Radiology's future rests on training and education

March 27, 2003

The vast financial, cultural, and political diversity of Asia-Pacific poses many challenges for the implementation and maintenance of high-quality radiological services. Skilled staff are often clustered in large cities where they can benefit from

The vast financial, cultural, and political diversity of Asia-Pacific poses many challenges for the implementation and maintenance of high-quality radiological services. Skilled staff are often clustered in large cities where they can benefit from organized training programs in institutions equipped with state-of-the-art technology. In more rural areas, radiologists are often stretched to the limit, relying on ultrasound rather than CT or MRI, and have few opportunities to attend training courses.

Prof. Lenny Tan, a professor of radiology at the National University of Singapore and chair of the organizing committee for next month's Asian and Oceanian Congress of Radiology (AOCR), acknowledges the many difficulties involved in unifying a disparate radiological community for which communication is a constant struggle. Eastern and western Chinese, for example, are unlikely to speak the same language, while radiologists in India could speak any one of over 100 different dialects.

Tan outlined the difficulties in setting standards across such a heterogeneous region during his keynote address at the International Congress of Radiology in Buenos Aires, Argentina, last September. The variation in radiological services is mirrored by the disparity in healthcare provision, he said. There are more than 4500 people to every doctor in Bangladesh, while in Japan the ratio is around 500:1. Similarly, the ratio of people to radiologists is just under 40,000:1 in Japan, while this figure soars to one million in Bangladesh (Tables 1 and 2).

The number of radiologists in each country is directly related to national wealth. Richer nations benefit from higher numbers of trained staff. Over half of India's one billion inhabitants live on less than US$1 per day, as do 350 million of China's 1.2 billion population. Supplying sufficient medical staff to cover such a large number of people spread across a wide area (3.3 million km2 in India, 9.6 million km2 in China) is no easy task, and, it is compounded by accelerating birth rates. Tan suggests that 1.7 new radiologists would have to qualify every day just to maintain a constant level of service in India, given the 18 million live births per annum.

A comparison of radiological training in India and China illustrates the differing approaches to teaching in the region. Of 162 medical colleges and universities in India, 49 offer programs in radiology. The ratio of radiologists to doctors throughout the country is 4500:395,000, with one radiologist to about every 220,000 inhabitants. China, on the other hand, has established a system of multiple levels of care to provide radiological services in every region. According to official figures, there are nearly 30,000 Chinese radiologists, or one for about every 42,000 inhabitants.

Like all statistics, however, these figures do not tell the whole story. While China boasts a high number of personnel with skills in radiology, the absence of national training criteria means that professional and technical standards, quality of service, and speed of delivery vary. Ambiguity about the precise nature of the skills required raises doubts about the quality of service, according to Tan, who is secretary/treasurer of the Asian and Oceanian Society of Radiology (AOSR).

"You ask them to define a radiologist and they can't," he said. "They really cannot because there is no national program, there are no national examinations; everything is done by the hospital. In other words, you could work in a department for some time and then you could call yourself a radiologist."

China is not alone in giving the same job title to all medical imaging staff, regardless of level of expertise. What it means to be a radiologist differs from country to country throughout the region, making it difficult to provide meaningful comparisons. The distinction between radiologists and radiographers/technologists is often blurred.

Asia's shortage of trained radiologists is compounded by widely varying standards of teaching and training and equally disparate levels of competence and practice. Tan sees a clear link between status and high standards in radiology and urges radiologists to improve their professional standing. By commanding respect from patients and other medical colleagues, radiologists can promote the status of their discipline. Because most patients still expect a radiologist to be a person who simply performs x-rays, Tan instructs his junior colleagues to introduce themselves clearly as doctors.

In addition to engaging in better public relations, Tan wants to see all radiologists meet minimum standards for training in diagnostic imaging. While the system should not preclude individuals from undertaking basic radiology training courses so that shortages can be quickly alleviated in regions where staffing is tight, doctors should undergo at least three years of training before attaining the status of a "full radiologist," he said. Clear distinction could then be made between medical school graduates with some experience in imaging techniques and senior doctors familiar with a range of modalities. Such a move would boost levels of diagnostic competence and increase patients' confidence in radiologists as medical professionals.

"I was talking to a doctor recently," Tan said. "I asked him: ?What do you take being a radiologist to mean? Have you done your training?' ?Well, I work in the radiology department, so I am a radiologist,' he told me."

Tan is critical of educational systems that provide few incentives for trainee doctors to upgrade their qualifications. At present, many medical students are trained in urban institutions before being sent to the countryside. When they return from the villages, they begin working as radiologists in city hospitals, after only a short period of unsupervised training in rural clinics.

"That being the case, who wants to go through a three- or four-year program? Everybody can do nine months' training and call themselves a radiologist," he said.

Standardization of training is an important issue. As a first step, the AOSR has compiled a series of recommended minimum requirements for training centers, including guidance for educators and advice on topics that should be covered. Compilation of the guidelines follows a widespread consultation exercise with representatives from across the region. A draft version should be distributed to all AOSR members for their comments before the end of this year.

Implementation of the guidelines and certification of specialists will remain the responsibility of individual countries, with the AOSR's role limited to making general recommendations. The diversity of healthcare provision among the 22 member countries allied with the AOSR would make any attempt at legislation unworkable. The society will instead act as a coordinating body, providing access to information on resources, teaching materials, programs, and conferences.

Strong Foundations

While the AOSR will provide encouragement and support for radiologists to improve their level of practice, Tan recognizes that the impetus for change must come from within. Good training programs do not come cheaply, however, and financing medical education is always problematic. Governments must provide adequate funding, he said.

The training programs envisaged by the AOSR will be tailored to the specific needs of radiologists working in different areas. Doctors who use and are familiar with plain radiography and ultrasound would gain little from lectures on spiral CT or even fluoroscopy. Targeted education is expected to prove more effective than blanket financial aid programs, often criticized for donating inappropriate equipment to developing countries and then failing to teach medical staff how to use it.

This plan is designed to build upon the success of the Asian-Oceanian Seminars on Diagnostic and Interventional Radiology (ASDIR). Launched in October 1996 by AOSR and Bracco International, the ASDIR seminars are directed toward young radiologists. The two to three-day meetings take place twice a year in various locations throughout the region, enabling participants from many countries to attend.

The objectives of the ASDIR seminars are twofold: to increase opportunities for education and to develop a core of proficient educators with whom participants can identify. Speakers are selected from different areas of Asia-Pacific and are encouraged to speak English. Familiarity with the English language is vital if Asian radiologists are to communicate with international colleagues and participate in major conferences. A certain proportion of money is set aside for younger doctors to attend the seminars, thereby fostering the next generation of radiologists and educators.

Investment in the future is providing impetus for change to the AOCR as well. This year's congress has been organized and will be hosted by the AOSR for the first time in the society's 32-year history.

Delegates at AOCR 2001 can look forward to viewing a showcase of technological excellence between the scientific sessions. Congress organizers promise that the technical exhibition will feature the latest innovations and developments in every aspect of diagnosis and image management. Yet the future strength of radiology may depend less on the availability of high-tech equipment and more on the success of initiatives to raise diagnostic competence. Investment in training for a new generation of radiologists, whose skills and expertise will be recognized both in and outside of the region, is a top priority.

Tan wants the AOCR to create a nest egg to help younger radiologists from around the region attend future meetings. A grant from Bracco supports awards for outstanding posters and fellowships that enable presenters from outside Singapore to attend AOCR 2001. The plan is to establish a semipermanent venue for the biennial AOCR. The Singapore Expo has been provisionally booked to host AOCR in 2003, although this will be reviewed after this year's meeting. Tan believes there are parallels with Europe, which saw the European Congress of Radiology settle in Vienna in 1991. The ECR is scheduled to remain in the Austrian capital until at least 2003.

At AOCR 2001, opportunities to display posters have been increased. Delegates can also attend interactive meet-the-expert sessions. Although the AOCR scientific program has three parallel sessions, the concept of the subspecialty radiologist has yet to take root in Asia-Pacific. Specialization is not practical in many institutions, which would struggle to finance the number of specialist teams needed on-call.

The AOCR will be held between 22 and 26 July. Contact:
The Secretariat, 9th AOCR
c/o Dept. of Diagnostic Imaging
National University Hospital
5 Lower Kent Ridge Road
Singapore 119074
Tel.: +65 7724210, Fax: +65 7730190