Thursday, February 12, 2015


Serghei and I along the Duoro riverfront
I spent this past weekend exploring Porto, Lisbon, and Braga. So much fun. Finally made my way down to the riverfront along the Duoro river, a must for anyone traveling to Porto. It was great to have Serghei, a medicine intern who moved to Porto 6 months ago from Moldova, and his wife as company. I went to Lisbon for a day just to get a taste of the city and ended up going to Sintra from Lisbon to see the Pena palace, a beautiful, multi-colored palace that used to serve as a summer home for royalty. Serghei, his wife, another Moldovan friend of his, and I went to Braga on Sunday to see a town recommended to me by some of the medical students. With the weather being sunny all weekend, it was a great way to spend a few days off.

Since I am applying into radiology, Dr. Basto set up this week for me within the department. I had an amazing time not only meeting faculty and seeing the department, but also getting to know the residents. They are so welcoming and took time to teach me each day. I've gotten to see the x-ray, MR, CT, IR, Cardiac MR, and Pediatric units.

Some observations:
-One of the first things I noticed this week was the size of the residency class. Each class has 2 residents, which is much smaller than the average of 10 or so residents for each radiology program in the US. Because of this, ED x-rays are reviewed and reported by ED physicians and inpatient x-rays by internists, pulmonologists, and others. It seems there is more work than can be done by the department so the focus is toward advanced imaging, such as CT and MR. In the US, as we continue to advance imaging modalities, I wonder if we, too, will shift x-ray reporting away from radiology to other branches of medicine. Clearly, with the radiology market being tough, we do not need to increase the number of residency seats. Yet the number of imaging studies continues to increase. A big gripe among radiologists is the increased pressure to read faster. We'll see when the tipping point will be.

Central square in Lisbon. The gate on the left was the entrance
to the city from the port.
-Here, radiologists, and I'm sure other physicians as well, work in both public and private hospitals. The public hospitals are academic and see more complex cases and have all subspecialties to manage these patients. However, per the radiologists, salary is an issue. Thus, they spend some time during the week at private hospitals. Interestingly, the market for private hospitals and private insurance is increasing to meet the needs of citizens who can pay for such services. One of the problems, I believe, is that it can take teaching opportunities away from residents who need attendings to review cases and edit radiology reports. On the other hand, it gives attendings the flexibility to see cases in both environments and tailor their work week. In the US, salary differences between academic and private practice physicians exist, but not enough to force academic physicians to have a private practice job. What is interesting, though, is the increase in research opportunities in the private practice setting. For example, CMC in Charlotte has a new Levine Cancer Institute that runs several clinical trials and is run by an oncologist with an academic background. With the private hospital system growing in Portugal, I wonder if research, primarily translational, will follow suit.

Pena Palace in Sintra

-One thing that radiologists at Sao Joao pride themselves in is their ability to both read and scan ultrasounds. Being able to scan has allowed them to hold onto the modality from other specialties. This is important to point out given the current debate over ED ultrasound and whether ED physicians or radiologists should read the imaging. It is great to see ultrasound being maximized as a modality because it is cost-effective and there is no radiation exposure. During my time in pediatrics, it was exclusively used on a wide variety of complaints. In the US, given the ongoing advances in imaging technologies, we sometimes forget the utility of the most basic modalities. Also, while ultrasonographers are an asset, it is important for radiologists to learn scanning skills since it is a skill that allows for great flexibility.

-Many of the attendings here mentioned how they spent time during their last year of residency to do externships at US institutions, such as UCSD, UCSF, Vancouver, and NYU. They were able to translate skills gained during this time into new procedures within the radiology department at Sao Joao. For example, one attending who gained experience in lung and abdominal biopsies grew that aspect of the department here. And he's only 33 so clearly many years left to teach residents. Another first saw cardiac MR 15 years ago and was trained by a US radiologist. He brought those skills back to Sao Joao and now runs the cardiac MR program in collaboration with the cardiology department. I have an interest in global health outreach. My mindset so far has been to target less developed countries and find ways to provide outreach. While this is important, my experience here has shown me another avenue through which to foster outreach and, more important, global collaboration. In the same way communities have sister cities, is there a way for academic departments to have sister cities in other countries? Through this, a constant radiology residency exchange program can allow for shared growth of knowledge. One of the problems in global health is that you want sites to become self-sufficient. Here is a case of a developed country advancing their own department by their own radiologists with the experiences gained from externships. These radiologists can further radiology practices within their own country in lesser-equipped parts of the country, if possible. Self-sufficiency from the top-down.

Lunch in Braga with new friends. Tried the francesinha; the sauce is so good.

What a great week in radiology. I'm so glad to have met many in the department here.

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