- Email: [email protected]
Pediatric Radiology Education in a Metropolitan Radiology Residency in West Africa: The Accra Experience
A VIEW FROM ABROAD BIRGIT ERTL-WAGNER, MD
Pediatric Radiology Education in a Metropolitan Radiology Residency in West Africa: The Accra Experience Hansel J. Otero, MD, Becky A. Appiah, MD, Yaw Mensah, MD INTRODUCTION Pediatric radiology is an important core radiology subspecialty, 1 of 5 listed by the ABR and 1 of 15 evaluated in the ABR core (qualifying) examination [1]. However, it remains a relatively small field of specialists. In the United States, there are roughly 1,000 pediatric radiologists, or about 3% of practicing radiologists [2,3]. Pediatric radiologists are also clustered in stand-alone children’s hospitals and academic institutions, with many residency programs having “away rotations” for dedicated pediatric training. Similarly, many radiology training programs in developing countries lack exposure to subspecialty trained pediatric radiologists. In sub-Saharan Africa, demographics impose the need for pediatric radiology training. Between 2010 and 2025, the child population of sub-Saharan Africa will rise by 130 million [4]. By 2030, sub-Saharan Africa will be the region with the greatest number of children under 18 years of age [4]. It is estimated that by 2050, one in every three births and almost one in every three children under 18 will be African [5]. Bringing pediatric radiology to sub-Saharan Africa is the logical next frontier of the subspecialty. There is also increased interest in pediatric radiology
originating from the region. For example, the 2015 Association of Radiologists of West Africa annual conference theme was “imaging the sick child” [6]. Ghana, in West Africa, is roughly the size of Oregon [7] and has a population of 26 million [8]. In 2010, the estimated number of radiologists in Ghana was 25 [9], increasing to approximately 80 by 2015 (including more than 30 trainees). Korle Bu Teaching Hospital (KBTH) is the major teaching hospital and referral center in Ghana [10]. The KBTH radiology department is the largest in the country and host to a major radiology residency program in the capital city of Accra. The department has eight consultants (ie, attending radiologists) and 18 residents. The department has a 1.5-T MR magnet, a 640-slice Toshiba Aquillion One CT scanner, eight ultrasound scanners, a fluoroscopy unit, and multiple conventional radiography units. RAD-AID International, an outreach radiology organization devoted to improving access to radiology in the developing world, has collaborated with KBTH since 2012 [11]. KBTH radiology residents had previously received at least four hours of pediatric radiology lectures per year by Dr Godfrey Gaisie, a native Ghanaian
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.04.010
pediatric radiologist from Akron’s Children’s Hospital in Ohio, who visits the country annually. In this report, we describe the experience of teaching pediatric radiology in a large metropolitan residency program in Ghana and discuss the need for increasing pediatric radiology outreach in sub-Saharan Africa with a flexible curriculum.
METHODS OF TEACHING PEDIATRIC RADIOLOGY In Person: Didactic Lectures During a 2015 visit to KBTH by the lead author (H.J.O.), residents received more than 12 hours of lectures. Because of its availability and lower cost, ultrasound was the focus of the majority of the lectures. Ultrasound topics included (1) brain, (2) bowel (ie, evaluation for suspected pyloric stenosis, intussusception, and appendicitis), (3) newborn abdominal masses, (4) fractures, (5) foreign bodies, (6) tonsils, and (7) advanced cases (eg, transperineal). Additional topics included (1) esophagography and voiding cystourethrography in children, (2) basic pediatric musculoskeletal cases, (3) how to perform pediatric CT angiography, and (4) basic MR physics using fetal imaging examples.
985
In Person: View Box and Scanner Teaching Similar to US-based programs, teaching at the workstation and view box during day-to-day work is a prime opportunity to teach a systematic approach to cases and search patterns. Plain films were read as hard copies in view boxes, whereas CT studies were read at workstations. Real-time cases were also an opportunity to practice ultrasound and fluoroscopy technique.
radiographic studies (plain films), particularly for inpatients, are not provided radiologic reports. The setup limits the residents’ exposure to NICU radiographs. With that in mind, multiple sets of NICU cases, including normally positioned lines and tubes, malpositioned lines and tubes, and neonatal “do-not-miss” cases, have been sent to the residents as quizzes. Subsequently, slides with the answers as well as individual misses are sent for each case set.
In Person: Introduction to Outreach Resources In the words of Dr Angtuaco, chair of the RSNA Committee on Radiology Education, “Educational efforts in radiology reach out from many different organizations to provide much-needed training and education across the globe. Yet, many of these resources go untapped because they are not well-known outside of the individual organizations providing them” [12]. Any educational outreach effort must introduce participants to these resources. In addition to the many educational resources and links provided at the RSNA’s International Radiology Outreach Resources website [12], KBTH residents were introduced to the World Federation of Pediatric Imaging website (www.wfpiweb.org), which is meant to be a repository of pediatric imaging educational materials.
Ongoing Collaboration: RADPrimer Through a licensing donation from Elsevier, KBTH residents received access to RADPrimer. RADPrimer is a web-based radiology curriculum that includes lessons, reading assignments, and practice questions that are image intensive and evidence based [13]. During the first 10 months, nine residents (50%) have used it, totaling more than 200 hours and answering more than 1,000 questions.
Ongoing Collaboration: Neonatal Imaging Cases At KBTH, the neonatal intensive care unit (NICU) does not perform as many invasive procedures as its American counterparts and relies heavily on clinical grounds, which translates into fewer radiographs obtained. In addition, some 986
Future Steps Future collaboration includes repeated visits by pediatric radiology faculty members as well as formal and informal consultation in challenging pediatric cases using a third-party teleradiology system. A research project that takes advantage of the larger number of retinoblastoma cases imaged with CT in Ghana and the possibility of an away rotation for residents in the United States are planned. DISCUSSION Years ago, while facing a critical shortage of pediatric radiologists in the United States, Bramson and Taylor [14] wrote that “pediatric radiology must demonstrate that it is an exciting, attractive career choice
for young physicians in training.” We believe that although the main goal of international outreach is different, the introduction of pediatric radiology to residents in developing countries remains a critical need for the long-term survival of the subspecialty. The experience described here represents just an initial approach to what we hope will become a fruitful professional collaboration. Previous pediatric radiology educational endeavors by Dr Gaisie from Akron’s Children’s Hospital, regional meetings, and an RSNA visiting pediatric radiology professorship to Ghana can only further our own collaborative objectives. We would consider the experience a huge success if any of the current residents decides to pursue a career in pediatric radiology, the first for an entire country. And if not? We still consider it a win that we exposed residents to additional educational resources that might prove useful while taking care of large populations of children. From the experience gathered, teaching pediatric radiology in an international setting required an “all of the above” approach with both inperson and online collaboration on the basis of both visiting faculty members’ and residents’ interest. Similar to how rotations are structured in the United States, residents must be exposed to a mix of basic, intermediate, and advanced topics to reflect the need of modern trainees to master basic skills while adapting to a new generation of imaging technologies. It is our belief that in developing countries, in the same way that adoption of cellular phone technology displaced landline and facsimile communications, ultrasound will be adopted for advanced applications, replacing crosssectional imaging and radiography.
Journal of the American College of Radiology Volume 13 n Number 8 n August 2016
CONCLUSIONS Exposure to pediatric radiology during radiology residency in sub-Saharan Africa is an important goal for the international radiology outreach community because of the demographic need and growth of diagnostic imaging in the region. Success in the long run will be defined by more international radiologists choosing pediatric radiology as their subspecialty and by the improvement and growth of imaging provided to children.
3.
4.
5.
6.
REFERENCES 1. American Board of Radiology. Home page. Available at: http://theabr.org. Accessed November 17, 2015. 2. Hughes D. How many radiologists? It depends on who you ask! Available at: http:// www.neimanhpi.org/commentary/how-
7.
many-radiologists-it-depends-on-who-youask/. Accessed November 16, 2015. Merewitz L, Sunshine JH. A portrait of pediatric radiologists in the United States. AJR Am J Roentgenol 2006;186:12-22. UNICEF. Children in Africa: key statistics on child survival, protection and development. Available at: http://www.unicef. org/about/execboard/files/Africa_Brochure_ Eng_14May14.pdf. Accessed March 30, 2016. You D, Anthony D. Generation 2025: the critical importance of understanding demographic trends for the children of the 21st century. Available at: http://www. unicef.org/about/execboard/files/Africa_ Brochure_Eng_14May14.pdf. Accessed January 1, 2015. Ghana Association of Radiologists. 53rd Annual General Meeting and Scientific Conference. Available at: http://www. gharad.org/index.php/arawa-news?id¼73. Accessed March 30, 2016. MapFight. [Ghana vs Oregon (US) size comparison.] Available at: http://mapfight. appspot.com/gh-vs-us.or/ghana-oregon-ussize-comparison. Accessed December 2, 2015.
8. Ghana Embassy. Population. Available at: http://www.ghanaembassy.org/index.php? page¼population. Accessed December 2, 2015. 9. GNA. Radiologists in West Africa attend 48th Annual General Meeting. Available at: https://www.modernghana.com/news/ 285496/1/radiologists-in-west-africa-attend48th-annual-gen.html. Accessed November 16, 2015. 10. Korle Bu Teaching Hospital. Home page. Available at: http://kbth.gov.gh/18/19. html. Accessed November 16, 2015. 11. RAD-AID International. RAD-AID Ghana. Available at: http://www.rad-aid.org/ countries/global-outreach/africa/ghana/. Accessed November 17, 2015. 12. Angtuaco T. International Radiology Outreach Resources (IROR). Available at: http://www.rsna.org/iror.aspx. Accessed November 16, 2015. 13. Amirsys. RADPrimer: about. Available at: http://www.radprimer.com/about/. Accessed November 17, 2015. 14. Bramson RT, Taylor GA. SOS: can we save pediatric radiology? Radiology 2005;235: 719-22.
Hansel J. Otero, MD, is from the Department of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, District of Columbia. Becky A. Appiah, MD, and Yaw Mensah, MD, are from the Department of Radiology, Korle Bu Teaching Hospital, Accra, Ghana. The authors have no conflicts of interest related to the material discussed in this article. Hansel J. Otero, MD: Department of Diagnostic Imaging and Radiology, Children’s National Health System, 111 Michigan Avenue, NW, Washington, DC 20010; e-mail: [email protected].
Journal of the American College of Radiology Otero, Appiah, Mensah n A View From Abroad
987
Pediatric Radiology Education in a Metropolitan Radiology Residency in West Africa: The Accra Experience Hansel J. Otero, MD, Becky A. Appiah, MD, Yaw Mensah, MD INTRODUCTION Pediatric radiology is an important core radiology subspecialty, 1 of 5 listed by the ABR and 1 of 15 evaluated in the ABR core (qualifying) examination [1]. However, it remains a relatively small field of specialists. In the United States, there are roughly 1,000 pediatric radiologists, or about 3% of practicing radiologists [2,3]. Pediatric radiologists are also clustered in stand-alone children’s hospitals and academic institutions, with many residency programs having “away rotations” for dedicated pediatric training. Similarly, many radiology training programs in developing countries lack exposure to subspecialty trained pediatric radiologists. In sub-Saharan Africa, demographics impose the need for pediatric radiology training. Between 2010 and 2025, the child population of sub-Saharan Africa will rise by 130 million [4]. By 2030, sub-Saharan Africa will be the region with the greatest number of children under 18 years of age [4]. It is estimated that by 2050, one in every three births and almost one in every three children under 18 will be African [5]. Bringing pediatric radiology to sub-Saharan Africa is the logical next frontier of the subspecialty. There is also increased interest in pediatric radiology
originating from the region. For example, the 2015 Association of Radiologists of West Africa annual conference theme was “imaging the sick child” [6]. Ghana, in West Africa, is roughly the size of Oregon [7] and has a population of 26 million [8]. In 2010, the estimated number of radiologists in Ghana was 25 [9], increasing to approximately 80 by 2015 (including more than 30 trainees). Korle Bu Teaching Hospital (KBTH) is the major teaching hospital and referral center in Ghana [10]. The KBTH radiology department is the largest in the country and host to a major radiology residency program in the capital city of Accra. The department has eight consultants (ie, attending radiologists) and 18 residents. The department has a 1.5-T MR magnet, a 640-slice Toshiba Aquillion One CT scanner, eight ultrasound scanners, a fluoroscopy unit, and multiple conventional radiography units. RAD-AID International, an outreach radiology organization devoted to improving access to radiology in the developing world, has collaborated with KBTH since 2012 [11]. KBTH radiology residents had previously received at least four hours of pediatric radiology lectures per year by Dr Godfrey Gaisie, a native Ghanaian
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.04.010
pediatric radiologist from Akron’s Children’s Hospital in Ohio, who visits the country annually. In this report, we describe the experience of teaching pediatric radiology in a large metropolitan residency program in Ghana and discuss the need for increasing pediatric radiology outreach in sub-Saharan Africa with a flexible curriculum.
METHODS OF TEACHING PEDIATRIC RADIOLOGY In Person: Didactic Lectures During a 2015 visit to KBTH by the lead author (H.J.O.), residents received more than 12 hours of lectures. Because of its availability and lower cost, ultrasound was the focus of the majority of the lectures. Ultrasound topics included (1) brain, (2) bowel (ie, evaluation for suspected pyloric stenosis, intussusception, and appendicitis), (3) newborn abdominal masses, (4) fractures, (5) foreign bodies, (6) tonsils, and (7) advanced cases (eg, transperineal). Additional topics included (1) esophagography and voiding cystourethrography in children, (2) basic pediatric musculoskeletal cases, (3) how to perform pediatric CT angiography, and (4) basic MR physics using fetal imaging examples.
985
In Person: View Box and Scanner Teaching Similar to US-based programs, teaching at the workstation and view box during day-to-day work is a prime opportunity to teach a systematic approach to cases and search patterns. Plain films were read as hard copies in view boxes, whereas CT studies were read at workstations. Real-time cases were also an opportunity to practice ultrasound and fluoroscopy technique.
radiographic studies (plain films), particularly for inpatients, are not provided radiologic reports. The setup limits the residents’ exposure to NICU radiographs. With that in mind, multiple sets of NICU cases, including normally positioned lines and tubes, malpositioned lines and tubes, and neonatal “do-not-miss” cases, have been sent to the residents as quizzes. Subsequently, slides with the answers as well as individual misses are sent for each case set.
In Person: Introduction to Outreach Resources In the words of Dr Angtuaco, chair of the RSNA Committee on Radiology Education, “Educational efforts in radiology reach out from many different organizations to provide much-needed training and education across the globe. Yet, many of these resources go untapped because they are not well-known outside of the individual organizations providing them” [12]. Any educational outreach effort must introduce participants to these resources. In addition to the many educational resources and links provided at the RSNA’s International Radiology Outreach Resources website [12], KBTH residents were introduced to the World Federation of Pediatric Imaging website (www.wfpiweb.org), which is meant to be a repository of pediatric imaging educational materials.
Ongoing Collaboration: RADPrimer Through a licensing donation from Elsevier, KBTH residents received access to RADPrimer. RADPrimer is a web-based radiology curriculum that includes lessons, reading assignments, and practice questions that are image intensive and evidence based [13]. During the first 10 months, nine residents (50%) have used it, totaling more than 200 hours and answering more than 1,000 questions.
Ongoing Collaboration: Neonatal Imaging Cases At KBTH, the neonatal intensive care unit (NICU) does not perform as many invasive procedures as its American counterparts and relies heavily on clinical grounds, which translates into fewer radiographs obtained. In addition, some 986
Future Steps Future collaboration includes repeated visits by pediatric radiology faculty members as well as formal and informal consultation in challenging pediatric cases using a third-party teleradiology system. A research project that takes advantage of the larger number of retinoblastoma cases imaged with CT in Ghana and the possibility of an away rotation for residents in the United States are planned. DISCUSSION Years ago, while facing a critical shortage of pediatric radiologists in the United States, Bramson and Taylor [14] wrote that “pediatric radiology must demonstrate that it is an exciting, attractive career choice
for young physicians in training.” We believe that although the main goal of international outreach is different, the introduction of pediatric radiology to residents in developing countries remains a critical need for the long-term survival of the subspecialty. The experience described here represents just an initial approach to what we hope will become a fruitful professional collaboration. Previous pediatric radiology educational endeavors by Dr Gaisie from Akron’s Children’s Hospital, regional meetings, and an RSNA visiting pediatric radiology professorship to Ghana can only further our own collaborative objectives. We would consider the experience a huge success if any of the current residents decides to pursue a career in pediatric radiology, the first for an entire country. And if not? We still consider it a win that we exposed residents to additional educational resources that might prove useful while taking care of large populations of children. From the experience gathered, teaching pediatric radiology in an international setting required an “all of the above” approach with both inperson and online collaboration on the basis of both visiting faculty members’ and residents’ interest. Similar to how rotations are structured in the United States, residents must be exposed to a mix of basic, intermediate, and advanced topics to reflect the need of modern trainees to master basic skills while adapting to a new generation of imaging technologies. It is our belief that in developing countries, in the same way that adoption of cellular phone technology displaced landline and facsimile communications, ultrasound will be adopted for advanced applications, replacing crosssectional imaging and radiography.
Journal of the American College of Radiology Volume 13 n Number 8 n August 2016
CONCLUSIONS Exposure to pediatric radiology during radiology residency in sub-Saharan Africa is an important goal for the international radiology outreach community because of the demographic need and growth of diagnostic imaging in the region. Success in the long run will be defined by more international radiologists choosing pediatric radiology as their subspecialty and by the improvement and growth of imaging provided to children.
3.
4.
5.
6.
REFERENCES 1. American Board of Radiology. Home page. Available at: http://theabr.org. Accessed November 17, 2015. 2. Hughes D. How many radiologists? It depends on who you ask! Available at: http:// www.neimanhpi.org/commentary/how-
7.
many-radiologists-it-depends-on-who-youask/. Accessed November 16, 2015. Merewitz L, Sunshine JH. A portrait of pediatric radiologists in the United States. AJR Am J Roentgenol 2006;186:12-22. UNICEF. Children in Africa: key statistics on child survival, protection and development. Available at: http://www.unicef. org/about/execboard/files/Africa_Brochure_ Eng_14May14.pdf. Accessed March 30, 2016. You D, Anthony D. Generation 2025: the critical importance of understanding demographic trends for the children of the 21st century. Available at: http://www. unicef.org/about/execboard/files/Africa_ Brochure_Eng_14May14.pdf. Accessed January 1, 2015. Ghana Association of Radiologists. 53rd Annual General Meeting and Scientific Conference. Available at: http://www. gharad.org/index.php/arawa-news?id¼73. Accessed March 30, 2016. MapFight. [Ghana vs Oregon (US) size comparison.] Available at: http://mapfight. appspot.com/gh-vs-us.or/ghana-oregon-ussize-comparison. Accessed December 2, 2015.
8. Ghana Embassy. Population. Available at: http://www.ghanaembassy.org/index.php? page¼population. Accessed December 2, 2015. 9. GNA. Radiologists in West Africa attend 48th Annual General Meeting. Available at: https://www.modernghana.com/news/ 285496/1/radiologists-in-west-africa-attend48th-annual-gen.html. Accessed November 16, 2015. 10. Korle Bu Teaching Hospital. Home page. Available at: http://kbth.gov.gh/18/19. html. Accessed November 16, 2015. 11. RAD-AID International. RAD-AID Ghana. Available at: http://www.rad-aid.org/ countries/global-outreach/africa/ghana/. Accessed November 17, 2015. 12. Angtuaco T. International Radiology Outreach Resources (IROR). Available at: http://www.rsna.org/iror.aspx. Accessed November 16, 2015. 13. Amirsys. RADPrimer: about. Available at: http://www.radprimer.com/about/. Accessed November 17, 2015. 14. Bramson RT, Taylor GA. SOS: can we save pediatric radiology? Radiology 2005;235: 719-22.
Hansel J. Otero, MD, is from the Department of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, District of Columbia. Becky A. Appiah, MD, and Yaw Mensah, MD, are from the Department of Radiology, Korle Bu Teaching Hospital, Accra, Ghana. The authors have no conflicts of interest related to the material discussed in this article. Hansel J. Otero, MD: Department of Diagnostic Imaging and Radiology, Children’s National Health System, 111 Michigan Avenue, NW, Washington, DC 20010; e-mail: [email protected].
Journal of the American College of Radiology Otero, Appiah, Mensah n A View From Abroad
987