Clin. RadioL (1972) 23, 399-400

S O M E P E R S O N A L T H O U G H T S ON T R A I N I N G IN D I A G N O S T I C R A D I O L O G Y

In support of the Generalist

ERIC SAMUEL

From the University of Edinburgh, Scotland

OF the 700 or so consultants engaged in the practice of diagnostic radiology in the United Kingdom, more than two-thirds practise in hospitals whose prime responsibility is the delivery of comprehensive radiological care to the community which their hospital serves. They are seldom involved with sophisticated equipment or esoteric investigations associated with the sub specialities of radiology such as neuroradiology, cardioradiology, etc. such as are usually associated with teaching or specialised centres. This does not deny the immense value and importance of such specialised groups where the concentration of expertise and the familiarity in dealing with the rare problems has added major dimensions to the general understanding of radiology, and has greatly enhanced the academic content of radiology. However the very drama associated with a brain or cardiac operation, so frequently high-lighted today by the mass media, has perhaps resulted in a disproportionate amount of radiological finance and perhaps of effort, being directed to these areas. The research and investi- gative impact of a sub-speciality of radiology cannot be denied, but its necessarily limited contribution to the total quantum of radiological care should be critically assessed in deciding priorities within the speciality of radiology.

The possible drift of some of our ablest students to these by-ways from the main stream of radiology, although conceivably providing more job satis- faction and a personally satisfying existence, may lead to a weakening of the main stream of radiology, occurring perhaps only ultimately at the expense of quality of radiological service available to general patient care.

The abrogation of the important part that such a radiologist with a specialised knowledge of these specialised fields can usefully contribute by 'feed back' to the advancement of general radiology, must also be carefully watched. The serious loss of clinical contact that some of the 'super specialists' lose with the main stream of radiology is a very real and disquieting develop- ment, and his lack of interest and even more of expertise with the more general aspects of radiology,

becomes progressively more with the passage of years. Recently, a further sub-section of radiology, apart from cardiology or neurology, namely that of paediatric radiology, has developed and it has indeed been suggested that training of radiology should be limited to one single aspect of the subject (Abrams, 1970). There can be no gainsaying that radiologists specialising wholly in paediatrics must necessarily develop in the centres where specialised knowledge in paediatrics is demanded, such as the larger children's hospitals. It should not be forgotten however that 70 per cent of the children in the United Kingdom are cared for, not by paediatricians, but by general physicians with a particular interest in children's diseases. It is equally true that the same applies to radiology and it is possible that this may be the means of providing the best coverage.

It has been argued that paediatric radiology is no different a problem from medicine or surgery and the above arguments must equally apply to cardioradiology and neuroradiology, but in the content of the comparable development of cardiac physicians and surgeons, neurologists and neuro- surgeons, it must be remembered that these have responsibility for the therapeutic care of the patients, a commitment considerably more demand- ing than that required from the radiologist specialising in the same branch.

Whether such a complete isolation of an individual in a sub-speciality by total commitment, as opposed to the development of a natural part- time interest in a particular branch of radiology, is the best way of serving radiology and indeed the patient, must be seriously considered.

Apart from determining the most efficient method of delivering radiological care to a community, how do these facts of ultra-specialisation affect the teaching and training of radiologists? Too often, much of our teaching is based on acquiring a detailed knowledge of many of these sub-specialities and at the expense of broader knowledge. Refer- ence to recent examination papers indicates the extent of the depth of such knowledge which is demanded. Yet the majority of practising radio-

399

400 CLINICAL RADIOLOGY

logists are hardly likely to under take or need, even a small fraction of this specialised work during the whole of their years in the practice of radiology.

On what then should our emphasis on teaching and examinat ion be? The earliest radiological manifestations of commoner diseases and the infinite variations of the normal are seldom emphasised to the degree they should be in t raining programmes, and whilst many training schools pay lip service to these aspects, they seldom seem prepared to act on it by setting questions to the budding radiologist in the qualifying examination. These may be mundane considerations bu t they are unfor tunate ly necessary ones, as they reflect on the interest and time the student is likely to devote to them during his studies.

Thus, we re turn to the central theme that the generalist radiologist, based on a broad and basic radiological training, should and must play ulti-

mately the greatest par t in the delivery of radio- logical care to a community . The place and influence of such a radiologist in a communi ty , the respect of his colleagues for his breadth of knowledge and the possibility of constant ly refreshing this by contact with his radiological colleagues working in diverse specialities, must surely provide the ' job satisfaction' that is c lamoured for today.

A critical reassessment of our t ra ining pro- grammes, particularly what aspects of radiology are taught and the depth to which the more detailed minut iae of the sub-specialised areas are taught and examined on, is urgently needed.

PROFESSOR ERIC SAMUEL

REFERENCE ABRAMS, H. L. (1970). Personal Communication.

B O O K R E V I E W

Mammography and Breast Diseases by ROBERT L. EGAN. 272 pages, 255 figures. Published by The Williams & Wilkins Company, 1970.

This treatise on mammography comprises Section 19 of Golden's 'Diagnostic Roentgenology' and represents a new section in this well known work which is undergoing revision and representation as Golden's 'Diagnostic Radiology'. Section 19 is available as a book or in loose-leaf form.

Professor Egan is an acknowledged authority on his subject and has done much to develop, popularise and teach the comparatively recently accepted technique of mammo- graphy. He has previously published two books entitled 'Mammography' and 'Technologist Guide to Mammo- graphy'. The work under review combines the information of these two books in one volume and in addition incorpo- rates further material on physical evaluation of techniques, and on pathology - both macroscopic and microscopic.

The book may be divided into five sections. The first section provides a general introduction to the problem of breast cancer and the history of mammography. This is followed by a description of the mammographic appearances of the normal breast types.

A detailed acount is then given of the meticulous technique used in Professor Egan's department with excel- lent illustrations and a full clear text. All the factors neces- sary for the production of a successful soft tissue radio- graph of the breast are discussed. Extension cylinders are preferred as collimators by Professor Egan but other people believe that adapted light beam devices can be entirely satisfactory. In addition at the time of publication, auto- rustic processing of industrial type films was not available but it is now known that excellent results can be obtained using rapid automatic processing.

An extensive third section is devoted to physical evaluation

of the characteristics of mammographic techniques and contains highly technical details of measurement and control of X-ray unit output, collimation, dosimetry and spectral quality. Fortunately the conclusions are conveniently and succinctly stated.

A fourth section of 72 pages deals with the correlated clinical, radiographic and pathologic approach to the study of breast diseases. The 'team work' between surgeon, radiologist and pathologist which is essential for a compre- hensive examination is stressed. A detailed account of the preparation and staining techniques used in 'Whole Organ Study' is given and also the radiographic techniques used in examination of these specimens. Several statements made in this section would not be universally accepted. Few people would agree that 'mammographic growth patterns of breast cancer allow reliable categories for prognostication'. In addition, it is not generally accepted that 'carcinomas are usually multiple' and that 'multiple sites of invasive carci- noma can be demonstrated in almost every breast with primary carcinoma'. An incidence of just over 5 ~ for simultaneous bilateral primary carcinoma in 76 cases of breast cancer must also be unusual. The advice given for localisation of biopsy specimens and the further examination of those specimens by radiographic methods is invaluable.

In the fifth and final section, an excellent descriptive account of the various malignant and benign conditions of the breast is given. The lesions are lavishly illustrated with radiographs of superb quality. Difficulties in interpretation are considered and the results, limitations, indications and applications of mammography are discussed.

This book can be recommended to all Radiologists interested in mammography and should find a place in all departmental libraries. It is a valuable reference book on the technique of mammography and interpretation of 1]3amrno- grams.

I. H. GghVELLE