The misuse of ultrasound in India for sex determination, leading to female foeticide, has prompted a debate in the radiological community about who should be allowed to perform ultrasound exams. And whether restricting it to only radiologists and gynaecologists will help curb its illegal and wrongful use.
The Indian Radiological and Imaging Association (IRIA) is of the view that limiting ultrasound to radiologists and gynaecologists will reduce the misuse of the modality. But ever since AuntMinnieIndia.com published an article on the IRIA's stand, we have received a number of responses questioning the validity of the association's stance and whether this will solve the problem.
We publish here the response, by Dr Suresh of Mediscan Systems Diagnostic Ultrasound Research & Training Centre in Chennai, that best sums up the viewpoint for why ultrasound should not be the exclusive preserve of radiologists and gynaecologists.
To practice good ultrasound, intensive and continuous training is necessary. This is true for radiologists and nonradiologists, and for graduates and postgraduates.
India is a very large country, and ultrasound is the simplest imaging modality that can be taken to remote parts and to the bedsides of patients. It is impossible to find enough postgraduate radiologists or obstetricians to cater to the needs of the country’s entire population. There are not enough radiologists to interpret even conventional X-rays, let alone ultrasound!
Over 50% of all ultrasound cases are obstetric ultrasound. This needs some knowledge of clinical obstetrics. So whether the person performing the exam is a radiologist or not, exposure to clinical obstetrics and extensive training in ob/gyn ultrasound is necessary.
If obstetric ultrasound is to be done only by postgraduates in obstetrics, again, not enough postgraduates are available and not enough are trained. Training obtained only during the postgraduate course is inadequate.
In India, several MBBS graduates who have opted for a career in ultrasound and have undergone adequate training are performing very well, on par with the best centres in the world. On the other hand, a good number of postgraduates who are performing substandard ultrasound and a large number of untrained graduates are not doing quality ultrasound. The problem, it appears, is universal to the medical community in India.
The Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act (PNDT Act) is specifically meant to regulate the misuse of ultrasound for sex determination. Its scope does not include certification of competency in ultrasound. This is a completely different aspect, and there is no guarantee that a radiologist will not do sex determination.
In actual practice, the misuse of ultrasound is largely driven by the individual's attitude and outlook. Prenatal sex determination leading to female foetcide is a despicable act that needs to be condemned. But to take up the matter with the Central Supervisory Board saying that postgraduates alone should perform ultrasound, implies a postgraduate doctor will never do sex determination. This is not true.
Qualification, sense of ethics, and morality are separate issues. When a sonologist resorts to sex determination, the motivation is money. The qualification does not come into the picture.
There needs to be a complete change of mind-set among us. We need to look at the larger picture. Being well-trained and certified in ultrasound is absolutely essential, and the time has come to be certified in specific areas of ultrasound such as ob/gyn, abdominal, vascular, musculoskeletal, etc., regardless of whether the person is a radiologist or not.
Let us take a look at the global picture. The American Institute of Ultrasound in Medicine (AIUM) has members from all specialities of medicine, and has continuous CME programmes. It is mandatory to keep abreast by obtaining CME credits every year. The Hungarian Institute of Ultrasound also has strict criteria for training and certification.
So let us move forward, and let the IRIA wake up and see how competency can be ensured in those who are performing ultrasound, instead of wasting time on the debate of "postgraduate" or "graduate". The IRIA can set up training programmes, start certifications, and set up a mechanism for ensuring competence. This will be the greatest service that can be done to the country because patients will benefit from it.
The responsibility of training also lies with the Federation of Obstetric & Gynaecological Societies of India (FOGSI) and the Indian Federation of Ultrasound in Medicine and Biology (IFUMB), which sadly seems oblivious to the issue. Centres where good quality ultrasound scans are being done should be accredited by national bodies for training. Large-scale training programmes are urgently required.
So the only words we need to take cognisance of are "training" and "continuing education". These are what will make us better and what will provide quality ultrasound to patients.
By Dr S. Suresh
October 7, 2004
Dr Suresh is director of Mediscan Systems Diagnostic Ultrasound Research & Training Centre in Chennai.
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