Emerg Radiol (2016) 23:101103
DOI 10.1007/s10140-016-1381-6
COMMENTARY
Nucleating emergency radiology specialization in India
Anjali Agrawal 1,2 & Niranjan Khandelwal 2,3
Received: 16 January 2016 / Accepted: 26 January 2016 / Published online: 16 February 2016
# American Society of Emergency Radiology 2016
Abstract Emergency radiology is being recognized as an im-
portant and distinct specialty of radiology which merits utmost
attention of educators, radiology program curricula commit-
tees, and radiology practices in India. Providing an accurate
but timely diagnosis requires a skilled judgement and a strong
process framework, particularly in acute trauma setting or a
life-threatening acute illness. However, due to a shortage of
radiologists in India and lack of awareness and suitable oppor-
tunities, there has been no concerted movement towards emer-
gency radiology subspecialty training or dedicated emergency
radiology positions. It was with these gaps in mind that the
Society for Emergency Radiology was envisioned in 2012 and
formulated in 2013. The proposed role of the Society for
Emergency Radiology is to identify deficiencies in the field,
namely, lack of adequate exposure, lack of mentorship by
experienced emergency radiologists, lack of suitable opportu-
nities for emergency radiologists; establish standards of prac-
tice; and promote education and implementation research to
Electronic supplementary material The online version of this article
(doi:10.1007/s10140-016-1381-6) contains supplementary material,
which is available to authorized users.
* Anjali Agrawal
draagrawal@hotmail.com; anjali.agrawal@telradsol.com
Niranjan Khandelwal
khandelwaln@hotmail.com
1
Teleradiology Solutions, 12B Sriram Road, Delhi 110054, India
2
Society for Emergency Radiology, Chandigarh, India
3
Department of Radiodiagnosis, Post Graduate Institute of Medical
Education and Research, Chandigarh 160012, India
bridge the gaps. Through collaboration with other societies
and partnership with the journal Emergency Radiology, the
Society for Emergency Radiology hopes to promote a free
exchange of ideas, protocols, and multi-institutional trials
across continents.
Keywords Emergency radiology . Emergency radiology in
India . Society for Emergency Radiology
Subspecialties emerge from confluence of unique sets of tech-
niques, soft skills, and experiences that translate into measur-
able differences in the quality of patient care. Emergency ra-
diology as a branch of radiology is distinguished mostly by
the adaptation to the clinical context in which we operate,
while using mostly the same tools as general diagnostic radi-
ology. These differences relate not only to a different mixture
of pathologies, particularly trauma and critical illnesses, but
also to a need for rapid identification of pathologies needing
surgical or intensive care. Providing an accurate but timely
diagnosis even on the most routine of cases requires a skilled
judgement and a strong process framework. The ability to
diagnose a complex tumor could steal more limelight than
providing a prompt accurate diagnosis of an infarct in the
brain. The two situations are differentin the former, there
is no pressure of time, and in the latter, Btime is brain.^
Recognition of these unique tenets of the practice of emer-
gency radiology has led to the institution of emergency radiol-
ogy fellowships in the USA. So far, such specialized training
does not exist in India. There are a few dedicated trauma and
acute care centers in India, a number that can be counted on the
fingers of one hand. Focused postgraduate courses in emergen-
cy medicine training have been developed and are recognized
as a distinct specialty by the Medical Council of India since
2009 and the National Board of Medical Examiners since
102
2014. Trauma and acute care surgical training has also made a
beginning. Albeit, imaging of trauma and emergent conditions
has to evolve towards a specialty in keeping with development
of the corresponding medical and surgical specialties.
However, so far there has been no concerted movement
towards emergency radiology subspecialty training. This is
attributable to two reasons. Firstly, there is a severe shortage
of radiologists in India. There are about 12,000 radiologists in
India, for a huge population of over 1.2 billion, leading to an
unfavorable ratio of 1:100,000 [1]. There are approximately
268 medical schools in India that provide radiology postgrad-
uate training. Approximately 747 candidates get enrolled into
a 3-year postgraduate training in radiology every year. Of
these, 537 are MD seats under Medical Council of India
(MCI) and 210 are Diplomate of National Board (DNB) seats
under National Board of Examinations (NBE). The MCI and
the NBE are two medical governing bodies in India.
Additionally, there are 253 2-year Diploma in Medical
Radiodiagnosis (DMRD) course positions in which candi-
dates are not given any research thesis and these graduates
are not eligible for teaching posts [2]. With this gap between
demand and supply, job prospects for radiologists are excel-
lent even without additional qualifications. So, the idea of
focused emergency radiologists may be premature and a dif-
ficult feat to accomplish without increasing the number of
radiology postgraduate positions in the country.
Secondly, there is a lack of a coordinated emergency care
environment for the most with the exception of a few dedicat-
ed centers, in which the presence of an emergency radiologist
would be expected to contribute to patient outcomes. This
fragmented care in critical trauma and emergency situations
may not be conducive to attracting professionals from the
already small radiology pool. Radiologists have other oppor-
tunities such as specialization in MRI, cardiovascular, or neu-
roradiology training, wherein there are ample and more lucra-
tive job opportunities in both standalone imaging centers and
tertiary care superspecialty private and government-aided hos-
pitals. Emergency care may not be the core of a multispecialty
private hospital because unlike orthopedics or cardiac care, it
may be a money-losing proposition. The majority of patients
are self-paying rather than through a health insurance, and
there may not be any assurance that the hospital bills will be
reconciled when a patient is cared for during trauma or critical
emergency. This would imply that government-aided institu-
tions will have to be at the vanguard of a movement towards
organized trauma and acute care and supporting imaging.
Failing this, we may see an unregulated and unplanned growth
leaving us with a more challenging divided landscape for
implementing a common forum.
It was with these gaps in mind that the Society for
Emergency Radiology (SER) was envisioned in 2012 by three
radiologists and formulated in 2013. These radiologists during
the course of informal meetings and conversations felt an
Emerg Radiol (2016) 23:101103
urgent need for emergency radiologists in the country, given
the changing face of medical care with an emphasis on visu-
alization and precise diagnoses, and an increased demand for
imaging in acute care. The solutions are obvious and intuitive,
including increased training, creating expert teachers, and an
attractive identity for emergency radiology. The proposed role
of the Society for Emergency Radiology is to identify defi-
ciencies in the field, namely, lack of adequate exposure, lack
of mentorship by experienced emergency radiologists, and a
perception of this field as Bglorified^ general radiology; for-
mulate standards of practice; and promote education and im-
plementation research to bridge the gaps. To meet the in-
creased demand for imaging in trauma and acute illnesses in
an environment of a limited radiology manpower,
teleradiology is an obvious choice supplementing, supporting,
and filling in the gaps of on-site radiology workforce. With
teleradiology, one could look into transmitting images across
sites in the same city, state, and zone or at a national level and
be able to provide timely radiology consultations for critically
ill patients in hospitals in far-flung areas, which may not have
r o u n d - t h e - c l o c k r a d i o l o g y s t a ff c o v e r a g e . S u c h
teleconsultations may also help on-call residents hone their
skills in interpretation of emergency and trauma cases.
Additionally, it would help in optimization of workflow by
transmitting the images from multiple locations to a central
hub or a radiologists home/personal office. Though prema-
ture from a national perspective, we could look into an inter-
national teleradiology practice model to obviate the need for
night shifts by deploying staff across the globe utilizing the
time zone difference advantage, with improved productivity
of radiologists and reduced interpretation errors [3, 4].
To enable effective functioning and gain a wider accep-
tance, the first annual conference of the SER was held at the
Post Graduate Institute of Medical Education and Research
(PGIMER), Chandigarh, in 2014. The second annual confer-
ence was hosted by the All India Institute of Medical
Sciences (AIIMS), New Delhi. AIIMS, New Delhi, and
PGIMER, Chandigarh, are both premier institutions of the
country with top-ranking radiology programs. To expand our
reach beyond the North zone, the third annual conference
will be held in Bangalore, the silicon valley of India, in
2016. The SER proposes to actively work towards spreading
education in the field through annual conferences, CMEs,
and workshops. There is also a drive towards instituting a
fellowship in emergency radiology and push for its recogni-
tion by the MCI and NBE. The issue of increasing radiology
training positions in the country is a tough one to tackle, and
perhaps may be brought up with a larger national radiology
forum like the Indian Radiological and Imaging Association
(IRIA).
Collaborations with other more established societies would
go a long way in helping a young society grow and flourish.
The SER has joined hands with the American Society of
Emerg Radiol (2016) 23:101103
Emergency Radiology and has adopted the journal Emergency
Radiology as its official journal. Partnership with other emer-
gency radiology and medicine societies, namely, the European
Society of Emergency Radiology (ESER), Asian Society of
Emergency Radiology (ASTER), Society for Emergency
Medicine India (SEMI), and Indian Society for Trauma and
Acute Care (ISTAC) will facilitate exchange of ideas and
practices in the field and allow for a coordinated approach
between clinical care and imaging. This we feel is the need
of the times, given the scale of mass casualties due to natural
calamities and terror attacks. All disaster preparedness is futile
without being part of the entire team, wherein protocols, role
assignments, triage, and workflow, in case of a sudden influx
of victims of these mass events, may be clearly outlined and
adhered to for a smooth and timely diagnosis and treatment.
Through this partnership with Emergency Radiology, we
hope to see a free exchange of ideas, protocols, and multi-
institutional trials across continents.
103
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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