Rationale and Objectives
Search patterns are important for radiologists because they enable systematic case review. Because radiology residents are exposed to so many imaging modalities and anatomic regions, and they rotate on-and-off service so frequently, they may have difficulty establishing effective search patterns. We developed Real View Radiology (RVR), an educational system founded on guided magnetic resonance imaging (MRI) case review and evaluated its impact on search patterns and interpretative confidence of junior radiology residents.
Materials and Methods
RVR guides learners through unknown examinations by sequentially prompting learners to certain aspects of a case via a comprehensive question set and then providing immediate feedback. Junior residents first completed a brief evaluation regarding their level of confidence when interpreting certain joint MRI cases and frequency of search pattern use. They spent four half-days interpreting cases using RVR. Once finished, they repeated the evaluations. The junior resident results were compared to third-year residents who had not used RVR. The data were analyzed for change in confidence, use of search patterns, and number of cases completed.
Results
Twelve first-year and thirteen second-year residents (trained cohort) were enrolled in the study. During their 4-week musculoskeletal rotations, they completed on average 29.3 MRI knee (standard deviation [SD], 1.6) and 17.4 shoulder (SD, 1.2) cases using RVR. Overall search pattern scores of the trained cohort increased significantly both from pretraining to posttraining (knee P < .01, shoulder P < .01) and compared to the untrained third-year residents (knee ( P < .01, and shoulder P < .01). The trained cohort confidence scores also increased significantly from pre to post for all joints (knee P < .01, shoulder P < .01, pelvis P < .01, and ankle P < .01).
Conclusions
Radiology residents can increase their MRI case interpretation confidence and improve the consistency of search pattern use by training with a question-based sequential reveal educational program. RVR could be used to supplement training and assist with search pattern creation in areas in which residents often do not acquire adequate clinical exposure.
Historically, effective learning for diagnostic radiology residents has been achieved via traditional educational pathways, such as the interpretation of daily cases at the clinical workstation, the review of departmental or online radiology teaching files, attendance at departmental didactic lectures, and/or case conferences, and the completion of assigned readings in radiology textbooks. Although individual learners ultimately choose styles that are best suited to them, case-based format remains at the core of radiology education. The advantages of the case-based approach are that it efficiently allows learners to see images, formulate differential diagnoses, and assimilate digestible amounts of information related to the disease processes.
Case-based learning is based on repetition where a trainee interprets a given study, reviews the correct interpretation, and mentally notes the discrepancies between the two interpretations. It is thought that the accumulation of such experiences leads imagers to form their own search patterns. Search patterns are important to radiologists because they allow each case to be reviewed with a systematic approach, such that all pertinent findings, whether the absence of normal findings or the presence of abnormalities can be identified. It has been shown that search patterns are conducted in a two-step fashion using both nonselective and selective processing . Although oversimplified, radiologists often refer to nonselective search as the “gestalt” of an image. Selective search then follows the gestalt interpretation where trained radiologists use cues from their gestalt and review a study using a more formal search pattern, thereby increasing their interpretation accuracy . Many factors influencing search patterns have been studied including the ability to detect additional abnormalities after an initial discovery, a concept well known as “satisfaction of search” .
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Materials and methods
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Creating the Content
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Trainee Using Real View Radiology
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Evaluation of Trainee
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Statistical Analysis
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Results
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Table 1
Number of Cases Completed by Cohort for Each Joint
Joint First Year ( n = 12) Second Year ( n = 13) First/Second Year Combined ( n = 25) Knee 27.6 (2.2), [16–37] 30.92 (2.3), [15–38] 29.32 (1.6), [15–38] Shoulder 17.3 (1.7), [2–23] 17.46 (1.9), [5–24] 17.40 (1.2), [2–24] Pelvis 1.33 (0.6), [0–6] 3.85 (1.2), [0–10] 2.64 (0.7), [0–10] Ankle 2.00 (0.9), [0–9] 3.23 (1.0), [0–9] 2.64 (0.7), [0–9]
The values are represented as mean (standard deviation), [range].
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Search Pattern
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Table 2
Pretraining and Posttraining Search Pattern Likert Scores for Each Cohort and Each Joint
Location Response First Year Second Year Third Year Pre Post Pre Post Knee Never (1) 4 (31%) 1 (9%) 1%–39% (2) 3 (23%) 3 (25%) 1 (9%) 40%–59% (3) 3 (25%) 1 (9%) 60%–79% (4) 1 (8%) 2 (17%) 5 (38%) 4 (36%) 80%–100% (5) 5 (38%) 12 (100%) 4 (33%) 8 (62%) 4 (36%) Shoulder Never (1) 4 (31%) 2 (17%) 1 (8%) 1%–39% (2) 3 (23%) 3 (25%) 1 (8%) 40%–59% (3) 1 (8%) 1 (8%) 2 (17%) 4 (33%) 60%–79% (4) 2 (15%) 2 (17%) 3 (25%) 5 (38%) 5 (42%) 80%–100% (5) 3 (23%) 9 (75%) 2 (17%) 8 (62%) 1 (8%) Pelvis Never (1) 7 (58%) 5 (42%) 4 (33%) 1 (8%) 3 (25%) 1%–39% (2) 2 (17%) 1 (8%) 3 (25%) 5 (38%) 4 (33%) 40%–59% (3) 1 (8%) 1 (8%) 3 (25%) 2 (15%) 4 (33%) 60%–79% (4) 1 (8%) 3 (25%) 1 (8%) 3 (23%) 1 (8%) 80%–100% (5) 1 (8%) 2 (17%) 1 (8%) 2 (15%) Ankle Never (1) 7 (58%) 4 (33%) 4 (33%) 2 (15%) 3 (25%) 1%–39% (2) 2 (17%) 1 (8%) 3 (25%) 2 (15%) 5 (42%) 40%–59% (3) 1 (8%) 1 (8%) 2 (17%) 2 (15%) 3 (25%) 60%–79% (4) 1 (8%) 2 (17%) 2 (17%) 6 (46%) 80%–100% (5) 1 (8%) 4 (33%) 1 (8%) 1 (8%) 1 (8%)
Values represent the number of residents in each cohort reporting Likert scores listed in the first column in parenthesis ranging from 1 to 5 with 5 representing search pattern use 80%–100% of the time.
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Confidence Scores
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Table 3
Pretraining and Posttraining Confidence Likert Scores for each Class and each Joint
Location Response First Year Second Year Third Year Pre Post Pre Post Knee 1 6 (46%) 1 (8%) 1 (8%) 2 1 (8%) 1 (8%) 1 (8%) 3 1 (8%) 3 (25%) 1 (8%) 4 3 (23%) 3 (25%) 4 (33%) 4 (33%) 5 2 (15%) 5 (42%) 2 (17%) 8 (62%) 3 (25%) 6 3 (25%) 1 (8%) 4 (31%) 1 (8%) 7 1 (8%) 2 (17%) Shoulder 1 9 (69%) 1 (8%) 1 (8%) 1 (8%) 2 1 (8%) 3 (25%) 1 (8%) 1 (8%) 3 1 (8%) 2 (17%) 5 (42%) 2 (17%) 4 2 (15%) 5 (42%) 1 (8%) 6 (46%) 7 (58%) 5 2 (17%) 2 (17%) 4 (31%) 6 2 (17%) 2 (15%) 1 (8%) 7 Pelvis 1 12 (92%) 6 (50%) 6 (50%) 1 (8%) 4 (33%) 2 1 (8%) 4 (33%) 4 (33%) 2 (15%) 1 (8%) 3 1 (8%) 1 (8%) 5 (38%) 3 (25%) 4 1 (8%) 1 (8%) 2 (15%) 2 (17%) 5 3 (23%) 2 (17%) 6 7 Ankle 1 13 (100%) 6 (50%) 5 (42%) 1 (8%) 3 (25%) 2 4 (33%) 6 (50%) 3 (23%) 4 (33%) 3 1 (8%) 4 (31%) 3 (25%) 4 1 (8%) 2 (15%) 1 (8%) 5 3 (23%) 1 (8%) 6 1 (8%) 7
Values represent the number of residents in each cohort reporting Likert scores ranging from 1 to 7 with 7 representing the highest degree of confidence at interpreting the examination.
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Case Completion Correlation
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Learning Preference
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Table 4
Training Cohort Learning Style Preference
Learning Preference First Year Second Year First/Second Year Combined RVR workstation 11 (92%) 9 (69%) 20 (80%) Static image teaching files 1 (8%) 0 (0%) 1 (4%) Whatever I get on PACS 0 (0%) 4 (31%) 4 (16%)
PACS, picture archiving and communication system; RVR, Real View Radiology.
Values represent the number and percentage of residents in each cohort who favored each type of learning.
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Discussion
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Appendix A
Knee template
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