Rationale and Objectives
There are little data as to whether appropriate, cost effective, and safe ordering of imaging examinations are adequately taught in US medical school curricula. We sought to determine the proportion of noninterpretive content (such as appropriate ordering) versus interpretive content (such as reading a chest x-ray) in the top-selling medical student radiology textbooks.
Materials and Methods
We performed an online search to identify a ranked list of the six top-selling general radiology textbooks for medical students. Each textbook was reviewed including content in the text, tables, images, figures, appendices, practice questions, question explanations, and glossaries. Individual pages of text and individual images were semiquantitatively scored on a six-level scale as to the percentage of material that was interpretive versus noninterpretive. The predominant imaging modality addressed in each was also recorded. Descriptive statistical analysis was performed.
Results
All six books had more interpretive content. On average, 1.4 pages of text focused on interpretation for every one page focused on noninterpretive content. Seventeen images/figures were dedicated to interpretive skills for every one focused on noninterpretive skills. In all books, the largest proportion of text and image content was dedicated to plain films (51.2%), with computed tomography (CT) a distant second (16%). The content on radiographs (3.1:1) and CT (1.6:1) was more interpretive than not.
Conclusions
The current six top-selling medical student radiology textbooks contain a preponderance of material teaching image interpretation compared to material teaching noninterpretive skills, such as appropriate imaging examination selection, rational utilization, and patient safety.
There is a growing emphasis in medical practice on the safe, cost effective, and appropriate ordering of radiology studies. Although this trend will reduce health care costs, it more importantly will improve patient care.
The efforts made toward improving ordering practices have largely been directed toward those already ordering imaging studies, namely practicing medical providers. Educational initiatives including the “Choosing Wisely” and “Image Gently” campaigns direct referring physicians to imaging options that are safer, involve lower radiation, and highlight clinical scenarios where imaging may be unnecessary. Additionally, the American College of Radiology (ACR) “Appropriateness Criteria” is available as a free, evidence-based, online resource designed to help ordering physicians choose the best imaging examination . These resources add transparency and are highly educational but are underused by students. One recent single-institution study that found the vast majority of senior medical students (96%) were not previously aware of the ACR Appropriateness Criteria; however, once introduced, almost all students found the resource useful (94%) and planned to use it in clinical practice (89%) . Undergraduate medical educators have also been quick to point out that teaching good imaging practices early on is far more effective than correcting ordering habits after they have formed .
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Materials and methods
Textbook Selection
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Data Extraction
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Interpretive Versus Noninterpretive Text
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Interpretive Versus Noninterpretive Image Content
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Subject Matter
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Statistical Analysis
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Results
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Interpretive Versus Noninterpretive Text and Images
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Table 1
Summed Number of Book “Pages” Containing Interpretive Versus Noninterpretive Content
Textbook Interpretive Text Content (Pages) Noninterpretive Text Content (Pages) Ratio of Interpretive to Noninterpretive Content Book 1 271.5 157.5 1.7:1 Book 2 56.5 29.0 1.9:1 Book 3 129.0 83.0 1.6:1 Book 4 279.0 184.5 1.5:1 Book 5 202.5 127.0 1.6:1 Book 6 189.5 223.0 0.9:1 Total 1128.0 804.0 1.4:1
Table 2
Summed Number of Images and Figures Depicting Interpretive Versus Noninterpretive Content
Textbook Interpretive Image Content (No. of Images) Noninterpretive Image Content (No. of Images) Ratio of Interpretive to Noninterpretive Content Book 1 505 7 72:1 Book 2 166 28 6:1 Book 3 548 10 55:1 Book 4 831 116 7:1 Book 5 806 17 47:1 Book 6 156 5 31:1 Total 3012 183 17:1
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Subject Matter
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Table 3
Percentage of Book Pages Dedicated to Radiologic Modalities
X-Rays (%) CT (%) MR (%) US (%) Nuc Med (%) Multiple (%) Other (%) Book 1 50.8 15.3 4.7 5.3 0.3 18.3 5.4 Book 2 73.9 12.7 0 0 0 0.7 12.8 Book 3 54.9 6.7 2.2 3.1 1.2 21.5 10.3 Book 4 45.8 17.3 4.8 6.7 2.6 15.8 7.0 Book 5 42.3 17.1 13.2 2.3 1.9 21.5 4.2 Book 6 39.6 27.0 8.8 3.6 1.1 14.6 5.3 Mean 51.2 16.0 5.6 3.5 1.2 15.4 7.5
CT, computed tomography; MR, magnetic resonance; Nuc Med, nuclear medicine; US, ultrasound.
Percentage represents the combined average of both text and image content.
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Discussion
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