Feedback from Dr. Carlos Zamora, MD, PhD

My 10-day visit to Recife was organized to coincide with the combined meeting of the Radiological Society of Pernambuco, which takes place annually, and the North-Northeastern Radiological Society. Here I gave a series of talks on white matter disease, intracranial infections, and congenital anomalies of the head and neck, followed by a conference with a potpourri of unknown cases. Attendance was high and consisted largely of radiologists, residents, and medical students from Recife and Northeastern Brazil. The audience was warm and receptive. This was a general radiology meeting and the neuroradiology block was relatively short but interesting. Among other things, I had the opportunity to learn about their experience with congenital infections and most notably the Zika syndrome.

Recife is the capital of the state of Pernambuco and one of the largest and most important cities in Northeastern Brazil with a population of over 1.6 million. It is the second largest medical hub after São Paulo and home to 60% of physicians in the entire state. With over 170 hospitals, the density of health care facilities in the urban area is high and quite palpable as one drives around the center of the city. However, the majority of hospitals are private and the extent of services provided is variable. Notably, there are wide differences in resource availability between institutions, which is most pronounced when comparing private and public facilities. The latter are maintained by either the state or federal government and serve a large portion of the population who cannot afford private care.

Radiology residency programs in Brazil are 3 years in length. Four of the 5 residency programs in Recife have between 6 and 15 residents (all years) and 1 program (the Integral Medicine Institute, IMIP) is an outlier with 42. Over the next several days following their annual meeting I visited all residency programs and I could spend time interacting with radiologists, trainees, technologists, and a small group of motivated medical students who followed me to each hospital. They showed me their facilities and imaging departments and shared their collections of interesting and challenging cases. Some of these had known diagnoses and others were yet to be determined. The case mix from each hospital is variable, with Getúlio Vargas, for instance, being a large-volume reference trauma center and the IMIP tending to pediatric patients with complex neurological diseases, amongst others. Each visit consisted mostly of separate case conferences on brain, head, neck, and spine, although some places like the IMIP preferred a structured lecture. As one might expect, I faced the challenge of presenting cases to various groups of people with diverse levels of training while trying to keep them engaged, a situation not too dissimilar from what we encounter in our own training programs where fellows and residents may attend the same conferences. Their residents, however, were sharp and highly motivated which made all sessions go smoothly.

The availability of radiological equipment in the different hospitals was quite variable and some of them lacked a functioning MRI scanner. Naturally, this poses a tremendous challenge but is particularly problematic for institutions that see a large number of patients with neurological disorders such as the IMIP. It is also a major obstacle for radiology training, and residents from hospitals that lack a specific modality (typically MRI) may need to rotate in other facilities in order to fill that gap. On the upside, however, this allows residents to interact with groups from other hospitals and to be exposed to a somewhat different case mix than what they would see at their home institution. In hospitals where there is no MRI, patients may need to be outsourced to private clinics and physicians often need to render a diagnosis and treat based on very limited resources, which is all the more remarkable. It was under these unique circumstances that the healthcare system was put to the test in 2015 when there was a sharp increase in unexplained cases of microcephaly. Recife was the epicenter of the Zika epidemic and the hardest-hit city in Brazil. I was fortunate to hear experiences from people who worked tirelessly day in and day out at the peak of the epidemic, as the level of alarm continued to rise in the country while the whole world watched expectantly. The incidence of Zika infections has since dropped significantly but cases continue to be reported or are under investigation.

One final activity that I participated in was the so-called Radiopizza. This is a popular event where residents from all programs in Recife gather once a month and listen to 2 to 4 didactic lectures while eating pizza in a relaxed environment. The idea was introduced in Recife and has rapidly spread to other cities. Here I talked about phakomatoses and neuroimaging of acute head trauma.

I met many wonderful physicians and trainees in Recife who work diligently to provide the best possible level of care. I made new friends and established links for potential research projects in the future. I would like to express my gratitude to the people who received me at each hospital, whose names are too many to include in this brief report. Everyone was extremely kind. I was shown places like Olinda, Old Recife, and the beautiful coastline. I am especially thankful to my host, Dr. Fátima Aragâo and her husband Dr. Mauricio Aragâo. Fátima has worked tirelessly for her society and also to promote continuing education in Pernambuco. She has also provided us with very valuable research on the neuroimaging of Zika related congenital malformations. Finally, I am grateful to the ASNR and to Dr. Osborn for facilitating this opportunity.