iRADiX

I read somewhere –“When in Rome, do as Romans do". If this was true, I would have become redundant as a Radiologist.

Libyan Radiology is a complete disaster.

The hospitals are well-equipped with latest diagnostic machines which are either out of order or not being used for lack of technicians or radiologists.

The surprising fact is that no Libyan radiologist performs Ultrasound examination or reports on conventional radiographs.

Everyone is busy reporting CTs or MRIs. And the reports can send any sane mind into turmoil!

The reports are not structured and very often are off the mark. They discuss about hypothetical diseases and tend to create an unusual disease manifestation. The reports would suggest the gravest disease when there none exists.

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It is true that that Radiology is the ‘backbone’ of any institution. If you have to forecast the success of any medical centre, one must start from the radiology department.  And this is not just at local level, its a global phenomenon. Institutions have been catapulted to heights of success by their strong radiology team.

However, Radiology in Africa takes a back seat.

Let us take a closer look into radiology practice in North Africa first.

The countries comprise of Egypt, Libya, Tunisia, Algiers and Morocco.

Radiology practice in Tunisia is at par with Indian standards with ‘cut’ culture. The equipment is ‘state-of-the-art’ only in the capital city of Tunis and the radiology skills are equally good. Elsewhere, the radiology machines are quite old. Most of the radiologists in Tunisia are educated in France which explains the reason for high-standards. There is quackery too, no doubt, as in India. For example, there are quacks with large size refrigerators and tall cupboards claiming ‘miracle’ treatment.

Egypt fairs equally well with a fair mix of ‘good’ and ‘bad’ radiologists. The equipment is both ‘state-of-the-art’and pretty obsolete too in a few centres. One could count good radiologists on finger tips. The best centres are based in Cairo and Mansoura cities along the river Nile. Egyptian radiologists score over all African nations in research publications and scientific presentations in international conferences.

Radiology in Morocco and Algiers is not even worth talking about.

Chest radiography is the most frequently performed diagnostic examination in the public hospitals and private practices.

Almost 150 million chest X-rays are performed every year in US.

This practice is based on a very simple misbelief and everyone thinks rather naively that :

• If a lesion is present in the lungs, it will show up on the x-ray,
• If a lesion shows up on the x-ray, it will be detected by the physician,
• If the lesion is detected by the physician, it will be correctly interpreted, and
• If the lesion is interpreted correctly, the right diagnosis will be made.

Large scale studies, spanning over 20 years, have shown that:

• 20 to 30% of radiographs considered as NORMAL are in fact PATHOLOGICAL (= FALSE NEGATIVES)

• And 1 to 20% of radiographs considered as PATHOLOGICAL are in fact NORMAL (= FALSE POSITIVES)

The perception of pulmonary lesions is influenced by numerous and complex factors.

The summer heat had set in and the sun was high in the sky. The clock had just struck noon when the idea to take a quick break flashed across my mind.

I had just finished the morning rush of patients for ultrasound.

Standing up from my chair, I told my secretary of my intention.

Receptionist entered to announce another patient from Germany with renal colic.

Considering his acute problem, I did not deem fit to delay the scan.

As the patient entered ultrasound suite, he glanced at me with a puzzled look.

The nurse draped a sheet on him and I started to take up the transducer when he suddenly sat up.

“Can you do an ultrasound examination?”

I was startled at his question and completely taken aback. Neither did I comprehend the reason for such a question nor could I justify it.

Here I was, having done more than 60,000 scans of all kinds in my career, faced with such a question.

In broad terms, diagnostic imaging offers the clinical investigator two principal types of information. Most imaging techniques provide information on macrosopic structure, by revealing the anatomy of organs and the morphology of lesions. A second major focus of imaging techniques is the circulatory system, in particular the vascularity of tissues and their perfusion by blood. Future diagnostic imaging modalities, currently used only in research settings, can provide information at the molecular level, such as the concentration of metabolites and the tissue density of proteins (e.g. receptors, enzymes).

Ultrasound (USG) provides information on both macroscopic structure and blood circulation. The capabilities of ultrasound can be improved and expanded by the use of a contrast agent, which does much more than simply improve the signal-to-noise ratio or compensate for inadequate instrumentation!

The role of contrast-enhanced ultrasound (CEUS) in liver imaging is very well established. However, its application in other organs is still controversial.

Herein I will describe a series of clinical examples to illustrate some of the varied uses of contrast-enhanced ultrasound beyond the common application in the study of focal liver lesions.

In our practice of Radiology, and especially in another country where the radiology services are quite not at par, we are under pressure to teach the fellow colleagues.

A ‘consultant’ is seen as a source of ‘new’ information and fellow medical colleagues are attracted like ‘bees’.

Often the situation becomes difficult to handle as in the case of my friend JS, who was travelling for the first time out of country to work in a new place. The pressure to teach on him was so overbearing that he succumbed to it and resigned from his job.

How should we deal with ‘pressure at work’?

Pressure can come from different quarters. It could just be ‘work pressure’, ‘peer pressure’ or pressure from the boss!

Focal liver lesions pose a diagnostic challenge to radiologist and clinician alike. Many focal liver lesions remain undiscovered throughout the patients’ life only to be discovered on autopsy.

Most focal liver lesions are incidental findings, especially at ultrasound examinations performed as part of the follow-up of tumor patients or in screening programs for liver cirrhosis.

How many of our colleagues in India use contrast-enhanced ultrasound or diffusion weighted MRI for characterization of liver lesions? And what about the cost?

What comes after ultrasound?

The quality of ultrasound findings varies with the experience of the examiner and the quality of equipment. Contrast-enhanced ultrasound is generally the preserve of specialized centres. In this situation, according to the EASL Barcelona guidelines, a triphasic CT scan or contrast-enhanced dynamic MRI scan should also be performed before the lesion can be characterized.

Radiology has come a long way since the introduction of X-rays when Wilhelm Röntgen took first "medical" x-ray of his wife's hand on 22 December 1895. The field of radiology has expanded beyond the realms of X-rays with nuclear magnetic resonance and ultrasound wave technology being the major players in modern times. Our attitude towards X-rays has also diversified with development of computed tomography.

With the advancement in technology has come vast expansion in the applications of radiological methods and the huge demand on radiologist to provide the correct diagnosis, sometimes even in most adverse circumstances.

This translates into a heavy burden and responsibility on the radiologists’ shoulder. And ‘to err is human’!

30% of medical law suits in US are related to missed diagnosis!

For the court a clinical examination is no longer sufficient to prove a case: Objective documents are requested, leading to numerous unnecessary examinations.

In the present scenario, the roles and responsibilities of radiologist must change with time.

The referring physicians need a clinical interface with radiology. For this, the radiologist should fully understand the clinical problem.

And the radiologist is expected to do this for every clinical problem and for all medical specialities!

I had finished my 43^rd ultrasound of the day and clock had struck 2:30 in the afternoon. I felt uncomfortable in my pelvis and wanted to attend to the nature’s call. As I got up to leave the ultrasound room, a patient at the door stopped me and said –

“Hey Doc! Where are you off to?”

Being very polite I replied unrevealingly - “I am just coming back. Please wait for me”.

“Ohhh! I have been waiting for over two hours for my turn just to get an ultrasound examination……..and now you tell me to wait a little longer?”

“I understand you very well and I have been trying to do as fast as I can. Don’t worry, I will see you first when I get back” I tried to bargain out of the situation.

“No doc. You cannot leave this room without doing my ultrasound. I am a patient and have already waited too long.”