- Email: [email protected]
Chairperson's rounds for radiology residents
Association of P r o g r a m Directors in Radiology Lee B. Talner, MD, Editor
Chairperson's Rounds for Radiology Residents Thomas J. Cusack, MD
I am confident that most department chairpersons, w h e n asked to submit a list of the attributes of their position as the department chair, would not include "sufficient time to do everything that I want to" a m o n g them. Department chairs are constantly trading off time spent on one aspect of their department for time spent on another. From time to time, major crises such as turf battles, faculty problems, or funding difficulties can be distracting for w e e k s on end. The result is that expanding administrative duties tend to erode the very aspects of their careers that led to the attainment of department chair status: teaching ability, research involvement, and direct patient care activities. Although most department chairs resist these erosive tendencies and generally guard and retain as m a n y Of these activities as possible, this is almost never accomplished as well as had b e e n projected w h e n these individuals accepted their administrative positions. When the chairperson occasionally does realize the n e e d or desire for increased teaching activity and sets aside time to engage in it, a format may not be in place that enables m a x i m u m efficiency and use of that time. For the residency programs, all of these forces acting on the chairperson's time tend to form an aggregate loss. The c o m p r o m i s e d ability of the chair to communicate directly to the residents his or her global perspective on new developments in radiology, political issues in radiology, and lessons learned in his or her o w n career experience cannot be accomplished b y delegating to more junior faculty. It is clear from comments
heard at recent national meetings that senior radiology residents today are highly distressed and concerned about their future in radiology. They n e e d the guidance and role-modeling and encouragement of successful individuals in their field. This requires relationships with those role models, and successful development of those relationships requires time and the proper setting. The purpose of this article is to provide a framework for solving these problems and to describe two examples of successfnl solutions. The most important factor in the solution is the format that is developed. The pressures that currently are competing for the chairperson's time will not diminish and likely will intensify. It is not enough to make a good-faith effort to institute a solution; the format must be designed so that it is sustainable in the face of continuing time pressures. To be sustainable, the format must have certain attributes. It must be time efficient, educationally effective, and, most important, rewarding for the chair. Finally, the net result should be positive for the residency. This last attribute implies that there are some trade-offs (discussed later). If any of these attributes are missing, I consider the program nonsustainable. In the remainder of this article, I describe a format that has proved successful in our department. The chairperson has two 1-hr sessions per w e e k with the residents. The first hour is devoted to the differential diagnosis (DDX) format, and the second hour is a textb o o k review.
From the Department of Radiology, University of Illinois College of Medicine, Peoria, IL Address reprint requests to T. J. Cusack, MD, Department of Radiology, University of Illinois College of Medicine, Box 1649, Peoria, IL 61656-1649. Received March 14, 1995, and accepted for publication after revision June 27, 1995. Acad Radiol 1995;2:1021-1025
© 1995, Association of University Radiologists
1021
CUSACK FORMAT 1: THE DDX EXERCISE
In these sessions, the residents are shown an image with an obvious abnormality, such as a pulmonary nodule or intracranial calcification or cystic adnexal mass. The image may be shown in film format, projected from a textbook illustration, or projected on a slide. After a brief study of the image by the residents, the nature of the abnormal finding is briefly discussed so that everyone understands what the finding is and what the DDX should be based on. At this point, the residents write, on a triplicate form designed specifically for this conference, the DDX for the abnormal finding. This can be done along the lines of the chair's preference for pathologic groupings or can be left for each resident to develop his or her o w n pathologic groupings. I generally use the pathologic groupings in the American College of Radiology's (ACR's) teaching file coding system as the template for the pathologic categories. After an appropriate amount of time (usually 37 min), the residents tear off the bottom sheet of the triplicate form and hand in the top two sheets. A general discussion of the DDX then ensues, led by the chairperson but contributed to b y all of the residents, particularly the more senior residents w h o may have a better understanding of the finding as it relates to the n e w e r modalities than the chairperson himself or herself. The discussion of the DDX is focused on organization. Published DDX lists are reviewed, and the residents are encouraged to make comments and critique these published lists. The residents can make additional notes on their copy of the DDX that they have retained. There are advantages to having the residents express their DDXs in written form rather than verbally. Many residents, particularly early in their careers, are much better at expressing themselves in written form than verbally. In teaching conferences, it is often a waste of time to have the entire group wait while a junior resident struggles with an unfamiliar DDX; it is for this reason that junior residents are sometimes not given the opportunities to demonstrate their knowledge as often as more senior residents. Written lists of DDXs for senior residents also are valuable in that the residents are unable to finesse information from the case presenter, by noting the subspecialty of the case presenter, the presenter's current rotation, or even the patient's surname. Finally, written DDXs can be graded, compared, and repeated at a later time to determine h o w the resident is progressing. It is reasonable to have a higher expectation for inclusiveness in written tables of DDXs because the resident
1022
Vol. 2, No. 11, November 1995
is able to review what has already been covered and add additional items that might have been omitted. Although I have no data to support this, I have wondered whether experience at developing written tables of DDXs may be helpful to some residents in later assembling the DDXs in verbal form. Sometime after the conference, the chairperson briefly reviews the written DDXs and makes a quick assessment of the residents' responses and grades them on a 5-point system (O [5], S+ [4], S [3], S- [2], and U [1]; O = outstanding, S = satisfactory, U = unsatisfactory). Because the expectations for residents will vary depending on their level of training, there is a section at the top of the page for residents to indicate what month of training they are in. Occasionally, along with the overall grade, written comments from the chair also may be appropriate (e.g., the resident overlooked an entire area of pathology in his or her response). The department secretary then returns one of the "graded" copies to residents; the remaining copy is kept in the department files. Quarterly, these are summarized by the department secretary, listing all residents' names, all DDXs that they attempted during the quarter, and their respective grades. The advantage of this format is that it emphasizes to residents the importance of developing DDXs for various radiographic findings early in their career. It also emphasizes the need to be able to recount these, in a somewhat orderly fashion, at any time and without prior warning. It enables residents whose manual dexterity or verbal skills may not be outstanding to express themselves in writing. Occasionally, residents demonstrate considerable knowledge and organization in written form that are much less obvious in verbal communication. The DDX exercise allows the department chair to constantly review c o m m o n and important tables of DDXs. It enables him or her to relate directly to the residents and to recount his or her experiences in these areas and the pitfalls that he or she might have encountered in the past. Most important, it enables the chair to interact directly with each of the residents on a weekly basis, emphasizing some of the fundamental concepts Of diagnostic radiology. The DDXs are periodically repeated. In this way, clear, written documentation of residents' progress or lack of progress can be developed. Persistent difficulty in composing appropriate DDXs indicates a major problem that will seriously affect the resident's career unless it is corrected or compensated for. The logistics of the pattern that I have found most useful and time effective are to obtain a standard text-
Vol. 2, No. 11, November 1995
b o o k of radiology and to cut out the illustrations that have the findings to be used in the exercise. These are then taped on an 8.5 x 11 inch piece of p a p e r and kept in a notebook. Attached to each of these is the caption for the photograph; frequently, a paragraph or two photocopied from the textbook also is attached. Photocopies from recent editions of "gamut" books and other tables of DDXs are also included and are reviewed during the discussion phase of the exercise. These cases are then coded with the ACR teaching file code and are incorporated into a table of contents. Perusal of the table of contents by the chair will quickly indicate the n u m b e r and type of each exercise that has already b e e n presented and will be valuable in identifying additional exercises so that the entire spectrum of medical imaging is covered. A variation of the DDX format is the designated diagnosis format. In this format, several images of a disease state are shown (e.g., Down's syndrome, neurofibromatosis). It is expected that the senior residents will be able to identify the disease state in most instances. The residents are asked to write d o w n the condition that is being s h o w n and to describe the condition in whatever detail they can, including pathophysiology and medical imaging findings.
FORMAT 2: TEXTBOOK REVIEW
The other hour of the chairperson's rounds is a textb o o k review. This practice is well established in m a n y departments. I will review the logistics of the exercise that have b e e n d e v e l o p e d so that they conform to the attributes of formats identified earlier in this article. Currently, w e use a 1,200-page textbook and cover it each year by requiring approximately 30 pages of reading per w e e k for a total of 40 weekly sessions (allowance is m a d e for vacations, holidays, the annual meeting of the Radiological Society of North America, and other w e e k s w h e n no session is held). At each session both the chair and the residents read the assigned pages, and the chair quizzes the residents on the material presented. Each response is graded on the 5-point system described earlier. To facilitate these verbal quizzes, the chair not only reads the assigned pages but also dictates study notes excerpted from the textbook relating to the assigned pages. These study notes are constructed so that the diagnosis (or finding or term of interes0 is listed along the left-hand side of the page and the appropriate
CHAIRPERSON'S
ROUNDS FOR RADIOLOGY
RESIDENTS
response is on the right-hand side of the page. In this manner, a set of questions is readily available that covers the material. Small Post-it Notes are then placed along the extreme right-hand margin of the paper prior to the session and the chair writes down, next to the questions, the initials of the resident to w h o m he or she is going to pose the question. The grade of the resident's response is then written next to the resident's initials, and the Postit Notes are left in place after the conference. The department secretary subsequently reviews the chair's noteb o o k and transcribes all of the answers into a computer data bank, which contains the resident's name, the question the resident was asked, and the grade for that question. These are also summarized quarterly and are available for review by the chair. Following questions on the material covered for that week, approximately 10-15 rain are devoted to asking questions from previous sessions during the year, which also have b e e n highlighted with Post-it Notes. This requires residents to always be prepared for all of the information in the chairperson's notes. The study notes for the chair are p h o t o c o p i e d and given to all residents. At the end of the year, the residents have a fairly complete set of notes on the textbook. In our program this constitutes a major portion of the core knowledge that the residents are expected to have mastered. The requirement to dictate study notes makes the first year of the textbook review much more labor-intensive for the chair. However, the ability to read a current general textbook of radiology cover to cover carefully enough to construct study notes is a luxury that most chairpersons will enjoy if they can justify the time commitment. This format provides that justification. Generally, the time required to review the indicated pages and excerpt the appropriate study notes is approximately 60-75 min per session. The major purpose of this format is to provide the residents with a core knowledge of radiographic information and to repeatedly drill them on that knowledge. This will be valuable to them in clinical situations and w h e n they take the boards. It will give them confidence that they have broad knowledge that has b e e n tested frequently and is recallable. In attaining this goal, the residents and the chair are methodically involved in a broad review of medical imaging of all modalities as it relates to pathology in all major organ systems. One of the most valuable aspects of this entire exercise emerged as a very pleasant surprise. The quarterly printouts of residents' scores have b e e n extremely valuable,
1023
CUSACK
vol. 2, No. 11, November 1995
particularly from the residents' viewpoint. An example of the DDX scoring for a resident is shown in Table 1. In this example there are no outstanding (5/0) grades, only one above-average (4/S+) grade and only one unsatisfactory (l/U) grade. The majority of the scores are in the average (3/S) to below-average (2/S-) range. If this were a first-year resident, it would indicate that the resident is learning the discipline on a broad fi-ont, a fairly reassuring report. If this were a second-year resident, it would be worrisome that there are no outstanding ( 5 / 0 ) grades and only one above-average (4/S+) grade. If this were a third-year resident, it would indicate clearly that the level of knowledge is far too superficial and that immediate corrective action is needed. The real-life grades from the textbook review (Table 2) show alternating groupings of outstanding ( 5 / 0 ) and
TABLE 1: Resident's Scoring in a Differential Diagnosis Conference Quarter Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer
1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994
Subject Adrenal masses Psoriatic arthritis Secondary hyperparathyroidism Pseudopseudohyoparathyroidism Esophageal web Bull's-eye lesion Intralobar sequestration Dandy-Walker malformation Mediastinal mass Angiomyolipoma Ureterocele Hydronephrosis Polycystic kidney disease
Reference Grade 86-01 43-01 81-01 89-01 71-01 77-01 -68-01 10-01 67-01 81-04 82-01 85-01 81-03
3/S 3/S 2/S1/U 3/S 2/S3/S 2/S3/S 3/S 2/S4/S+ 3/S
S = satisfactory, U = unsatisfactory.
TABLE 2: Resident's Scoring in the Textbook Review Quarter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter
1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995
Subject Eggshell calcification Cobalt lung Radiopaquedust pneumoconioses Maple-bark disease Industrial and war gases Paraquat lung Vinyl and polyvinyl chloride exposure Anomalous left coronary artery Aberrant left pulmonary artery Adenocarcinoma Bronchioloalveolar carcinoma Pancoast tumor Pancoast syndrome Malignant histiocytosis Round atelectasis
S = satisfactory, U = unsatisfactory,O = outstanding. 1024
DISCUSSION
Reference Grade P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/32 P&J/32 P&J/29 P&J/29 P&J/29 P&J/29 P&J/29 P&J/30
unsatisfactory ( l / U ) readings. This indicates not only that the resident is not reading the assignment regularly, but also that w h e n the resident does n o t read the assignment there is no core knowledge to fall back on. This resident is therefore developing a core level of knowledge with major gaps, and this needs to remedied. This type of objective scoring of residents is not easy to obtain in our program and, I suspect, in many others. Although residents are graded on their clinical rotations by faculty members w h o make a good-faith effort, the shortcomings of this type of evaluation are well-known. Problem residents are not identified early enough. The evaluations tend not to indicate to the residents significant areas of weakness. Finally, and most important, residents are frequently not positively recognized for excellence in the performance of their duties. Although some external examinations (e.g., the in-training examination for diagnostic radiology residents offered by the ACR) are helpful, annual feedback is too infrequent. Quarterly sessions with each of the residents to review their performance on the DDX conferences and textbook review have b e e n uniformly gratifying for the chair and helpful to the residents. In response to a resident's concern that much of the textbook scoring is based on very current reading and m a y not indicate long-term knowledge, a variation has b e e n instituted in which questions on the current material will be kept separate in the printouts from review questions that are asked at each session. By comparing these two scores, then, s o m e w h a t of a "retention index" can be determined. The residents have observed, tongue-in-cheek, that the amount of knowledge that is not shown on the initial testing of current material can be used to calculate a "resistive" index.
4/S+ 1/U 1/U 4/S+ 4/S+ 1/U 1/U 1/U 1/U 5/O 5/0 5/0 5/0 5/0 5/O
The results have been very encouraging. The residents genuinely seem interested in these conferences and do not like to see them canceled, particularly for minor reasons. Initially, there was some uneasiness about turning in written "tests" and having records kept of the chair's grades for individual responses to specific questions. This has not been a continuing problem. The younger residents, in particular, are anxious to demonstrate h o w well they are progressing. For the more advanced residents, it is increasingly difficult to be impressive on the upside and increasingly possible to demonstrate a major gap in their knowledge that is embarrassing. The major advantage of this program is that it involves the department chair directly with the residents in an
Vol. 2, No. 11, November 1995
area (teaching) in which most department chairs have previously demonstrated considerable ability. It enables the department chair, in a fairly nonthreatening manner, to continue to learn about new modalities. It enables the department chair to stress the importance of the fundamental radiographic findings and the basic approach to medical imaging that he or she has found useful in his or her o w n life. Although not intended to be an undermining process, it does, in fact, enable the chair to more quickly pick up on attitudes of the residents toward their learning process and difficulties that the residents may be having within the department than would otherwise be obtained. Moreover, it also enables the department chair to assess any areas of weakness in the department's educational activities by giving him or her an opportu-
C H A I R P E R S O N ' S R O U N D S FOR R A D I O L O G Y R E S I D E N T S
nity to routinely review the entire spectrum of pathology with the residents. In this era of medicine, it is particularly important for residents to be exposed to the chairperson's perspective on new developments in radiology, political issues in radiology, and career experience interacting with other radiologists, referring physicians, and administrators. The chair frequently has a different perspective on m a n y issues than do program directors and other faculty members, and it is valuable to have in place a setting that exposes the residents to that perspective. Finally, it is heartwarming for a department chair to see the residents progressing month b y month and to feel that he or she is not only an indirect but also a direct influence on that progression.
1025
Chairperson's Rounds for Radiology Residents Thomas J. Cusack, MD
I am confident that most department chairpersons, w h e n asked to submit a list of the attributes of their position as the department chair, would not include "sufficient time to do everything that I want to" a m o n g them. Department chairs are constantly trading off time spent on one aspect of their department for time spent on another. From time to time, major crises such as turf battles, faculty problems, or funding difficulties can be distracting for w e e k s on end. The result is that expanding administrative duties tend to erode the very aspects of their careers that led to the attainment of department chair status: teaching ability, research involvement, and direct patient care activities. Although most department chairs resist these erosive tendencies and generally guard and retain as m a n y Of these activities as possible, this is almost never accomplished as well as had b e e n projected w h e n these individuals accepted their administrative positions. When the chairperson occasionally does realize the n e e d or desire for increased teaching activity and sets aside time to engage in it, a format may not be in place that enables m a x i m u m efficiency and use of that time. For the residency programs, all of these forces acting on the chairperson's time tend to form an aggregate loss. The c o m p r o m i s e d ability of the chair to communicate directly to the residents his or her global perspective on new developments in radiology, political issues in radiology, and lessons learned in his or her o w n career experience cannot be accomplished b y delegating to more junior faculty. It is clear from comments
heard at recent national meetings that senior radiology residents today are highly distressed and concerned about their future in radiology. They n e e d the guidance and role-modeling and encouragement of successful individuals in their field. This requires relationships with those role models, and successful development of those relationships requires time and the proper setting. The purpose of this article is to provide a framework for solving these problems and to describe two examples of successfnl solutions. The most important factor in the solution is the format that is developed. The pressures that currently are competing for the chairperson's time will not diminish and likely will intensify. It is not enough to make a good-faith effort to institute a solution; the format must be designed so that it is sustainable in the face of continuing time pressures. To be sustainable, the format must have certain attributes. It must be time efficient, educationally effective, and, most important, rewarding for the chair. Finally, the net result should be positive for the residency. This last attribute implies that there are some trade-offs (discussed later). If any of these attributes are missing, I consider the program nonsustainable. In the remainder of this article, I describe a format that has proved successful in our department. The chairperson has two 1-hr sessions per w e e k with the residents. The first hour is devoted to the differential diagnosis (DDX) format, and the second hour is a textb o o k review.
From the Department of Radiology, University of Illinois College of Medicine, Peoria, IL Address reprint requests to T. J. Cusack, MD, Department of Radiology, University of Illinois College of Medicine, Box 1649, Peoria, IL 61656-1649. Received March 14, 1995, and accepted for publication after revision June 27, 1995. Acad Radiol 1995;2:1021-1025
© 1995, Association of University Radiologists
1021
CUSACK FORMAT 1: THE DDX EXERCISE
In these sessions, the residents are shown an image with an obvious abnormality, such as a pulmonary nodule or intracranial calcification or cystic adnexal mass. The image may be shown in film format, projected from a textbook illustration, or projected on a slide. After a brief study of the image by the residents, the nature of the abnormal finding is briefly discussed so that everyone understands what the finding is and what the DDX should be based on. At this point, the residents write, on a triplicate form designed specifically for this conference, the DDX for the abnormal finding. This can be done along the lines of the chair's preference for pathologic groupings or can be left for each resident to develop his or her o w n pathologic groupings. I generally use the pathologic groupings in the American College of Radiology's (ACR's) teaching file coding system as the template for the pathologic categories. After an appropriate amount of time (usually 37 min), the residents tear off the bottom sheet of the triplicate form and hand in the top two sheets. A general discussion of the DDX then ensues, led by the chairperson but contributed to b y all of the residents, particularly the more senior residents w h o may have a better understanding of the finding as it relates to the n e w e r modalities than the chairperson himself or herself. The discussion of the DDX is focused on organization. Published DDX lists are reviewed, and the residents are encouraged to make comments and critique these published lists. The residents can make additional notes on their copy of the DDX that they have retained. There are advantages to having the residents express their DDXs in written form rather than verbally. Many residents, particularly early in their careers, are much better at expressing themselves in written form than verbally. In teaching conferences, it is often a waste of time to have the entire group wait while a junior resident struggles with an unfamiliar DDX; it is for this reason that junior residents are sometimes not given the opportunities to demonstrate their knowledge as often as more senior residents. Written lists of DDXs for senior residents also are valuable in that the residents are unable to finesse information from the case presenter, by noting the subspecialty of the case presenter, the presenter's current rotation, or even the patient's surname. Finally, written DDXs can be graded, compared, and repeated at a later time to determine h o w the resident is progressing. It is reasonable to have a higher expectation for inclusiveness in written tables of DDXs because the resident
1022
Vol. 2, No. 11, November 1995
is able to review what has already been covered and add additional items that might have been omitted. Although I have no data to support this, I have wondered whether experience at developing written tables of DDXs may be helpful to some residents in later assembling the DDXs in verbal form. Sometime after the conference, the chairperson briefly reviews the written DDXs and makes a quick assessment of the residents' responses and grades them on a 5-point system (O [5], S+ [4], S [3], S- [2], and U [1]; O = outstanding, S = satisfactory, U = unsatisfactory). Because the expectations for residents will vary depending on their level of training, there is a section at the top of the page for residents to indicate what month of training they are in. Occasionally, along with the overall grade, written comments from the chair also may be appropriate (e.g., the resident overlooked an entire area of pathology in his or her response). The department secretary then returns one of the "graded" copies to residents; the remaining copy is kept in the department files. Quarterly, these are summarized by the department secretary, listing all residents' names, all DDXs that they attempted during the quarter, and their respective grades. The advantage of this format is that it emphasizes to residents the importance of developing DDXs for various radiographic findings early in their career. It also emphasizes the need to be able to recount these, in a somewhat orderly fashion, at any time and without prior warning. It enables residents whose manual dexterity or verbal skills may not be outstanding to express themselves in writing. Occasionally, residents demonstrate considerable knowledge and organization in written form that are much less obvious in verbal communication. The DDX exercise allows the department chair to constantly review c o m m o n and important tables of DDXs. It enables him or her to relate directly to the residents and to recount his or her experiences in these areas and the pitfalls that he or she might have encountered in the past. Most important, it enables the chair to interact directly with each of the residents on a weekly basis, emphasizing some of the fundamental concepts Of diagnostic radiology. The DDXs are periodically repeated. In this way, clear, written documentation of residents' progress or lack of progress can be developed. Persistent difficulty in composing appropriate DDXs indicates a major problem that will seriously affect the resident's career unless it is corrected or compensated for. The logistics of the pattern that I have found most useful and time effective are to obtain a standard text-
Vol. 2, No. 11, November 1995
b o o k of radiology and to cut out the illustrations that have the findings to be used in the exercise. These are then taped on an 8.5 x 11 inch piece of p a p e r and kept in a notebook. Attached to each of these is the caption for the photograph; frequently, a paragraph or two photocopied from the textbook also is attached. Photocopies from recent editions of "gamut" books and other tables of DDXs are also included and are reviewed during the discussion phase of the exercise. These cases are then coded with the ACR teaching file code and are incorporated into a table of contents. Perusal of the table of contents by the chair will quickly indicate the n u m b e r and type of each exercise that has already b e e n presented and will be valuable in identifying additional exercises so that the entire spectrum of medical imaging is covered. A variation of the DDX format is the designated diagnosis format. In this format, several images of a disease state are shown (e.g., Down's syndrome, neurofibromatosis). It is expected that the senior residents will be able to identify the disease state in most instances. The residents are asked to write d o w n the condition that is being s h o w n and to describe the condition in whatever detail they can, including pathophysiology and medical imaging findings.
FORMAT 2: TEXTBOOK REVIEW
The other hour of the chairperson's rounds is a textb o o k review. This practice is well established in m a n y departments. I will review the logistics of the exercise that have b e e n d e v e l o p e d so that they conform to the attributes of formats identified earlier in this article. Currently, w e use a 1,200-page textbook and cover it each year by requiring approximately 30 pages of reading per w e e k for a total of 40 weekly sessions (allowance is m a d e for vacations, holidays, the annual meeting of the Radiological Society of North America, and other w e e k s w h e n no session is held). At each session both the chair and the residents read the assigned pages, and the chair quizzes the residents on the material presented. Each response is graded on the 5-point system described earlier. To facilitate these verbal quizzes, the chair not only reads the assigned pages but also dictates study notes excerpted from the textbook relating to the assigned pages. These study notes are constructed so that the diagnosis (or finding or term of interes0 is listed along the left-hand side of the page and the appropriate
CHAIRPERSON'S
ROUNDS FOR RADIOLOGY
RESIDENTS
response is on the right-hand side of the page. In this manner, a set of questions is readily available that covers the material. Small Post-it Notes are then placed along the extreme right-hand margin of the paper prior to the session and the chair writes down, next to the questions, the initials of the resident to w h o m he or she is going to pose the question. The grade of the resident's response is then written next to the resident's initials, and the Postit Notes are left in place after the conference. The department secretary subsequently reviews the chair's noteb o o k and transcribes all of the answers into a computer data bank, which contains the resident's name, the question the resident was asked, and the grade for that question. These are also summarized quarterly and are available for review by the chair. Following questions on the material covered for that week, approximately 10-15 rain are devoted to asking questions from previous sessions during the year, which also have b e e n highlighted with Post-it Notes. This requires residents to always be prepared for all of the information in the chairperson's notes. The study notes for the chair are p h o t o c o p i e d and given to all residents. At the end of the year, the residents have a fairly complete set of notes on the textbook. In our program this constitutes a major portion of the core knowledge that the residents are expected to have mastered. The requirement to dictate study notes makes the first year of the textbook review much more labor-intensive for the chair. However, the ability to read a current general textbook of radiology cover to cover carefully enough to construct study notes is a luxury that most chairpersons will enjoy if they can justify the time commitment. This format provides that justification. Generally, the time required to review the indicated pages and excerpt the appropriate study notes is approximately 60-75 min per session. The major purpose of this format is to provide the residents with a core knowledge of radiographic information and to repeatedly drill them on that knowledge. This will be valuable to them in clinical situations and w h e n they take the boards. It will give them confidence that they have broad knowledge that has b e e n tested frequently and is recallable. In attaining this goal, the residents and the chair are methodically involved in a broad review of medical imaging of all modalities as it relates to pathology in all major organ systems. One of the most valuable aspects of this entire exercise emerged as a very pleasant surprise. The quarterly printouts of residents' scores have b e e n extremely valuable,
1023
CUSACK
vol. 2, No. 11, November 1995
particularly from the residents' viewpoint. An example of the DDX scoring for a resident is shown in Table 1. In this example there are no outstanding (5/0) grades, only one above-average (4/S+) grade and only one unsatisfactory (l/U) grade. The majority of the scores are in the average (3/S) to below-average (2/S-) range. If this were a first-year resident, it would indicate that the resident is learning the discipline on a broad fi-ont, a fairly reassuring report. If this were a second-year resident, it would be worrisome that there are no outstanding ( 5 / 0 ) grades and only one above-average (4/S+) grade. If this were a third-year resident, it would indicate clearly that the level of knowledge is far too superficial and that immediate corrective action is needed. The real-life grades from the textbook review (Table 2) show alternating groupings of outstanding ( 5 / 0 ) and
TABLE 1: Resident's Scoring in a Differential Diagnosis Conference Quarter Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer Summer
1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994 1994
Subject Adrenal masses Psoriatic arthritis Secondary hyperparathyroidism Pseudopseudohyoparathyroidism Esophageal web Bull's-eye lesion Intralobar sequestration Dandy-Walker malformation Mediastinal mass Angiomyolipoma Ureterocele Hydronephrosis Polycystic kidney disease
Reference Grade 86-01 43-01 81-01 89-01 71-01 77-01 -68-01 10-01 67-01 81-04 82-01 85-01 81-03
3/S 3/S 2/S1/U 3/S 2/S3/S 2/S3/S 3/S 2/S4/S+ 3/S
S = satisfactory, U = unsatisfactory.
TABLE 2: Resident's Scoring in the Textbook Review Quarter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter Winter
1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995
Subject Eggshell calcification Cobalt lung Radiopaquedust pneumoconioses Maple-bark disease Industrial and war gases Paraquat lung Vinyl and polyvinyl chloride exposure Anomalous left coronary artery Aberrant left pulmonary artery Adenocarcinoma Bronchioloalveolar carcinoma Pancoast tumor Pancoast syndrome Malignant histiocytosis Round atelectasis
S = satisfactory, U = unsatisfactory,O = outstanding. 1024
DISCUSSION
Reference Grade P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/27 P&J/32 P&J/32 P&J/29 P&J/29 P&J/29 P&J/29 P&J/29 P&J/30
unsatisfactory ( l / U ) readings. This indicates not only that the resident is not reading the assignment regularly, but also that w h e n the resident does n o t read the assignment there is no core knowledge to fall back on. This resident is therefore developing a core level of knowledge with major gaps, and this needs to remedied. This type of objective scoring of residents is not easy to obtain in our program and, I suspect, in many others. Although residents are graded on their clinical rotations by faculty members w h o make a good-faith effort, the shortcomings of this type of evaluation are well-known. Problem residents are not identified early enough. The evaluations tend not to indicate to the residents significant areas of weakness. Finally, and most important, residents are frequently not positively recognized for excellence in the performance of their duties. Although some external examinations (e.g., the in-training examination for diagnostic radiology residents offered by the ACR) are helpful, annual feedback is too infrequent. Quarterly sessions with each of the residents to review their performance on the DDX conferences and textbook review have b e e n uniformly gratifying for the chair and helpful to the residents. In response to a resident's concern that much of the textbook scoring is based on very current reading and m a y not indicate long-term knowledge, a variation has b e e n instituted in which questions on the current material will be kept separate in the printouts from review questions that are asked at each session. By comparing these two scores, then, s o m e w h a t of a "retention index" can be determined. The residents have observed, tongue-in-cheek, that the amount of knowledge that is not shown on the initial testing of current material can be used to calculate a "resistive" index.
4/S+ 1/U 1/U 4/S+ 4/S+ 1/U 1/U 1/U 1/U 5/O 5/0 5/0 5/0 5/0 5/O
The results have been very encouraging. The residents genuinely seem interested in these conferences and do not like to see them canceled, particularly for minor reasons. Initially, there was some uneasiness about turning in written "tests" and having records kept of the chair's grades for individual responses to specific questions. This has not been a continuing problem. The younger residents, in particular, are anxious to demonstrate h o w well they are progressing. For the more advanced residents, it is increasingly difficult to be impressive on the upside and increasingly possible to demonstrate a major gap in their knowledge that is embarrassing. The major advantage of this program is that it involves the department chair directly with the residents in an
Vol. 2, No. 11, November 1995
area (teaching) in which most department chairs have previously demonstrated considerable ability. It enables the department chair, in a fairly nonthreatening manner, to continue to learn about new modalities. It enables the department chair to stress the importance of the fundamental radiographic findings and the basic approach to medical imaging that he or she has found useful in his or her o w n life. Although not intended to be an undermining process, it does, in fact, enable the chair to more quickly pick up on attitudes of the residents toward their learning process and difficulties that the residents may be having within the department than would otherwise be obtained. Moreover, it also enables the department chair to assess any areas of weakness in the department's educational activities by giving him or her an opportu-
C H A I R P E R S O N ' S R O U N D S FOR R A D I O L O G Y R E S I D E N T S
nity to routinely review the entire spectrum of pathology with the residents. In this era of medicine, it is particularly important for residents to be exposed to the chairperson's perspective on new developments in radiology, political issues in radiology, and career experience interacting with other radiologists, referring physicians, and administrators. The chair frequently has a different perspective on m a n y issues than do program directors and other faculty members, and it is valuable to have in place a setting that exposes the residents to that perspective. Finally, it is heartwarming for a department chair to see the residents progressing month b y month and to feel that he or she is not only an indirect but also a direct influence on that progression.
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