Paediatric radiology in India

In February 2010, I had published an editorial in the Indian Journal of Radiology and Imaging, where I had discussed a survey on the status of paediatric radiology among the radiologists who had attended a paediatric radiology update in November 20091. Paediatric radiologists from the Hospital for Sick Children in Toronto, Canada and local radiologists from India with an interest in paediatric radiology had conducted this meeting jointly. These findings have recently also been published in Paediatric Radiology2.

The main findings as reported in the editorial were quite interesting. Almost 63 per cent of the radiologists surveyed said that they had received less than two weeks of dedicated paediatric radiology training with 82 per cent believing that their institutions did not really place any importance to dedicated paediatric radiology training. Having said that, 45 per cent on a scale of 1-5 believed that it was not really important to have adequate training in paediatric radiology (scores 1 and 2), whereas 23 per cent were equivocal (score of 3), while 57 per cent agreed that the training was inadequate as well (scores 1 and 2), 17 per cent being equivocal (score 3).

When the questions were rephrased from a patient’s perspective, 77 per cent believed that children were receiving inadequate care with respect to medical imaging (scores 1 and 2), while another 17 per cent were equivocal. When the question was reworded and they were asked whether the radiologists were competent or not when handling children, 47 per cent were equivocal, 30 per cent thought they were not competent, but 22 per cent believed that they were competent. This is not surprising since radiologists will in general blame the system rather than themselves for deficiencies in care and will also believe that they are better than the others around them. However, surprisingly, 75 per cent of those present thought that paediatric radiology will gain more and more importance in the future.

What the survey revealed is that training in paediatric radiology in India is inadequate, the focus on training is all but absent and this translates into inadequate and perhaps poor care in the majority of radiology centres and departments across the country.

It is obvious that we have to sub-specialise. That is the only way we will be able to speak the language of our clinical colleagues and answer the questions that they have. In India, there is some semblance of sub-specialisation in neuroradiology and interventional and vascular radiology, but beyond these two disciplines, there is a significant resistance to sub-specialisation.

So ultrasonologists who can very well afford to sub-specialise in obstetrics will still do Achilles tendon scans and mammologists will also handle the testes. We often have CT scan and MRI sub-specialists, but chest, cardiac, bone, gastrointestinal and genitourinary or abdominal sub-specialists are few and far between.

The reasons are many; lack of training or focus during residency; a fear that organ sub-specialisation will lead to a reduced value in the job- market, if and when jobs have to be changed; a sense of not wanting to let go; a lack of peers around who can serve as role models, etc.

Paediatric radiology more than any other discipline needs sub-specialists. Infants and children are not just young adults. Radiologists who understand how to adjust protocols, and who can speak the same language as the paediatricians and paediatric surgeons, are sorely required, if we are to be an integral part of the teams that manage infants and children. Until then we will remain image-producers, not doctors who can make a positive difference!

In 2012, I was invited by the Indian Society of Pediatric Radiology to deliver the Arcot Gajaraj Memorial Oration. I decided to speak on “The Challenge of Pediatric Radiology in India” I repeated another survey in 2012.

The main question I asked was, “What is the role of a paediatric radiologist in a private practice group and a hospital?” The vast majority said that a paediatric radiologist is an asset in a hospital, but there is very little role in private practice and the reasons ranged from economic to the fear of being sub-specialised and then perhaps unemployable.

All of this gets further complicated by the fact that while we think of paediatric radiology as a sub-speciality, adult sub-speciality radiologists are branching out into their respective paediatric organ sub-speciality. For example, neuroradiologists are now becoming exclusive paediatric neuroradiologists. They don’t come from a paediatric radiology background, but typically from a neuroradiology background. Similarly, paediatric musculoskeletal (MSK) experts come from an MSK background, not from a paediatric radiology background. In major paediatric institutes around the world, the main role of a generalist paediatric radiologist is now limited to body radiology, typically the chest and abdomen. This still however constitutes a large volume, especially in paediatric hospitals.

In India, the radiologists who practice pure paediatric radiology would be less than 10. Given that we have a population of 1.2 billion with one-third below the age of 15, this is woefully inadequate2. But then we have only around 15,000 radiologists for the whole country, clustered in metros, with so much work to be done in all other sub-specialities, that there is no reason for anyone to branch out into paediatric radiology, unless one has a passion for the subject and even then it may be difficult to find a hospital that supports this passion.

Unless there is a structured, government/ Medical Council of India (MCI) led directive on adequate sub-specialisation, the situation is unlikely to change.

References:

1. Jankharia B. The subspecialization conundrum. Ind J Radiol Imag 2010;20:1
2. Sidhu A, Sheikh N, Chavhan G et al. Ped Radiol 2014;44:657