“Challenges of education research are multiplied in radiology”

February 5, 2019 0 By S Harachand

Dr Hemant Patel is President Elect, Indian Radiological & Imaging Association (IRIA) — a national body promoting the study and the practice of diagnostic, radiological and imaging modalities. A recipient of molecular imaging award and prestigious cum laude award from the Radiological Society of North America (RSNA), Dr Patel has done extensive work in MRI, CT scan and fusion imaging. A renowned academician, entrepreneur and professional sportsman, he is currently working as a Consultant Radiologist in Gujarat Imaging Centre. Excerpts from his conversation with FM

Role of radiologists getting bigger by the day with the integration of advancing technology in clinical practice. How do you see the situation emerging in India? 

Radiology has come a long way from the era of radiographs and conventional barium procedures to state-of-the-art cross-sectional imaging modalities with increased spatial and temporal resolutions to digitization with ‘filmless’ technology.

Over time, diagnosis in radiology has become easier with remarkably improved and advanced imaging modalities and the new generation of radiologists may not know how difficult things once had been.

Today we have made remarkable advances in diagnostic radiology with ever improvising cross-sectional imaging modalities. New generation CT scanners with higher slice systems (improved image quality, reduced scan times, eliminate stitching artifacts, freeze cardiac and respiratory motion), new detector technology (reduces electronic noise and enables sharper images), and iterative reconstruction (provides diagnostic image clarity on low dose scans).

The most recent advances in magnetic resonance imaging (MRI) technology have been software innovations that have opened new possibilities to expand the use of MRI. The short duration of the exam is especially a comforting factor to the pediatric & geriatric patients.

Intra-operative MRI is a reality today as it enables clinically validated brain study in a very short time (just 5 min). Neuro-navigation software with image processing facilitates surgical mapping and improves efficiency in the OR.

Despite the immense advancements in imaging technology, we still have a large population in rural India that does not have access to these newer advancements. Progressively, imaging modalities though refurbished machines or old generation scanners are being installed and facilities coming up in these parts of the country. Telemedicine and web-based remote viewing systems are bringing them a step forward, providing access to expert opinions in remote locations, reducing expenses and thus improvising patient care and management.

Currently, the most prominent or pressing clinical applications of molecular imaging are in the fields of oncology and cardiovascular disease. In oncology, molecular imaging has already resulted in some breakthroughs in cancer staging and treatment response assessment and it is anticipated to facilitate early disease detection. In cardiovascular disease, molecular imaging is expected to serve a central role in addressing basic questions regarding cell therapy for cardiac repair and vulnerable plaque detection

Integration of artificial intelligence (AI) is a big wave in Radiology and imaging. In clinical practice of the future, it won’t take away our responsibilities as a radiological provider, but they will shift how we handle our workload. “Just like Excel spreadsheets changed the way accountants work, deep learning AI will prove the same thing is true in radiology,”

Algorithms will tee up some of the routine things for us so we’re more efficient with mundane tasks and routine screenings. It will give us more time to focus on the unusual and atypical scans.

We, radiologists, are fortunate to live in such exciting times, and today’s researchers have fascinating scientific breakthroughs awaiting them. Only time will tell if the present exciting era ever will be regarded as ‘golden era of radiology’ 

Some radiologists say that the decision as to what imaging modality is required for a case should be taken by the radiologist and not the referring physician. What is your comment?

Unlike other specialties, the field of radiology entails wide spectrum of imaging modalities like X-rays, sonography, CT scan, MRI, nuclear medicine etc. It is a task to master even a single modality, let alone all of them. Each of these modalities has their own distinct advantages and limitations, and there are newer innovations and constant technological improvisations, which are best understood by the radiologists. At the same time, medicine, in general, is progressing at such a fast pace in all its sub-specialties and the expectations of the referring are also increasing to answer smallest queries, which is possible today with the better understanding of these modalities.

I believe that referring clinicians and surgeons ask the right questions to which they need answers from the radiologist to help in the management of the patient and can rely on the radiologists to correctly use the optimal imaging modality to provide the most satisfying answers, thus benefitting the patient. For example, now it is a routine practice to combine MRI pelvis with contrast CT imaging for female pelvis imaging or combining the dynamic evaluation of USG with a higher spatial resolution of MRI for MSK pathologies. So only by the continuous liaisoning and communication with our referring colleagues can we keep pace with the progressive understanding of the science, learn and find answers to the ever-increasing demands and thus provide a better and higher standard of care to our patients. 

Interventional radiology is coming up as a subspecialty to radiology. What is the current status of IR training in India? 

Interventional radiology (IR) is a subspecialty which provides minimally invasive image-guided diagnosis and treatment of disease. According to statistics, only one interventional radiology expert is available per every 2.18 lakh population in India – so there is a huge lacuna to fill.

Nevertheless, there has been a steady growth in this field worldwide and in India, mostly because of increasing demands from referring physicians, the widespread availability of imaging equipment for guided procedures, IR’s potential to serve as a convenient alternative to open surgical procedures and reduce recovery time, and the tremendous advances in IR hardware.

Today we have a wide variety of new IR techniques that are successfully incorporated into clinical practice, which involve the use of catheters, guide wires, glide wires, balloons for angioplasty, coils, liquid embolizing agents, stents and stent grafts, radiofrequency ablation devices, thrombectomy devices, etc.

IR has a promising future with the continuing advances in this field – namely the clinical gene therapy – which is rapidly developing and promising therapeutic modality.

Gene therapy involves ‘transferring recombinant genetic material (DNA/ RNA) into the host cell in order to change the gene expression in the host cell to gain a therapeutic effect.’ Interventional radiologists will ‘play’ an important role in the transmission of genetic materials to the target cells, using percutaneous injection or catheter systems. In the times ahead, interventional radiologists will play an increasingly important role in selecting, guiding, and monitoring clinical gene therapy.

Research in gene therapy applications is underway in diverse areas, including infections, malignancies, metabolic disorders, and enzyme deficiencies. It also has a role in the treatment of ischemia of the myocardium and extremities with angiogenetic growth factors to promote collateral artery development as well as in treating stenoses following balloon angioplasty or stenting and in therapeutic angiogenesis.

It is therefore important that interventional radiologists be prepared, continuously updating their knowledge to keep abreast of the advances in molecular imaging and clinical gene therapy applications and issues. The interventional radiologist must know it all: from the awareness of gene therapy terminology to concepts in cloning, vectors, and detection of their expression; from a functional knowledge of molecular imaging and immunology, to understanding the different types of catheters used in the practice of gene transfer technology, such as pressure diffusion, passive diffusion, and mechanical and electrically strengthened catheters. Interventional radiologists should also recognize and be aware of the ongoing advances in the development of novel treatment technologies, commonly used targeted tracers and probes, and of the visualization tools employed to analyze targeted therapy. The time is not far when catheter-based delivery of tagged stem cells to target lesions becomes an established procedure.

As president-elect of IRIA, what are the areas in profession and practice that you think deserve immediate consideration?

It is the role of academic and research institutions to gather knowledge and dedicate resources in the newly emerging fields. The radiological community needs to invest in this future through education and participation and by creating relevant research facilities. Well, I have taken lead and started with the IRIA Research and Education Foundation. As on today medical education research is not as well understood or established in India. Compared with medicine in general, these challenges are multiplied in radiology, where there are relatively fewer extramural research money available and skilled investigators to carry out radiology education research. The reasons for this are many, but most importantly, there is insufficient funding for medical education and a dearth of skilled and experienced medical education researchers.

IRIA Research & Education Foundation’s mission is to improve Radiology Education, training, orations, fellowships, journals and research projects within India. To Improve patient care by supporting education in radiology and related scientific disciplines through arranging radiology seminars, funding grants and awards to individuals and institutions that will advance radiologic research, education, and practice. To enhance radiology outreach programmes., So radiology science and updates can reach to smaller states, districts and towns.  Eventually, This will also help to uplift level of medical services and patient care in India.

 But it is not only research – clinical radiologists have to be aware of the ongoing innovations in our profession and support training and education of the next generation.  We need to make vigorous efforts for the motivation of students and radiology residents in all the leading Indian medical institutions so that we can create our next generation of super-specialized diagnostic and interventional radiologists who can gradually step into the shoes of the current practitioners, as is happening in many other countries. IRIA organizes hundreds of CME throughout the country for knowledge sharing and uplift of radiology standards. I foresee a very bright future of this wonderful fraternity of medicine.