- Email: [email protected]
Engaging Senior Residents in Medical Student Education: A Resident’s Perspective
OPINION
Engaging Senior Residents in Medical Student Education: A Resident’s Perspective Allison M. Aripoli, MD, Kirk A. Miller, DO, Shelby J. Fishback, MD, Rustain L. Morgan, MD, MS INTRODUCTION Academic medical centers possess a powerful teaching resource that is largely underutilized in radiology— resident physicians. The critical role of residents as educators in other disciplines is supported by medical students, who report that up to a third of their education is provided by residents [1,2]. The ACGME emphasizes resident teaching [3], and, in response, many institutions implement resident-as-teacher programs. These programs aim to improve resident teaching skills, thereby enhancing the educational experience of residents and medical students throughout their training [4]. Consistent resident-as-teacher program themes include establishing student learning goals, providing feedback, acting as a role model, and facilitating group teaching [5]. Prior research has shown that formal resident-as-teacher programs are beneficial to both students and residents [6,7]. However, literature specific to radiology is limited and primarily focuses on medical student perception of resident and attending radiologists as educators. When comparing radiology residents to staff radiologists, Scheiner and Mainiero [8] and Naeger et al [9] concluded that radiology residents were just as effective as attending radiologists at presenting standardized lecture material to medical students [9],
with lectures delivered by residents receiving similar evaluations as lectures delivered by faculty [8]. Incorporating radiology residents in medical student education is a potential area for meaningful growth. This trainee perspective explores challenges unique to radiology medical student education in an effort to raise awareness and offer a small number of potential solutions.
CHALLENGES UNIQUE TO MEDICAL STUDENT RADIOLOGY EDUCATION Passive Educational Experience Medical student education in radiology is wrought with inherent challenges distinct from clinical rotations, the principle of which is the passive educational model [10]. Several reasons may account for passive shadowing in the reading room. First, radiology is dependent on advanced computer systems, and actively integrating medical students into daily reading room workflow is inefficient due to workstation availability and the need for specialized PACS training. Second, only 10% to 25% of US medical school graduates are required to take radiology as a clinical rotation [11,12]. As a result, universal adoption of a standardized curriculum is lacking, even though a published curriculum is available through nationally recognized sources such as the Alliance of Medical Student Educators
ª 2016 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.12.012
in Radiology [13]. Third, intermittent student presence in reading rooms prevents the ability to consistently assign students meaningful tasks [10], limiting opportunities for active learning. Similarly, shiftlike rotations of attending radiologists and residents may limit our perceived responsibility for teaching and supervising medical students.
Faculty Time Another challenge is that teaching medical students takes time, an increasingly scarce resource in a practice environment that thrives on timeliness and productivity. Radiology faculty time availability is the most cited barrier hindering implementation of effective medical imaging education according to a survey of radiology department chairs and medical school deans conducted in 2012 [14]. The survey also revealed that only about 10% of radiology faculty were actively engaged in medical student teaching and less than two-thirds of faculty (57%) strongly supported medical student education. The ideal time-intensive teaching interaction between students and attending radiologists is at odds with the reality that academic institutions are pressured to devote increasing time to clinical demands. Time dedicated to teaching medical students at the reading station, in case-based
1
sessions, and during didactic lectures almost certainly results in decreased clinical productivity. Greater resources and an increased appreciation for faculty who choose to focus on education may alleviate this challenge.
Appropriate Utilization In 1994, the ACR established a task force to develop appropriate imaging guidelines using evidence-based principles [15], which led to the creation of the ACR Appropriateness Criteria (AC), an internet-based resource. [16]. Despite its availability, several studies have shown limited awareness of appropriateness criteria among medical students and nonradiology resident trainees [17-19]. In an institution with a required radiology clerkship, 96% of senior medical students were not aware of the ACR AC before attending the clerkship’s didactic or small-group session on principles of evidencebased imaging [18]. Similarly, when 175 interns across the country from various post graduate year 1 (PGY-1) specialties were surveyed, 81% of interns indicated they had never heard of nor utilized appropriateness criteria [19]. Promising short-term increases in student awareness and intentions to utilize imaging algorithms such as the ACR AC have been achieved by incorporating evidence-based imaging strategies in medical student curricula [18,20,21]. Assessing students’ long-term knowledge retention or beneficial changes in attitudes or behaviors is an area for future study. DISCUSSION The quality of medical student education today will ultimately impact the quality of health care in the 2
future [22]. In the current state, the majority of medical student radiology education occurs during fourth-year elective rotations. However, students acknowledge there is value in having radiology as a regular aspect of their education, regardless of curriculum requirements and career choice [11]. Early, regular, and integrated exposure to radiology has the potential to impact future practices of medical students in all specialties.
WHAT CAN WE DO? Although faced with daily work-list demands, the reading station does present an opportunity to more actively engage medical students. For example, we can set an expectation for medical students to proactively review patient history and imaging indications, which will reduce passive shadowing and place image interpretation in a more familiar clinical context. Having students review the examination indication will also prompt discussion of appropriate imaging utilization. Senior residents interested in academic medicine can assist in modernizing two particular weaknesses in radiology education: preclinical education and appropriate examination utilization. Although significant alterations in preclinical education will take time and support from academic and departmental leadership, residents can help by offering to present lectures or facilitate group teaching sessions. Building relationships with preclinical medical students could encourage motivated students to consider radiology as a career earlier in their training and increase future collaboration with radiologists, regardless of a student’s eventual specialty [23]. Finally, as program flexibility in the final year of radiology residency
allows, selection of a “resident liaison” for medical student education may significantly ease faculty burden with respect to medical student curricula [24]. The resident would have responsibilities related to the development and delivery of educational content, as shaped by designated mentoring faculty. As a reciprocal benefit for residents interested in an academic career, this position would also provide foundational experiences to help prepare them for future academic roles.
REFERENCES 1. Barrow MV. Medical student opinions of the house office as a medical educator. J Med Educ 1966;41:807-10. 2. Snell L. The resident-as-teacher: it’s more than just about student learning. J Grad Med Educ 2011;3:440-1. 3. Karani R, Fromme HB, Cayea D, et al. How medical students learn from residents in the workplace: a qualitative study. Acad Med 2014;89:490-6. 4. Morrison EH, Friedland JA, Boker J, et al. Residents-as-teacher training in U.S. residency programs and offices of graduate medical education. Acad Med 2001;76 10 suppl:S1-4. 5. Fromme HB, Whicker SA, Paik S, et al. Pediatric resident-as-teacher curricula: a national survey of existing programs and future needs. J Grad Med Educ 2011;3: 168-75. 6. Wamsley MA, Julian KA, Wipf JE. A literature review of “resident-as-teacher” curricula: do teaching courses make a difference? J Gen Intern Med 2004;19: 574-81. 7. Hill AG, Yu TC, Barrow M, Hattie J. A systematic review of resident-as-teacher programmes. Med Educ 2009;43:1129-40. 8. Scheiner JD, Mainiero MB. Effectiveness and student perceptions of standardized radiology clerkship lectures: a comparison between resident and attending radiologist performances. Acad Radiol 2003;10: 87-90. 9. Naeger DM, Wilcox C, Phelps A, et al. Residents teaching medical students: how do they compare with attending educators? J Am Coll Radiol 2014;11:63-7. 10. Naeger DM, Phelps A, Kohi M, et al. Reading room electives: say goodbye to the “radi-holiday.” J Am Coll Radiol 2013;10: 442-8. 11. Poot JD, Hartman MS, Daffner RH. Understanding the US medical school requirements and medical students’ attitudes
Journal of the American College of Radiology Volume - n Number - n - 2017
12.
13.
14.
15.
about radiology rotations. Acad Radiol 2012;19:369-73. Prezzia C, Vorona G, Greenspan R. Fourth-year medical student opinions and basic knowledge regarding the field of radiology. Acad Radiol 2013;20:272-83. Webb EM, Neager DM, McNulty NJ, Straus CM. Needs assessment for standardized medical student imaging education: review of the literature and a survey of deans and chairs. Acad Radiol 2015;22: 1214-11220. Straus C, Webb EM, Kondo KL, et al. Medical student radiology education: summary and recommendations from a national survey of medical school and radiology department leadership. J Am Coll Radiol 2014;11:606-10. Cascade PN. Setting appropriateness guidelines for radiology. Radiology 1994;192: 50A-4A.
16. American College of Radiology. ACR Appropriateness Criteria. Available at: https://acsearch.acr.org/list. Accessed January 10, 2017. 17. Chiunda AB, Mohammed TH. Knowledge of ACR thoracic imaging appropriateness criteria among trainees: one institution’s experience. Acad Radiol 2012;19:635-9. 18. Dillon JE, Slanetz P. Teaching evidencebased imaging in the radiology clerkship using ACR appropriateness criteria. Acad Radiol 2010;17:912-6. 19. Saha A, Roland RA, Hartman MS, Daffner RH. Radiology medical student education: an outcome-based survey of PGY-1 residents. Acad Radiol 2013;20: 284-9. 20. Leschied JR, Knoepp US, Hoff CN, et al. Emergency radiology elective improves second-year medical students’ perceived
21.
22.
23.
24.
confidence and knowledge of appropriate imaging utilization. Acad Radiol 2013;20: 1168-76. Nadgir R, Slanetz PJ. Integrating evidencebased imaging into the radiology core clerkship: a proposed teaching tool of imaging strategies. J Am Coll Radiol 2010;7: 517-21. Gunderman RB, Kang YK, Fraley RE, Williamson KB, et al. Teaching the teachers. Radiology 2002;222: 599-603. Cizman Z, Hammer M, Mollard B, et al. A resident perspective on adding value as radiologists. Acad Radiol 2016;23: 517-20. Webb EM, Ahearn B, Naeger DM. A designated “teaching resident”: a novel leadership position to promote educational skills and an academic career. J Am Coll Radiol 2016;13:77-80.
Allison M. Aripoli, MD, Kirk A. Miller, DO, and Shelby J. Fishback, MD, are from the Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas. Rustain L. Morgan, MD, MS, is from the Department of Radiology, University of Colorado’s Anschutz Medical Campus, Denver, Colorado. The authors have no conflicts of interest related to the material discussed in this article. Allison Aripoli, MD: University of Kansas Medical Center, Department of Radiology, 3901 Rainbow Boulevard, Mail Stop 4032, Kansas City, KS 66160; e-mail: [email protected].
Journal of the American College of Radiology Aripoli et al n Opinion
3
Engaging Senior Residents in Medical Student Education: A Resident’s Perspective Allison M. Aripoli, MD, Kirk A. Miller, DO, Shelby J. Fishback, MD, Rustain L. Morgan, MD, MS INTRODUCTION Academic medical centers possess a powerful teaching resource that is largely underutilized in radiology— resident physicians. The critical role of residents as educators in other disciplines is supported by medical students, who report that up to a third of their education is provided by residents [1,2]. The ACGME emphasizes resident teaching [3], and, in response, many institutions implement resident-as-teacher programs. These programs aim to improve resident teaching skills, thereby enhancing the educational experience of residents and medical students throughout their training [4]. Consistent resident-as-teacher program themes include establishing student learning goals, providing feedback, acting as a role model, and facilitating group teaching [5]. Prior research has shown that formal resident-as-teacher programs are beneficial to both students and residents [6,7]. However, literature specific to radiology is limited and primarily focuses on medical student perception of resident and attending radiologists as educators. When comparing radiology residents to staff radiologists, Scheiner and Mainiero [8] and Naeger et al [9] concluded that radiology residents were just as effective as attending radiologists at presenting standardized lecture material to medical students [9],
with lectures delivered by residents receiving similar evaluations as lectures delivered by faculty [8]. Incorporating radiology residents in medical student education is a potential area for meaningful growth. This trainee perspective explores challenges unique to radiology medical student education in an effort to raise awareness and offer a small number of potential solutions.
CHALLENGES UNIQUE TO MEDICAL STUDENT RADIOLOGY EDUCATION Passive Educational Experience Medical student education in radiology is wrought with inherent challenges distinct from clinical rotations, the principle of which is the passive educational model [10]. Several reasons may account for passive shadowing in the reading room. First, radiology is dependent on advanced computer systems, and actively integrating medical students into daily reading room workflow is inefficient due to workstation availability and the need for specialized PACS training. Second, only 10% to 25% of US medical school graduates are required to take radiology as a clinical rotation [11,12]. As a result, universal adoption of a standardized curriculum is lacking, even though a published curriculum is available through nationally recognized sources such as the Alliance of Medical Student Educators
ª 2016 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.12.012
in Radiology [13]. Third, intermittent student presence in reading rooms prevents the ability to consistently assign students meaningful tasks [10], limiting opportunities for active learning. Similarly, shiftlike rotations of attending radiologists and residents may limit our perceived responsibility for teaching and supervising medical students.
Faculty Time Another challenge is that teaching medical students takes time, an increasingly scarce resource in a practice environment that thrives on timeliness and productivity. Radiology faculty time availability is the most cited barrier hindering implementation of effective medical imaging education according to a survey of radiology department chairs and medical school deans conducted in 2012 [14]. The survey also revealed that only about 10% of radiology faculty were actively engaged in medical student teaching and less than two-thirds of faculty (57%) strongly supported medical student education. The ideal time-intensive teaching interaction between students and attending radiologists is at odds with the reality that academic institutions are pressured to devote increasing time to clinical demands. Time dedicated to teaching medical students at the reading station, in case-based
1
sessions, and during didactic lectures almost certainly results in decreased clinical productivity. Greater resources and an increased appreciation for faculty who choose to focus on education may alleviate this challenge.
Appropriate Utilization In 1994, the ACR established a task force to develop appropriate imaging guidelines using evidence-based principles [15], which led to the creation of the ACR Appropriateness Criteria (AC), an internet-based resource. [16]. Despite its availability, several studies have shown limited awareness of appropriateness criteria among medical students and nonradiology resident trainees [17-19]. In an institution with a required radiology clerkship, 96% of senior medical students were not aware of the ACR AC before attending the clerkship’s didactic or small-group session on principles of evidencebased imaging [18]. Similarly, when 175 interns across the country from various post graduate year 1 (PGY-1) specialties were surveyed, 81% of interns indicated they had never heard of nor utilized appropriateness criteria [19]. Promising short-term increases in student awareness and intentions to utilize imaging algorithms such as the ACR AC have been achieved by incorporating evidence-based imaging strategies in medical student curricula [18,20,21]. Assessing students’ long-term knowledge retention or beneficial changes in attitudes or behaviors is an area for future study. DISCUSSION The quality of medical student education today will ultimately impact the quality of health care in the 2
future [22]. In the current state, the majority of medical student radiology education occurs during fourth-year elective rotations. However, students acknowledge there is value in having radiology as a regular aspect of their education, regardless of curriculum requirements and career choice [11]. Early, regular, and integrated exposure to radiology has the potential to impact future practices of medical students in all specialties.
WHAT CAN WE DO? Although faced with daily work-list demands, the reading station does present an opportunity to more actively engage medical students. For example, we can set an expectation for medical students to proactively review patient history and imaging indications, which will reduce passive shadowing and place image interpretation in a more familiar clinical context. Having students review the examination indication will also prompt discussion of appropriate imaging utilization. Senior residents interested in academic medicine can assist in modernizing two particular weaknesses in radiology education: preclinical education and appropriate examination utilization. Although significant alterations in preclinical education will take time and support from academic and departmental leadership, residents can help by offering to present lectures or facilitate group teaching sessions. Building relationships with preclinical medical students could encourage motivated students to consider radiology as a career earlier in their training and increase future collaboration with radiologists, regardless of a student’s eventual specialty [23]. Finally, as program flexibility in the final year of radiology residency
allows, selection of a “resident liaison” for medical student education may significantly ease faculty burden with respect to medical student curricula [24]. The resident would have responsibilities related to the development and delivery of educational content, as shaped by designated mentoring faculty. As a reciprocal benefit for residents interested in an academic career, this position would also provide foundational experiences to help prepare them for future academic roles.
REFERENCES 1. Barrow MV. Medical student opinions of the house office as a medical educator. J Med Educ 1966;41:807-10. 2. Snell L. The resident-as-teacher: it’s more than just about student learning. J Grad Med Educ 2011;3:440-1. 3. Karani R, Fromme HB, Cayea D, et al. How medical students learn from residents in the workplace: a qualitative study. Acad Med 2014;89:490-6. 4. Morrison EH, Friedland JA, Boker J, et al. Residents-as-teacher training in U.S. residency programs and offices of graduate medical education. Acad Med 2001;76 10 suppl:S1-4. 5. Fromme HB, Whicker SA, Paik S, et al. Pediatric resident-as-teacher curricula: a national survey of existing programs and future needs. J Grad Med Educ 2011;3: 168-75. 6. Wamsley MA, Julian KA, Wipf JE. A literature review of “resident-as-teacher” curricula: do teaching courses make a difference? J Gen Intern Med 2004;19: 574-81. 7. Hill AG, Yu TC, Barrow M, Hattie J. A systematic review of resident-as-teacher programmes. Med Educ 2009;43:1129-40. 8. Scheiner JD, Mainiero MB. Effectiveness and student perceptions of standardized radiology clerkship lectures: a comparison between resident and attending radiologist performances. Acad Radiol 2003;10: 87-90. 9. Naeger DM, Wilcox C, Phelps A, et al. Residents teaching medical students: how do they compare with attending educators? J Am Coll Radiol 2014;11:63-7. 10. Naeger DM, Phelps A, Kohi M, et al. Reading room electives: say goodbye to the “radi-holiday.” J Am Coll Radiol 2013;10: 442-8. 11. Poot JD, Hartman MS, Daffner RH. Understanding the US medical school requirements and medical students’ attitudes
Journal of the American College of Radiology Volume - n Number - n - 2017
12.
13.
14.
15.
about radiology rotations. Acad Radiol 2012;19:369-73. Prezzia C, Vorona G, Greenspan R. Fourth-year medical student opinions and basic knowledge regarding the field of radiology. Acad Radiol 2013;20:272-83. Webb EM, Neager DM, McNulty NJ, Straus CM. Needs assessment for standardized medical student imaging education: review of the literature and a survey of deans and chairs. Acad Radiol 2015;22: 1214-11220. Straus C, Webb EM, Kondo KL, et al. Medical student radiology education: summary and recommendations from a national survey of medical school and radiology department leadership. J Am Coll Radiol 2014;11:606-10. Cascade PN. Setting appropriateness guidelines for radiology. Radiology 1994;192: 50A-4A.
16. American College of Radiology. ACR Appropriateness Criteria. Available at: https://acsearch.acr.org/list. Accessed January 10, 2017. 17. Chiunda AB, Mohammed TH. Knowledge of ACR thoracic imaging appropriateness criteria among trainees: one institution’s experience. Acad Radiol 2012;19:635-9. 18. Dillon JE, Slanetz P. Teaching evidencebased imaging in the radiology clerkship using ACR appropriateness criteria. Acad Radiol 2010;17:912-6. 19. Saha A, Roland RA, Hartman MS, Daffner RH. Radiology medical student education: an outcome-based survey of PGY-1 residents. Acad Radiol 2013;20: 284-9. 20. Leschied JR, Knoepp US, Hoff CN, et al. Emergency radiology elective improves second-year medical students’ perceived
21.
22.
23.
24.
confidence and knowledge of appropriate imaging utilization. Acad Radiol 2013;20: 1168-76. Nadgir R, Slanetz PJ. Integrating evidencebased imaging into the radiology core clerkship: a proposed teaching tool of imaging strategies. J Am Coll Radiol 2010;7: 517-21. Gunderman RB, Kang YK, Fraley RE, Williamson KB, et al. Teaching the teachers. Radiology 2002;222: 599-603. Cizman Z, Hammer M, Mollard B, et al. A resident perspective on adding value as radiologists. Acad Radiol 2016;23: 517-20. Webb EM, Ahearn B, Naeger DM. A designated “teaching resident”: a novel leadership position to promote educational skills and an academic career. J Am Coll Radiol 2016;13:77-80.
Allison M. Aripoli, MD, Kirk A. Miller, DO, and Shelby J. Fishback, MD, are from the Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas. Rustain L. Morgan, MD, MS, is from the Department of Radiology, University of Colorado’s Anschutz Medical Campus, Denver, Colorado. The authors have no conflicts of interest related to the material discussed in this article. Allison Aripoli, MD: University of Kansas Medical Center, Department of Radiology, 3901 Rainbow Boulevard, Mail Stop 4032, Kansas City, KS 66160; e-mail: [email protected].
Journal of the American College of Radiology Aripoli et al n Opinion
3