An Integrated Model for Radiology Education

Rationale and Objective

In 2004, Harvard Medical School initiated a pilot program, the Cambridge Integrated Clerkship, in which students study the core third-year medical disciplines in a longitudinal yearlong experience. In this paper, the authors describe the design of the radiology portion of this program and compare outcomes to those of students in a traditional curriculum.

Materials and Methods

Students in the integrated curriculum were compared to students in traditional clerkships on the basis of Objective Structured Clinical Examination cases, final exams, fourth-year comprehensive exam scores, and choice of specialty.

Results

Scores on Objective Structured Clinical Examination cases and imaging final exams were not statistically different between the two groups, but Integrated Clerkship students had statistically lower scores on final exams. Integrated Clerkship students scored higher on the fourth-year radiology comprehensive exam than traditional students, but differences were not statistically significant. Choice of radiology as a specialty was not statistically different between the two groups.

Conclusions

Teaching radiology in an integrated yearlong curriculum is feasible, with a minimal drop in exam scores but no changes in other evaluative measures and no decrease in the choice of radiology as a specialty. The program may give students a better appreciation of the role of radiology in an ambulatory setting and in relationship to other specialties.

Changes in the US health care delivery system, with shortening of hospital stays and a shift toward ambulatory care, have had a negative impact on the educational environment for medical students during many clinical rotations . In the traditional hospital-based intensive-immersion model of clinical education, medical students have less time with patients and fewer substantial duties in patient care, with little emphasis on generalist or primary care skills . Some traditional clerkships have responded by increasing outpatient experiences or changing the proportion of time in acute care environments, but these changes may be difficult depending on the specific practice setting. In an attempt to rethink the way third-year medical students are trained, a pilot program was developed at a teaching hospital with extensive ambulatory sites, Cambridge Health Alliance, a teaching hospital of Harvard Medical School (HMS), that included a major shift away from hospital-based settings as well as integration over a yearlong period of all core disciplines, including radiology .

In this paper, we describe the methodology and evolution of the radiology component of the Cambridge Integrated Clerkship. Preliminary results comparing student outcomes on summative radiology examinations are presented, as well as information on residency selection by students in the traditional clerkship compared to the Integrated Clerkship over the past 4 years. Future plans for the program are also presented, along with a discussion of the limitations of this approach.

Materials and methods

Initial Clerkship Design

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Table 1

Patients Followed by Students in the Cambridge Integrated Clerkship, Year 4, by Discipline

Student Medicine Neurology Obstetrics/Gynecology Pediatrics Psychiatry Surgery Total ∗ Visits † 1 24 8 7 8 15 12 74 540 2 17 5 10 17 20 5 74 432 3 12 11 10 4 8 4 49 411 4 22 19 8 17 8 18 92 666 5 11 1 3 3 0 2 20 125 6 17 6 6 25 5 8 67 529 7 19 9 9 8 24 7 76 579 8 4 7 5 15 7 11 49 337 9 9 9 9 20 15 9 71 523 10 20 9 5 18 11 13 76 482 11 18 1 10 8 11 14 62 414 Average 15.7 7.7 7.5 13 11.3 9.4 64.5 459

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Table 2

Introductory Radiology Topics in the Cambridge Integrated Clerkship, Years 1 to 4

Variable Year 1 Year 2 Year 3 Year 4 Total number of sessions 5 5 4 2 Total number of hours 15 14 5 2 Topic list 1. Introduction to chest radiography, plain films 1. Chest radiography, plain films 1. Course organization, chest radiography 1. Course organization, overview of radiology 2. Introduction to CT, KUB 2. KUB, CT, IR 2. CT, MR 2. Basics of image interpretation, terminology 3. Brain and spinal MR and CT 3. Neuroimaging 3. Ultrasound 4. Ultrasound, nuclear medicine 4. Ultrasound, nuclear medicine, abdominal imaging 4. Other areas 5. MSK imaging, trauma, systems and safety 5. MSK imaging, safety

CT, computed tomography; IR, interventional radiology; KUB, kidneys, ureter, and bladder; MR, magnetic resonance; MSK, musculoskeletal.

Table 3

Comparison of Tutorial Topics, Years 1 and 4, in the Cambridge Integrated Clerkship, with Indication of Those That Included Radiology

Variable Year 1 Year 4 Total number of tutorials 43 41 Tutorials with radiology 30 (70%) 29 (71%) Topic list 1. Introduction to small-group learning (smoking cessation) ∗ 1. Understanding clinical research 2. Well child/newborn ∗ 2. Introduction to small-group teaching ∗ 3. Pregnancy ∗ 3. Pediatrics, prevention ∗ 4. Jaundice ∗ 4. Geriatrics 5. Joint pain ∗ 5. Prenatal care ∗ 6. Fever ∗ 6. Adolescence 7. Glomerular disease ∗ 7. Personality disorders 8. Shortness of breath ∗ 8. Lower extremity edema ∗ 9. Somatic symptoms 9. Acute abdominal pain ∗ 10. Confusion 10. Confusion ∗ 11. Headache ∗ 11. Pediatric fever ∗ 12. Low back pain ∗ 12. Pelvic pain ∗ 13. Abnormal vaginal bleeding ∗ 13. Unexplained somatic symptoms 14. Pelvic pain ∗ 14. Shortness of breath ∗ 15. Breast lump ∗ 15. Abnormal uterine bleeding ∗ 16. Lower extremity edema ∗ 16. Headache ∗ 17. Chest pain ∗ 17. Chest pain ∗ 18. Sadness, hopelessness 18. Breast lump ∗ 19. Acute renal failure ∗ 19. Sadness 20. Alcoholism ∗ 20. Pregnancy and its complications ∗ 21. Substance abuse 21. Anxiety, including PTSD 22. Asthma ∗ 22. Fluid and electrolytes 23. COPD ∗ 23. Alcoholism and substance abuse 24. Congestive heart failure ∗ 24. Schizophrenia 25. Pediatric CHF ∗ 25. Diabetes mellitus 26. Depression, anxiety 26. Hypertension ∗ 27. Type 1 diabetes, diabetes in pregnancy ∗ 27. Congestive heart failure ∗ 28. Type 2 diabetes, obesity ∗ 28. HIV ∗ 29. Acid-base balance 29. Colon cancer ∗ 30. Acute abdomen ∗ 30. Pediatric asthma ∗ 31. HIV ∗ 31. Pediatric leukemia 32. Hypertension ∗ 32. Obesity 33. TIA/CVA ∗ 33. Low back pain ∗ 34. Movement disorders 34. Seizure disorders ∗ 35. Schizophrenia 35. Stroke ∗ 36. Potassium balance and management 36. Liver and gallbladder disease ∗ 37. Shock ∗ 37. Renal disease ∗ 38. Anemia ∗ 38. Student directed (4) ∗ 39. Renal function, salt and water management 40. Adolescent behavior 41. Student-led tutorials (3) ∗

CHF, congestive heart failure; chronic obstructive pulmonary disease; CVA, cerebrovascular accident; HIV, human immunodeficiency virus; PTSD, posttraumatic stress disorder; TIA, transient ischemic attack.

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Changes in Clerkship Design in Subsequent Years

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Comparison to Traditional Clerkship

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Results

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Table 4

Comparison of the Amount of Time to Teach Radiology per Student, Traditional Clerkship Versus Cambridge Integrated Clerkship

Clerkship Duration of Course (wk) Total Didactic Sessions (h) per Student Total Observation Sessions (h) Total Contact Hours per Year Difference Traditional ∗ 4 40 (60) L 8 (24) 85 1 (1) C Integrated † 49 49 (74) R 2 (6) 114 +34% 30 (30) T 4 (2) O 2 (2) C

C, case report consultation; L, lectures; O, Objective Structured Clinical Examination sessions; R, radiology rounds; T, tutorial.

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Table 5

Comparison of Final Exam Scores, OSCE Scores, and Comprehensive Exam Scores, Traditional Clerkship Versus Cambridge Integrated Clerkship

Variable Cumulated Traditional ‡ Year 1 Integrated Year 2 Integrated Year 3 Integrated Year 4 Integrated Cumulated Integrated ∗ Number of students 205 8 8 11 11 38 Final MCQ exam score 81 ± 7.6, 98/57 79 ± 6.6, 84/64 (.53) 72 ± 5.8, 80/63 (.003) 76 ± 3.7, 82/70 (.001) 75 ± 7, 88/68 (.015) 75 ± 6.1, 88/63 (.00001) Final imaging exam score 82 ± 7.8, 100/60 85 ± 9.3, 98/72 (.34) 76 ± 7.7, 89/67 (.054) 80 ± 6.3, 89/67 (.32) 80 ± 5.2, 89/71 (.16) 80 ± 7.5, 98/67 (.15) OSCE cases † 74 ± 8, 94/54 68 ± 7.9, 82/61 (.05) 72 ± 9.2, 83/57 (.46) 73 ± 6.5, 81/60 (.6) 80 ± 7.7, 88/59 (.05) 74 ± 8.7, 88/57 (.64) Comprehensive exam, radiology § 68 ± 18.5, 100/5 N/A N/A N/A N/A 72 ± 20.3, 100/10 (.37)

MCQ, multiple-choice-question; N/A, not available; OSCE, Objective Structured Clinical Examination.

Data are expressed as mean ± standard deviation, maximum/minimum ( P value). P values compare each year of Integrated Clerkship students and the cumulated total of Integrated Clerkship students with the cumulated traditional clerkship students.

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Discussion

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An Integrated Model for Radiology Education

Rationale and Objective

Materials and Methods

Results

Conclusions

Materials and methods

Initial Clerkship Design

Changes in Clerkship Design in Subsequent Years

Comparison to Traditional Clerkship

Results

Discussion

References

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