Better training leads to less costly health system
hile visiting two European countries, Ruritania and Autobahnia, I recently met with two distinguished radiologists, one from each nation.
In Ruritania, the leading radiologist has been in diagnostic radiology for the last thirty years. During our meeting, which took place in his clean and tidy office lined with filing cabinets, he told me his hospital had acquired its first – and only – CT scanner eight years ago. The hospital's only ultrasound machine is not only outdated but malfunctioning.
Therefore, he bases his practice mostly on conventional x-ray examinations. He relies to a great extent on knowledge and intuition as well as on the images he has stored in his brain since he began his career the several decades ago. I could not help but admire such a memory.
The radiologist I met in Autobahnia was a very busy man. Our conversation took place in his oak-furnished office while he continued answering his telephone and talking to his private patients in the adjacent room. One of them was a patient suspected of having a liver tumor. After the patient was sent in, the radiologist made an ultrasound examination with the machine in his office. He then took a pen, marked the boundaries of the liver on the patient’s skin and forwarded him to radiation therapy.
In his hospital, the Autobahnian radiologist is in charge of diagnostic radiology, interventional radiology, ultrasound, magnetic resonance imaging, radiation therapy, and nuclear medicine. I, too, have had training in all these disciplines, but was amazed to find someone practicing all of them simultaneously. Did he really “know” everything or had he just “heard” of everything?
Initially, my visits left me with the impression that I had encountered radiology's polar opposites. However, the more I thought about these two radiologists, the more convinced I became that they were not all that different.
They had at least three things in common, the most important of which is that both deliver services to the best of their knowledge and abilities. They also share the same age. Both are in their late fifties and received their training in radiology more than twenty years ago. The Ruritanian is still very much involved in conventional radiology, however, while his counterpart in the country of the superhighways spends his time with computed imaging modalities.
The third common denominator is continuing education – or actually, their lack of it. The only time devoted to continuing education by either radiologist is during national or international conferences they attend. Because of the nature and size of these conferences, neither radiologist asks questions when he does not understand what the speaker is talking about, ultimately reducing the quantity and quality of learning. Anyhow, even active participation in the annual or biannual meetings of radiological societies is insufficient to stay up to date in radiology.
Twenty years ago, when both radiologists were finishing their education in the field, modern imaging technologies such as CT, digital subtraction angiography, interventional radiology, ultrasound, and magnetic resonance imaging were unknown. These technologies have developed at such a fast pace that only recently graduated radiologists have been trained in them as part of their formal education, even if superficially.
For the Autobahnian radiologist, however, it has been sound business sense to incorporate all these technologies into his practice; he would be left behind by his colleagues otherwise. His problem has been finding time to learn them in depth because he is overwhelmed with administrative tasks.
The Ruritanian radiologist, whether by choice or by circumstance, has taken a different path by implementing technologies only as absolutely necessary. His hospital cannot afford to keep up with new developments and he is in no hurry to convince them about their usefulness because he would have to start by learning about them in order to make his case – and why learning something for which there is no money?
In totally different situations and for completely different reasons, these two radiologists have not kept up to date with advances in the field. To do so, they would need retraining, but the circumstances and pressures of their positions prevent them from getting it. Actively learning radiology after residency could have a negative impact on their status and, more important, their income; in addition, it would hardly be tolerated by the health bureaucrats.
Only basic training and continuing education with retraining guarantee the best and most economical use of medical technology and, perhaps, a decrease of healthcare costs. How many hospitals and practices are showcases of equipment being used by radiologists who do not realize the equipment's full potential and appropriate indications, as may be the case in Autobahnia? And how many are using obsolete or inadequate techniques, with high running and maintenance costs, to the detriment of their patients, as could be the case in Ruritania?
But, of course, education is not free. On the contrary, good education and training are frequently very expensive. Really good educational material can often only be provided by pharmaceutical companies. It is not their task to invest in this; but who else does? Furthermore, it is to be expected that the material they produce is mostly related to their products and, thus, not comprehensive.
Today it is nearly impossible for a single radiologist to be up to date or even to completely understand all radiological techniques. In the future it will be even worse. Therefore, a feasible solution would be to establish a cooperation between several radiologists to set the standards in a hospital or a private practice.
Beyond this we need national standards or better a European standard in training and continuing education in medical imaging. This standard must be decided upon, continuously upgraded – and implemented and enforced. It is worth nothing if it exists only on paper.
Once such a precedent has been set, the need to develop training and continuing education programs would be apparent, thus destroying the attitude and sometime the myth among some of them, that graduating is enough and, on the part of other institutions and organizations, that there is little benefit in investing in continuing education.
The Commission of the European Communities would be the authority of choice to create such a system. Unfortunately, this seems to be a low priority task for Brussels. The question is: Who else can take establish and implement a standard for continuing education?