key: cord-0047839-ahb9ahy4 authors: Pedrosa, C. title: Are we ready?() date: 2020-07-17 journal: nan DOI: 10.1016/j.rxeng.2020.06.001 sha: 9cc98e535c4039abcc49ea9bea1c337f14a82803 doc_id: 47839 cord_uid: ahb9ahy4 nan The first response that I received referred to professionals in a radiology department. "Did you know? Paco and Luis were dispatched to the emergency department ----not to radiology, but to care for patients as though they were emergency medicine physicians". The second response referred to radiologists from another major city. "Did you know? Francisco, the expert in musculoskeletal radiology, was commissioned to read chest X-rays. Yesterday he had 40 cases to report. You can just imagine the surprise. He did read a lot of chest X-rays years ago, and he copes quite well." Similar situations have arisen throughout Spain in recent weeks, immediately begging several questions, the first being: are Spanish radiologists trained to deal with a medical emergency? This first question pertains to initial medical training, i.e. training received during residency and that which could be considered to be continuing education. The "rotating internship" was created in response to the fact that medical students were not getting enough clinical training at university. Under the Spanish Médicos Internos Residentes [Resident Intern Physician, MIR] system, which was implemented from Oviedo throughout Spain in 1964, the internship was the foundation of the training programme. In fact, the internship was offered at many hospitals. It was abolished, not because the problem had been solved, but rather due to haste on the part of some, in addition to the interests of certain hospitals which complied poorly with the necessary requirements. ଝ Please cite this article as: Pedrosa C. ¿Estamos preparados? Radiología. 2020. https://doi.org/10.1016/j.rx.2020.05.001 The internship was replaced with a shortened internal medicine residency, which subsequently varied depending on hospitals' needs. Is particular clinical training prior to radiological training necessary today? I am aware of the limitations that exist with respect to training time and to the marked increase in tasks that must be learned with new technologies; even so, I have little doubt that initial clinical training is a necessity. I defended that idea before the chair of the Spanish National Radiodiagnosis Commission, and I continue to defend it now. Talk to them if you want less professional training. It is true that the three years of internal medicine at the Fundación Jiménez Díaz [Jiménez Díaz Foundation] and the rotating internship that I did in my first year in the United States had an impact on me, but it is no less true that my professional successes over the years were, in my opinion, fundamentally rooted in my prior clinical training. I would like to mention that, in the United States, a prior year of "clinical" training, with an emphasis on medicine or surgery, remains a requirement for entry into a residency in any specialisation. In fact, in some programmes, first-year American radiology residents have been reassigned to assist on medical or surgical units in response to COVID-19. We must also ask ourselves whether we are making proper use of the continuing education of our professionals. I am aware of courses on resuscitation, use of emergency equipment, etc. at specific centres. However, the question is whether such continuing education programmes are widespread and whether they are sufficient to meet needs. In light of recent events, a new response, one that includes analysis of clinical signs requiring an emergency response, is probably required. It would not be overly complicated to mandate certain required annual training. The second major question is: are our professionals, who are so well-trained in their specific area of knowledge, ready to read chest X-rays in times of need? There is little doubt around the major advantages of specialisation in different areas of diagnostic imaging for the specialty and for medical practice. The degree of trust in our professionals grows as clinicians trust in their peers, and they only do so when radiologists have been solidly trained in their area of expertise. There are many answers to the question asked, because to my mind there are several important facts: 1 Chest X-ray, despite undeniable advances in slicing techniques, remains valuable for diagnosis. Its use has increased in recent years and it will continue to be useful. 1,2 2 Interpretation of a chest X-ray is one of the most difficult tasks in our specialisation and requires prior training. Those who believe thatänybodycan read a chest X-ray are deluding themselves. I recall my response to a clinician who assumed that he did not need a radiologist because he was perfectly capable of reading a chest Xray on his own.Ẅhat worries me is not what you see,Ï told him.Ẅhat worries me a great deal is what, I am sure, you do not see.Ït is possible that the use of artificial intelligence in the coming years will facilitate standardisation of chest X-ray reading, to the point that readings by non-expert radiologists become as reliable as readings by expert radiologists. 3 3 The difficult task of interpreting early lesions on a chest Xray becomes complicated if it is entrusted to a radiologist who has not read chest X-rays on a regular basis for years. Let's be realistic. Professionals who have dedicated their time to another branch of diagnostic imaging must refresh themselves, albeit briefly. This refresher training cannot be limited solely to recognition of pulmonary infiltrates in, for example, a pandemic of respiratory transmission like COVID-19, since reading undoubtedly requires recognition of other diseases (cancers, cardiovascular diseases, bone diseases, etc.). 4 The degree of training in chest radiology during residency has surely been uneven across different centres and therefore critical for an unknown number of radiologists. 5 Many hospitals have dispensed with routine reading of conventional imaging and, even worse, the routine reading of chest imaging in the emergency department. 6 The speed and efficiency with which the Spanish Society of Medical Radiology (SERAM) has responded to the challenge by publishing information, standards and guidelines for action have most definitely been very helpful for radiologists. 4 Would putting together an optional refresher training programme, an annual course on emergency chest radiology, be very complicated for the SERAM? It could be online, if the required monitoring guidelines are followed. Department heads could leverage their authority to make it necessary. The third and final major question is: is the MIR the right solution to the current problem? The MIR system, conceptually impeccable, is today a system of inertia. Initial efforts to drive the programme had a major impact, it enjoyed substantial institutional support and it was the solution to an existing problem. Yet, over the years, it has become a routine system, with a lack of necessary investment and too many salary problems, training deficiencies and lax accreditation of centres and hospitals where residents are used as cheap labour. To complete the picture, in recent years, some media have hinted at the transfer of MIR training to some other organisation. I hope that such nonsense does not make it past the usualsounding board. Despite all its deficiencies, the MIR programme ensures high-quality specialised training, warts and all. It is clear that the pandemic will have major repercussions. First and foremost, it will have economic repercussions. Difficult times are afoot; health in general and the MIR system in particular could be subject to significant cuts. But the vision of the medical profession and its practitioners will evolve, too. Substantial changes will be proposed and we must be alert to them. Our specialisation's curriculum will have to adapt to a new era, not just new technologies. We will have to adapt our teaching practice by including new techniques that lead to participation that stimulates more interactive learning, particularly distance learning. 5, 6 I believe the SERAM, which has been taking such extraordinary action, should be the vehicle by which we arrive at a common position and attempt to circulate it among pertinent individuals and organisations. This is what is currently known as adaptive leadership and it includes, among other things, understanding the problem, fighting against inevitable rejections, motivating professionals, accepting diversity, having empathy with those affected by the measures that must be taken and managing the necessary political contacts. 7 These problems, difficult as they may seem today, will be overcome, and we have to be prepared for that moment. I want to be an optimist. So I cannot accept, with the difficulties the virus has caused, with the problems lack of foresight and incompetence have created, that proactive alternatives that promote high-quality medicine will not come about. In the words of Winston Churchill: "A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty." We must see the opportunity in this difficulty. Increasing utilization of chest imaging in US Emergency Departments from 1994 to 2015 the role of chest imaging in patient management during the COVID-19 pandemic: A Multinational consensus statement from the Fleischner society Automated triaging of adult chest radiographs with deep artificial neural networks Tutorial sobre la Rx de tórax en el actual contexto de pandemia por COVID-19, indicaciones, hallazgos, informe y escala radiológica de valoración para el ingreso o alta del paciente (ERVI) y seguimiento The Impact of COVID-19 on Radiology Trainees A Review of innovative teaching methods Adaptive leadership: Tips from the business world Jefe del Servicio de Diagnóstico por la Imagen (retirado)