanesa Beslagic recently completed ultrasound training at Thomas Jefferson University, and Sarajevo University will become Bosnia's regional ultrasound training center. Training will be extended to other specialties that now rotate through radiology to pick up the fundamentals of ultrasound. Nearly all other specialties conduct their own ultrasound exams.

"It's our duty to patients to see that clinicians who use ultrasound are trained to do so," Dalagija said.

With memories of the war and severe medical needs fresh in their minds, the radiologists and residents in Sarajevo expressed a desire to improve the quality of care their fellow Bosnians receive. As foreign aid has tapered off, that task has become more challenging: The economy, wrecked along with most of the nation's infrastructure, remains stagnant.

In this climate, a fully qualified radiologist can expect to make US $6000 per year. Many young Bosnians look instead to computer-based industries or other fields rather than pursue a medical career, said Dr. Edib Muftiz, a second-year resident from Mostar. Some who end up studying radiology may have waited several years before committing to the specialty, hoping to be accepted for a surgical specialty first but ultimately needing to begin training before falling under age limitations similar to Croatia's.

Despite the challenges, radiologists in Bosnia-Herzegovina express great excitement about the field and the future. This year they will hold their second-ever scientific congress, with colleagues from surrounding countries expected to attend.

"It's a very difficult time in Bosnia-Herzegovina, with no jobs and small salaries, and many young people leaving for other countries," Dalagija said. "At the same time, we are drawing very energetic students, some from foreign countries. In our residency program, radiology is blossoming."