Radiology should not be treated as a commodity, according to Prof. Mark Khangure, immediate past president of the Royal Australian and New Zealand College of Radiologists. In this question-and-answer interview, he talks about the challenges faced by radiology in remote regions and the innovative strategies developed by the RANZCR to defend the discipline’s interests in the healthcare system. Khangure is a neuroradiologist at St. John of God Hospital, Subiaco, Western Australia.
Radiology should not be treated as a commodity, according to Prof. Mark Khangure, immediate past president of the Royal Australian and New Zealand College of Radiologists (RANZCR). In this question-and-answer interview, he talks about the challenges faced by radiology in remote regions and the innovative strategies developed by the RANZCR to defend the discipline’s interests in the healthcare system. Khangure is a neuroradiologist at St. John of God Hospital, Subiaco, Western Australia.
Q: How is radiology doing in Australia and New Zealand today? A: Radiology is booming in Australia and New Zealand with growth in diagnostic imaging services running at approximately 7% per annum. However, the shortage of radiologists and radiographers presents real challenges in satisfying demand while ensuring quality service and safe workloads. In addition, the Australian government’s universal health insurance scheme (Medicare) does not adequately reimburse patients for the cost of diagnostic imaging services, resulting in increased financial burden on patients. Formed in 1949, the Royal Australian and New Zealand College of Radiologists, which is responsible for training, continuing education, and professional standards in radiology and radiation oncology, is working to address these and other quality issues.
Q: How many radiologists are currently working in Australia and New Zealand? What is the proportion of men, women, and young people? How does it compare to the whole population (how many radiologists for how many inhabitants)?
A: There are approximately 1660 radiologists in active practice in Australia (1380) and New Zealand (280).
In 2006 20% of the Australian radiology workforce and 30% in New Zealand was female. Of the current radiology trainees, 34% are female. Twenty percent of fully qualified radiologists are over 60 and about 25% are under 40.
Q: How do you see the demography of your profession evolving in the near future?
A: The RANZCR is concerned that the current number of training positions is inadequate to produce the required number of radiologists, based on our estimate of likely retirements in the next five to 10 years and increasing demand. There is no shortage of young doctors seeking to be trained, but we do not have enough funded, accredited training positions. One of our key challenges is to persuade governments and to encourage private practices to support new training positions. In addition, doctors generally are questioning their work time commitment and “lifestyle balance” and many are seeking to reduce working hours.
Q: How is Australian and New Zealand radiology meeting the growing need for a multidisciplinary approach in radiology?
A: Radiology is rapidly moving in the direction of organ-based rather than modality-based expertise, with care delivered in clinical teams, of which the radiologist is a central participant. We have much to learn from our radiation oncology colleagues in this regard. This multidisciplinary trend is particularly evident in hospital-based services but also increasingly in private ambulatory practices.
Q: Skilled staff are a prerequisite for the implementation and maintenance of high-quality radiological services. What do you do to promote postgraduate education and training in modern imaging methods?
A: The college is responsible for the training of radiologists and radiation oncologists in our two countries. RANZCR conducts a five-year apprenticeship-model training program, which is regularly reviewed and accredited by the Australian Medical Council and the Medical Council of New Zealand. The curriculum for radiology training is currently being redeveloped to reflect modern imaging and best practice education, and adopts the CanMEDS physician competencies framework.
RANZCR also conducts a continuing professional development program. Members of the college are expected to participate in this program, which involves accruing CPD points over a triennium with minimum subrequirements for different kinds of educational activities, including audit. In addition we run our four-day Annual Scientific Meeting in October each year, as well as smaller meetings in New Zealand and most states of Australia. For rural and provincial centers the college has various CPD sessions delivered by videoconference and through the web.
Q: Is there any competition between Australian/New Zealand radiological services and other services? If so, how does radiology work together with those specialties to improve the situation?
A: Other clinical disciplines are always ready to move in on imaging “territory” innovatively developed by radiologists and to claim that they have the specialist skills in their particular area. This occurs in obstetrics and gynecology, neurology and neurosurgery, vascular surgery, psychiatry, and cardiology. The answer is in having skills and specialist knowledge that are at least comparable plus the advantage of having a thorough understanding and training in imaging and the ability to integrate the clinical and laboratory findings with imaging. It also means recognising the need for and creating linkages with other clinicians in value-adding partnerships.
This issue raises significant questions about the extent to which we can train generalist radiologists and at what stage in training subspecialty skills should be developed.
Q: How relevant is the use of teleradiology in a country as wide as Australia and as remote as New Zealand?
A: Teleradiology is increasingly being used to provide services to more remote regions that are not able to support radiologists onsite. It also enables access to the expertise of specialist radiologists and assists with out-of-hours and on-call arrangements. Most teleradiology is delivered from other sites within Australia and New Zealand, but some services are provided internationally.
The college believes that teleradiology must be subject to the same quality standards and meet certain minimum requirements, such as ensuring that the radiologist providing the opinion is a qualified specialist who meets the appropriate training, registration, certification, licensure, credentialing, malpractice insurance, and CPD requirements for the referring and interpretation sites. The college subscribes to the principles for International Clinical Teleradiology developed by the International Radiology Quality Network.
Q: What are the challenges faced by the specialty in these two countries?
A: The uniqueness of radiology in Australia and New Zealand is related to several factors: The challenges of delivering services to small populations in remote and isolated communities, as well as in large population centers in the major capital cities; the complications of services being delivered in different political and economic jurisdictions between Australia and New Zealand and eight different jurisdictions (the states and territories) within Australia; the different environments, modes of practice, and service delivery between the public and private sectors, in part related to the funding models underpinning them.
The major current challenges are: The shortage of radiologists and insufficient funding of training positions; increasing workload pressures with a risk of diminishing quality and safety; the need for a much greater presence for radiology in medical schools’ curricula, especially in relation to appropriateness of imaging; the need for academic radiology positions in universities to help shape teaching and research; and resisting the tendency for the health system to treat radiology as a commodity rather than a consultative clinical service providing an expert medical opinion that directly contributes to patient care and clinical problem solving.
Q: What strategy is RANZCR developing to address the situation?
A: The college’s strategic planning includes: Lobbying governments and private sector practices to fund more training positions; developing and promulgating standards of practice that promote safe and quality care, including acceptable workloads of radiologists and technical staff; lobbying universities and governments to support academic positions in radiology; and engaging with key stakeholders in the health system to establish structures, a culture, and funding mechanisms that promote and support quality radiology services.
Q: Can you tell me more about the Quality Use of Diagnostic Imaging Program?
A: The Quality Use of Diagnostic Imaging Program is a research and development program providing an evidence base for diagnostic imaging in Australia and New Zealand. The college, through the QUDI Program, has commissioned a wide range of projects addressing quality issues from the perspectives of consumers, referrers, and radiology providers, as well as considering economic issues in the delivery of services.
The program commenced in 2005 and has been fully funded by the Australian federal government and managed by RANZCR. Its current annual budget is AU$1 million. It aims to promote safe, effective, efficient, and sustainable imaging services that lead to optimal diagnosis and treatment, support consumer choice and empowerment, are delivered by accredited practitioners using evidence-based guidelines, and are sustainable within the national health system “budget.” Comprehensive information on QUDI can be accessed at its website.
Q: Where exactly is it put in practice? What changes will it bring, and how?
A: The QUDI Program has been able to bridge the gap between policy and radiology practice in hospital and community settings. It has been able to improve quality at a national level, for example, through informing the development of the RANZCR’s standards of practice and the curriculum for radiology trainees. A national resource is being developed to provide information that is reliable, credible, and consistent for both healthcare referrers and consumers. These materials will be available from a variety of sources and formats via a variety of media. At a local level, the program has run a successful pilot project that has resulted in radiation dose reduction in pediatric CT examinations and has implemented clinical guidelines in a variety of local settings. Trainees and members are also being trained in evidence-based medicine and critical appraisal of literature through interactive workshops delivered online and face to face.
Q: What future trends and challenges do you foresee in radiology?
A: The key trends are likely to include: Increasing demand for imaging as clinicians seek to have as much diagnostic information available as possible and greater consumer awareness of imaging technologies and demand for access to them. Diagnostic imaging will be used much more widely in screening and prevention programs; molecular imaging will provide new opportunities and challenges; other clinical disciplines will continue to claim ownership of imaging within their sphere of practice. The trend for radiologists and other medical practitioners to want to control their workloads and to work flexibly and part-time, together with increasing demand for services, will require a major expansion in workforce and challenge the profession’s ability to provide the required training.
Subspecialisation of the radiology workforce will continue in response to the increasing sophistication of technologies and practice in multidisciplinary teams.
A version of this article originally appeared in the 2009 ECR Today congress newspaper. Interview by Mélisande Rouger.