Radiology subspecialisation in Africa: A review of the current status

Background Radiology subspecialisation is well-established in much of Europe, North America, and Australasia. It is a natural evolution of the radiology speciality catalysed by multiple factors. Objectives The aim of this article is to analyse and provide an overview of the current status of radiology subspecialisation in African countries. Methods We reviewed English-language articles, reports, and other documents on radiology specialisation and subspecialisation in Africa. Results There are 54 sovereign countries in Africa (discounting disputed territories). Eighteen African countries with well-established radiology residency training were assessed for the availability of formal subspecialisation training locally. Eight (Egypt, Ethiopia, Kenya, Morocco, Nigeria, South Africa, Tanzania, and Tunisia) out of the 18 countries have local subspecialist training programmes. Data and/or information on subspecialisation were unavailable for three (Algeria, Libya, and Senegal) of the 18 countries. Paediatric Radiology (Ethiopia, Nigeria, South Africa, Tunisia) and Interventional Radiology (Egypt, Kenya, South Africa, Tanzania) were the most frequently available subspecialist training programmes. Except Tanzania, all the countries with subspecialisation training programmes have ≥ 100 radiologists in their workforce. Conclusion There is limited availability of subspecialist radiology training programmes in African countries. Alternative models of subspecialist radiology training are suggested to address this deficit.


Introduction
Clinical and non-clinical knowledge, procedural expertise, computer literacy/proficiency in information technology, knowledge of diagnostics, and non-interpretive skills are an integral part of postgraduate training in radiology: 1,2,3 generalist maintains a broad scope of practice. 7,8 A general radiologist is one who has undergone a radiology residency without completing a fellowship or any other subspeciality training. 9 A subspeciality is a narrow field of professional knowledge, skills, expertise, and focus within a broader medical speciality: 10 Subspecialisation entails the devotion of intellectual energies to understand more and more about a narrower aspect of a speciality. It provides an intense exposure to a subspeciality area allowing a focused development of clinical and surgical skills related to that subspeciality area. 11,12 Subspecialisation requires knowledge, expertise, and practice beyond that of a specialisation. Specific personnel, equipment, technology, dedicated curriculum, accredited training centres, logbooks, exposure to complex cases, high case volumes, subspecialist international journals, international subspecialist societies/associations, and relevant scientific breakthroughs in the field are the sine qua non of subspecialisation. 13 In essence, a radiology subspeciality should have a unique body of knowledge that cannot be subsumed under general radiology, a peculiar applicability distinct from general radiology, an evidence of improved patient care because of subspecialist input, a structured formal training, and accruable benefits which outweigh any negative impact on the extant general radiology or other radiology subspeciality. 14 Factors such as the expansive and multifaceted nature of radiology, rapid development of new imaging modalities, the need for subspecialist radiology interpretation for subspecialist referring physicians, more competitive job market, increased prospects of better remuneration, improved professional standing (status symbol), and so on, are the chief drivers of the quest for subspecialisation in radiology. 15 Existing radiology subspecialities include system-based subspecialities (Cardiovascular Imaging, Chest Imaging, ORL/Dental Imaging, Breast Imaging, Musculoskeletal Imaging, Gastrointestinal Imaging, Uroradiology, Obstetric & Gynaecological Imaging, Neuroradiology); techniquebased subspecialities (Nuclear Medicine/Radionuclide Radiology, Interventional Radiology [IR]); disease-based subspecialities (Oncological Imaging, Trauma Imaging, Emergency Radiology); age-based subspecialities (Paediatric Imaging); and emerging subspecialities (Global Radiology, Radiology Informatics, Forensic Radiology). 16 In general, 'radiology' arrived in Africa, not too long after Roentgen discovered X-rays in 1895, when X-ray machines became available in South Africa (1896), 17 Egypt (1906), 18 Uganda (1907), 19 Nigeria (1913), 20 and so on. However, the commencement of radiology postgraduate residency and subspecialisation in African countries seems to have lagged behind the rest of the world.
An article published in 2019 reported that subspeciality training was available in 0%, 55%, and 74% of African, European, and Asian countries, respectively. 21 The pros and cons of radiology subspecialisation had been discussed comprehensively by other authors. 9,22,23,24,25,26 This research aims to investigate the current status of radiology subspecialisation training programmes in Africa and to identify the obstacles to the actualisation of this laudable aspiration. The focus is on the availability of local formal training programmes rather than the presence or absence of practising subspecialist radiologists in the health workforce of the countries evaluated.

Methods
We searched the literature using Google search engine (primarily), Google Scholar, and African Journal Online. The keywords comprised the name of the countries together with the words radiology, specialisation, and subspecialisation in various combinations. The references cited in the retrieved articles provided additional information. The country reports published by RAD-AID International (https://radaid.org/resource-center/country-reports) were invaluable sources of data. The last search was performed on 20th April 2021. A few North African radiologists were also contacted by email to provide information about their countries, but we received a response from only one of them.

Results
A summary of available subspecialist radiology training programmes in different African countries is presented in Table 1. Only those countries with well-established radiology residency training were assessed for the availability of formal subspecialisation training locally. Eight (Egypt, Ethiopia, Kenya, Morocco, Nigeria, South Africa, Tanzania, and Tunisia) out of the 18 African countries with well-established radiology residency training have local subspecialist training programmes. East Africa (three countries), North Africa (three countries), Southern Africa (one country), and West Africa (one country) make up the regional spread. Data/ information on subspecialisation were unavailable for three of the 18 countries (Algeria, Libya, and Senegal). Except for Tanzania, all the countries with subspecialisation training programmes have ≥ 100 radiologists in their workforce.

Paediatric radiology
Paediatric radiology subspeciality training is available in South Africa, Ethiopia, and possibly, Tunisia.

South Africa
In South Africa, paediatric radiology subspeciality training began in 2009 at the Red Cross War Memorial Hospital in Cape Town. It is a 1-year programme after which successful candidates are awarded a postgraduate diploma in paediatric radiology by the University of Cape Town. Subspeciality training in paediatric imaging is also available at the Nelson Mandela Children's Hospital in Johannesburg (opened officially in December 2016). 27 Also in South Africa, the World Federation for Paediatric Imaging (

Continental Professional Association/Society
The African Society of Paediatric Imaging (AfSPI) was formalised on 30th October 2012. 55

Interventional radiology
Subspeciality training in IR is available in Egypt, South Africa, Kenya, Tanzania, Tunisia, and Morocco. 29,56,57 South Africa

Egypt
In Egypt, there is no structured nationwide IR fellowship yet; however, IR subspeciality certification is currently organised via two pathways for doctors who have already completed their diagnostic radiology training. Firstly, there Finally, there is circumstantial evidence of IR subspeciality training in Morocco and Tunisia, 59 but details of the programmes could not be obtained.

Continental Professional Association/Society
The Society of African Interventional Radiology and Endovascular Therapy (SAFIRE) is the continental professional association of interventional radiologists in Africa. Some of the North African countries are also members of the Pan Arab Interventional Radiology Society (PAIRS).

Women's imaging
There is anecdotal evidence of institution-based subspeciality training in Women's Imaging at Cairo University in Egypt.

Discussion
As stated at the introduction, a previous article published in 2019 reported inaccurately that subspeciality training was available in 0% of African countries. This misinformation is likely because of the general paucity of information on the evolution of radiology in African countries. As can be seen from our data, IR training had been available in South Africa since 2002. The quest for radiology subspecialisation seems to have accelerated in the last 5 years across the continent. In spite of this positive development, many hurdles still remain.

Obstacles to the establishment of radiology subspecialisation in Africa
Africa, being a continent of mostly developing and underdeveloped countries, faces many challenges to the smooth implementation of radiology subspecialisation. Some of these obstacles include lack of funding, equipment and infrastructure deficit, unavailability of expertise, politics, emigration of radiologists, perfectionism, and so on.

Funding
Generally, the health sector is not adequately funded by many African governments and other stakeholders. The improvement of any field or speciality requires adequate funding for optimal growth and development. Sufficient funding allows for proper training of radiologists and scholarly research in the field of radiology.

Equipment and infrastructure
Modern equipment and infrastructure are crucial to the training of competent subspecialist radiologists. The poor funding of health care in many African nations has made it impossible to acquire new equipment. These inadequacies impede the creation of the top-level educational environment required for specialist and subspecialist tutoring. 63

Expertise
The quality of experts in a field is a product of the training that the specialists had received. It takes a subspecialist to train a subspecialist. Currently, many African countries have insufficient subspecialist manpower, which makes it difficult to initiate subspecialisation training programmes.

Emigration
Many African medical graduates aim to leave the continent for greener pastures abroad. This medical exodus robs the continent of critically needed expertise. 64,65 The mass emigration further worsens the already low radiologist-to-population ratio in many African countries.
African radiologists seeking subspecialisation often travel outside Africa to train, but many of them do not return to their home country once they find better opportunities abroad. If subspecialisation programmes are established locally, the attrition of African radiologists might be mitigated. 66,67 Politics Sometimes, obtaining approval for new programmes requires savvy political manoeuvring, lobbying, and horse-trading. Bureaucratic red tape is a feature of governmental regulatory agencies worldwide, and African nations are no different. Radiology is a relatively 'invisible'/'behind-the-scenes' medical speciality. Consequently, it might be an uphill task to secure governmental backing and funding for programmes without accruable political mileage. 68 Interprofessional rivalries at the universities and teaching http://www.sajr.org.za Open Access hospitals could also derail the successful take-off of new training programmes. 69

Recommendations
Given the perennial obstacles to subspecialisation enumerated above, especially funding constraints, African radiologists (with foreign collaboration when needed) can leverage existing and emerging technologies and innovative training/learning methods to streamline the training of subspecialist radiologists.
Web-based training was piloted in Ethiopia over a 20-month period using pre-recorded online lectures, case reviews, and learning modules, overseen by subspeciality-trained radiologists of the Johns Hopkins University School of Medicine. 21 A similar web-based learning tool for paediatric radiology (with users all over the United States and 53 other countries) is used to deliver paediatric radiology curriculum internationally by paediatric radiologists in the USA. 70,71 Web-based training is cheaper, adaptable, more accessible, and effective. 21,72 The European diploma in emergency radiology subspeciality is delivered using a combination of self-directed learning, webinars, workshops, research & teaching, as well as on-thejob training. 73 Electronic teaching files and internet-accessible case collections are also being used increasingly for radiology subspecialisation training in other European countries with limited access to complex equipment. 25 Simulation-based technology and immersive training environment for IR have also been proposed. 74,75 A complementary business model of medical subspeciality training that incorporates the private sector has been developed for reproductive medicine in South Africa by Dalmeyer et al. 76,77 The authors are convinced that the model can be applied to other subspecialities.

Conclusion
There is limited availability of subspecialist radiology training in African countries. Cost-effective and innovative approaches to training are needed to address this deficit.
This study was limited by unavailability of data on subspecialisation in Algeria, Libya, and Senegal.

Ethical considerations
This article followed all ethical standards for research.

Funding information
This research received no specific grant from any funding agency in public, commercial or not-for-profit sectors.

Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.