For the fourth and most recent OGSH faculty visit with the ENT Department at Mbarara University of Science and Technology (MUST), the decision was made to devote the week to a non-surgical training module focused on improving CT-scan interpretation.
During the first week of March 2015, Mary Beth Cunnane, M.D., a Radiologist at the Massachusetts Eye and Ear, gave a week-long course in CT interpretation for pathologies of the head and neck. In keeping with previous onsite training, Dr. Cunnane conducted pre- and post- oral exams and skills assessment tests (OSATs) to provide a measure of the knowledge/skills transfer to the residents participating in the intensive.
When I teach clinicians in the United States, I focus on the findings directly related to their specialty. It is only radiologists residents that I admonish to search for any possible finding on the film – related to the complaint or incidental – in the same organ system of interest or include in another organ which is partially imaged on the last slice of the exam. In Mbarara, the residents may be the only physicians reading the exam. I forced them to include the brain, the vessels, the spine, and the lungs in their checklist so that if there is a lung cancer which is incidentally included on a neck CT, someone will see it. Despite their lack of exposure, by the end of the week, when they took their post-tests, their checklists were complete.” Mary Beth Cunnane, M.D.
Accurate reading of CT scans was a skill/knowledge gap made apparent through previous testing assessments and discussions with MUST ENT residents and faculty. Radiology, like Anesthesia, is a frequently overlooked, but necessary,component of a functional health system capable of delivering safe surgical care. The guidance of radiological images is critical to clinicians accurately diagnosing and surgically treating a variety of ENT conditions.
Radiology in many LMIC countries is limited, both through equipment availability and healthcare workforce staffing of medical radiologists and radiologic technicians. While Mbarara, Uganda is a relative outlier, having CT scanners in both the public training hospital, Mbarara Regional Referral Hospital (MRRH), and a local private hospital, patients requesting CT scans must pay $100 or more US dollars for the scan and, in the private setting, an additional charge for the report. The resulting low volume of CT scans makes it difficult for clinicians to develop familiarity with various anatomical presentations. Minimal backup from radiology due to a limited staff and the lack of additional imaging studies to confirm any finding further complicate the situation.
In the United States, clinicians learn to interpret CT scans both through direct instruction and via experience, looking at multiple imaging studies every day, each of which is accompanied by a report composed by a radiologist conversant in the subject matter. If there is no report, a radiologist is often available for consult. Because the threshold for imaging is lower in the U.S., the incidence of abnormal findings is also lower than it will be in Mbarara, as a result of the cost barrier.
Their challenge is daunting but their attitude is that they will do what is necessary to provide the best care they are able to deliver to their patients. Their knowledge of anatomy will improve in conjunction with their knowledge of surgical anatomy. The more CT scans they read, the more they will be accustomed to reconstructing a series of 2-dimensional images into a 3-dimensional understanding of a patient’s disease.” Mary Beth Cunnane, M.D.
Dr. Cunnane’s aim for her lecture series was not only to advance basic understanding of the radiological presentation of head and neck pathologies but to highlight the importance of communication between clinicians and radiologists, which leads to smarter imaging choices and improved patient outcomes. During the week, Dr. Cunnane’s lectures were attended not only by the ENT residents, but Radiology residents, medical students, and members of the surgical faculty. Dr. Cunnane was able to have an immediate impact in part because of her previous work with the program, consulting via videoconference with Dr. Mugisha and providing ENT radiology support for previous OGSH faculty trips.
Though my primary objective was to instruct ENT residents, I was fortunate to interact with the MUST radiologist Julius Mugisha. The first radiologist at MUST, he is working to create a strong teaching department which currently includes 3 radiology residents. Each day we met and discussed cases I had brought with me, and cases which came in for his consultation. In Mbarara I gave lectures to attendings, residents and medical students. In every case I found people engaged and thirsty for the latest information.” Mary Beth Cunnane, M.D.
We would like to convey our thanks to the ENT Faculty at MUST, Drs. Evelyn Llowet and Doreen Nakku, and the MMed candidates, Drs. Victoria Nyaiteera (3rd year), Jamilah Nabukenya (2nd year), and Esther Nakasaga (2nd year) for their hard work and dedication. We would also like to thank Dr. Julius Mugisha (MUST Radiology) for his continuing partnership as well as our Radiology co-collaborators at MGH and UVA.