Neelam Dugar champions technology, embraces its advances, is excited by its potential. Alongside colleagues, she oversaw the digitisation of her own radiology department in Doncaster and until September, she chaired the informatics committee of the RCR (Royal College of Radiologists).
The interplay between tech and technician, between artificial and human intelligence, is central to her specialty. But in recent years, that relationship has become uneasy.
An acute national shortage of radiologists coupled with ever-rising demand for diagnostic imaging has meant increased reliance on technological solutions, not least to tackle mounting backlogs.
Some fear this move could further undermine a specialty already in crisis. Dr Dugar, a consultant radiologist, is no Luddite. But she warns technology’s potential to revolutionise imaging is being overstated. Humans with specialist medical training will always be needed – and their role needs to be better understood.
‘I love technology and I’m always pushing at its boundaries to improve patient care – but you still need a human arbitrator,’ she says.
The shift to virtual consulting owing to COVID has piled on the pressure for already hard-pressed radiologists.
At times during the pandemic, the number of patients waiting for MRI scans in Dr Dugar’s trust rose to 2,000 to 3,000, excluding those who had been given an appointment.
That range is 10 times higher than pre-pandemic levels.
The waiting list for ultrasounds is even longer: 7,000 to 8,000 patients, at the time of writing.
I love technology... but you still need a human arbitratorDr Dugar
The latest NHS England statistics for imaging waiting times, published in January, showed 20.7 per cent of patients were waiting six weeks or more from referral.
‘I find it very hard when I see how long people are waiting because I know, among them, there’ll be unsuspected cancer cases,’ says Dr Dugar.
But the demands on radiology departments have been rising for years, with an increasing number of NICE (National Institute for Health and Care Excellence) guidelines recommending imaging for its diagnostic strengths.
‘When I joined as a consultant in Doncaster almost 20 years ago, on a Sunday we perhaps would do one emergency CT on the head of a patient who they thought might have a bleed,’ says Dr Dugar.
‘Today, over a Sunday, one of our quietest days, we would regularly do over 100 CTs. The volume of work has increased phenomenally compared to any other specialty.’
Her department now regularly does 1,000 examinations a day.
The volume of work has increased phenomenallyDr Dugar
Simultaneously, radiology is facing a staffing crisis of several years’ standing. The RCR warned last April that the ‘NHS radiologist workforce is now short-staffed by 33% and needs at least another 1,939 consultants to meet safe staffing levels and pre-coronavirus levels of demand for scans’.
Mounting workloads have elicited some extra government funding in recent months, but for Dr Dugar’s trust, this has led to outsourcing.
CT and MRI mobile vans have been drafted in, to help clear the backlog.
These services are staffed by radiographers, the technical specialists who acquire the images for the scans – but the scans still need to be analysed and medically interpreted by radiologists.
Radiology has been something of a technology pioneer, albeit sometimes of necessity – and the UK has led the charge internationally, Dr Dugar believes.
The advent of teleradiology means that, for more than a decade now, night-time emergency imaging at Doncaster has been outsourced to Australia. Nationally, the RCR says that 14 per cent of the reporting of all medical scans in the NHS happens overseas.
Outsourcing is here to stay, says Dr Dugar. ‘It’s work we won’t get back.’ Artificial intelligence, in the sense of both ‘computer audition’ and ‘computer vision’, are already firmly embedded in Dr Dugar’s department.
Voice-recognition dictation software has revolutionised report-writing, for example. AI is also being used in brain imaging for stroke recognition: Dr Dugar admits that her AI machine sometimes outclasses her in recognising fine details such as lung nodules.
‘Computer vision does not tire,’ she adds. And AI will quickly improve, she believes, so that it may soon be entrusted with simple tasks such as identifying fractures, without the need for human verification.
But predictions about technology’s potential are overblown, she says. Some believe they have exacerbated the workforce crisis, putting off potential recruits: Dr Dugar tends to blame Health Education England for not investing in enough training places.
The bigger picture
Technology’s limitations lie in the fact that it cannot ‘see’ the bigger picture that a radiologist’s experience and access to patient health records afford.
Dr Dugar helped develop integration between existing healthcare IT systems in her trust, so patients’ information and images are accessible seamlessly.
‘As radiologists, we interpret the images in the light of all the other information that we have, information I can access with one click: whether that’s a blood test, a histopathology report, or notes that tell me the patient has been feeling dizzy. I can also ring up the clinician and ask for more information, for clarification,’ she says.
‘In reporting on a chest X-ray, I’ll compare it with the previous one. If I see a shadow that existed five years ago, it’s probably benign. If I see a shadow that wasn’t there five years ago, it could be malignant. Teleradiologists often don’t have access to as much information as a local radiologist and AI may not either.’
The NHS radiologist workforce is now short-staffed by 33%Dr Dugar
Misunderstanding about the role of radiologists – even among medical colleagues – and the need for radiologists to vet scan requests to manage workloads can strain relationships with other departments.
Human interaction, albeit sometimes mediated by technology such as Teams or Zoom, is important for strong teamwork – which in turn is vital to effective diagnosis and treatment, says Dr Dugar.
‘Our multidisciplinary oncology team meetings, for example, have been gamechangers for radiologists. They’ve brought the radiologists out of their offices and on to the front line of helping manage patients’ care, and mutual respect and a partnership approach have developed.
‘I don’t say no to the doctors requesting scans. What I tend to say is: “What is your question? How is the best way we answer it?” We might sometimes suggest a different test.
‘But the end goal is the same for everyone: we want to get a diagnosis for the patient and start the appropriate treatment.’