„No one can know it all”
Radiologist Karthik Ganesan and oncologist Mohan Menon have recently started to collaborate in Mumbai, Maharashtra, India. With the rising incidence of cancer in India, their field of teamwork is continuously growing.
radiology.bayer.com (rbc): How has medicine changed in the last decade?
Mohan Menon (MM): Medicine has transitioned from something based on individual opinion – more of an art – to something more objective based on data. This process has led to specialization. No one can know it all. Once the decision to collaborate is made, it is a lot easier.
Karthik Ganesan (KG): The way medicine has grown in the last 15 to 20 years is like an explosion – the amount of information is extensive. Way back in 2000, we were dealing with 4-slice scanners and we were limited by the reconstructions. We were hardly getting any data. Now we are working with 384-slice scanners, which means by just covering the abdomen and the pelvis, a radiologist has to read about 1300 to 1400 images.
We are literally cutting through the body without actually cutting it, which the biggest advantage we have. And if you have the patient’s trust and you have your colleagues’ trust, you can actually get a ton of information from that data set.
This is really mandatory to be part of a multidisciplinary team, especially for branches like radiology and pathology. The more information you can get from a particular area, the more beneficial you are going to be to the entire team. It has to be teamwork.
A Paradigm Shift
rbc: This seems to be a true paradigm shift?
KG: It is already happening.
MM: It is already there to a large extent in most big institutions. It is a transition from something based on opinion to be based on data. This process involves looking at the same issue from multiple angles. The surgeon views it from a different point of view, so does a radiologist, a medical oncologist, a pathologist, and a radiation oncologist. These are the big specialties right now.
New specialties may come up which we can’t even think of at this time. Data is that big and I think it’s likely to continue.
Setting Up Multidisciplinary Teams
rbc: You make it very clear that there is no way around multidisciplinary processes. How can you set them up?
MM: I already have experience with that. It’s been about six months since I came back to India from the US, and we already had a plan to set up a thoracic multidisciplinary team as part of the hospital. We visited a program in New Hampshire and talked to the people that had a multidisciplinary team.
I think the essence of it comes down to having a meeting. It is about coming to a place at a suitable time. It’s never suitable for everyone, but you try to find a time that works for everybody so long as everybody wants to do it.
rbc: On a daily basis?
MM: No, weekly is appropriate, but it depends on the volume of the particular center. You talk about cases prospectively and discuss cases retrospectively. You can’t leave a patient hanging for too long, but anything more than weekly is hard to do, because everybody has other things going on.
rbc: How long does it take to become successful?
KG: Within a few months, we already started profiting.
The advantage of having these meetings was manifold, but in an institution with academics going on simultaneously, it also significantly impacts junior doctors. Why? Because they are introduced to a system where learning is not just about their specialization.
When I was a junior doctor, I found these meetings really useful: I would see clinicians, radiologists, and people from other fields interacting in a way I would never have seen otherwise: People would usually not present their best cases, but the ones where they got something wrong. So you end up learning a lot more. Academics really build up when you have these meetings.
When I worked in San Diego, everything was based on multidisciplinary: I never remember being called a radiologist, you were taken as part of the entire team and that brings a lot of conduct, because you get different points of view. I have been able to bring that practice here to India. If people have different opinions, those viewpoints are also addressed. You see issues dynamically treated, and you sometimes realize ‘oh my god, I didn’t make the right choice’ or ‘I didn’t give this information and next time I need to give it’. It is a win-win situation for everybody.
Meeting The Challenges
rbc: What were the challenges of starting from scratch like you did?
KG: It is difficult because, ideas and all processes have to match in terms that people should be comfortable discussing a case, which they have reported with somebody else. We communicate it as a learning process. It does not criticize what one does. You’ve got to give something, but you’re going to take back lots more.
rbc: So it is medical and personal?
KG: It’s manifold. If I don’t interact with Menon as an oncologist, I’m not going to get those fine points, which are going to change me as a radiologist. At the same time, he practices not only in my hospital, but also somewhere else. He may learn or get information from radiology here, which he doesn’t get from somewhere else, so he is maybe going to share that information with the other radiologists.
MM: I think one has to realize that you all want the same thing: you all want the patient to do better. We are all on the same side. As Karthik correctly mentioned, we may all have different opinions about things, but then it’s like that saying ‘if everybody is thinking alike, then nobody’s thinking’. It’s important that every voice is heard. It is true that there is a hierarchy in medicine to a certain extent, but I have not seen that hierarchy not allowing a second view of the same issue. A lot of times, we’re not perfect and there are different lines of thought.
Benefits for the Patient
rbc: How often are you surprised by each other’s view?
MM: When we had a thoracic team back in the US at Hartford we were almost always prepared to be surprised when a case was presented. So you present with the presumption that this is the path or this is the stream of the specialty and it almost never went in that direction, it always went in a different direction. You were on the edge of your seat sometimes, but I think a fair number of times you can expect to be surprised.
KG: It’s very interesting if you’re working in tandem or in groups – like Menon just said – you should not get surprised that you’re going to get surprised. Like in a case we had a few months back, which just strengthened the core process substantially that many of the times diseases are going to come in the most uncommon of locations, with the most uncommon of presentations, and they are going to mimic far more commonly known diseases.
I remember a phone call with Menon about a patient that seemed to have a primary liver disease, which was compressing the bile duct and causing jaundice. When we did the imaging, we were completely surprised that the disease was not in the organs, but throughout the peritoneal cavity.
This also occurs often in our country in tuberculosis; we might be seeing TB at least once a week at our hospital. If you go up to a medical hospital run by the state or by the city, you will see it at least twice or thrice a day. If I’m not involved in multidisciplinary meeting as a radiologist, and I see it for the first time, the first thing I’m going to think is TB. I’m going to pick up the clinician and say ‘this is TB’. Because I knew the background that he had a history of primary hepatic cancer some time back, I would not straight away jump to tuberculosis. This case highlighted two things: a) you need to interact and to get information from either side, and b) how widely even a small piece of information could change the diagnosis or the match.
Disease Incidences Differ
rbc: How does the spectrum of oncologic disease in India differ from other countries?
MM: Habits determine the diseases people get. There are around 6,000 hepatic cancers a year in the US, plus or minus, while there are somewhere around 180,000 cases of lung cancer. If you come to India, that balance is turned on its head. You see a lot more hepatic cancers as opposed to lung cancers. This depends on how tobacco is consumed. In the US, tobacco is inhaled and not many people chew tobacco. In India, we chew a lot more tobacco than we inhale. Similarly, we see a lot of gall bladder cancers in certain parts of India. The average lifespan of a patient in the US is a little longer, so consequently we see more prostate cancers, and we see a lot more breast cancers relative to the population in the US.
rbc: How did your perception of non-radiology specialists change?
KG: It just kind of popped into my brain that certain things are going to remain the same – for example, the anatomy of a human being, the physiology and the biochemistry, which form the base of any living thing. The thing changing is the way look at these things, the way you’re going to try to identify disease and then the way we treat. That is the way evolution is going to happen.
When I was starting with radiology, there would probably be few 1.5 Tesla scanners, many would be low-field magnets. So, the information we got was not so good. It was okay. From 2003/4 onwards, radiology exploded. Exploded! When we got the first 3 Tesla magnet in 2004/5, UCSD did not have a 3 Tesla magnet. By the time I moved to UCSD in 2007, they had eight 3T scanners. We in India got our scanners much ahead of them, so we were moving dramatically. Oncological treatment was also expanding. In order to interpret what happens after giving the medication, radiology is the only way. So radiologists also had to expand. They got more data. What do you do with more data? You need newer techniques to evaluate it. As soon as you’ve got newer techniques, the amount of data coming in is substantially more. So, at the end of the day, it’s a dynamic process. It’s changing as we are doing it.
rbc: How do you keep up with all these technical developments?
MM: I don’t think I need to know all these things, all I need to have is the radiologist I trust who will look into it for me.
rbc: When did you know you could trust him?
MM: Well, I think actions speak louder than words. Trust is based on two things, one is the competence of the person, and two is ‘can you interact at a level where both of you can see a similar picture’? Like I said, differences are normal, they are important for the process, as long as you both understand where you are coming from.
rbc: It an occasional turf battle coming out of this as well?
MM: I don’t think turf battles is something I’m worried about; as long as the other person has a point of view that is appropriate, I think that the problems will see to themselves. And I have not run into a situation here in India where I’ve not been able to solve it.
Formalizing Multidisciplinarity In India
rbc: How could multidisciplinarity be formalized more on the country level?
KG: It’s an extremely difficult question, because the first thing about a multidisciplinary team is to agree to disagree in a very amicable way. I think we would thrash out intellectual or academic stuff, try to discuss without becoming personal, approach it in a very scientific way, you know. If it’s data driven, then it’s even better. When it comes to training, education and taking it beyond, it is a very complex issue, because each institution has its own dynamics.
rbc: Where do you see the major challenges for your specialties and your collaboration over the next decade?
MM: One thing we can expect is that the incidence of cancer is likely to double, at least this the prognosis from 2015 for 2025. It is something that we need to deal with. From a public health perspective, another issue is the role of obesity. Obesity is a big problem and there is a clear association between obesity and a number of cancers. So can we do something about that? Those are some things that I expect may be problems going forward.
KG: Demographically, if you look at numbers, about 60 to 70 percent of the population is in that 30 to 40 age bracket. In 30 years’ time, this same bracket is going to move to 60 to 70, as people start to live longer simply because the country is booming economically. You expect incomes to go up, lifestyles to change, but along with this, you expect newer diseases to come in. When I was at UCSD, we did a lot of work on the fat content of the liver, also in pediatric populations. Mexicans are genetically most prone to develop fatty level disease; with all its complications. I was surprised during my time over there that Asians, and especially sub-continent Asians, are the second highest population genetically prone to obesity. If you put this into context with the population of 1.2 billion, who are going to eat a different kind of diet, we are going to get a massive healthcare problem at some point, especially in grade 2 obesity and then cancer.
I look at it as an opportunity for healthcare to really make an impact. When radiologists and oncologists work together, they are in a position to pick up some of these disease non-invasively, and we are in a good situation to even help oncologists to treat it.
The problem of dissipating that information remains. My wife works in a municipal hospital where the doctor-patient ratio is completely skewed. If she was sitting in a single out patient department, they might have between 400 to 500 patients. How are you going to be able to look at each of these patients, give the information, sit together with colleagues, and be able to choose the right line of management and then take it forward?
rbc: A big challenge?
KG: It is a very big challenge. The government has to do a lot of things, public-private partnerships have significantly enhanced. We do it, we teach, we bring in people to workshops, we bring CMEs down, we have to scale up. Because fortunately or unfortunately, this doctor to patient ratio is likely just going to get worse and worse as we go on. Right now, if you look at 1200 oncologists for a population for 1.2 billion, you understand the problem.
About Karthik Ganesan
Karthik Ganesan is a radiology consultant and the Radiology Division Head at Sir.H.N.Reliance Foundation Hospital in Mumbai, Maharashtra, India.
About Mohan Menon
Mohan Menon is an American Board certified medical oncologist, practicing at Lilavati Hospital and HN Reliance Hospital in Mumbai, Maharashtra, India. He is also part of the visiting faculty at Hartford Healthcare Cancer Institute in Hartford, CT, USA. Mohan Menon also has a Masters in Business Administration from Alvernia University, Pennsylvania.
The entire interview (Duration: 20 minutes).