Tearing Down The Walls
Sree Chitra Tirunal Institute for Medical Sciences and Technology in Trivandrum, India
Radiologist Chandrasekharan Kesavadas and neurologist Ramshekhar Menon have been working together for many years in Trivandrum in the South Indian state of Kerala. They share their views about their respective roles in successful tearing down walls between their medical disciplines.
radiology.bayer.com (rbc): How do you set up your multi-disciplinary work?
Ramshekhar Menon (RM): We as neurologists try to achieve a clinical diagnosis. The cornerstone of clinical localization is anatomical localization. After we reach an anatomical diagnosis, we go on to a physiological diagnosis, where we figure out how the functioning of the patient is affected. So, it’s the anatomical diagnosis, physiological diagnosis, and finally the clinical diagnosis. Once we reach that state of a clinical diagnosis, we are going for imaging of that part of the neuro-axis which we think is involved.
So, for example, if we think that the patient’s brain is affected, we ask for an MRI of the brain. Now, the important thing that we need to decide is to how urgently we need to plan that decision. The first point of contact would be getting an appointment. Once we get the appointment and we do the neuro imaging and we corroborate the imaging findings with our clinical diagnosis, that’s the point where we actually go and discuss. We usually make it a point to individually go to the radiologist, see if there is a difference of opinion as far as the imaging findings go, and what difference should the diagnosis we are looking at and what way that would actually determine the management of the patient. Most of the radiology that we learn as neurologists is directly by these interactions with the radiologists.
rbc: Learning by doing?
RM: Yes, learning by doing. The neuro imaging part of it is direct – not by textbooks or by viewing atlases – it is based on one to one interaction with the radiologist.
There are so many aspects in MRI beyond the physics. So ultimately, it is our job to learn the clinical and radiological correlation and that is where the radiologists really help us. I would think that the majority of neurology is heavily dependent on what the radiologist believes is the actual etiology of the syndrome and ultimately to determine the management.
rbc: What percentage of your patients would you send to your radiology colleagues?
RM: About 70%. When we are dealing with peripheral neuromuscular problems, there is the central neuro-axis, and the peripheral neuro-axis, meaning nerves, muscles, and the neuromuscular junction. Most of those are diagnosed based upon clinical impressions and electrophysiology.
When it comes to the central neuro-axis, which is primarily the brain, cranial nerves, and the spiral cord, we really rely on neuroimaging. At least in my practice, it would be to the tune of 80 to 90 percent, but based upon what a neurologist is doing, the numbers might vary. If a person has an expertise in peripheral neuromuscular disorders, he might not be referring as much to the radiologist. But most general neurologists, I would put the figure at 75-80%.
rbc: When a resident is coming to your department, what do you tell him first about imaging?
RM: We start off with just the plain history. Most of the diagnoses are made at the end of the history and then we go on to neurological examination and that ultimately corroborates your findings. There is no neurologist who will confidently say that I rely only on neuro imaging to achieve a diagnosis – because neurological syndromes are clinically diagnosed. That's the bottom line. That’s what we train our residents to do: That you can’t be relying on the MRI or the CT brain, you need to have your own neurological diagnosis before discussing with the radiologist.
rbc: What would you recommend to a leading physician, who wants to focus more on multi-disciplinary work?
RM: The one-to-one interaction as well as patient management conferences where you have a multi-disciplinary team coming together would make a big difference to the management of patients.
Interaction is informal, but we document whatever we have discussed and the final conclusion. And we communicate the same to the patient. It is also important that we communicate that we have had this multidisciplinary discussion. This is the problem that we think you have, this is what we think needs to be done in terms of your management. So, I think it makes a difference to patient management as well as patient understanding. They have the confidence that I am not the only person who has been taking a judgement on their problem.
CK: I still remember one patient with an MR that went as a normal study in the radiology department. This was an epilepsy patient with seizures not being controlled by drugs, so it was intractable epilepsy. The plan was to find out whether surgery was possible, but the MR had to find something, and it was reported as normal. The MR report went back to the neurologist and after doing an EEG they found that almost all the seizures were coming from the right frontal lobe. The neurologist had a suspicion of small particle dysplasia. The resident came back to the neuroradiology department, including myself, and we were all sitting together, and asked ‘Do you think that this is a dysplasia?’ We looked at it and said ‘yes’, this is a dysplasia.
So the resident could pick it up. When two departments come together there is a very high chance of picking up some of these lesions and the diagnosis becomes much better. If you are sitting independently, you would have actually missed that.
RM: Neuroimaging is an important part of neurologists’ curriculum. I mean you really need to learn from your radiologist. If we are to achieve something close to an anatomical diagnosis you have to know your neuroradiology. So, a neurologist also has to be a part time radiologist.
Specialization Instead of Turf Wars
rbc: You say you have to be a bit of a radiologist to get along with each other and vice-versa - how do you exchange that kind of knowledge?
CK: The first thing that I tell my residents or my students of radiology, what I do is I become better, I have to be better than a neurologist. To really tell I’m a neuroradiologist and to report an MR, so how can I be better? I have to do a lot of new techniques that are coming up whether it is profusion imaging, diffusion or diffusion tensor, functional MRI, you start doing these things and become better by these things. Once you become better then naturally, some amount of your training you can definitely help the neurologist, tell them also so that they also get basic skills at imaging. So, I don’t think that there’s a big turf war there with the neurologists, because once you are confident and you think you are better and you have better skills, then I don’t think there should be any [turf war]- so that is what is the radiologist should be doing, they have to improve their skills and by improving your skills, it is ultimately the patient who is going to benefit.
The radiologist has to be good, that is the most important and that is where radiologists have to do a few things. They have to specialize. For example, neurologists specialize to the extent that there are sub-specialties of epilepsy, movement disorders, stroke and all these things. But radiologists in India they have a three-year course after their basic medical degree and after that many do not specialize. If the radiologist starts specializing, then they become neuroradiologists or any other interventional radiologist and are able to do very good work. The second point is the number of neurologists that are coming out every year in India is huge compared to the number of radiologists. There has to be a higher number of radiologists who then go and then specialize and try to become the best. Then their reports will be valued by any clinician, any neurologist or orthopedist or gastroenterologist.
Improving Multidisciplinary Work
rbc: What do you think should improve in that multi-disciplinary setting in India?
RM: One thing would be to strengthen the curriculum to get more clinical and radiological interactions done. At the community level, the best thing would be to really provide basic infrastructure for more CT scans and more MRIs at community healthcare centers. At the same time, develop telemedicine facilities or what we do in stroke called tele-stroke facilities. Even an MD radiology person should be able to run such a set up at a basic level and should be able to initiate management protocols at that level.
CK: Regarding radiology training, I think the first importance in the first three years’ basic radiology training that in India is called the MD or the DMB. During that training, the residents should be taught the importance of clinical medicine or clinical surgery. As the most important thing before you start interpreting the images, you need to understand that the patient’s clinical diagnosis and getting more into clinical diagnosis and decision making. There should be multi-disciplinary meetings by which these residents can train better. That is one thing that has to come up in these institutions.
We have it in about 3-4 major institutions in the country. That is not enough, it should start in all the medical colleges and there should be sub-specializations in say pediatric radiology, muscular skeletal radiology, or gastrointestinal radiology. So those residents that have done these courses will definitely be able to help the teams in which they are working.
There should also be auditing. Many times, that is not happening in many of the institutions across India. We have to learn from the mistakes.
RM: We have mortality meetings where we discuss and it’s largely the neurologist has to really explain as to why this particular patient died. Those aspects require multiple inputs so, so the radiologist is an important part of it.
rbc: What would be your recommendation for a first step towards multidisciplinary work?
RM: Be willing to learn. And keep your ego apart when you are going in for such discussions, to put it plain and simple. The cornerstone of any approach is to be reasonably confident of your neurological diagnosis and go to the most likely explanation of the same. If you just follow that particular protocol of going to the most likely explanation of a particular neurological syndrome and make sure you got your localization right, you are likely to get your diagnosis in there. The radiologist is expected to confirm your clinical opinion.
CK: What I would recommend is, every radiologist or in fact any person who is practicing medicine should know that the field is expanding very, very fast, you have to update yourself with whatever new is coming. Radiology especially has a lot of new technology that is coming up and you have to actually try these technologies and see. Take perfusion imaging for example: Unless you try it, you cannot say this particular technique is useful for this diagnosis – you have to have experience with perfusion imaging. A lot of these new techniques are coming. You have to update yourself, try the new techniques and see whether they are useful.
About Chandrasekharan Kesavadas
Chandrasekharan Kesavadas is professor of radiology at the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Trivandrum, the capital of the South Indian State of Kerala.
His research focuses on MRI, neuroradiology medical imaging informatics and brain Computer interfaces. He has published more than 275 scientific articles. The Government of India has awarded him with the National Bioscience Award for Career Development for his contributions to biosciences in 2009. It is one of the highest Indian science awards.
About Ramshekhar Menon
Neurologist and epileptologist Ramshekhar Menon works at the R Madhavan Nayar Center for Comprehensive Epilepsy Care & Cognition-Behavioural Neurology Centre, at the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Trivandrum, India. His research focuses on epilepsy, EEG, cognitive neurology, neuroimmunology and clinical neurology.
The entire interview (Duration: 21 minutes)