Radiology Education in Medical School and Residency

Rationale and Objectives

The authors of this study used the perspectives of residency program directors (PDs) nationally to explore whether trainees are adequately prepared to utilize and interpret medical imaging as interns, to identify the types of imaging skills most important for residency, and to begin to address current shortcomings in radiology education.

Materials and Methods

The authors created a survey using a modified version of Accreditation Council for Graduate Medical Education radiology milestones and sent it to 100 randomly selected PDs each in pediatrics, internal medicine, obstetrics and gynecology, and general surgery. The survey asked PDs to assess the actual and desired imaging skills of their incoming interns, the incoming interns’ variability of skill level upon matriculation, and which imaging skills were most important from the PDs’ perspective.

Results

PDs from all specialties identified a significant shortcoming relative to their expectations for both image interpretation and utilization skills. Additionally, PDs identified a significant variability in imaging skills, and described that variability as a hindrance to their programs. All of the potential imaging skills were rated as highly important with little clinically relevant difference between them.

Discussion

This multidisciplinary national survey found a deficiency in imaging education among interns across specialties and substantiates calls for formalized and improved radiology education in undergraduate medical education. Additionally, PDs had difficulty distinguishing which skills were most important, suggesting an unclear understanding of imaging ability needs for interns in respective specialties. More specific needs assessments are warranted on a national level.

Introduction

Medical imaging has become increasingly integral to the practice of medicine and, accordingly, increasingly emphasized in undergraduate medical education (UME) . However, there are variations in how much is taught in medical school, ranging from no formal imaging education to required radiology clerkships . Additionally, there are large variations in what is taught to medical students , despite the existence of published curriculum recommendations . Prior studies report that graduate medical education (GME) trainees, medical school deans, and radiology chairs desire a concerted effort to strengthen imaging skills in the UME curriculum . Importantly, some major specialties, such as internal medicine, fail to include even one imaging milestone in their standardized assessments , currently leaving formal development and assessment of imaging skills solely to the UME curriculum.

Considering these existing shortcomings, it seems unlikely that current UME in the United States is sufficiently providing the imaging skills most useful for intern year. In fact, a national study of interns recently reported a lack of confidence in a variety of important imaging skills, including determining normal from abnormal in basic imaging modalities, indications for various imaging tests, and when to consult radiologists . A convenience sample survey of program directors (PDs) from a variety of specialties identified that interns were generally adequately prepared ; however, this early study had a limited sampling frame and did not account for variation between specialties. Thus, the question remains whether UME is sufficiently preparing students for clinical practice as interns.

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Materials and Methods

Questionnaire

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TABLE 1

(a) Current Diagnostic Radiology Milestones for Imaging Interpretation (“Medical Knowledge 2: Interpretation of Examinations”). (b) Modified \* Milestone Tool to Assess Interpretation Skills Below Level 1

(a) Level 1 Level 2 Level 3 Level 4 Level 5 Makes core observations, formulates differential diagnosis, and recognizes critical findings Makes secondary observations, narrows the differential diagnosis, and describes management options Provides accurate, focused, and efficient interpretations Makes subtle observations Demonstrates expertise and efficiency at a level expected of a subspecialist Prioritizes differential diagnoses and recommends management Suggests a single diagnosis when appropriate Advances the art and science of image interpretation Differentiates normal from abnormal Integrates current research and literature with guidelines to recommend management

(b) Level 1 Level 2 Level 3 Level 4 Unable to consistently recognize major anatomical landmarks Recognizes normal from abnormal Makes core observations, formulates differential diagnosis, and recognizes critical findings Makes secondary observations and narrows the differential diagnosis

Part (a) is the Milestone language pulled directly from published Accreditation Council for Graduate Medical Education residency milestones regarding image interpretation skills. Part (b) is the modified Milestone language used in the survey. Language was simplified and shortened to increase clarity, and additional levels below the original level 1 were added to provide better representation of the imaging skills of recent medical school graduates.

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TABLE 2

(a) Current Diagnostic Radiology Milestones for Imaging Utilization (“Patient Care and Technical Skills 1: Consultant”). (b) Modified \* Milestone Tool to Assess Utilization Skills Below Level 1

(a) Level 1 Level 2 Level 3 Level 4 Level 5 Uses established evidence-based imaging guidelines such as American College of Radiology (ACR) Appropriateness Criteria Recommends appropriate imaging of common conditions independently Recommends appropriate imaging of uncommon conditions independently Integrates current research and literature with guidelines, taking into consideration cost-effectiveness and risk-benefit analysis, to recommend imaging Participates in research, development, and implementation of imaging guidelines Appropriately uses the Electronic Health Record to obtain relevant clinical information

(b) Level 1 Level 2 Level 3 Level 4 “Shotgun” order imaging Uses evidence-based imaging guidelines (such as the American College of Radiology Appropriateness Criteria) Uses appropriate imaging of common conditions without need of guidelines or senior staff Uses appropriate imaging of uncommon conditions without need of guidelines or senior staff

Part (a) is the Milestone language pulled directly from published Accreditation Council for Graduate Medical Education residency milestones regarding imaging utilization skills. Part (b) is the modified Milestone language used in the survey. Language was simplified and shortened to increase clarity, and an additional level below the original level 2 was added to provide better representation of the imaging skills of recent medical school graduates.

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Questionnaire Paradata

National Data

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Analyses

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Institutional Review Board (IRB) Approval

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Funding

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Results

Reliability and Validity Evidence

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Respondents and Demographics

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TABLE 3

Demographics of Responding Program Directors (PD), 2016–2017

National Pediatrics Internal Medicine Obstetrics and Gynecology General Surgery PD Age [y] M (SD) 49.6 (9.1) 47.9 (8.8) 50.3 (8.3) 49.5 (8.1) 50.7 (10.9) PD Male N (%) 134 (62.9) 28 (52.8) 29 (59.2) 35 (62.5) 42 (76.4) PD Tenure [y] M (SD) 6.26 (6.02) 7.4 (6.2) 6.8 (5.8) 6.8 (7.3) 4.1 (3.7) Program size [total residents] M (SD) 35.8 (28.2) 39.6 (25.9) 59.9 (36.6) 17.7 (8.3) 29.3 (17.3) Geography West n (%) 33 (15.3) 8 (15.1) 12 (24.5) 8 (14.0) 5 (9.1) Midwest n (%) 68 (31.5) 17 (32.1) 7 (14.3) 16 (28.1) 27 (49.1) South n (%) 63 (29.2) 15 (28.3) 20 (40.8) 17 (29.8) 12 (21.8) Northeast n (%) 50 (23.1) 13 (24.5) 10 (20.4) 16 (28.1) 11 (20.0)

M, mean; n , number; SD, standard deviation.

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Instructional Resources

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Interpretation Ability: Expected and Actual

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TABLE 4

Survey Responses of Program Directors, Both Nationally and by Specialty, 2016–1017

National Pediatrics Internal Medicine Obstetrics and Gynecology General Surgery Actual interpretation ability M (SD) 1.70 (0.53) 1.98 (0.46) 1.70 (0.46) 1.49 (0.50) 1.65 (0.58) Expected interpretation ability M (SD) 2.25 (0.35) 2.28 (0.46) 2.44 (0.50) 2.00 (0.50) 2.31 (0.51) Interpretation discrepancy (expected-actual) M (SD) 0.55 (0.63) .30 (0.50) 0.74 (0.63) 0.51 (0.60) 0.66 (0.70) Actual utilization ability M (SD) 1.57 (0.80) 1.60 (0.82) 1.36 (0.66) 1.67 (0.80) 1.63 (0.89) Expected utilization ability M (SD) 2.17 (0.55) 2.06 (0.63) 2.18 (0.39) 2.12 (0.60) 2.33 (0.51) Utilization discrepancy (expected-actual) M (SD) 0.60 (0.64) .45 (0.64) 0.82 (0.52) 0.44 (0.60) 0.69 (0.70) When to order imaging tests M (SD) 3.76 (0.64) 3.67 (0.55) 3.79 (0.68) 3.80 (0.68) 3.79 (0.67) What imaging tests to order M (SD) 3.77 (0.75) 3.67 (0.68) 3.72 (0.80) 3.75 (0.78) 3.92 (0.74) Communication of imaging results with physicians M (SD) 4.08 (0.81) 4.04 (0.77) 4.05 (0.72) 4.04 (0.94) 4.19 (0.77) Communication of imaging results with patients/caregivers M (SD) 4.01 (0.76) 4.08 (0.62) 4.02 (0.72) 3.85 (0.98) 4.08 (0.68) Optimal to teach imaging in residency, yes, n (%) 130 (65.0) 32 (60.4) 26 (60.5) 40 (74.1) 32 (64.0) Amount of formal imaging instruction M (SD) 3.01 (0.89) 3.08 (0.76) 3.14 (0.89) 3.19 (0.91) 2.65 (0.93) Variability in imaging skills M (SD) 3.25 (0.85) 3.17 (0.75) 3.60 (0.73) 3.08 (0.90) 3.24 (0.92) Expected improvement from uniform imaging skills M (SD) 3.36 (0.93) 3.30 (0.85) 3.50 (0.67) 3.24 (1.12) 3.42 (1.00) Expected improvement from uniform medical skills M (SD) 3.54 (0.99) 3.53 (0.99) 3.88 (0.77) 3.37 (0.90) 3.46 (1.18)

M, mean; n , number; SD, standard deviation.

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Interpretation Ability: Discrepancies

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TABLE 5

Ranked Comparison by Residency Program Directors of the Mean Interpretation Discrepancy, by Specialty, 2016–2017 \* , †

Mean Interpretation Discrepancy Ordinal Rank 1 2 3 4 IM 0.74 1 1.00 0.59 0.07 <.001 Surgery 0.66 2 1.00 0.22 0.002 ObGyn 0.51 3 1.00 0.04 Pediatrics 0.30 4 1.00

IM, internal medicine; ObGyn, obstetrics and gynecology; Surgery, general surgery.

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Utilization Ability: Expected and Actual

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Utilization Ability: Discrepancies

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TABLE 6

Ranked Comparison by Residency Program Directors of the Mean Utilization Discrepancy, by Specialty, 2016–2017 \* , †

Mean Utilization Discrepancy Ordinal Rank 1 2 3 4 IM 0.82 1 1.00 0.31 0.002 0.001 Surgery 0.69 2 1.00 0.06 0.04 Pediatrics 0.45 3 1.00 0.88 ObGyn 0.44 4 1.00

IM, internal medicine; ObGyn, obstetrics and gynecology; Surgery, general surgery.

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Imaging Education Variability

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TABLE 7

Ranked Comparison by Residency Program Directors of the Mean Variability Among Incoming Trainees, by Specialty, 2016–2017 \* , †

Mean Variability Among Incoming Trainees Ordinal Rank 1 2 3 4 IM 3.60 1 1.00 0.04 0.007 0.005 Surgery 3.24 2 1.00 0.65 0.38 Pediatrics 3.17 3 1.00 0.62 ObGyn 3.08 4 1.00

IM, internal medicine; ObGyn, obstetrics and gynecology; Surgery, general surgery.

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Specific Skills

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TABLE 8

Responses for the Importance of Specific Imaging Skills

Not at All Important Of Little Importance Of Average Importance Very Important Absolutely Essential Communication of imaging results with physicians, n (%) 0 (0.0) 6 (3.0) 41 (20.5) 87 (43.5) 66 (33.0) Communication of imaging results with patients/caregivers, n (%) 1 (0.5) 5 (2.5) 39 (19.6) 103 (51.8) 51 (25.6) What imaging tests to order, n (%) 0 (0.0) 10 (5.0) 54 (27.0) 108 (54.0) 28 (14.0) When to order imaging tests, n (%) 0 (0.0) 3 (1.5) 62 (30.9) 116 (57.7) 20 (10.0)

n , number.

TABLE 9

Ranked Comparison by Residency Program Directors of Specific Imaging Skills, 2016–2017 \* , †

Mean Importance of Skill Ordinal Rank 1 2 3 4 Communication of imaging results with physicians 4.08 1 1.00 0.28 <.001 <.001 Communication of imaging results with patients/caregivers 4.01 2 1.00 0.002 <.001 What imaging tests to order 3.77 3 1.00 0.67 When to order imaging tests 3.76 4 1.00

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Nonresponse Bias Analysis

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Discussion

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Shortcomings in Medical School Imaging Education

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Specific Skills

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Future Implications

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Limitations

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Conclusion

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Acknowledgments

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Supplementary Data

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Appendix S1

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Radiology Education in Medical School and Residency

Rationale and Objectives

Materials and Methods

Results

Discussion

Introduction

Materials and Methods

Questionnaire

Questionnaire Paradata

National Data

Analyses

Institutional Review Board (IRB) Approval

Funding

Results

Reliability and Validity Evidence

Respondents and Demographics

Instructional Resources

Interpretation Ability: Expected and Actual

Interpretation Ability: Discrepancies

Utilization Ability: Expected and Actual

Utilization Ability: Discrepancies

Imaging Education Variability

Specific Skills

Nonresponse Bias Analysis

Discussion

Shortcomings in Medical School Imaging Education

Specific Skills

Future Implications

Limitations

Conclusion

Acknowledgments

Supplementary Data

References

Further Reading

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