ScholarMD Edvent had a tete-a-tete with two of its senior faculties in Fetal Medicine - Dr. T L N Praveen and Dr. Bimal Sahani. Here is verbatim transcript of the same.
ScholarMD (SMD): Dr. T L N Praveen sir, how and when did you realize your passion for Foetal Medicine?
Dr. TLN Praveen (TLNP): You see 70 to 80% of my day to day ultrasound practice involves fetal imaging. That created special interest in Fetal Medicine, which, over a period of time, became a passion for me.
ScholarMD (SMD): Dr. Bimal Sahani sir, developing expertise in Fetal Medicine in a non-metro city - how has been the experience?
Dr. Bimal Sahani (BS): It is true that there are not many Fetal Medicine experts from non-metro cities. But I never let myself feel bogged down by the possibility of my work not being recognized due to my non-metro residential status. I believe that one should just keep on practicing scientifically, doing good work, documenting everything systematically, and someday someone will definitely acknowledge it. Some 25 years ago, it was difficult for an individual from small town to showcase his work on a bigger platform, but in today's era of internet and social media, you can easily reach out to not only national but even international audience. And then there are some seniors like Dr. Ashok Khurana who keep hunting for fresh talent and giving them opportunities. I was indeed lucky to have him. And now I am trying to walk in his footsteps. Today, if I find someone doing good work, I make sure to motivate him or her to come forward and present it.
SMD: As a Radiologist Fetal Medicine expert, what transformation have you seen in your practice over the years?
TLNP: The more you get involved in fetal medicine, the more it becomes challenging. With present technology, the understanding of fetal pathophysiology has become much better.
SMD: Radiologists generally believe that a subspecialty like Fetal Medicine has scope only in bigger cities. What is your take on this?
BS: The reason behind the general perception that Fetal Medicine is an urban branch is that Fetal Medicine is team-work. You need Genetic Laboratories, Clinical Geneticists, Fetal Pathologists, Neonatologists, Pediatric Surgeons and Pediatric Cardiologists around. Now most of the smaller cities do not have such superspecialists easily available. And it is precisely because of this reason that it becomes all the more important for Radiologists from smaller places to become Fetal Medicine specialists. Since Fetal Medicine experts in smaller cities do not have much back-up, they need to take most of the decisions, including counseling the patients regarding prognostication, further testing, the treatment options available and also the need for reference to higher centres.
SMD: If a young Radiologist interested in taking up Fetal Medicine as a career came to you for advice, what are the most important things you would like to emphasize upon him / her?
TLNP: Patience and perseverance are the two most important factors that youngsters need to cultivate in order to develop a successful career.
SMD: One of the hotly debated topics among Radiologists fraternity now-a-days is cut-practice. You are known to be an ethical practitioner. Practicing Fetal Medicine ethically - how has been the experience?
BS: If you practice ethically, you do face some hardships, mostly in the initial period. You will probably have less number of patients initially. But then, that also gives you more time to devote to your patients. Your diagnosis improves. You gradually realise that your competence and diagnostic accuracy are the only unique selling propositions you have. So you constantly upgrade yourselves in terms of knowledge. This is a vicious cycle. I can say that one of the major reasons I have been able to achieve what I have today is ethical practice. Fetal Medicine set me free in a way. And if I can do it, anyone can.
SMD: Sir, could you please cite for us an instance or two from your career as a Fetal Medicine expert which had a lasting impact on your practice?
TLNP: Fetal medicine is challenging. It requires a holistic approach to maternal and fetal care, plus a human touch. There have been quite a few instances in my career where the job was demanding, and it continues to be so. Practicing fetal medicine calls for total involvement in identifying the disease process, counseling and guiding the parents in decision making. These are the key factors which have a lasting impact on us Fetal Medicine practitioners.
SMD: Radiologists do anomaly scans day in and day out. So why do they need to know anything more about Fetal Medicine?
BS: There is a big difference in attitude once you start thinking of yourself as a Fetal Medicine person. Just to give you an example, for someone doing a regular anomaly scan, ventriculomegaly is a diagnosis, and he or she is quite happy with it. The moment you start thinking of yourself as a Fetal Medicine specialist, ventriculomegaly becomes just a finding, a manifestation of a disease process, and hence you work the patient up to get to a diagnosis. I remember a case I read about in one of our Fetal Medicine groups. A lady delivered a baby with antenatally diagnosed intestinal obstruction. Baby was operated upon, but succumbed. In the next pregnancy, diagnosis of fetal intestinal obstruction was made once again. Patient was suggested karyotyping and mutation study for cystic fibrosis. The parents got the karyotyping done but opted not to go for the mutation study. Subsequently, the baby was delivered and, unfortunately, succumbed. In the third pregnancy, the patient came to this Fetal Medicine expert. Upon comprehending the patient's history, the Fetal Medicine expert called-up the Genetic Lab where the patient had got karyotyping done, and, to his surprise, he found that the Lab had preserved the fetal DNA. He strongly advised the patient to get a mutation study done on the preserved DNA sample, and subsequently that turned-out to be positive for Cystic Fibrosis. So, he went ahead and did a Chorionic Villous Sampling for the patient, and unfortunately it turned-out to be positive for cystic fibrosis. The pregnancy was thus terminated. However, the couple was saved from undergoing the psychological trauma which they had experienced in the previous two pregnancies. This shift in attitude backed by knowledge is what actually transforms a Radiologist into a Fetal Medicine specialist.
SMD: An average Radiologist-fresher in India today is caught between the choice of choosing a subspecialty in radiology over general radiology practice, which is mostly x-ray / ultrasound. Looking at the future, what would be your advice for such a Radiologist?
TLNP: I personally think that it is the sub-specialization in various subdivisions of Radiology which is going to dominate the future. Sub-specialization is here to stay.
SMD: There is lot of apprehension among Radiologists, not just in India but worldwide, about constant turf-erosion in Ultrasound. Your take on the issue and advice for young Radiologists?
BS: See turf-encroachment in Radiology is a world-wide phenomenon. As long as the law of the land does not prevent someone from practicing something, nothing can be done about it. I personally don’t believe in it. I feel rather than cribbing about it, we need to improve ourselves to such a level that we won't be worried about competition from other specialties. A major part of the answer to this question lies in the examples that I have given earlier (in this interview). Now most of us report minor ultrasound markers of aneuploidy, but we do not want to take responsibility of risk assessment and counseling the patient. If we are taking the responsibility of doing a mid-trimester genetic sonogram, then we should also take the responsibility of letting the patient know what the significance of the marker is in their particular case. Who else is supposed to do it? If we, as Radiologists, are just going to do routine work, then everyone will find it easy enough to encroach our turf. So the mantra is - bring yourselves up to a different level; let others do what they want. If you are good with what you are doing, your turf will never get eroded.
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