About RAD-AID and the Mission
What is RAD-AID, and why did you decide to participate?
RAD-AID is a US-based nonprofit founded by a radiologist that is focused on access to radiology and radiation therapy in both the developing world and in middle-resource or lower-resource portions of the US. They do a lot of work in Africa and Southeast Asia. But one thing I didn’t know until we started to work with RAD-AID is that they also support critical access domestically. I just saw they did a project in Appalachia – I’m from Kentucky, so that spoke to me. They sponsored a mobile mammography unit at Denver Health, which is a unit in an RV to go to underserved communities. I had already been testing it for a couple of years, and in talking to the RAD-AID people I realized ‘oh, this was you guys?!’
CAMP is actually trying to find more ways to partner with RAD-AID as a company. Jerry White, one of our original founders, did a lot of volunteer work, both domestically and internationally. Inspired by him, we’re trying to find more ways to do programs like this.
” To improve and optimize access to medical imaging and radiology in low resource regions of the world for increasing radiology’s contribution to global public health initiatives and patient care.” – RadAid’s Official Mission
How did this specific Indonesia trip come about?
This trip was sponsored by Siemens Asia group. Siemens makes medical equipment and they know that Indonesia’s nuclear medicine capacity is growing really quickly. They’re doubling every five years or so. This trip came up, and they needed a physicist to go. RAD-AID’s director of medical physics knew I had a lot of nuclear medicine experience. So he asked if I would be willing to go and I agreed
Who was on your team and how long were you there?
I was there for just about two weeks with one other nuclear medicine technologist, Juan, from Eastern Washington. We spent the whole time on the island of Java. We spent our first week in a smaller town called Surabaya, which is a couple of million people, about an hour and a half flight east of Jakarta. Then we spent time in Jakarta.
Siemens local staff helped get us around, which was awesome. They’d pick us up from the hotel, take us to the hospital, and bring us back each day. At each site, we were working with the local hospital clinical nuclear medicine team. This was typically a nuclear medicine physician, a physicist, and some technologists and nurses.
What did a typical day look like?
We would go to the hospital each day. They were very welcoming, and would often have a welcome ceremony. The director of the hospital would come and thank us. We essentially spent our time in nuclear medicine, working with the staff and conducting observations to see how they practiced, and then asking questions. Initially we’d drive the conversation from our end with “here’s how we typically practice in the US. Are you doing similar things?” But once we had developed a relationship we should ask them, “What are your problems? What are the things that you’ve been struggling with? How can we help answer those questions?”
Challenges and Cultural Observations
What were the main challenges you encountered?
Probably the biggest challenge was language. Almost everyone spoke a little English, but often the nurses’ and technologists’ English was pretty limited. The physicists’ and physicians’ English was generally better. Juan and I gave seven or eight lectures across the two weeks, and they were also on Zoom to all the other nuclear medicine departments across the country. There would often be around 100 people on Zoom watching these. I think everyone’s English was good enough to understand the basics of what we said, but the lectures were probably more difficult.
Were their technical challenges similar to what you see in rural US hospitals?
They are pretty similar because they actually have similar imaging equipment. They have the same gamma cameras and nuclear medicine technology that we have here, the same Siemens and GE scanners. So Juan and I were very used to those.
Mostly, their problems are that nuclear medicine is just a newer thing in Indonesia. The training curricula for the technologists and the physicists aren’t as well-developed yet as ours in the States are. They have problems that are cost-driven, and they lack access to more expensive radiopharmaceuticals, so they’re trying to find ways around that.
They also have a different regulatory environment than we do. A lot of what we do in the US is driven by regulations that say we have to do these things. Over there, the regulations are not quite as explicit.
How is nuclear medicine growing in Indonesia?
There’s been some nuclear medicine capacity in Indonesia for a few decades, but it’s been relatively limited. Of the four departments I visited, two were less than five years old. The Indonesian government is working to establish access to nuclear medicine and PET on most of the major islands within each region of Indonesia, but that’s a challenge because nuclear medicine requires radioactive tracers. For PET scanning, particularly, those have a short half-life – they decay away about half every two hours. So they have to be produced close to where they will be used.
Success Stories and Impact
Can you share a specific example of a meaningful impact you made?
I think one time was in Jakarta at a hospital called Dharmais, which is the National Cancer Hospital for Indonesia. They had two nuclear medicine scanners and one PET scanner, and several medical physicists who were very eager to learn.
One of the things we were talking about is that in PET scanning, we use a value called the standard uptake value, the SUV value. In PET scanning, the brighter something lights up, the more likely it is to be cancer. That SUV value is a way of quantifying how bright that is. These SUV values are really important in either assessing if something is cancer or in tracking the response to cancer therapy.
I asked Ghani, their lead physicist, what they were doing to check that SUV accuracy. He didn’t really know of anything, and they don’t have the same phantoms and equipment we have here. So I suggested that even with one basic phantom, we can do a scan that mimics a clinical scan and verify that the SUV value is what we think it should be, within 10%. We showed him how to do that one afternoon, and he was really excited to implement that. He came back the next day and had built a spreadsheet to track that and do it more frequently.
His eagerness to learn and his initiative to start implementing suggestions was really impressive. I think that’ll really have an impact on care at the National Cancer Institute, which is also where many medical physicists in Indonesia go to train. So training him feels like a nice way to distribute that knowledge.
Learning and Professional Growth
What did you learn from the Indonesian healthcare model?
It made me think about why our roles as physicists and technologists are the way they are in the US. In the US, nuclear medicine technologists have a very broad scope – they prepare the radiopharmaceuticals, inject patients, position patients for imaging, acquire and process images, and do all the quality control in the department. We as physicists are usually supervising safety and testing equipment, but may be there less frequently.
In Indonesia, they have radiopharmacists preparing the radiopharmaceuticals, nurses injecting them, and technologists mainly just acquiring the images. But almost every site in Indonesia has a full-time physicist on staff in nuclear medicine, which is very different from the US. The number of physicists per machine is much higher there. So the physicists are responsible for checking the daily quality control and running the weekly quality control, something that in the US we don’t do simply because there aren’t enough of us.
It made me think about what the physicists are bringing to the department in Indonesia that we don’t. What can they do with having more time there and more dedicated staff per machine? Some things are better – they’re more engaged in the daily and weekly quality control, but some things are worse – they’re less involved in the annual tasks. Because if you only support one camera, you only do annual testing once a year, so you don’t get very good at it.
Was this your first international medical physics trip?
Yes, this was my first medical physics trip. Before grad school, I took a year off and volunteered with a group in Louisville that works with water issues in the developing world. I went on one trip to Haiti to do water work there, which was really challenging but rewarding.
As medical physicists, we spend a long time in school, then a long time training after we finish school, then we take all these exams and do continuing education and professional development. Our skills are very deep and very specialized. Because of that, it’s generally hard for us to find ways other than volunteering for a professional organization to truly volunteer or give back. So that felt really cool – this was a trip that really needed all the various expertise I have, all the different clinical environments I’ve seen in the US, all the different types of equipment I’ve seen across the years.
Conference and Academic Engagement
Tell us about the Indonesian Medical Physics Conference.
This trip was coordinated with the Indonesian Medical Physics Conference, which was in Surabaya. It’s a relatively new field, but they had 300 people attend this conference. Like the US, it has three subtracks – radiation therapy, diagnostic imaging, and nuclear medicine. I gave two different talks, but I gave one plenary talk to all 300 people on internal dosimetry, which is how we track how radioactive material moves around within the body.
It was especially meaningful for me to get to talk about that. I attended graduate school at Vanderbilt University and took numerous classes from Professor Mike Stabin, who was the leading expert in the US on internal dosimetry. He was a really great professor who taught me everything I know about that topic. He just passed away this summer, about eight weeks ago. So I was really honored to get to open a talk on internal dosimetry, pausing for a moment and reflecting on his contributions to the field. That was really cool and powerful for me personally. To get to say, “hey, anything I know about this topic, I owe to this guy” was really meaningful.
We also gave lectures at the local university in Surabaya, at Airlangga University’s Department of Physics. I gave a lecture on the basic physics of nuclear medicine to undergraduate and graduate physics students. They were really interested, and I was able to give the talk from a technical perspective because they’re physicists while introducing them to nuclear medicine.
Future Impact and Relationships
Do you consider the trip a success?
Yes. One of the main purposes of a trip like this is to show healthcare workers in more isolated settings that they’re facing the same challenges we see everywhere. We’re telling people in a newer field, in a country with less international collaboration, ‘you guys see the same problems as we do’.
While we have our own specific problems, most of our problems are pretty similar. That’s a weird way to put it because that’s not a concrete thing to improve or an action item, but what it can be is a confidence booster for local capacity. It’s great to say “yeah, you guys are doing good work. Here’s a couple of little things we can work on, but all this other stuff you’re doing is great.”
I think starting to build relationships with the Indonesian medical physics community through the conference and these other connections was quite successful. We want to establish relationships that become a two-way dialogue on what the problems are they’re facing in their practice and how we can support them in those. A lot of that we can do remotely.
That’s what I’m hoping to take out of it – create relationships where if they run into a problem or aren’t sure how to do something new, they can send me a message and I can send them advice, or a paper on the topic, or share a template we use here.
What surprised you most about the experience?
The people were so welcoming, and really eager to learn how we do things in the US. They wanted to learn our ideas and then try to integrate those. There’s a clear desire and recognition that this field is newer there and they were very open to advice.
I kept trying to tell them that this new hospital called the Vertical Hospital of Surabaya was fancier than the new hospitals I see in the US, and I felt like they didn’t quite believe me! They had really nice equipment. I’m not sure the US can hold a candle to them for some of these new facilities.
Any plans for future collaboration?
RAD-AID as an organization is thinking about the best way to support nuclear medicine in Indonesia. Is it more trips like this, where we try to hit a bunch of different sites and build capacity broadly? Or is it trying to pick a couple of hospitals that have more resources and develop deeper expertise there, let those sites become the expertise that domestically people will go to train at?
This trip was a little different than the typical RAD-AID trip. Often they try to form longer-term partnerships so that it’s not just a single visit where we impart information and walk away. Usually it’s more relationship and mentorship development. CAMP is still looking at doing that within RAD-AID – could we partner with a hospital somewhere in the world that has radiology and radiation oncology both, and CAMP could support both services?
This was a really amazing opportunity for me professionally – something I’ll never forget. I hope it’s driving more people to consider how to utilize their professional skills in volunteering, or encouraging volunteering with RAD-AID, or simply facilitating these international collaborations that are now easier to achieve with modern technology,
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