AJTCCM VOL. 29 NO. 1 2023 5
EDITORIAL
A chest radiograph is one of the most common investigations in
medicine. In the evaluation of patients, a radiograph is oen the rst
test to conrm, or seek additional, clues aer a history and clinical
examination. Thereafter however, the experience and skill of the
doctor in interpretation is paramount to establishing a definitive
diagnosis, or a focused investigation, and path to resolution. All too
oen, in my personal experience, it is at this stage that problems are
encountered. ere is a failure to make an accurate diagnosis owing to
misinterpretation. is can lead to unnecessary and expensive further
investigations, treatment, and potentially, dire consequences. ese
could be in the short- or long-term – where patients are misdiagnosed for
months to years – with attendant morbidity and mortality. Competency
in radiographic interpretation is especially important in Africa, where
the burden and prole of respiratory disease is particularly unique.[1,2]
ere are many reasons for a lack of prociency in radiographic
interpretation. Firstly, to the best of my knowledge, there are no
National Standards for competency for doctors who are not radiologists.
Secondly, in most, if not all, public facilities in South Africa (SA), a
radiologist does not report on basic radiological tests. irdly, there are
highly variable radiological university programmes in the country, oen
with doctors having to self-learn in their undergraduate training or on-
the-job thereaer. Again, in my personal experience, having engaged
with recent graduates from Health Sciences faculties throughout SA,
and a host of other doctors throughout the country, some with decades
of experience, areas of deciency are noted. Some common examples
encountered are:
• inability to recognise a pneumothorax,
• inability to recognise active tuberculosis (TB) or the inability to
appreciate old TB,
• misdiagnosing TB for lung cancer and vice versa,
• not recognising lobar collapse (which can be extremely subtle), and
• inability to recognise bronchiectasis.
In this issue of the AJTCCM, Dreyer and colleagues[3] studied chest
radiology competence at a SA medical school. ey analysed the skills of
medical sta interpretation of radiographs, by both years of experience
and seniority. In both groups, there were no scores >50%. e diagnostic
accuracy per years of experience was: 27% (0 – 5 years), 43% (6 - 10
years) and 48% (>10 years). For the dierent sta designations, the
accuracy of consultants was 50%, registrars 41%, medical ocers 36%
and interns 20%. e authors further point out that competency is also
required in emergency situations (oen amongst junior doctors) and
that the lack of skills may well endanger patients’ lives with possible
attendant medico-legal repercussions. They further note that, for
physicians, the College of Medicine, to date, has no precise directive for
radiology expertise.[4]
In terms of competency, this nding is not new. It has been reported in
many countries for many years.[5-7]
What are the possible solutions?
e persistence of the problem over decades points to inadequacies in
the number of radiologists available to report on radiographs; which
is extremely unlikely to be improved. Machine learning systems are
yet to be realised in low-resource settings. e responsibility therefore
defaults to the trainers - preferably lead by pulmonologists, who could
co-opt radiologists - to coordinate the up-skilling of all sta. is
should be embedded in medical curricula and expanded to district
hospitals and other clinics. e opportunity should also be sought
at relevant annual conferences and update meetings to do the same.
It is surprising how particular problems are encountered regularly
in medicine, yet no systematic process is put in place to rectify the
situation; as regards chest radiology interpretation. It is time for the
pulmonology committee to change the narrative. It is also hoped that
the new initiative of the CMSA on Workplace Based Assessment will
be fully embraced and incorporate enhanced radiology expertise.
Together with the academic representatives of the various medical
schools on the SA oracic Society, an attempt could be made to
develop the rst National Standard for Chest Radiology competency
amongst non-radiologists.
All important issues in life need a champion or champions to initiate
and sustain awareness and spearhead campaigns to change the situation
– this is long overdue for chest radiology competence.
Elvis Irusen, PhD
Emeritus Professor of Pulmonology,
Stellenbosch University and Tygerberg Academic Hospital
eirusen@sun.ac.za
1. Glaziou P, Sismanidis C,Floyd K, Raviglione M. Global epidemiology of tuberculosis.
Cold Spring Harb Perspect Med. 2015;5(2):a017798. https://doi.org/10.1101/
cshperspect.a017798.
2. Yang IA, Jenkins CR,Salvi SS. Chronic obstructive pulmonary disease in never-smokers:
risk factors, pathogenesis, and implications for prevention and treatment. Lancet Respir
Med. 2022(5):497-511. https://doi.org/10.1016/S2213-2600(21)00506-3.
3. Dreyer RG, van der Merwe CM, Nicolau MA, Richards GA. Assessing and comparing
chest radiograph interpretation in the Department of Internal Medicine at the University
of the Witwatersrand medical school, according to seniority. Afr J oracic Crit Care
Med 2023;29(1):e265. https://doi.org/10.7196/AJTCCM.2023.v29i1.265
4. CMSA portfolio of learning fellowship of the college of physicians of South Africa. 2021.
https://www.cmsa.co.za/view_exam.aspx?QualicationID=28 (Accessed on 1 February
2023)
5. Potchen EJ, Cooper TG, Sierra AE, etal. Measuring performance inchest radiography
Radiology. 2000;217(2):456-459. do https://doi.org/10.1148/radiology.217.2.r00nv14456.
6. Fabre C, Proisy M, Chapuis C, etal. Radiologyresidents’ skill level inchestx-ray reading.
Diagn Interv Imaging. 2018;99(6):361-370. https://doi.org/10.1016/j.diii.2018.04.007.
7. Mehdipoor G, Salmani F, Arjmand S A. Survey of practitioners’ competency for
diagnosis of acute diseases manifest on chest X-ray. BMC Med Imaging 2017;17(1):49.
https://doi.org/10.1186/s12880-017-0222-8.
Afr J Thoracic Crit Care Med 2023;29(1):e892. https://doi.
org/10.7196/AJTCCM.2023.v29i1.892
Chest radiographic interpretation – an essential competency
forAfrica
