Radiology's leading lady

Professor Helen Carty President - ECR 2004

Involvement with the European Congress of Radiology (ECR)
Professor Carty was invited lecturer at the ECR in 1991, a year in which she also became a member of the ECR’s Scientific and Paediatric committees. In 1999 she was elected member of the Executive Committee and became a member of the ECR Council in 2000. The following year, Professor Carty became President Elect 2004. She is now President of the European Congress of Radiology.

Plans are well underway for the next congress, she said, in a recent interview with Brenda Marsh, Editor-in-chief of European Hospital, in which she also described her hopes for ECR 2004, and some ideas about the future of radiology.

Helen Carty: I want to build on the excellence that has already been established and to continue to develop its role as the major multinational European meeting for science and education in radiology. The ECR has already attained a very high reputation for the quality of both and, in particular, for its recognition of developments in radiology - and, indeed, for supporting them. With this in mind, for ECR 2004 we will hold separate scientific sessions on molecular imaging, followed by a sub-committee for molecular imaging, and there will be several special focus and new horizon sessions on that subject.

Hands-on workshops will cover musculoskeletal ultrasound, vertebroplasty and virtual reality angiography - sessions created with the enthusiasm and help of radiologists from across Europe and supported by companies. I’m very grateful to both.

All these developments are at the cutting edge of radiology. Mindful that the spectrum of radiology is huge, we are also developing a clinical radiology foundation course, to be further developed in subsequent years. This will lay down the standards of knowledge required for trainees across Europe and will be the basis for the standard of the European Diploma.

Brenda Marsh: What other issues will you highlight and why?
HC: I specialise in paediatric radiology, and we will highlight particularly relevant aspects in this field for radiologists who are not specialists in paediatrics. Not every child can have radiographs reported by a specialist paediatric radiologist - this is not only impractical but impossible. However, it is important that continuing support and refresher courses are available for those who must do a small amount of paediatrics, to keep them up to date with developments, and to ensure children are not treated as ‘small adults’.

BM: How have the lecturers been selected?
HC: For 2004 lecturers were chosen following advice from the European specialist societies, who were asked to identify outstanding speakers in their own fields and, in addition to the tried and trusted, to introduce new speakers - ensuring continuing refreshment in the meetings.
Most suggestions came from the societies, but the final balancing - to achieve a reasonable spread of speakers from across European nations - is undertaken by the ECR Programme Planning Committee. However, I’d like to emphasise that ECR is constantly looking out for new, good speakers, and welcomes suggestion and advice (including self-nominations, appropriately supported). As before, all the talks will be in English.

BM: What other targets have you set?
HC: We also want to encourage colleagues from the Middle East, South America, the Far East and Australasia, to come to ECR and develop further links with the continent of Europe. Many colleagues, particularly in Australasia and South America, have their roots here, so ECR provides a golden opportunity for them to combine science and CME with a return to the background of their ancestors. With this in mind, ECR Meets - a great success in 2003 - will expand. An invitation has been sent to Poland, as the European nation for ECR Meets, and to Korea, the first overseas nation to attend.

BM: Will there be a debate on - and what are your views on - EU harmonisation of qualifications?
HC: No, a formal debate on this is not envisaged. The subject is discussed at EAR. The role of ECR is to provide the basis of science and education to support any decision made about the harmonisation of qualifications.
My own personal view about the harmonisation of qualifications is that one should make haste slowly. Training methods are variable and I would like to see co-ordination of training and standards of training established before one embarks upon examination structures. Personally, I find that the standards of European radiologists are mainly very high, with core knowledge at a relatively uniform level. If these standards can be harmonised, then any qualification that follows will fall into place. However, I believe there are considerable difficulties about translation of multiple choice questions into different languages, because nuances, if not carefully translated, can vary significantly.

BM: Do you have ideas to improve staff shortages?
HC: I am not Solomon! I’m in no better position to solve staff shortages than our political masters. The basic problem is that doctors’ training has been controlled for a very long time, for various economic reasons. And when you run into staff shortages it takes about twelve years - for basic medical training plus postgraduate training - before you can redress any staff shortages, at which stage it is obviously too late to catch up. The issue is basically one of economics and of failure to shift resources in the context of alternative developments in different fields. A good example might be largely the replacement of upper GI barium studies with endoscopy. This resulted in a significant reduction in upper GI contrast studies, but the resources used by upper GI contrast studies have long since been absorbed by an increase in ultrasound and, of course, cross sectional imaging. As both these fields continue to expand almost exponentially, with each taking a significant length of time for any individual radiologist to interpret them, shortages will inevitably continue.
The attraction of trying to train non-radiologically qualified staff or, indeed, even non-medically qualified staff, to do single task jobs is great, but the difficulty with this is that, although at the individual level they are extremely effective, it removes the flexibility of someone who is trained across many fields. We should never forget that technology is only one component of radiology. The term used in the UK is clinical radiology, and without correlation and understanding of clinical issues one cannot practise radiology - which is why I believe that one needs a basic medical degree for safe practice across the board. This does not mean that I don’t respect the professions supplementary to medicine or, indeed, technicians doing tasks that were previously radiological, but one still has to have an overview of the clinical problems if safe practice is to be maintained.
As I said during my talk on Evidence Based Medicine, in Vienna, (when I was billed as the Cynic): patients and disease do not totally follow scientific rules and it is vitally important that radiologists retain a broad view of a subject so that they can spot, almost instinctively, the uncommon presentation of an illness or, indeed, the uncommon cause of a group of symptoms.

BM: You have seen many changes in your career. Which are the most significant, and which, among R&D projects, do you foresee as affecting radiology most significantly?
HC: Yes, as a UK consultant radiologist spanning 28 years, and all of that spent in paediatric practice, I’ve seen many, many changes, the most obvious being the explosion in the imaging fields available to us. Of course, cross sectional imaging, in the broadest sense, is the most significant. I think the advent of spiral CT is, in fact, going to have a continuing huge impact on medical practice. So much can be done and diagnosed with a spiral CT, non-invasively and so quickly that I think it will become almost the primary tool of investigation of most acute presentations in medicine.
I’m fully conscious of the significance of the radiation issue. I think this is an area where there will have to be increasing and continuing co-operation between industry, radiation physicists and clinicians, to ensure that the use of radiation in CT is kept as economical as possible, consistent with diagnostic imaging. In this context it is important that the concept of risk/benefit is discussed, not just risk. Because, if risk is what is emphasised to a patient, then it may interfere with case management in the long term, if the patient should then refuse to have the appropriate investigation for their problems.
Though I grew up in the era of a high understanding of plain radiographs, I am increasingly conscious of the relative lack of understanding of these by trainees, beguiled as they are by the detailed anatomy presented in cross sectional imaging. I fear that plain radiographs will become increasingly relegated, which is sad, because a properly interpreted, straight radiograph remains something that can guide patient management properly. However, I hope I am not obtuse and I accept that cross sectional imaging can supplant quite a lot of them and give far more information faster. This, in itself, has a huge impact on health economics, as rapid diagnosis leads to rapid treatment and probably saves money in the long term.  More importantly, it also has great benefits for the patient, reducing anxiety and improving quality of medical care.  This inevitably begs the question that there will have to be an increase in the availability of that technology 24 hours a day and, because looking at a spiral CT takes longer than a plain radiograph the number of radiologists will have to increase.
The second field I foresee having a huge future impact will be molecular imaging, using the term in the broadest sense. This will give increased insights into disease pathology and, once that understanding is achieved, we can begin to design more appropriate therapies, in which I believe radiology will have a huge impact.

BM: Due to advances - and the volume of learning involved with each - could radiology become increasingly more sliced into specialities, say, according to equipment skills? And in this context, how do you perceive the role of the radiologist in future years? Is there, for example, the possibility that, one day, intervention may be undertaken solely by a radiologist, superseding the work of the surgeon?
HC: I think the role of interventional radiology will increase in the future, not only in the way we understand it today but also as a consequence of molecular imaging advances, with the possibility of delivering precise drug treatments for certain types of cancer. This will have to be carried out in co-operation with our clinical colleagues. With a bit of sensible planning this could occur without turf battles - which bedevil medicine.
It is possible that radiological training will alter to a core training, followed by training in interventional radiology for perhaps three or four years, rather than the current four-year core training followed by interventional radiology. This model may be attained in several other subspecialties of radiology.
The days of someone being able to do everything are rapidly diminishing. However, this is one of the advantages to date of radiology: most radiologists know a little about a lot, rather than a lot about a little, which is the way medicine has gone. Each subspecialty is now so confined to its own area that the broad sweep of general medicine is something that has virtually disappeared from clinical practice, and this can lead to delays in diagnosis if the patient gets into the wrong field. The same could arise in radiology, if the core knowledge does not remain fairly broad before embarkation on specialist training. However it’s a little different, for example, for interventional radiology, where technical skills are so very important and understanding of various diseases is in more limited fields.
My personal view is that when a new technique is discovered it should be developed so that there is a specialist in that technique but, as information is acquired and disseminated, radiologists should shift from being technique-based to system-based, because this is in the best interests of patients. Technology is beguiling, and you can forget underlying clinical issues. The best advances are achieved by a symbiosis of those with deep knowledge of a technique combined with an equal knowledge of the clinical issues.
I do not believe one can lay down a blueprint for the future that is unalterable. As situations change, I think the best way to ensure the continuation of high standards is to have enough wise and far-seeing people in radiological developments in different countries, to be able to anticipate the need for change early enough and to ensure that it is achieved smoothly.

BM: How do you view the arrival of teleradiology and out-sourcing?
HC: Teleradiology is happening and is here to stay and I believe it can work to the benefit of patients. However, I am concerned about teleradiology being practised in different countries, when what is proffered is an opinion on a scan or X-ray based on very limited clinical information, and without the availability of dialogue with the clinical consultants in charge of the patient. It may be expedient for governments to try and cover their shortages by using such technology, but I do not believe it is in the interests of patients.
However, within one’s own country, in the context of seeking second opinions, this is an invaluable resource. I believe that, for subjects like paediatric radiology, what will ultimately evolve is a core of fairly major paediatric hospitals, employing more radiologists than they need, but who would provide, by teleradiology and videoconferencing, paediatric radiological opinions to hospitals within a much wider surrounding area. These would work on the basis of hub and spoke, with specialist radiologists going out to the more peripheral units to do procedural work, as necessary.

01.07.2003

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