Working as a musculoskeletal radiologist in India and in the UK: Similarities and differences in daily professional engagements
How to cite this article: Narayanaswamy S, Thaker S, Gupta H, Botchu R. Working as a musculoskeletal radiologist in India and in the UK: Similarities and differences in daily professional engagements. Indian J Musculoskelet Radiol 2021;3(1):30-3.
A UK-trained musculoskeletal (MSK) radiologist relocating back to India may face numerous challenges while setting up subspecialty MSK radiology services. The National Health Service (NHS) and the Indian healthcare system are inherently different from each other in finance, governance, administration, and clinical services provision. The NHS can offer numerous opportunities to an MSK radiologist, including a diverse case mixture, protected work time divided between direct clinical care and supporting professional – academic, management, leadership, and continuous professional development – activities, flexible work hours, five days a week work pattern, continuous reflective learning from missed findings, and opportunities for advanced training in MSK tumour work and complex interventions. Indian MSK radiology services, compared to the NHS, are relatively curtailed and limited to metro cities with very few centres offering dedicated MSK imaging services and image-guided interventions. From an economic perspective, MSK radiologists in both countries earn more or less similar, given high taxation rates in the UK. Although Indian radiologists may face pressures to provide rapid radiology reports from the management, patients, and relatives, one can enjoy better image quality, liberty to customize scans, ease to start new intervention services, necessary breaks during work hours, and extended family support. A re-relocated MSK radiologist can survive and thrive in Indian healthcare, primarily corporate medical institutions, if one can strike a balance between professional and personal life.
India and the UK
UK musculoskeletal radiology
Migration of the health care workers is an extremely complicated issue, affected by a multitude of socioeconomical, cultural, and personal reasons. Radiologists can enjoy relatively less stringent criteria for international medical registration, straightforward opportunities for consultant posts, and more relaxed visa norms for relocation, being a “shortage occupancy” health-care specialty. The exodus of Indian health care workers, especially doctors, is well known. Recent logistical and technological changes in the Indian healthcare system have complicated the emigration-immigration issue even further. Advances in radiology, such as tele-radiology and artificial intelligence as well as the influence of the corporate sector and its gradual takeover of the health-care industry, have further complicated this issue. Many radiologists working in the UK have started to give a thought to move back to India for good, citing financial, family, and childcare reasons.
Working in the Indian health-care system and the UK National Health Services (NHS) are fundamentally different. The NHS model aims to provide a sustainable, relatively high quality, health care to the entire community for free, while the Indian health-care system is exceptionally divergent where one can receive health care at par with international standards in large cities, unlike rural health care which lacks adequate workforce and logistics.
The views expressed in this particular perspective article are entirely personal perceptions from an Indian origin, UK-trained musculoskeletal (MSK) radiologist who worked for the NHS for a couple of years before relocating to India and India-trained radiologists who have been trained further in the UK NHS and settled. The core idea of this article is to provide a general overview to an aspiring radiologist who is willing to pursue higher training or career in MSK radiology in the UK and also to have thoughts of relocating back to India if need be. The reader should use his/her discretion depending on one’s individual circumstances to gain maximum insights from this article. We neither aim to compare fundamentally different health-care systems of both countries having their advantages and shortcomings nor try proving superiority over one another. In this article, we compare, contrast, and discuss [Table 1] different facets of engagement of a MSK radiologist everyday clinical activity. For better understanding, we have divided professional avenues into three different categories: (1) Image acquisition and technical factors, (2) direct clinical care, and (3) interpersonal relationships including non-clinical staff, management, patients, and family.
|Image quality||Equal (Sometimes better in India)|
|Customize scan according to findings||Yes||No|
|Case mix||Different demographics, but similar to district general hospital in the UK||Different demographics, academic institutions may get advanced case|
|Musculoskeletal tumor work||Uncommon||Yes|
|Starting a new intervention service||Easier||Very hard|
|Segregation of direct clinical care from administrative and management duties||No||Yes|
|Phone calls after work hours||Yes (in private and corporate establishments)||No|
|Communication with non-clinical staff including radiographers||Easy to make changes||Tricky to communicate|
|Management pressure||Yes (in private and corporate establishments)||Yes/No|
|Pressure from patients||Yes (in private and corporate establishments)||No|
|Family and personal time||Less (Better in government institutions – dedicated leaves/vacations)||More|
|Work pattern||6 days a week||5 days a week|
IMAGE ACQUISITION AND TECHNICAL FACTORS
Techniques and quality of imaging vary significantly depending on the place of work throughout India. Multiple factors – demographics, the socioeconomic standard of region, and involvement of government, corporate, and private health-care partners affect this. Most of the imaging equipment including MRI, CT, ultrasound scanners, and radiography machines in Indian cities are comparable with those used in the NHS. In terms of quality, sometimes, diagnostic imaging quality can be better in India as compared to the UK due to lack of time constraints and absence of pressure to produce specified numbers of the scan in a given time frame. In addition, there is the freedom to customize scan by radiologist not only according to clinical question but also on the discovery of an incidental or additional finding which might be of clinical significance.
DIRECT CLINICAL CARE
Case mix of a MSK radiologist in India is comparable to that of any district general hospital in the UK. However, etiology and demographics vary significantly to the UK. A re-relocated MSK radiologist in India may find establishing MSK radiology practice a bit challenging and may require a complete reinvention/reconfiguration of one’s clinical practice. The MSK as a subspecialty is fast developing in India, but still, the caseload is not significant in the majority of the hospitals to employ a full-time MSK radiologist. The corporate/private hospitals expect doctors to undertake general radiology work during the initial days of relocation until the person manages to establish a referral base for himself. Although MSK radiologist in India may perform a number of the interventional MSK procedure in due course, MSK tumor work and vertebroplasties are relatively uncommon as usually orthopedic and spinal surgeons perform them. Conversely, it may be easier to establish a new intervention MSK service if the MSK radiologist is ready to take the onus of its provision and sustainment in sharp contrast to NHS in which starting a new service may be extremely challenging, and one may come across numerous red tapes.
There is a complete distinction between direct clinical care, administrative, management, and teaching activities in the job plan of a MSK radiologist in the UK which can be time protected. Unfortunately, the delineation between described professional activities in India is somewhat blurred, and the doctor is expected to undertake all clinical and non-clinical administrative, academic, teaching, and so on within the given schedule, which is not time protected. Emergency work creates an inseparable part of NHS work pattern. The radiologist should expect no work-related call once the clinical duty is over. In sharp contrast, one may have to take such calls even after completion of stipulated work in India, especially in the private and corporate establishments.
Again, the complexity of MSK radiology work in the UK depends on the choice of workplace and hospital. Subspecialty work differs significantly between district general hospitals (DGHs) and teaching hospitals, for the latter, being referral centers, offers services for more complicated cases on an elective basis. On the other hand, private work in the NHS returns varying financial returns depending on the type of work and hospital affiliation. Sometimes, the UK MSK radiologist may have to contribute to acute general radiology services, which is usually supported by registrars and clinical fellows during regular hours and on-call services.
The working pattern and caseload are different for a MSK radiologist in DGH compared to a tertiary hospital. The proportion of MSK radiology work at a DGH is over about 50%, but one has to do general radiology work and on calls. Compared to DGH, MSK radiologists in tertiary NHS hospitals can primarily focus on providing high-quality MSK radiology service. MSK radiologists, additionally, may participate in on-call rota sustaining emergency radiology services. Most of the tertiary MSK radiology centers manage the bone and soft-tissue tumors and complex spine and spinal oncology. In these centers, one does diagnostic and interventional work ranging from simple biopsy to complex radiofrequency ablation and vertebroplasty. These centers have dedicated MSK fellowships and consultants’ duty involving supervising and training them. There are several opportunities for research, academic work, and delivering lectures on different topics locally, nationally, and internationally. These are challenging to do in a DGH set up.
Furthermore, the UK MSK radiology services mandate robust documentation of consents and procedures, reflection on missed findings in discrepancy meeting, yearly appraisal, job planning, mandatory training, and continuous professional development and additional high accountability of the radiologist enforced by medicolegal obligation culture and clinical governance.
In addition to much admired clinical radiology practice, the UK NHS also offers non-clinical roles such as academic or research fellows. Such opportunities usually involve obtaining MD (a research degree in the UK which is separate from Indian postgraduate degree) or PhD from one of the National Institute for Health Research after producing thesis at the end of the program. One might feel a lack of clinical touch while pursuing academic programs but once obtained, the degrees as mentioned earlier are widely recognized in the academia.
INTERPERSONAL RELATIONSHIPS INCLUDING NON-CLINICAL STAFF, MANAGEMENT, PATIENTS, AND FAMILY
With non-clinical staff, particularly with radiographers, Indian radiologists share a unique “Love-hate relationship” where radiologist can freely express concerns about imaging standards and improvement, whereas in the UK, expressing concerns to radiographers on imaging quality can be much more challenging.
Communication with referrers and clinical colleagues is utterly different in Indian system as compared to the UK. It is based on direct communication between clinical colleagues with very little involvement of house officers or registrars when it comes to significant findings or critical diagnoses making communication less error-prone and escalates management instantaneously.
Indian MSK radiologists have 6 days a week dent in family time. Those who are working in private and corporate institutions face intense management pressure to provide 24 h imaging facility. Furthermore, they have to review and report imaging within a too tight timeframe. For instance, one has to report an MRI or a CT within 4 h, ultrasound within 30 min, and X-ray within 1 h. In addition to these, patients and their relatives may also pressurize to expedite reports even further.
Time constraints may coerce private or corporate sector radiologists; the caseload may overwhelm the radiologists working in the government institutions. The radiologists working in the government establishments enjoy dedicated leave allowance, support from registrars (residents) and junior doctors, virtually non-existent time constraints, multidepartmental support while managing complications, especially during complex MSK interventions, and plentiful opportunities for academics, research, and teaching. However, one may have trade financial aspect of the profession whilst choosing working in the government set up as many of the Indian states do not allow simultaneous government and private clinical practice.
In the current scenario, the caseload is not significant in the majority of the Indian hospitals to employ a full-time MSK radiologist. The corporate/private hospitals expect doctors to undertake general radiology work during the initial days of relocation until the person manages to establish a referral base for himself. Although MSK radiologist in India may perform a number of the interventional MSK procedure in due course, MSK tumor work and vertebroplasties are relatively uncommon as usually orthopedic and spinal surgeons perform them.
From financial point-of-view, Indian radiologists working in the private sector have to invest heavily while commencing MSK practice which mostly relies on professional loans from the banks. Once established, one can enjoy steep economic gains and profits from the practice. Another popular private sector model is “multiple partners” model which involves a few like-minded radiologists forming imaging establishment promoting subspecialty MSK radiology work with a background of providing general radiology services. In corporate and government institutions, salaries are mostly capped and usually plateau once one hit the financial ceiling.
Conversely, in the NHS, all consultants receive band pay and leave allowance where “band” of an individual radiologist is defined by the years of NHS service. In addition to the band pay, one can get “Clinical Excellence Awards” for professional achievements which may translate into additional financial reward. These awards, however, attract additional taxation according to the UK tax laws.
To summarize, practicing MSK radiologist in the UK NHS requires no financial involvement at work, better subspecialty work and can enjoy fixed working hours, an excellent work-life balance, virtually zero competition, continuing professional education through feedback and multidisciplinary team meetings. There are also opportunities to work in extended NHS practices which usually return higher pays. However, such professional life comes a cost of higher living cost, relatively rigid operating procedures, tricky to communicate with radiographers, plateauing income, and lack of family support in childcare. Re-relocating MSK radiologist to India must make peace with differences in the Indian health-care system from the UK NHS to establish oneself, sustain, and thrive while balancing professional life to personal and family life. Whilst practicing in India, one may find it challenging to strike a right work-life balance due to long working hours, calls even after working hours, predominant general practice, cut-throat competition, and management pressures if working in private institutions. The road to establishing a successful subspecialty service is long and challenging. Once established, one can enjoy great professional satisfaction, financial outcomes, and respect in the subspecialty colleagues and clinicians.
The article is based on experiences of all authors during radiology training, early and established professional lives both in India and the UK. Hence, no references were cited.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Conflicts of interest
Dr. Rajesh Botchu is on the Advisory Board of this journal.