Review of 2011

In a year characterised by international political turmoil and economic uncertainty, there are numerous issues which are of simmering concern to South African radiologists, as political initiatives may dramatically change healthcare economics. There are also significant changes imminent in how we become radiologists and aspects of how we practice.

Congratulations to Professor Savvas Andronikou on again being elected President of the College of Radiology, and thanks to Professor Coert de Vries for the time he has served. In recognition of the need for time to cover the syllabus, some institutions are using the primary exam as an entrance examination to the registrar programme, while others are looking to a 5-year curriculum. The unification of the curricula and the unified examination with dissertation are becoming a reality. The SAJR continues to strengthen; it is a vehicle for publication of dissertations, and the collaboration through the ISR with Professor Eric Stern’s GO RAD initiative is a welcome enhancement to the international profile of our journal. Congratulations and thanks to Professor Jan Lotz and all those involved for the work being done.

The CME Fund, now formally constituted with trustees Dr Thami Ngoma, Professors Zarina Lockhat and Leon Janse van Rensburg, and Dr Johan Basson, is fully functional and has healthy finances. During this year, funds were made available to the academic institutions for the purchase of books for departmental libraries. I was able to visit many of these and was impressed by the enthusiasm on the ground; it is our hope that, through the CME Fund, we will be able to pursue initiatives that can further strengthen radiology training and academic radiology within South Africa. The active congress programme organised by Professor Leon Janse van Rensburg is anticipated to cover major areas of the syllabus over a 4 - 5-year cycle, giving all radiologists, and particularly those in training, the opportunity to continually update knowledge with renowned international speakers visiting South Africa. The hands-on CT workshops have proved popular and are excellent learning experience, but the nature of these meetings is that spaces are limited.

The SORSA-RSSA meeting in Durban is part of an ongoing collaboration with radiographers, and panel discussions on contrast injection by radiographer, and radiographer role extension, were a specific focus this year. The clinical mammography and MRI course was popular. There were two key messages: BI-RADS should become the standard reporting format, and breast MRI is assuming an increasingly important role. An important parallel session was the Functional MRI of Physiological Processes workshop. The RSSA short course on Current Ethical issues in Radiology has now been presented in Cape Town, Johannesburg and Durban.

At the RSSA MDCT congress in Sandton this year, our prizes for poster and paper presentations were awarded (see report in this section of the journal). The international judges were impressed by the high quality of both the paper presentations and the posters, and all who participated are to be commended. Of the subgroups, SAMSIG (musculoskeletal) continues to be active, and the formal formation of SASNI (neuroradiology) and SASPI (paediatric radiology) was completed this year. It is hoped that the Red Cross Paediatric Fellowship will be reinstated, and we anticipate new fellowships in neuro-imaging and musculoskeletal imaging in which the expertise within these subgroups will play a major role. And it is anticipated that a breast imaging sub-group will take shape this year!

The RSSA has been invited to participate in the ‘ESR meets South Africa’ programme at ECR 2013, and we look forward to the opportunity to show work that has been done in South Africa, particularly in HIV and TB. The ESR continues to extend the hand of friendship to those beyond the borders of the EU, and visiting fellowships and other educational opportunities are available via RSSA affiliation with the ESR. The links are on the website.

If you are a member of the RSSA, please ensure that your details are up to date so that we can keep you informed of upcoming events; and if you are not, please join. For those not in private practice, the fees are low and members enjoy the free journal and cheaper rates at our congresses. Contact Patricia Trietsch, Radiological Society of South Africa, email radsoc@iafrica.com, and website www.rssa.co.za, tel. 011 794 4395 and fax 011 794 4313.

For those in private practice, the reference price list as promoted by the Department of Health on a cost-based methodology is at an advanced stage of development and, in anticipation of NHI, will provide a defensible transparent tariff structure. It has become clear, however, that the HPSCA will not be in a position to publish tariff lists for 2012; no other body has authority to do so. Other statutory bodies, such as the Law Society and that for architects, have published tariff guidelines for many years without any intervention from the competition commissioner, and it is hoped that healthcare will eventually have a robust published tariff structure.

Co-payments remain contentious. Co-payments are permissible as a percentage of the fee for an examination and were designed to ensure that patients, by assuming responsibility for a part of the fee for an examination, would not undertake these examinations lightly. However, funders are increasingly using fixed high co-payments as a tool to avoid payment for examinations that fall below the co-payment value. This is contrary to what was originally envisaged and, on an ethical basis, highly questionable as it amounts to the removal of benefits by stealth. The patient does not have sufficient knowledge to be involved in the choice of examination, and co-payment considerations can lead to inappropriate choice of modality. The Society accepts the principal of co-payment as a percentage of the examination fee. However, we cannot countenance the use of co-payments by funders to, in effect, withdraw benefits from patients. As co-payments increase, the number of examinations not actually covered increases.

National health insurance, with the publication of the green paper, is starting to assume a more concrete form. However, there is still little detail. Risk-adjusted capitation at the primary level is suggested, with global budgets at the hospital level. Currently, whether the patient or the funder is responsible for payment may depend on the patient status as an inpatient or outpatient. For radiology, this makes little sense. Radiology occupies a unique space at the cusp serving the needs of inpatients and outpatients, and many of our investigations determine who will be admitted and who can be safely sent home. Image-guided, minimally invasive procedures performed on outpatients may prevent costly admissions altogether. There does not yet seem to be any indication as to how radiology will be funded in a future NHI environment or how to ensure a level playing field. We have an opportunity to comment on the contents before the end of December this year, and I would encourage all radiologists to read the document and submit comment to the Society to ensure that all radiologist concerns are adequately addressed in our formal submission on the green paper. Universal coverage is a noble ideal that has broad support. Problems in the public sector should be addressed as a priority. It is encouraging that the Minister of Health recognises a role for the private sector, and acknowledges that correcting problems in one sector should not destroy the other. Expertise, infrastructure and capacity in the private system should be used to extend quality health care. There are future opportunities for radiologists to contribute to training in our own speciality, to service delivery particularly using electronic image transfer, and by providing a quality service to a population currently underserved.

Radiology is a referred-to specialty, and it is appropriate that the clinician requesting the examination does not stand to benefit from the performance of the examination. Our aim should be to practice appropriate evidence-based radiology. Bad referrer habits and funding considerations may work against this ideal. The RSSA has succeeded in securing the right to use the ACR guidelines, which will be of use to referrers, radiologists and funders whether private or public.

The attenuation of the Road Accident Fund has lead to significant increased activity of lawyers touting for business in the media, with the main focus of the business being medical litigation. The Medical Protection Society has experienced a dramatic increase in medico-legal cases in both the private and public sectors, and this is a trend of major concern. This problem has previously developed in other jurisdictions in which the MPS operate, and they have advised that we need to be proactive in two aspects:

Firstly, at the level of the legislative framework in which we operate, it is important to note that legal contingency fees are a contributing factor not only to the increased number of cases but also to the size of the settlement demanded and, if we are to avoid malpractice insurance becoming unaffordable, it is essential that the underlying causes are addressed. It is inherently repugnant that, where a patient has suffered and is justly deserving of a high settlement, the lawyer involved is entitled to disproportionately high remuneration that is at the expense of the remainder of the health budget, in the case of the public sector or those contributing to malpractice insurance in the private setting. It is hoped that the MPS engagement with the relevant ministries will be successful.

Secondly, we need to re-examine the way in which we practice and ensure that we do so in such a way that opportunities for medical litigation are limited. Poor communication, or failure of communication, is a factor in at least 70% of litigation cases. It is essential that, as radiologists, we ensure that communication with our clinical colleagues is above reproach and, in particular, to ensure that urgent or important results are communicated effectively to the referring clinician. The continued roll-out of RIS PACS systems brings renewed problems, with a conflict between considerations of patient confidentiality and the ability of clinicians to easily view the images from other clinicians, institutions and systems. Image distribution systems are critical, particularly as doctors in theatres may be using images on the systems, and they need to be able to function even when the supply of power may be unreliable. Proper communication is sufficiently important in respect of medical malpractice that the MPS has arranged a series of free workshops which carry ethics CPD points, and radiologists are actively encouraged to attend these workshops. At a meeting with the MPS that I recently attended, a representative from the HPCSA was present, and it is possible that attendance at MPS workshops may become part of the ethics requirement.

I thank all those within the RSSA who have the ability or aptitude to contribute in some way and have done so by teaching of registrars, supporting academic departments, volunteering to become examiners or reviewers, and contributing to the journal or participating in subgroups.

Finally; the recent liquidation in radiology is a sober reminder to hospitals, vendors, investors who may have burnt their fingers, and funders that, in an industry with high fixed costs, viability can be precarious.

May I close by wishing all RSSA members, in private and public settings, success in 2012.

Clive Sperryn

President, RSSA

Visit by RSSA President to Stellen-bosch University

Dr Clive Sperryn, President of the Radiological Society of South Africa, was the guest of the Division of Radiodiagnosis at Tygerberg Academic Hospital on 1 August 2011. Dr Sperryn joined the Division for lunch and was an invited speaker at the weekly modular Academic Programme, during which he made a donation of selected textbooks to the value of R25 000 to the Division’s imaging reference library. This formed part of the RSSA’s broader donation of textbooks to university radiology departments nationwide.

In thanking Dr Sperryn for the very generous donation, Professor Richard Pitcher, Head of the Division, acknowledged the RSSA’s sustained support of academic radiology in South Africa. Professor Pitcher made particular mention of the significant growth, over the last five years, of the Society’s official mouthpiece, the South African Journal of Radiology, under the editorship of Professor Jan Lotz. He also cited the Society’s highly successful Conference Programme convened by Professor Leon Janse van Rensburg, which had culminated in the formation of the RSSA’s CME Fund, from which the national library donations had been made. In addition, over the past years, a number of Stellenbosch University registrars had been able to attend international congresses as recipients of CME Fund Travel Awards, made for prize-winning oral and poster presentations at the Society’s annual national congress.

Leuven lung imaging

The first of the RSSA/Leuven HRCT lung imaging courses will take place on 17 - 19 February 2012 at the Sandton Sun Hotel in Johannesburg, and on 24 - 26 February 2012 at the Spier Estate near Stellenbosch in the Western Cape.

This hands-on, interactive teaching course on high resolution computed tomography (HRCT) of the lung is internationally acclaimed and recognised as the lung course to do, and is in extremely high demand. The course is conducted by internationally renowned and leading Belgian radiologists Professors Dr Johny Verschakelen and Walter De Wever, of the Department of Radiology, University Hospitals, Catholic University of Leuven, (K.U. Leuven), Belgium. This is the first time that two back-to-back courses will be conducted and, on behalf of the RSSA, I extend our most sincere appreciation and gratitude to Professors Dr Verschakelen and De Wever.

A cost-effective, pragmatic and comprehensive HRCT imaging approach to patients with lung disease is of particular importance to all radiologists providing a service to these patients, as well as the clinicians and therapists caring for them. The human and social impact, and financial implications, of lung disease are far-reaching, especially in developing countries.

The aim of the course is to train and update radiologists and teach those in training in state-of-the-art HRCT imaging of the lung. On completion of the course, participant should be able to recognise the different basic disease patterns that can be seen on HRCT of the lungs, and to make a diagnosis or suggest a differential diagnosis. The indications and limitations of HRCT in different lung diseases will be emphasised.

Starting with an overview of lung disease and applied radiological anatomy, the course will focus upon the HRCT appearance of common and uncommon lung diseases and the interpretation of findings. Apart from lectures, practical teaching will be done during workshops where participants will have the opportunity to test and expand their knowledge by reviewing clinical cases, with direct tutoring and feedback from the teachers.

The course will be held at the modern, impressive and conveniently
situated Sandton Sun Hotel in Johannesburg and again at the historic, beautiful and tranquil Spier Estate, surrounded by the verdant mountains and vineyards of the Stellenbosch area Owing to the technical and logistical requirements in presenting such a course, and to ensure interactivity with the teachers, enrolment is limited to 80 RSSA member participants per course. Please go to http://www.rssa2012lungcourse.co.za/registration for course and registration details.

The organization of such an event is challenging and no small feat. I extend my sincere appreciation to the RSSA congress event organiser, ConsultUS and the audio-visual team Presentation Staging, for making this possible.

I take great pleasure and pride in welcoming Professors Dr Johny Verschakelen and Walter De Wever to South Africa, and wish them an enjoyable visit.

Leon Janse van Rensburg

RSSA Congress Chair

RSSA MDCT course – August 2011

The first RSSA Essentials in MDCT/CTA Course was held at the Sandton Convention Centre from 26 - 28 August 2011. The central location, easy access from the airport via the Gautrain, and the international faculty of four exceptional international radiologists contributed to a record attendance of 340 of whom 270 were radiologists. Congratulations to Professor Leon Janse van Rensburg who was able to persuade distinguished Professor Elliot Fishman of John Hopkins University School of Medicine, USA, to co-ordinate the course.

The course focussed on 64-slice MDCT and newer systems including dual-source CT scanners. The programme consisted of a series of 40-minute lectures that concentrated on specific topics in depth, including state-of-the-art technology and software. Participants had the opportunity to expand their knowledge of the latest concepts and principles of spiral/helical CT, with Professor Fishman emphasising the importance of studying the volumes and interacting with the datasets to optimise image interpretation. Professor David Naidich elucidated HRCT and provided a fascinating insight into imaging of the sub-solid nodule. Professor Jill Jacobs highlighted the intricacies of cardiac CT and CTA. Professor Karen Horton emphasised the complementary 2D and 3D techniques in CT colonography and imaging of small-bowel neoplasms. The use of CT in the GI tract, including the liver, spleen and kidneys, were all extensively covered.

There were anxious moments for the visiting faculty who had their return travel arrangements disrupted by Hurricane Irene on the east coast of the USA. Our thanks to them all for making the trip to South Africa, and we hope that they will return.

Congratulations to all those who participated in the poster and paper presentations. Our esteemed international judges were extremely impressed, and confirmed that these presentations were of an international standard. The prizes were awarded as follows:

2011 RSSA Travel Award: R40 000. To Dr Lizelle Clark: The role of multi-detector CT angiography as an adjunctive tool in the evaluation of paediatric cardiac disease in an African setting.

2011 RSSA Travel Award: R20 000. To Dr Braham van der Merwe: How we eyeball the small bowel: Newly introduced CT enteroclysis at Tygerberg Hospital.

2011 RSSA Best Poster Prize R15 000. To Dr Vicci du Plessis: Baseline chest radiograph appearances of HIV-infected children eligible for anti retroviral therapy.

2011 RSSA Poster Prize R10 000. To Dr Werner Steyn: Vanishing white matter disease, MRI imaging over four years.

2011 RSSA Poster Prize R5 000. To Dr Nishentha Govender: Adequacy of paediatric renal tract ultrasound.

Thanks to the Scientific Committee of Professor Victor Mngomezulu (chairperson), Professor Zarina Lockhat and Dr Christelle Ackermann; to Sune van Rooyen and the ConsultUS team for seamless organisation; and to all our sponsors for their support. We greatly appreciate their commitment to radiology training and teaching.

Clive Sperryn

President, RSSA

(From left to right) Professors Leon Janse van Rensburg, Jill Jacobs (USA), Margaret Kinsana (Univ. Limpopo), David Naidich (USA), Zarina Lockhat (Univ. Pretoria) and Elliott Fishman (USA).