A têtê-à- têtê with Dr. C. Kesavadas (Prof. & Head, Dept. of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences & Technology, Trivandrum)
Q. What made you chose this field?
At the time I completed my post-graduation in Radiodiagnosis in 1994, nobody used to speak about subspecialization. During our post-graduation, we used to visit the Department of Radiology at Sree Chitra Institute & Regional Cancer Centre. I was fascinated by the work in these two institutions, especially that in Interventional Radiology at Sree Chitra Institute. Hence, I looked for an opportunity in Sree Chitra Institute. This became possible in 1995, when I joined as an ad hoc consultant radiologist in the department. The main interest of the department was neuro- and vascular interventional procedures.
In the initial years, I got good training in neuroimaging, neurovascular and vascular interventional procedures. In the year 2000, I was selected for a research fellowship in functional neuroimaging at the San Raffaele University Hospital in Milan, Italy. One year of training at this institution made me realize the importance of focused work in disease diagnosis, patient management and clinical research.
Back in India, I started focusing in neuroimaging because I felt that our hospital had very good expertise in interventional radiology, but needed more expertise in neuroimaging.
The decision of having to leave interventional radiology was a difficult one, but I knew that in our department there were others in the department who were better and more passionate in intervention than myself. At the same time, I felt that I could put the best use of my training abroad for developing best practices for clinical neuroimaging and research. And thus, I chose the field of diagnostic neuroradiology.
Q. Tell us about the beginnings of DM Neuroradiology in SCTIMST and how it stands today.
The department was conducting a post-doctoral certificate course (PDCC) in Neuro- and Cardiovascular Radiology since the year 1985.
In the 70s and early 80s, most of the radiological procedures (both diagnostic and interventional) were performed using X-ray and fluoroscopic techniques. In the subsequent years, the department was equipped with CT, MRI and Doppler ultrasound machines. Along with this, the subspeciality of Neuroradiology was growing world over and newer neuro-interventional procedures for treating neurovascular diseases were being evolved. Fellowships in Neuroradiology were being offered in several universities in the developed world, mainly in the US and Europe. Our department also realized the importance of starting a 3-year programme in Neuroradiology, giving equal importance for diagnostic and interventional neuroradiology.
The first student in the DM Neuroradiology programme joined in 1999. The programme was later renamed as DM Neuroimaging and Interventional Neuroradiology to emphasize the importance of training in neuro-interventions. At present, we have 2 candidates per year. The number of applicants has increased over the years, with an average of about 30 candidates per year. Every year, the institute gets sponsored candidates from the defense services. We also conduct a 1-year PDCC course in Diagnostic Neuroradiology.
Q. Roughly speaking, how long would it take for a radiologist to be proficient in neuroradiology?
With the advent of CT, MRI and neuro-interventional procedures in the disease management of neurological diseases, neuroradiology has grown in the last two decades. It will take at least three years to acquire skills in neuroimaging and interventional neuroradiology for a person who has completed MD or DNB in Radiology. Hence the DM Neuroradiology program in all MCI recognized Indian institutions is for 3 years with both diagnostic and interventional neuroradiology in their curriculum. The radiologist needs to have good knowledge of clinical neurology & neurosurgical procedures and should be able to work closely with neurologists and neurosurgeons.
Q. What, in your opinion, is the most promising advancement(s) in neuroradiology in recent times?
Functional neuroimaging, Radiomics and Imaging genomics are promising advancements in diagnostic neuroradiology. These newer techniques can improve our understanding of neurological diseases. These techniques may aid in the diagnosis and management of neurological and psychiatric diseases. In interventional neuroradiology, newer gadgets and improved armamentarium are being developed, which have made neuro-interventional procedures more safe and effective. New effective interventional methods are also being developed eg. Mechanical thrombectomy in acute stroke treatment.
Q. What about Artificial Intelligence (AI)? Will it take over neuroimaging? Why or why not?
The radiologist needs to embrace AI just like any other field of science and technology. Rather than taking over any field of imaging, it will improve our diagnostic capabilities and work flow in the radiology department. We should work on AI techniques, which can improve the quality of images and aid us in giving the correct diagnoses.
Q. What does the future hold for a budding neuroradiologist?
The young neuroradiologist should decide to work closely with the neurologists, neurosurgeons, neuropathologist, oncologist and other specialities in such a way that his / her expertise can be maximally used for disease diagnoses and management. If the young neuroradiologist is ready to take up such collaborative work, he / she will find himself / herself to be an important and useful member in the patient management team. There is a need for young neuroradiologists to dedicate some amount of time for research, the results of which can be useful for the medical community.
Q. What are your practical suggestions to widen the subspeciality practice at different levels in the state?
First of all, the young radiologist should understand the need for subspecialization. We have to consider the patient’s perspective. He / she would want a person with the best expertise and skill to diagnose his / her disease and get treated accordingly.
Secondly, Government and Private Medical colleges across the country should start PDCC or DM programmes in various subspecialities of radiology. This program should get recognition of Medical Council of India (though sometimes the process of recognition may take more than a year).
Short-term fellowship programmes (3 to 6 months) in very specialized areas (for eg. musculoskeletal ultrasound / liver imaging / paediatric neuroimaging) can be conducted under the guidance of experts in corporate, private hospitals and diagnostic centres. Such short-term fellowships need to get recognition from academic bodies such as the Indian College of Radiology.
Finally, we also need to conduct 4-5 day hands-on training courses in a specialized area to increase the skills of practicing radiologists (for eg. conducting a course on cardiac CT), after which certificates need to be given by reputed medical institutions or academic bodies that conducts such programmes.
Over the period of years, the medical practitioner has morphed from a jack-of-all-trades to a highly qualified individual with a particular subset of skills / know-how which makes him / her the expert in the field. It should, therefore, come as no surprise when the field of radiology also travels along this path.
As Dr. Kesavadas pointed out, by putting the patient first, we realize that only an expert could do justice to the patient by offering him / her the best in patient care, diagnosis and management. The ever-expanding medical knowledge base makes it practically impossible to become an expert in all fields.
AI will enhance the skills of a radiologist, but may not replace them altogether. The fundamental basis of artificial intelligence is machine learning and cloud intelligence. It cannot deal with multiple variables (which a practicing clinician deals with on a day-to-day basis) or replace human intuition. “What to do when machines do everything” by Malcolm Frank is a good read about AI.
Medical colleges and other medical institutions should conduct sufficient training programmes ranging from DM or PDCC, to other short term fellowship programmes, so as to enable the common radiologist to subspecialize and become experts in their respective fields; thereby not only enabling them to advance further in their careers, but also doing the greater good.
– Dr. Jassim Koya