In the past several years, the reimbursement for radiology examinations has decreased because of code bundling and reduced payment per code. Academic radiologists have responded by working harder to maintain clinical revenues and personal income. Reports from the Association of Administrators in Academic Radiology show an 11.9% increase in RVUs per faculty over the last 3 years. At the same time, more effort has been required to improve and document the quality of radiology services. With these increasing demands on radiology faculty time, training radiology residents has become increasingly challenging.
The field of radiology continues to expand, and every year, there is more to learn to become a competent radiologist. Not only is a strong knowledge base required, but also residents must spend enormous amounts of time reading cases on the clinical services. This clinical experience is most valuable when supervised by faculty interested in their education and willing to devote even small amounts of time teaching them the fine points of image interpretation.
One-on-one reading of cases at the PACS station with an attending remains a cornerstone of resident education in radiology. For conventional radiographs, first-year residents generally select random studies from a long daily worklist or may be assigned to read cases obtained during a particular time slot. In our institution, and probably in many others, the typical first-year resident reads about 20% of the chest radiographs seen each day, with the attending interpreting the remainder. If the resident and attending are reading in separate rooms, only cases of teaching-file quality are shared with the resident. Even if the attending and resident are in the same reading room, calling over the resident to see a case is infrequent because it disrupts the work flow. This is especially true for cases that may not be earth-shattering, but illustrates a relatively common abnormality that a new resident may never have encountered or offers a subtle teaching point. Consequently, there are a substantial number of cases of educational benefit to which the resident is never exposed.
An alternative approach used by the author is for the attending to select cases with teaching value for the resident to interpret. For the initial day or two on the chest service, the first-year resident is restricted to posteroanterior and lateral examinations, many of which are preoperative studies and those with a history of “positive PPD.” This approach allows the resident to develop a pattern for viewing conventional chest radiographs and to see a spectrum of normal appearances. After this introductory period, the attending selects for the resident cases that illustrate basic abnormal findings, as well as how physiological factors (such as the degree of inspiration and upright vs supine position) influence the appearance of structures on conventional radiographs. At times, it is the comparison image that demonstrates the pathology, with the new study showing partial or complete clearing of the process. Every case with a misplaced tube or catheter, pneumothorax, or pneumonia is assigned to the resident, who thus is exposed to a large number of these critical findings during the rotation and becomes proficient at detecting these abnormalities. Some cases are selected to raise management issues, especially in clinical situations when additional imaging studies should be recommended.
This system for selecting resident cases takes minimal additional time on the part of the attending. At an initial glance, it is usually obvious whether a case has educational benefit for a first-year resident, and the PACS system permits an attending to put the case into the resident’s reading queue in a few seconds with a few key strokes. In addition to the teaching opportunities that this approach provides for the resident, it also has value for the attending. First, it ensures that the readout will be more pleasurable and rewarding, because having a discussion about positive findings is far more enjoyable than looking at a series of normal examinations. Second, having the resident interpret cases for which abnormal findings need to be communicated to the referring physician gives the resident experience in this important type of interaction. Moreover, because this can be a relatively time-consuming activity, the result is that the attending is freed up to interpret a larger number of cases.
Over the past few years, first-year residents on the chest rotation have responded enthusiastically to being given cases selected for their teaching value rather than ones randomly taken from the general PACS worklist. Moreover, as the author can attest, the readouts are much more satisfying. The selected case system is beneficial for residents and attendings alike—try it and see if you agree!