Pediatric radiology requires wide skill set

One radiological subspecialty does not deal with a single organ or organ system. Nor does it concentrate on a single imaging modality. On the contrary, it evaluates and takes care of the entire body, reflecting on how it and its metabolism work and how they change with age and physical development.

This might sound like an occupation for sophisticated people. Indeed, some professionals performing this subspecialty claim that they are the last disciples of the haute ecole of radiology, the art of radiology. If you give it a second look, you see their point.

The profession we speak of is pediatric radiology. Its practitioners must have a complete command of anatomy, physiology, pathophysiology, metabolism, and disease for human beings weighing between 250 g and 60 kg, from birth (or even preterm) to near adulthood. Children (0 to 14 years) and adolescents (15 to 18 years) make up 19% to 25% of the general population in European countries.1 They also account for 15% to 20% of medical patients.

Yet doctors practicing pediatric radiology are a marginal group in the medical imaging community. In Germany, there are approximately 50 radiologists per million adults but only five pediatric radiologists for every million children and adolescents.2 Neuroradiology appears to be the most stable radiological subspecialty, and interventional radiology will most likely develop further as a bone of contention between medical disciplines. Meanwhile, pediatric radiology, a marginal stepchild, will continue life in the back room.

Pediatric radiologists are easy to distinguish from their patients. You rarely find the sophisticated gentleman; more often a sophisticated lady. She is most likely to be the benevolent-looking person with gray hair, close to 60 years of age. Her position will not be filled after she retires.

There are, apparently, some pediatric radiologists in private practice, though I do not know any of them personally. Survival must be very difficult, given that pediatric radiology examinations show little profit. Examinations involving children, particularly young children, are time-consuming and consequently expensive. Dealing with crying infants is not a terribly sexy job. Performing heart transplants, brain surgery, or even interventional procedures is cooler.

NOT JUST SMALL ADULTS

Hardly anybody outside the world of pediatric radiology realizes the difficulties of imaging studies involving children. Hospital managers or health politicians have other things on their minds. Losing money is not one of them. I still remember the friendly remark made by a local politician on the board of our university department. We were discussing the budget for the following year.

"Why don't you close down one MRI machine? It will cut costs," he said.

Why not get rid of all schoolteachers who become politicians? They won't get sick any more. It will cut costs.

Permanent quarrels about turf reach deep into pediatric radiology. There are the pediatricians who want to do ultrasound on children, claiming that pediatric radiologists are not needed for these examinations. "We can handle this ourselves" is a statement that pediatric radiologists have to live with. Then there are the general radiologists who say, "Children or adults, I take care of everything."

Pediatric radiologists cannot be blamed when they accuse their "adult" colleagues of arrogance and presumptuousness. The notion that a general radiologist-usually a subspecialist-can cover everything in medical imaging from ultrasound to nuclear medicine, from interventional procedures to pediatric radiology, is bizarre and mistaken. Yet some people believe that they know the discipline without proper training. They argue, "We have to do these examinations on children because there are not enough pediatric radiologists." Insecurity and lack of knowledge are covered up.

Arguments using analogies to adults don't count: They might be easily wrong. Knowledge about special characteristics in healthy and diseased children, of differing ages, is fundamental for the choice of imaging technique and image interpretation.

Children needing x-rays are usually examined in the general radiology section. How I remember that. Everybody hated it. Crying and fighting little brats block the examination rooms, putting technologists and radiologists in a bad mood. The mother complains. The father threatens. There was no separate waiting room for children, but such a place is necessary if you want the youngsters to relax. You need special furniture, toys, books-and a bar for the accompanying parents.

Whose demands do pediatric radiologists cater to? Patients? Most patients do not know that radiologists exist and would never ask to be helped by one. Or are pediatric radiologists focusing on the needs of parents, referring physicians, or health administrators?

The most powerful lobby for pediatric radiology would be the parents of sick children. This is a volatile, difficult-to-reach group, however. Here today, gone tomorrow. Most parents also follow the common trend of believing in high technology rather than the people using their brains and knowledge. They equate having a bigger scanner with a better service, never mind who is operating it or reporting the results.

RADIATION PROTECTION

Imaging examinations of children are usually performed by radiologists who most often examine adults. "Children are not just small adults" is a phrase often repeated by pediatricians. Children are defenseless and need protection. When it comes to examinations involving ionizing radiation, children are especially vulnerable.

There are clear recommendations on the technologies that should be used for imaging studies in children. CT studies should be performed only when searching for pulmonary changes and after accidents to diagnose or rule out multiple or craniocerebral injuries. This should also hold for pediatric oncology patients, many of whom will survive their childhood cancer but then develop another cancer later in life. Extensive CT examinations may be part of the cause.

The first choice of imaging modality for children and adolescents is ultrasound, with MRI next in line. Both of these modalities are readily available across Europe. X-ray should be considered only when nothing else is available.3 Radiation protection is of utmost concern and must have a high priority. If there are no dedicated machines for pediatric imaging, practitioners should have flexible access to the adults' top-notch equipment.

Clinical practices vary markedly in different countries. Ultrasound is performed by technologists in the U.S., for example, while in Canada it is carried out by radiologists. Pediatric radiology is not included in the board training of radiologists in Germany, whereas in Switzerland it is part of the curriculum.

ONGOING DILEMMA

France is a model within Europe for pediatric radiology. Training is supported, and a pool of qualified pediatric radiologists has been built up. Generally, however, this subspecialty faces a staffing crisis, and the number of pediatric radiologists is decreasing rapidly.4-7

Who is responsible? Looking for culprits and rounding up the usual suspects does not reveal too much. Minorities are usually blamed, but here, it is the pediatric radiologists themselves who are the minority. They cannot be responsible for their own imminent demise.

What happens if there are no more pediatric radiologists? Somebody else has to perform these studies. Perhaps a general radiologist, a pediatrician, a physician from another specialty, or a technologist. Pediatric radiologists have tried attracting medical students or young radiologists into their subspecialty for some time. Their public relations endeavors have included lectures, weekly image reading sessions for pediatricians and other referring physicians, and excellent continuing education courses on a European level.

Could physicians working in pediatrics move straight into radiology, as has been suggested?4 It has been argued that these practitioners would not need to learn much "adult" radiology because many features of general radiology are irrelevant to pediatric imaging. This is an unpalatable solution for established pediatric radiologists and a solution that would be impossible in many European countries. Why not raise awareness within the radiology community that pediatric radiology is a worthwhile specialty that demands special knowledge and skills and that should remain in the domain of specially trained radiologists and not be released to other disciplines as an added skill?

It is quite interesting to learn the opinions of the younger U.S. generation on this topic. They place a large emphasis on lifestyle, finances, and flexible working. Of course, there is no reason why a pediatric radiologist should earn less than a general radiologist.

The ultimate focus should be the patient. Children cannot or do not speak for themselves and do not have a strong political lobby. As one pediatric radiologist observed, "Children have the right to be treated by somebody who is properly educated." Politically minded doctors and academic radiologists should take on this issue and press for a stronger, younger pediatric radiology.

One final thought. A team of politicians interested in health matters traveled through a European country recently to determine which hospital departments should be sponsored and subsidized in the future. The three started their journey at a pediatric ward in a big provincial hospital, and were very impressed with what they observed. The first politician wrote a check for 100,000 Euro.

The next stop was a dermatology department at a university hospital. Again, the politicians were impressed, and the second politician wrote a check for 200,000 Euro. Their final stop was the psychiatric ward of the country's biggest prison. Here, the last politician left a check for 5 million Euro. When asked by her follow travelers why she was so generous, she responded, "Do you think that we will ever be hospitalized in a pediatric ward?"

PROF. DR. RINCK is visiting professor at the University of Mons in Belgium. He can be reached at peter.rinck@umh.ac.be

References

• U.S. Census Bureau. www.census.gov/ipc/www/idbpyr.html.

• Benz-Bohm G. Kinderradiologie. 2nd ed. Stuttgart: Thieme, 2005:vii.

• Strahlenschutzkommission [Radiation protection commission of Germany]. Bildgebende Diagnostik beim Kind ? Strahlenschutz, Rechtfertigung und Effektivitat [Imaging diagnostics in children?Radiation protection, justification, and efficiency]. Bonn 2006. German

• Bramson RT, Taylor GA. SOS: can we save pediatric radiology? Radiology 2005 235(3):719-722.

• Grunz DJ, Bramson RT, Taylor GA. Pediatric radiology. Radiology 2006;238(3):1072-1073; author reply 1073-1074.

• van Rijn RR, Owens CM, Avni F, et al. The future of pediatric radiology: a European point of view. Radiology 2006;238(3):1074;author reply 1074-1075.

• Kalifa G, Panuel M. Can pediatric radiology be saved? J Radiol 2005;86(11):1647-1648. French