HealthManagement, Volume 11 - Issue 1, 2011

Professional Challenges for Medical Imaging in Bulgaria Today

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Prof. Vassil Hadjidekov
Dept. of Diagnostic Imaging University Hospital "Alexandrovska" Sofia, Bulgaria
President, Bulgarian Association of Radiologists
[email protected]

Our Radiology Department Houses Bulgaria's Only University Teaching Structure.

The department of diagnostic imaging at the University Hospital "Alexandrovska" in our nation's capital, Sofia, is the oldest hospital department of radiology. The radiology department has conserved its unique function as the first university teaching structure in Bulgaria. Today the department employs two professors, 12 radiologists, 24 technicians and 10 other team members. The equipment at the moment includes one MR-unit, two CT scanners (one of them a 64 MDCT), angiography room, several pieces of equipment for conventional radiology that are located close to surgical, internal and paediatric departments, mammography, ultrasound and several mobile units in the intensive care departments.

There is a High Concentration of Imaging Centres in the Area: Supply Outstrips Demand.

More than 25,000 patients pass through my department each year. The number of examinations is not as high as one might imagine for a large facility due to numerous external and internal factors. The external factors are the result of the organisation of our healthcare system: such as the type of healthcare and the so-called "health map" in this country. There is a concentration of hospital and diagnostic centres in the vicinity and the offer of radiological services is higher than the demand. That is why today's government strategy is resizing the map, defining the number of hospitals and medical centres and classifying them according to their medical activities and performance. The whole budget for radiology services in the country is relatively low. An important reason for the relatively low number of examinations is also the fact that doctors are involved in teaching activities – medical students, residents and the qualification of specialists. As we are part of a reference hospital, our radiology team ensures 24-hour coverage for all imaging services onsite.

Remuneration for Hospital Radiologists is Low Compared to EU Averages.

In general, in comparison with other European countries, the remuneration of radiologists, especially hospital radiologists, remains among the lowest. This is the reason why in the last few years, many radiologists are leaving for positions abroad and for the present shortage of radiologists in the country. However, in a few but growing number of cases radiologists are enjoying better revenues in Bulgaria. Very often in such cases, some external factors impact, like private investments, fewer radiologists covering a relatively larger area or a higher patient flow. Many radiologists work part-time in private dignostic laboratories and centres, which in the main are owned by non-medical entities. Apart from the abovementioned "health maps", another factor is that the essential funding of hospitals is based on the model of "clinical pathways", where the one mandatory national insurance company contracts the hospital and not the radiology department itself. So, subjective factors and turf battles play a role in financing. In the ministry of health strategy, it is foreseen within the next year to begin transitioning to the DRG system and the radiology society in its majority approves of this.

There are no Officially Recognised Subspecialties in Bulgarian Radiology Yet.

There are no officially recognised subspecialties in radiology in Bulgaria at present. However, the radiology society is at the moment establishing groups (subspecialty societies) within the main radiology specialties. Interventional radiology in particular has well established training rules. Trainees must already have a specialty in radiology before applying. The training includes two years of work under the supervision of a certified interventional radiologist in a hospital with a determined number of procedures per year. It includes as well a number of theoretical lectures and is finished with a final exam. The curriculum is based on CIRSE's model and adapted to local conditions. The certificate is issued only by medical universities and must be signed by a rector. Still, the number of interventional procedures is low due to economic reasons. Few centres fulfil the requirements and very often they are orientated within the profile of the hospital. There is a pronounced turf battle here, especially between cardiologists and vascular surgeons.

There is Limited Access to MRI Due to Low Reimbursement Levels.

The number of radiology exams is limited due to financial factors. There is very limited access to MRI due to restrictions on the number of exams being reimbursed. Few parts of the population can afford private cover for the more expensive radiological procedures. So waiting lists exist, but they are short and not a real challenge.

Nuclear Medicine is a Separate Specialty in Bulgaria and is Strictly Regulated.

Nuclear medicine is a separate specialty in Bulgaria and forms separate departments. The supply of radiopharmaceuticals is organised by the Ministry of Health and the strict regulations sometimes has its drawbacks. PET-CT is an emerging modality for Bulgaria. There are two installations for nuclear medicine in the country - one in our hospital and one in the next biggest medical university. There is a memorandum between the radiology society and nuclear medicine society that this equipment is to be run by both specialists in nuclear medicine and radiologists. At the moment 18FDG is imported from abroad. Our hospital is preparing a project to apply for European funding for establishing a cyclotron that will supply both, and eventually to increase the number of installations.

Accreditation is Implemented Proactively in Bulgarian Radiology Departments.

There is a system of accreditation in Bulgaria that is constantly upgraded. It includes several requirements for quality assurance. In the accreditation team a radiologist is included as an expert. Experts are preliminarily trained. Accreditation is based on national standards. The standard in any specialty is elaborated by representatives of the national society, is approved by the national medical council and is validated by the Minister of Health. Teaching activities are accredited by a national agency of accreditation for higher education in a similar way. Accreditation follows different criteria according to the target group – medical students, PhD students, residents, etc.

The Bulgarian Association of Radiology is an Active Player in Education & Training.

Representatives of the national society of radiology set the curriculum for training, based on the ESR curriculum and adapted. It is reviewed periodically by the council of educators, which includes all active professors in the country. Teaching hospitals are identified after the mentioned accreditation. The curriculum is for the duration of four years. There is an entry exam to enrol in the programme, 10 ongoing exams and a final exam (oral and written, theoretical and practical) held in front of the states' committee appointed by the Minister of Health. Traditionally, the only place for this exam is at our hospital. Members of the commission include professors from the four medical universities and the three major national specialised teaching hospitals.

Access to the Latest Technologies is a Significant Challenge for Radiologists.

Radiology in Bulgaria has a long way to go, and much work needs to be done to achieve and attain a level of excellence. The economic level of the state and the future of healthcare reform will always impact on the radiology community. Access to modern technologies is a challenge for Bulgarian radiologists. In the past decade, the country is well supplied with CT equipment for example, but the majority are supplied second-hand. There is a big difference between the levels of medical services in different hospitals, which depending on the demand for medical services. These differences reflect as well on the interest of different groups of radiologists. The low level of equipment means only a small number of research and scientific activities. Still, the heath system is too centralised. Radiology practice depends very much on general regulations. The Ministry of Health undertakes several activities for renewing the major radiologic equipment at the moment, in the most important district hospitals across the country. Quality standards require such renewal.

Creating Small Task Groups has Encouraged Greater Interest in the Success of the Department at Large.

An oft-encountered issue in management, it's difficult to motivate people to follow both the common interest of the department and their own personal interests. I have tried to overcome this challenge by creating small task groups within the team to present ideas for resolving specific problems and take responsibility for their achievement. It is my aim to work on including more and more people in teaching activities, reinforcing their self-confidence and motivating them. More of our staff should be included in decision-making. 

The second big challenge for me is ensuring adequate financing for the renewal of equipment. In what is quite a centralised system, the issues end in multiple disputes in front of the health authorities as well as expanding education for referrers on what radiology examinations to request. Another interest of mine is motivating radiologists to stay up to date with the modern trends of radiologic practice and teaching. One of the ways that I found very useful is organising international teaching events. Teaching by prominent international speakers who show a different view on a topic or share wide experience are especially motivating to young colleagues.

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Author: Prof. Vassil Hadjidekov Chairman Dept. of Diagnostic Imaging University Hospital "Alexandrovska" Sofia, Bulgaria President, Bulgarian Association o

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