- Email: [email protected]
Assessing Medical Students’ Knowledge of IR at Two American Medical Schools
CLINICAL STUDY
Assessing Medical Students’ Knowledge of IR at Two American Medical Schools Clayton W. Commander, MD, PhD, Waleska M. Pabon-Ramos, MD, MPH, Ari J. Isaacson, MD, Hyeon Yu, MD, Charles T. Burke, MD, and Robert G. Dixon, MD
ABSTRACT Purpose: To determine if there was a difference in the level of knowledge about interventional radiology (IR) between medical students in preclinical years of training compared with medical students in clinical years of training at two medical schools and to compare awareness of IR based on the curriculum at each school: one with required radiology education and one without such a requirement. Materials and Methods: An anonymous survey was distributed to students at two medical schools; the survey assessed knowledge of IR, knowledge of training pathways, and preferred methods to increase exposure. Responses of the preclinical and clinical groups were compared, and responses from the clinical groups at each school were compared. Results: “Poor” or “fair” knowledge of IR was reported by 84% (n ¼ 217 of 259) of preclinical students compared with 62% of clinical students (n ¼ 110 of 177; P o .001). IR was being considered as a career by 11% of all students (15%, n ¼ 40 of 259 preclinical; 5%, n ¼ 9 of 177 clinical). The main reason respondents were not considering IR was “lack of knowledge” (65%, n ¼ 136 of 210 preclinical; 20%, n ¼ 32 of 162 clinical). Students in the clinical group at the institution with a required radiology rotation reported significantly better knowledge of IR than clinical students from the institution without a required clerkship (P ¼ .017). Conclusions: There are significant differences in knowledge of IR between preclinical and clinical students. Required radiology education in the clinical years does increase awareness of IR.
ABBREVIATIONS MSE = medical school with elective radiology component, MSR = medical school with required radiology component
Driven by technologic advances, the number of minimally invasive image-guided procedures has increased in recent years (1). As a result, the subspecialty of interventional radiology (IR) has continued to grow and mature (2–5). Likewise, medical school graduates have demonstrated increased interest in IR. In 2009, From the Division of Vascular and Interventional Radiology, Department of Radiology (C.W.C., A.J.I., H.Y., C.T.B., R.G.D.), University of North Carolina at Chapel Hill, 107 Old Clinic Building, CB# 7510, Chapel Hill, NC 27599; and Division of Vascular Interventional Radiology, Department of Radiology (W.M.P.-R.), Duke University Medical Center, Durham, North Carolina. Received March 9, 2014; final revision received June 9, 2014; accepted June 9, 2014. Address correspondence to C.W.C.; E-mail: [email protected] From the SIR 2014 Annual Meeting. None of the authors have identified a conflict of interest. Appendices A and B and Tables E1–3 are available online at www.jvir.org. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1801–1806 http://dx.doi.org/10.1016/j.jvir.2014.06.008
54% (99 of 185) of all IR fellowship positions were filled (6), whereas in 2013, 4 90% (208 of 224) were filled (7). In addition, the subspecialty of IR is evolving into its own specialty. At the present time, IR training involves completing a diagnostic radiology residency, followed by a 1-year IR fellowship. Becoming board-certified in IR involves obtaining the American Board of Radiology Diagnostic Radiology certificate, followed by the American Board of Radiology Certificate of Added Qualification in IR. However, the certification and training requirements are changing. Because of a “growing heterogeneity in the learning experiences of radiology trainees” with regard to IR and because of vague program requirements delineated by the Accreditation Council for Graduate Medical Education for IR, a task force was created to develop guidelines for training in the field of IR (8). In addition, the need for a primary certificate in IR that still includes the core imaging components of diagnostic radiology was recognized because of the rapid expansion of IR; the competitive pressures on the specialty; and the demand
1802
’
Medical Students’ Knowledge of IR
for improved delivery of direct patient care before, during, and after procedures (2). In 2012, the American Board of Medical Specialties approved a dual certificate in IR and diagnostic radiology. As a result, IR leadership is developing detailed requirements and guidelines for an IR residency that will lead to a combined IR and diagnostic radiology certificate. The implementation of this new training pathway is projected for fall 2016 (9). For IR faculty, educating medical students regarding the field to recruit them for the anticipated IR residency program is necessary. There has been increased interest more recently in determining medical students’ level of knowledge and preferred methods for learning more about IR (10–12). This vital information enables medical educators and interventionalists to incorporate IR into busy medical school curricula (11). The purpose of the present study was to determine if there was a difference in the level of knowledge about IR between medical students in preclinical years of training compared with medical students in clinical years of training at two medical schools in the United States. This study also compared awareness of IR based on the curriculum at these two institutions: one medical school with a required radiology component (MSR), and one medical school with an elective component (MSE).
MATERIALS AND METHODS This study was deemed exempt by the institutional review boards at the University of North Carolina School of Medicine and Duke University School of Medicine. An anonymous, web-based survey was distributed via e-mail to 524 medical students attending a public medical school at which there is no required radiology clerkship (MSE) and to 321 students attending a private medical school that has a required radiology clerkship (MSR). The surveys were administered using the Qualtrics Research Suite (Qualtrics, Provo, Utah). The survey administered to MSE students contained 17 questions (Appendix A [available online at www.jvir. org]), and the survey administered to MSR students contained 15 questions (Appendix B [available online at www.jvir.org]). The questions were developed following those in the survey administered by O’Malley and Athreya (12). Questions ranged from self-reported knowledge of IR, level of interest in IR and diagnostic radiology as a career, training required to become an interventional radiologist, knowledge of IR procedures, and preferred methods to learn more about IR. Questions differed between schools only when related to the particular school curriculum. At the MSE, the survey was administered to 185 firstyear students, 179 second-year students, and 160 thirdyear students. At this school, the first and second years are preclinical, and the third and fourth years are
Commander et al
’
JVIR
clinical. The survey was not administered to fourthyear medical students because survey administration occurred in the spring, after these students selected their specialties and matched into their respective residencies. The survey was available from March 2013–May 2013 with monthly reminder e-mail messages sent via the class mailing list using LISTSERV (L-Soft International, Inc, Landover, Maryland). This school’s curriculum does not include a required radiology clerkship. However, students have exposure to diagnostic imaging throughout their preclinical years, predominantly during the anatomy course in the first year, in which weekly didactic lectures by a member of the radiology faculty are given corresponding to the gross anatomy being studied at the time. One such lecture is devoted to IR. The students also have opportunities to take clinical electives in radiology, including a fourth-year month-long rotation in IR (which was implemented after administration of this survey). At the MSR, the survey was administered to 113 firstyear students, 105 second-year students, and 103 fourthyear students. At this school, the first year is preclinical, the second and fourth years are clinical, and the third year is dedicated to research. The survey was not administered to students in the research year. Survey administration occurred in the fall, before the fourthyear students had selected their specialties and started residency interviews. Students were given 1 month (September 2013) to respond to the survey. Weekly reminder messages were sent via the class e-mail list. This school’s curriculum includes a required 4-week radiology clerkship during the second year. During the clerkship, students rotate through each subspecialty (thoracic imaging, neuroradiology, IR, body imaging, breast imaging, pediatric imaging, musculoskeletal imaging, and nuclear medicine) and receive daily didactic lectures. Data were analyzed using Intercooled Stata 10 (StataCorp LP, College Station, Texas). Differences between categorical data were assessed using the χ2 test, and the Wilcoxon-Mann-Whitney test was used for Likert scale data (13). Combined P values were computed using Fisher’s method (14). A P value o .05 was used to indicate statistical significance.
RESULTS Of 845 students, 436 (52%) responded to the survey: 63% (n ¼ 274 of 524) from the MSE and 37% (n ¼ 162 of 321) from the MSR (Table 1). Most students at both institutions (76%, n ¼ 207 MSE; 74%, n ¼ 120 MSR) rated their overall knowledge of IR as “poor” or “fair” (Table 1). Only 4% (n ¼ 12) of MSE students and 9% (n ¼ 14) of MSR students rated their knowledge as either “excellent” or “very good” (P ¼ .391). However, among only the clinical students, 18% (n ¼ 11 of 60) of
Volume 25
’
Number 11
’
November
’
2014
1803
Table 1 . Respondents’ General Knowledge of IR and Career Considerations MSE (n ¼ 274)
MSR (n ¼ 162)
Preclinical,
Clinical,
Preclinical,
Clinical,
Answer Options
n ¼ 157 (57.3%)
n ¼ 117 (42.7%)
n ¼ 102 (63.0%)
n ¼ 60 (37.0%)
Self-reported knowledge of
Excellent
1 (0.6%)
4 (3.4%)
0 (0.0%)
4 (6.7%)
IR compared with other specialties
Very good Good
5 (3.2%) 24 (15.3%)
2 (1.7%) 31 (26.5%)
3 (2.9%) 9 (8.8%)
7 (11.7%) 19 (31.7%)
Fair
61 (38.9%)
45 (38.5%)
40 (39.2%)
20 (33.3%)
Considering a career in DR
Poor Yes
66 (42.0%) 21 (13.4%)
35 (29.9%) 7 (6.0%)
50 (49.0%) 16 (15.7%)
10 (16.7%) 9 (15.0%)
Not sure
61 (38.9%)
9 (7.8%)
47 (46.1%)
3 (5.0%)
No Yes
75 (47.8%) 25 (15.9%)
100 (86.2%) 4 (3.4%)
39 (38.2%) 15 (14.7%)
48 (80.0%) 5 (8.3%)
Not sure
62 (39.5%)
13 (11.1%)
61 (59.8%)
7 (11.7%)
No Lack of knowledge
70 (44.6%) 81 (61.4%)
100 (85.5%) 27 (23.9%)
26 (25.5%) 55 (70.5%)
48 (80.0%) 5 (10.2%)
Question
Considering a career in IR
Reasons given by respondents who would
about the field
not consider IR or who were unsure
Lack of interest Lifestyle concerns
31 (23.5%) 5 (3.8%)
52 (46.0%) 1 (0.9%)
13 (16.7%) 1 (1.3%)
18 (36.7%) 5 (10.2%)
Radiation exposure
4 (3.0%)
2 (1.8%)
1 (1.3%)
3 (6.1%)
concerns Other
11 (8.3%)
31 (27.4%)
8 (10.3%)
18 (36.7%)
Heard of DR/IR dual
Yes
10 (6.5%)
25 (21.6%)
1 (1.1%)
6 (10.9%)
certification Seen patients treated by IR
No Yes
144 (93.5%) 43 (27.9%)
91 (78.5%) 94 (81.0%)
90 (98.9%) 27 (30.3%)
49 (89.1%) 51 (92.7%)
Not sure
48 (31.2%)
13 (11.2%)
27 (30.3%)
2 (3.6%)
No Yes
63 (40.9%) 106 (69.2%)
9 (7.8%) 79 (68.1%)
35 (39.3%) —
2 (3.6%) —
Interested in 2-week IR experience during surgery rotation
Not sure
37 (24.2%)
25 (21.6%)
—
—
No
10 (6.5%)
12 (10.3%)
—
—
DR ¼ diagnostic radiology; IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component.
MSR students rated their knowledge as either “excellent” or “very good” compared with 5% (n ¼ 6 of 117) MSE students (P ¼ .017). Clinical students at both institutions reported significantly greater knowledge of IR than preclinical students (P ¼ .036 MSE; P o .001 MSR; P o .001 combined) (Table 1). When asked about IR as a potential career choice, 63% (n ¼ 163) of preclinical students were either considering or unsure compared with 16% (n ¼ 29) of students in their clinical years (P o .001 MSE; P o .001 MSR; P o .001 combined). However, when the responses from the two schools were compared, 54% (n ¼ 88) of students from the MSR were either considering a career in IR or were unsure compared with 38% (n ¼ 104) of students at the MSE (P ¼ .003). Of the students who were unsure (n ¼ 136), 82% reported that they did not know enough about the specialty to consider it (Table 1). Answers to questions regarding required training pathways for interventional radiologists are listed in Table E1 (available online at www.jvir.org). When asked what had provided the most knowledge about IR, most clinical students (51%) at the MSE
indicated that it was through exposure during nonradiology clerkships. At the MSR, 77% (n ¼ 47) of clinical students reported learning about IR during the required radiology elective (P o .001) (Table 2). At the MSE, 31% (n ¼ 47) of preclinical students indicated they have had no exposure to IR, with 18% (n ¼ 27) reporting knowledge via self-directed learning. Similarly, 51% (n ¼ 18) of preclinical students at the MSR reported no exposure to IR, with 17% (n ¼ 6) reporting knowledge via self-directed learning (Table 2). As a means of learning about IR, both preclinical and clinical students at the MSE overwhelmingly preferred to hear lectures from IR faculty during preclinical training and to rotate through the division during the clinical years as opposed to self-directed learning, multidisciplinary meetings, small group exercises during the preclinical years, or the radiology interest group (Table E2 [available online at www.jvir.org]). At the MSE, 47% (n ¼ 55) of clinical students and 37% (n ¼ 56) of preclinical students thought a required rotation would be beneficial. In contrast, 69% of all students at the MSE (68%, n ¼ 106 preclinical;
1804
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
Table 2 . Respondents’ Means of Primary Exposure to IR MSE*
MSR*
Preclinical, n ¼ 153
Clinical, n ¼ 116
Preclinical, n ¼ 35
Clinical, n ¼ 61
Radiology elective Lectures from IR faculty
1 (1%) 16 (10%)
3 (3%) 6 (5%)
0 (0%) 3 (9%)
47 (77%) 0 (0%)
Preclinical small group exercises Rotations other than radiology
27 (18%) 0 (0%)
2 (2%) 59 (51%)
2 (6%) 0 (0%)
0 (0%) 1 (2%)
Radiology interest group
12 (8%)
1 (1%)
1 (3%)
0 (0%)
Multidisciplinary meetings Self-directed learning
8 (5%) 27 (18%)
4 (3%) 12 (10%)
1 (3%) 6 (17%)
1 (2%) 3 (5%)
No exposure
47 (31%)
21 (18%)
18 (51%)
5 (8%)
Other
15 (10%)
8 (7%)
4 (11%)
4 (8%)
Exposure
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component. *P o .001.
69%, n ¼ 79 clinical) indicated an interest in taking a 2week elective in IR if it were offered during the 8-week surgery clerkship (P ¼ .5). Students at both institutions were asked to name procedures performed by interventionalists. At the MSE, 69% (n ¼ 190) of students listed at least one procedure performed by interventional radiologists (Table E3 [available online at www.jvir.org]); 48% (n ¼ 131) named three procedures, 12% (n ¼ 33) named two procedures, and 9% (n ¼ 26) named one procedure. At the MSR, 53% (n ¼ 87) of students named at least one procedure performed by interventional radiologists; 76% (n ¼ 66) named three procedures, 14% (n ¼ 12) named two procedures, and 10% (n ¼ 9) named one procedure. The most commonly named procedure was “stent placement,” which was identified by 22% of all respondents (n ¼ 61). Other commonly identified procedures are listed in Table E3 (available online at www.jvir.org).
DISCUSSION Although clinical applications of IR are increasing worldwide (1,4,5) and graduate medical education for the specialty is evolving (2,8), IR education has not yet established a formal role in most medical school curricula. Given the recent distinction of IR as a primary specialty by the American Board of Medical Specialties (9), the need to expose medical students to IR early in their education is important so that they can make informed career decisions. Investigations into the impact of early exposure to specific specialties have shown that students have more favorable opinions of specialties with which they are familiar and are more likely to consider them for a future elective or as a career (10,15–18). The opposite also holds true: lack of knowledge and lack of early exposure in medical school contribute to fewer applicants (19,20). It has also been argued that increasing exposure to radiology early in
medical training is beneficial for the field even if students do not go on to become radiologists because they will be more knowledgeable as the future referral base (21). The results of this study underscore the perceived lack of knowledge of IR reported by preclinical medical students. In this study, 76% of all students rated their knowledge as either “fair” (38%) or “poor” (37%), with 84% of preclinical students reporting this level of knowledge compared with 62% of clinical students (P o .001) (Table 1). These results are similar to European (22) and Canadian (12) studies, in which 66% and 63% of respondents had “poor” or “no” knowledge of IR, respectively. Additionally, our study found that 25% of all respondents reported no exposure to IR. Preclinical students fared worse in this category with 35% reporting no exposure compared with 15% of clinical students (Table 2). This percentage is lower overall than percentages reported in previous studies, which identified 33%–66% of students reporting no exposure to the field (10,12). This difference may be due to differences in the levels of organized educational exposure in the institutions of prior studies (2) compared with the institutions in this study. An interesting finding is the large difference between preclinical and clinical student interest in pursuing IR as a career. The data suggest that preclinical students consider IR more so than clinical students; this could be due to the knowledge gap between preclinical and clinical students and the narrowing of interests as students enter the clinical years of training. Given the impact of early awareness, this information could be used by educators and interventionalists who are involved in the development and restructuring of medical school curricula. One solution is for IR faculty to become more involved in preclinical instruction, including giving lectures and leading small group exercises, as affirmed by the results of this study (Table E2 [available online at www.jvir.org]). Lectures could be
Volume 25
’
Number 11
’
November
’
2014
given on interventions that coincide with the pathophysiology of the organ system being studied. For example, indications, techniques, and complications of nephrostomy tube and ureteral stent placement could be described during the genitourinary section. Similarly, a radiologist could be added to small group discussions in the preclinical years, which should not negatively impact other specialties. At the MSE, preclinical small group sections always include a pathologist and a clinician. It is a natural extension to include a radiologist to review imaging findings relevant to the case. Finally, interventional radiologists could be involved in gross anatomy instruction describing the location of the vasculature and other anatomic structures relevant to various procedures. Another important conclusion demonstrated by this study is the increased awareness of IR by the clinical students at the MSR with a mandatory radiology clerkship compared with students without one at the MSE. It is suggested that integrating dedicated radiology clerkships into the medical school curriculum would have a positive impact on medical students’ awareness of IR and, by extension, have a positive impact on interest in IR as a career. However, most U.S. medical schools do not have a required radiology clerkship. In a survey of medical students in the United States, only 1.7% reported that their school had a required diagnostic radiology rotation, and only 0.4% (n ¼ 3 of 723) indicated that their curriculum included a required rotation in IR (11). As patient contact has been demonstrated to be important to students rotating in radiology (23,24), a required radiology rotation would demonstrate the amount of patient contact involved in IR, allowing programs to capitalize on this facet of patient care as the specialty continues to evolve (25). The students in the present study expressed the desire to have a 2-week IR rotation as part of their surgical clerkship (Table 1). This IR rotation would allow students to explore the field, meet faculty, and develop relationships. Interested students could take a dedicated elective in their senior year and continue to foster a relationship with a mentor and career goals advisor. When considering such changes to curricula, one must consider what might be sacrificed for IR to have increased exposure. At both schools surveyed, during the core surgery rotation, students spend 4 weeks on a general surgery service (eg, trauma and acute care, oncologic surgery, colorectal surgery) and then have two 2-week experiences on specialty services (eg, neurosurgery, orthopedics, vascular, urology) that are selected by the student. Integrating a 2-week IR elective into this type of curriculum would be well received by students. It would allow the students to work on the vascular IR consultation service, performing histories and physical examinations before procedures, assisting with the procedures, and making ward rounds on patients with complex conditions in subsequent days.
1805
The present study has several limitations. As with all voluntary surveys, response bias is a possibility, with students more interested in radiology and IR more likely to respond. However, the self-reported level of knowledge about IR was similar to prior studies (11,12,22). Also, the question regarding self-reported knowledge of IR did not include “no knowledge” as an answer choice as in prior studies, limiting a direct comparison (7,18). In addition, the decision to exclude the third-year research group at the MSR from the survey could have excluded students who might have learned about IR through the research project. However, this exclusion is thought to have had little impact on the overall results because very few students historically are involved in IR research at this level of training in the MSR, and no students were involved in IR research at the time of this study. Finally, the students surveyed are from schools that are in close geographic proximity. It is possible that there is regional bias and that respondents’ attitudes about radiology and IR are not generalizable across the United States. In conclusion, IR is an enigmatic specialty to most medical students. This study shows that preclinical medical students have less knowledge and awareness than clinical students at two medical schools in the United States. In addition, the MSR students had more knowledge than the MSE students, suggesting that a required radiology rotation in the clinical years is one way to increase awareness. Additional solutions include increased IR faculty involvement in preclinical instruction and a 2-week elective during the surgery rotation. Further research is needed to assess more fully strategies for providing increased IR education to medical students. Additionally, exposure to IR by clinical students should be studied more carefully to determine why students ceased considering IR as a career. As medical curricula evolve, incorporating IR into preclinical and clinical training serves not only to attract interested students early but also to improve the overall level of knowledge for all students, including students who will ultimately pursue other specialties that rely on the services provided by interventionalists.
ACKNOWLEDGMENT Funding for this study was provided from the Department of Radiology, University of North Carolina.
REFERENCES 1. Sunshine JH, Lewis RS, Bhargavan M. A portrait of interventional radiologists in the United States. AJR Am J Roentgenol 2005; 185: 1103–1112. 2. Kaufman J. Primary certificate in vascular and interventional radiology. J Vasc Interv Radiol 2006; 17:S183–S186. 3. Becker GJ. 2000 RSNA annual oration in diagnostic radiology: the future of interventional radiology. Radiology 2001; 220:281–292. 4. Becker GJ. Interventional oncology: perspectives on current scholarly productivity and potential for future growth. Radiology 2010; 257: 309–312.
1806
’
Commentary: Demystifying the “Black Box” of IR
5. Goldberg SN, Bonn J, Dodd G, et al. Society of Interventional Radiology Interventional Oncology Task Force: interventional oncology research vision statement and critical assessment of the state of research affairs. J Vasc Interv Radiol 2005; 16:1287–1294. 6. National Resident Matching Program, Results and Data. Specialties matching service 2009 appointment year. 2009. Available at: http://www. nrmp.org/match-data/nrmp-historical-reports/. Accessed March 19, 2014. 7. National Resident Matching Program, Results and Data. Specialties matching service 2013 appointment year. 2013. Available at: http:// www.nrmp.org/match-data/nrmp-historical-reports/. Accessed March 19, 2014. 8. Siragusa DA, Cardella JF, Hieb RA, et al. Requirements for training in interventional radiology. J Vasc Interv Radiol 2013; 24:1609–1612. 9. American Board of Radiology. Interventional radiology/diagnostic radiology (IR/DR)—latest information. 2014. Available at: http://www.theabr.org/sites/ all/themes/abr-media/pdf/ABR-IR-DR-FAQ.pdf. Accessed May 18, 2014. 10. Ghatan CE, Kuo WT, Hofmann LV, Kothary N. Making the case for early medical student education in interventional radiology: a survey of 2ndyear students in a single U.S. institution. J Vasc Interv Radiol 2010; 21: 549–553. 11. Nissim L, Krupinski E, Hunter T, Taljanovic M. Exposure to, understanding of, and interest in interventional radiology in American medical students. Acad Radiol 2013; 20:493–499. 12. O’Malley L, Athreya S. Awareness and level of knowledge of interventional radiology among medical students at a Canadian institution. Acad Radiol 2012; 19:894–901. 13. Likert R. A technique for the measurement of attitudes. Arch Psychol 1932; 22:55. 14. Fisher RA. Statistical Methods for Research Workers. Edinburgh: Oliver and Boyd; 1925. 15. Branstetter BF 4th, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007; 188:W9–W14.
Funaki and Siragusa
’
JVIR
16. Donnelly LF, Racadio JM, Strife JL. Exposure of first-year medical students to a pediatric radiology research program: is there an influence on career choice? Pediatr Radiol 2007; 37:876–878 17. Branstetter BF 4th, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinions about radiology. Acad Radiol 2008; 15:1331–1339. 18. Gunderman RB, Alexander S, Jackson VP, Lane KA, Siddiqui AR, Tarver RD. The value of good medical student teaching: increasing the number of radiology residency applicants. Acad Radiol 2000; 7:960–964. 19. Singh N, Causey W, Brounts L, Clouse WD, Curry T, Andersen C. Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions. J Vasc Surg 2010; 51:252–258. 20. Malikova MA, Doros G, Joglar F, Rybin D, Petros JG, Farber A. A thirdyear surgery clerkship with extensive exposure to vascular surgery improves knowledge about vascular disease and the role of vascular surgeons in its management. Vasc Endovasc Surg 2010; 44:361–367. 21. Rogers LF. Imaging literacy: a laudable goal in the education of medical students. AJR Am J Roentgenol 2003; 180:1201. 22. Leong S, Keeling AN, Lee MJ. A survey of interventional radiology awareness among final-year medical students in a European country. Cardiovasc Intervent Radiol 2009; 32:623–629. 23. Fielding JR, Major NM, Mullan BF, et al. Choosing a specialty in medicine: female medical students and radiology. AJR Am J Roentgenol 2007; 188:897–900. 24. Schlesinger AE, Blane CE, Vydareny KH. First-year medical students’ attitudes toward radiology. Invest Radiol 1992; 27:175–178. 25. Baerlocher MO, Asch M. Protecting the future: attracting interventional radiology trainees–a medical student’s perspective. Can Assoc Radiol J 2006; 57:147–151.
INVITED COMMENTARY
IR—Demystifying the “Black Box” Brian Funaki, MD, and Daniel Siragusa, MD Any important decision should be an informed one. To make an informed decision, one must first have a working understanding of the facts, implications, and future consequences of the decision being considered (1). For example, as medicine is a “black box” for most laypeople, a critical component of a physician’s responsibility consists of educating patients on the pros, cons, and alternatives to any treatment so that an informed decision can be made. As interventional radiologists, we obtain informed consent daily from all patients before any invasive therapy we perform.
From the Department of Vascular and Interventional Radiology (B.F.), University of Chicago, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637; and Division of Vascular and Interventional Radiology (D.S.), University of Florida, Gainesville, Florida. Received July 16, 2014 accepted July 16, 2014. Address correspondence to B.F.; E-mail: [email protected] Neither of the authors has identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1806–1807 http://dx.doi.org/10.1016/j.jvir.2014.07.019
As medicine is a black box for patients, it appears that interventional radiology is a black box for medical students. Commander et al (2) evaluated the level of knowledge of interventional radiology in preclinical and clinical medical students in two different institutions and found that 84% of preclinical students reported their own knowledge as “poor” or “fair.” More disturbing was that 62% of clinical students reported the same. Students at a second institution, which had a required radiology rotation, reported significantly better awareness of interventional radiology compared with the first one. However, overall, it appears that our profession still remains nebulous to many students. Why is this important? First, with the advent of the new interventional radiology residency, we are entering an era of training in which future interventional radiologists must choose the specialty while in medical school, rather than after 2 years of a radiology residency. The fact that few training institutions currently have structured, robust interventional radiology experiences for medical students is problematic. Interventional radiologists of the near future will be asked to commit to
1807e.1
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
APPENDIX A Survey Administered at the Public Medical School (MSE) 1. What is your current year of medical school? a. MS1 (class of 2016) b. MS2 (class of 2015) c. MS3 (class of 2014) 2. How would you rate your knowledge of interventional radiology compared with other medical specialties? a. b. c. d. e.
Excellent Very good Good Fair Poor
3. Have you completed or do you plan to complete an elective in radiology a. Yes b. Not sure c. No 4. Are you considering a career in diagnostic radiology? a. Yes b. Not sure c. No 5. Are you considering a career in interventional radiology? a. Yes b. Not sure c. No 6. Please choose the most appropriate reason why you chose “No” or “Not sure” in answer to the previous question. a. I don’t find it interesting. b. I don’t know enough about it. c. I don’t like the lifestyle. d. Radiation exposure concerns. e. Other (please specify) ____________________ 7. An interventional radiologist must complete a residency in: a. b. c. d. e.
Radiology Surgery Internal medicine Both radiology and surgery Other (please specify) ____________________
8. Are you familiar with the combined diagnostic radiology/interventional radiology pathway? a. Yes b. No 9. Have you seen patients who were treated by an interventional radiologist? a. Yes b. Not sure c. No 10. Please list three interventional radiology procedures. a. _______________ b. _______________ c. _______________
Volume 25
’
Number 11
’
November
’
2014
1807.e2
11. Interventional radiologists can admit patients to the hospital. a. True b. False 12. What has provided you with the most knowledge of interventional radiology? a. b. c. d. e. f. g. h. i.
Radiology elective Lectures from interventional radiologists MS1 or MS2 small group exercises MS3 rotations (other than radiology) Radiology interest group Multidisciplinary meetings (eg, careers lunches) Self-directed learning I have no exposure to interventional radiology Other (please specify) ____________________
13. How would you prefer to gain more exposure to interventional radiology? a. Radiology elective b. Lectures from interventional radiologists c. Multidisciplinary meetings d. MS1 or MS2 small group exercises e. Self-directed learning f. Radiology interest group
Strongly Avoid (1) Avoid (2) Indifferent (3) Prefer (4) Strongly Prefer (5) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
14. Do you think a mandatory radiology rotation would be beneficial? a. Yes b. Not sure c. No 15. How many weeks should this clerkship last? a. b. c. d.
1 week 2 weeks 4 weeks Other (please specify) ____________________
16. Would you be interested in doing a 2-week interventional radiology elective if it was offered during the 8-week surgery clerkship? a. Yes b. Not sure c. No 17. Do you have any additional comments about the role of interventional radiology in the medical school curriculum? MSE ¼ medical school with elective radiology component.
APPENDIX B Survey Administered at the Private Medical School (MSR) 1. How would you rate your knowledge of interventional radiology compared with other medical specialties? a. Excellent b. Very good c. Good d. Fair e. Poor
1807e.3
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
2. Are you considering a career in diagnostic radiology? a. Yes b. Not sure c. No 3. Are you considering a career in interventional radiology? a. Yes b. Not sure c. No 4. Please choose the most appropriate reason why you chose “No” or “Not sure” in answer to the previous question. a. I don’t find it interesting b. I don’t know enough about it c. I don’t like the lifestyle d. Radiation exposure concerns e. Other (please specify) ____________________ 5. Did you complete a fourth-year interventional radiology elective? a. Yes b. No 6. Traditionally, an interventional radiologist must complete an internship in: a. Radiology b. Surgery c. Internal medicine d. Transitional year e. Don’t know f. Other (please specify) ___________________ 7. Traditionally, an interventional radiologist must complete a residency in: a. Radiology b. Surgery c. Internal medicine d. Both radiology and surgery e. Don’t know f. Other (please specify) ___________________ 8. Are you familiar with the combined diagnostic radiology/interventional radiology (“direct”) pathway? a. Yes b. No 9. Have you heard about the new interventional radiology residency? a. Yes b. No 10. Have you heard about the new American Board of Medical Specialties dual certificate in diagnostic radiology and interventional radiology?
a. Yes b. No 11. Have you seen patients who were treated by an interventional radiologist? a. Yes b. Not sure c. No 12. Please list three interventional radiology procedures. a. __________________________ b. __________________________ c. __________________________
Volume 25
’
Number 11
’
November
’
2014
1807.e4
13. Can interventional radiologists admit patients to the hospital? a. Yes b. No 14. What has provided you with the most knowledge of interventional radiology? a. Second-year radiology clerkship b. Fourth-year interventional radiology elective c. Lectures from interventional radiologists d. MS1 or MS2 small group exercises e. MS3 research project f. Radiology interest group g. Multidisciplinary meetings h. Self-directed learning i. I have had no exposure to interventional radiology j. Other (please specify) _________________________ 15. How would you have preferred to gain more exposure to interventional radiology? Please rank the following from 1 (most interested) to 5 (least interested).
a. b. c. d. e. f. g. h. i.
First-year lectures by interventional radiologists More days in interventional radiology during the second-year required radiology clerkship Third-year research project Fourth-year interventional radiology elective Multidisciplinary meetings MS1 or MS2 small group exercises Radiology interest group Interventional radiology interest group Self-directed learning
MSR ¼ medical school with required radiology component.
Table E1 . Respondents’ Knowledge of IR Training and Privileges MSE (n ¼ 274)
MSR (n ¼ 162)
Preclinical,
Clinical,
Preclinical,
Clinical,
Question
Answer Options
n ¼ 157 (57.3%)
n ¼ 117 (42.7%)
n ¼ 102 (63.0%)
n ¼ 60 (37.0%)
Traditionally, an interventional
Radiology
101 (65.6%)
97 (83.6%)
57 (62.6%)
53 (96.4%)
Surgery Radiology and
5 (3.25%) 44 (28.6%)
3 (2.6%) 13 (11.2%)
0 (0.0%) 6 (6.6%)
0 (0.0%) 1 (1.8%)
Internal medicine Other
1 (0.7%) 3 (2.0%)
0 (0.0%) 3 (2.6%)
0 (0.0%) 0 (0.0%)
0 (0.0%) 0 (0.0%)
Yes
112 (72.7%)
80 (69.0%)
57 (64.8%)
39 (70.9%)
No
42 (27.3%)
36 (31.0%)
31 (35.2%)
16 (29.1%)
radiologist must complete a residency in:
surgery
Interventional radiologists can admit patients to the hospital
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component.
1807e.5
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
Table E2 . Respondents’ Preferred Method of Learning More about IR
Answer Choice Radiology elective*
Lectures from IR faculty during preclinical training Small group exercises
Level of
Strongly
Avoid,
Indifferent,
Prefer,
Strongly
Institution
Training
Avoid, n (%)
n (%)
n (%)
n (%)
Prefer, n (%)
MSE†
Preclinical
9 (6%)
7 (5%)
42 (28%)
71 (47%)
23 (15%)
MSR‡
Clinical Preclinical
1 (1%) 0 (0%)
6 (5%) 0 (0%)
23 (20%) 5 (14%)
51 (45%) 11 (31%)
32 (28%) 20 (56%)
Clinical
2 (4%)
3 (6%)
10 (21%)
11 (23%)
22 (46%)
MSE
Preclinical Clinical
1 (1%) 0 (0%)
7 (5%) 4 (4%)
28 (18%) 25 (22%)
92 (60%) 66 (58%)
25 (16%) 19 (17%)
MSR
Preclinical
0 (0%)
1 (3%)
15 (42%)
14 (39%)
6 (17%)
MSE‡
Clinical Preclinical
4 (9%) 8 (5%)
3 (6%) 15 (10%)
11 (23%) 46 (30%)
20 (43%) 65 (42%)
9 (19%) 19 (12%)
Clinical
6 (5%)
20 (18%)
41 (37%)
34 (30%)
11 (10%)
MSR
Preclinical Clinical
0 (0%) 4 (9%)
7 (21%) 9 (20%)
12 (36%) 12 (27%)
10 (30%) 15 (33%)
4 (12%) 5 (11%)
MSE
Preclinical
1 (1%)
18 (12%)
58 (38%)
61 (40%)
13 (9%)
MSR
Clinical Preclinical
4 (4%) 1 (3%)
16 (14%) 4 (12%)
45 (39%) 10 (56%)
39 (34%) 8 (24%)
10 (9%) 2 (6%)
incorporating IR during preclinical training Multidisciplinary meetings
Self-directed learning
Radiology interest group
Clinical
4 (9%)
4 (9%)
15 (34%)
19 (43%)
2 (5%)
MSE
Preclinical Clinical
10 (7%) 5 (4%)
38 (25%) 21 (18%)
56 (37%) 53 (46%)
40 (26%) 30 (26%)
7 (5%) 5 (4%)
MSR
Preclinical
3 (9%)
8 (23%)
17 (49%)
6 (17%)
1 (3%)
MSE
Clinical Preclinical
5 (11%) 8 (5%)
4 (9%) 23 (15%)
25 (56%) 58 (39%)
8 (18%) 53 (35%)
3 (7%) 8 (5%)
Clinical
3 (3%)
16 (14%)
52 (46%)
31 (27%)
11 (10%)
Preclinical Clinical
4 (12%) 9 (20%)
2 (6%) 5 (11%)
13 (38%) 19 (42%)
9 (26%) 10 (22%)
6 (18%) 2 (4%)
MSR
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component. *Combined P o .05. † Wilcoxon-Mann-Whitney P o .01. ‡ Wilcoxon-Mann-Whitney P o .05.
Table E3 . Ten Most Common IR Procedures Named by Respondents No. Respondents (Preclinical, Clinical),
% All Respondents (Preclinical, Clinical),
% MSE Respondents (Preclinical, Clinical),
% MSR Respondents (Preclinical, Clinical),
n ¼ 178 (132, 146)
n ¼ 178 (132, 146)
n ¼ 190 (95, 95)
n ¼ 87 (36, 51)
61 (27, 34) 57 (11, 46)
22 (20, 23) 21 (8, 32)
21 (15, 28) 16 (8, 24)
23 (25, 14) 30 (6, 45)
fibroids) Angiography
54 (19, 35)
19 (14, 24)
21 (11, 32)
15 (16, 10)
TIPS
50 (3, 45)
18 (2, 31)
12 (0, 23)
32 (6, 45)
Drain placement IVC filter placement
40 (4, 36) 35 (4, 31)
14 (3, 25) 13 (3, 21)
17 (1, 34) 8 (1, 15)
8 (6, 8) 23 (6, 33)
Image-guided biopsy
33 (11, 22)
12 (8, 15)
13 (6, 20)
9 (10, 6)
Central line placement Thrombolysis
33 (10, 23) 22 (8, 14)
12 (8, 16) 8 (6, 10)
12 (5, 19) 7 (3, 12)
11 (10, 10) 9 (10, 6)
Angioplasty
21 (15, 6)
8 (11, 4)
7 (13, 2)
Procedure Stent placement Embolization (including uterine
8 (6,8)
IR ¼ interventional radiology; IVC ¼ inferior vena cava; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component; TIPS ¼ transjugular intrahepatic portosystemic shunt.
Assessing Medical Students’ Knowledge of IR at Two American Medical Schools Clayton W. Commander, MD, PhD, Waleska M. Pabon-Ramos, MD, MPH, Ari J. Isaacson, MD, Hyeon Yu, MD, Charles T. Burke, MD, and Robert G. Dixon, MD
ABSTRACT Purpose: To determine if there was a difference in the level of knowledge about interventional radiology (IR) between medical students in preclinical years of training compared with medical students in clinical years of training at two medical schools and to compare awareness of IR based on the curriculum at each school: one with required radiology education and one without such a requirement. Materials and Methods: An anonymous survey was distributed to students at two medical schools; the survey assessed knowledge of IR, knowledge of training pathways, and preferred methods to increase exposure. Responses of the preclinical and clinical groups were compared, and responses from the clinical groups at each school were compared. Results: “Poor” or “fair” knowledge of IR was reported by 84% (n ¼ 217 of 259) of preclinical students compared with 62% of clinical students (n ¼ 110 of 177; P o .001). IR was being considered as a career by 11% of all students (15%, n ¼ 40 of 259 preclinical; 5%, n ¼ 9 of 177 clinical). The main reason respondents were not considering IR was “lack of knowledge” (65%, n ¼ 136 of 210 preclinical; 20%, n ¼ 32 of 162 clinical). Students in the clinical group at the institution with a required radiology rotation reported significantly better knowledge of IR than clinical students from the institution without a required clerkship (P ¼ .017). Conclusions: There are significant differences in knowledge of IR between preclinical and clinical students. Required radiology education in the clinical years does increase awareness of IR.
ABBREVIATIONS MSE = medical school with elective radiology component, MSR = medical school with required radiology component
Driven by technologic advances, the number of minimally invasive image-guided procedures has increased in recent years (1). As a result, the subspecialty of interventional radiology (IR) has continued to grow and mature (2–5). Likewise, medical school graduates have demonstrated increased interest in IR. In 2009, From the Division of Vascular and Interventional Radiology, Department of Radiology (C.W.C., A.J.I., H.Y., C.T.B., R.G.D.), University of North Carolina at Chapel Hill, 107 Old Clinic Building, CB# 7510, Chapel Hill, NC 27599; and Division of Vascular Interventional Radiology, Department of Radiology (W.M.P.-R.), Duke University Medical Center, Durham, North Carolina. Received March 9, 2014; final revision received June 9, 2014; accepted June 9, 2014. Address correspondence to C.W.C.; E-mail: [email protected] From the SIR 2014 Annual Meeting. None of the authors have identified a conflict of interest. Appendices A and B and Tables E1–3 are available online at www.jvir.org. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1801–1806 http://dx.doi.org/10.1016/j.jvir.2014.06.008
54% (99 of 185) of all IR fellowship positions were filled (6), whereas in 2013, 4 90% (208 of 224) were filled (7). In addition, the subspecialty of IR is evolving into its own specialty. At the present time, IR training involves completing a diagnostic radiology residency, followed by a 1-year IR fellowship. Becoming board-certified in IR involves obtaining the American Board of Radiology Diagnostic Radiology certificate, followed by the American Board of Radiology Certificate of Added Qualification in IR. However, the certification and training requirements are changing. Because of a “growing heterogeneity in the learning experiences of radiology trainees” with regard to IR and because of vague program requirements delineated by the Accreditation Council for Graduate Medical Education for IR, a task force was created to develop guidelines for training in the field of IR (8). In addition, the need for a primary certificate in IR that still includes the core imaging components of diagnostic radiology was recognized because of the rapid expansion of IR; the competitive pressures on the specialty; and the demand
1802
’
Medical Students’ Knowledge of IR
for improved delivery of direct patient care before, during, and after procedures (2). In 2012, the American Board of Medical Specialties approved a dual certificate in IR and diagnostic radiology. As a result, IR leadership is developing detailed requirements and guidelines for an IR residency that will lead to a combined IR and diagnostic radiology certificate. The implementation of this new training pathway is projected for fall 2016 (9). For IR faculty, educating medical students regarding the field to recruit them for the anticipated IR residency program is necessary. There has been increased interest more recently in determining medical students’ level of knowledge and preferred methods for learning more about IR (10–12). This vital information enables medical educators and interventionalists to incorporate IR into busy medical school curricula (11). The purpose of the present study was to determine if there was a difference in the level of knowledge about IR between medical students in preclinical years of training compared with medical students in clinical years of training at two medical schools in the United States. This study also compared awareness of IR based on the curriculum at these two institutions: one medical school with a required radiology component (MSR), and one medical school with an elective component (MSE).
MATERIALS AND METHODS This study was deemed exempt by the institutional review boards at the University of North Carolina School of Medicine and Duke University School of Medicine. An anonymous, web-based survey was distributed via e-mail to 524 medical students attending a public medical school at which there is no required radiology clerkship (MSE) and to 321 students attending a private medical school that has a required radiology clerkship (MSR). The surveys were administered using the Qualtrics Research Suite (Qualtrics, Provo, Utah). The survey administered to MSE students contained 17 questions (Appendix A [available online at www.jvir. org]), and the survey administered to MSR students contained 15 questions (Appendix B [available online at www.jvir.org]). The questions were developed following those in the survey administered by O’Malley and Athreya (12). Questions ranged from self-reported knowledge of IR, level of interest in IR and diagnostic radiology as a career, training required to become an interventional radiologist, knowledge of IR procedures, and preferred methods to learn more about IR. Questions differed between schools only when related to the particular school curriculum. At the MSE, the survey was administered to 185 firstyear students, 179 second-year students, and 160 thirdyear students. At this school, the first and second years are preclinical, and the third and fourth years are
Commander et al
’
JVIR
clinical. The survey was not administered to fourthyear medical students because survey administration occurred in the spring, after these students selected their specialties and matched into their respective residencies. The survey was available from March 2013–May 2013 with monthly reminder e-mail messages sent via the class mailing list using LISTSERV (L-Soft International, Inc, Landover, Maryland). This school’s curriculum does not include a required radiology clerkship. However, students have exposure to diagnostic imaging throughout their preclinical years, predominantly during the anatomy course in the first year, in which weekly didactic lectures by a member of the radiology faculty are given corresponding to the gross anatomy being studied at the time. One such lecture is devoted to IR. The students also have opportunities to take clinical electives in radiology, including a fourth-year month-long rotation in IR (which was implemented after administration of this survey). At the MSR, the survey was administered to 113 firstyear students, 105 second-year students, and 103 fourthyear students. At this school, the first year is preclinical, the second and fourth years are clinical, and the third year is dedicated to research. The survey was not administered to students in the research year. Survey administration occurred in the fall, before the fourthyear students had selected their specialties and started residency interviews. Students were given 1 month (September 2013) to respond to the survey. Weekly reminder messages were sent via the class e-mail list. This school’s curriculum includes a required 4-week radiology clerkship during the second year. During the clerkship, students rotate through each subspecialty (thoracic imaging, neuroradiology, IR, body imaging, breast imaging, pediatric imaging, musculoskeletal imaging, and nuclear medicine) and receive daily didactic lectures. Data were analyzed using Intercooled Stata 10 (StataCorp LP, College Station, Texas). Differences between categorical data were assessed using the χ2 test, and the Wilcoxon-Mann-Whitney test was used for Likert scale data (13). Combined P values were computed using Fisher’s method (14). A P value o .05 was used to indicate statistical significance.
RESULTS Of 845 students, 436 (52%) responded to the survey: 63% (n ¼ 274 of 524) from the MSE and 37% (n ¼ 162 of 321) from the MSR (Table 1). Most students at both institutions (76%, n ¼ 207 MSE; 74%, n ¼ 120 MSR) rated their overall knowledge of IR as “poor” or “fair” (Table 1). Only 4% (n ¼ 12) of MSE students and 9% (n ¼ 14) of MSR students rated their knowledge as either “excellent” or “very good” (P ¼ .391). However, among only the clinical students, 18% (n ¼ 11 of 60) of
Volume 25
’
Number 11
’
November
’
2014
1803
Table 1 . Respondents’ General Knowledge of IR and Career Considerations MSE (n ¼ 274)
MSR (n ¼ 162)
Preclinical,
Clinical,
Preclinical,
Clinical,
Answer Options
n ¼ 157 (57.3%)
n ¼ 117 (42.7%)
n ¼ 102 (63.0%)
n ¼ 60 (37.0%)
Self-reported knowledge of
Excellent
1 (0.6%)
4 (3.4%)
0 (0.0%)
4 (6.7%)
IR compared with other specialties
Very good Good
5 (3.2%) 24 (15.3%)
2 (1.7%) 31 (26.5%)
3 (2.9%) 9 (8.8%)
7 (11.7%) 19 (31.7%)
Fair
61 (38.9%)
45 (38.5%)
40 (39.2%)
20 (33.3%)
Considering a career in DR
Poor Yes
66 (42.0%) 21 (13.4%)
35 (29.9%) 7 (6.0%)
50 (49.0%) 16 (15.7%)
10 (16.7%) 9 (15.0%)
Not sure
61 (38.9%)
9 (7.8%)
47 (46.1%)
3 (5.0%)
No Yes
75 (47.8%) 25 (15.9%)
100 (86.2%) 4 (3.4%)
39 (38.2%) 15 (14.7%)
48 (80.0%) 5 (8.3%)
Not sure
62 (39.5%)
13 (11.1%)
61 (59.8%)
7 (11.7%)
No Lack of knowledge
70 (44.6%) 81 (61.4%)
100 (85.5%) 27 (23.9%)
26 (25.5%) 55 (70.5%)
48 (80.0%) 5 (10.2%)
Question
Considering a career in IR
Reasons given by respondents who would
about the field
not consider IR or who were unsure
Lack of interest Lifestyle concerns
31 (23.5%) 5 (3.8%)
52 (46.0%) 1 (0.9%)
13 (16.7%) 1 (1.3%)
18 (36.7%) 5 (10.2%)
Radiation exposure
4 (3.0%)
2 (1.8%)
1 (1.3%)
3 (6.1%)
concerns Other
11 (8.3%)
31 (27.4%)
8 (10.3%)
18 (36.7%)
Heard of DR/IR dual
Yes
10 (6.5%)
25 (21.6%)
1 (1.1%)
6 (10.9%)
certification Seen patients treated by IR
No Yes
144 (93.5%) 43 (27.9%)
91 (78.5%) 94 (81.0%)
90 (98.9%) 27 (30.3%)
49 (89.1%) 51 (92.7%)
Not sure
48 (31.2%)
13 (11.2%)
27 (30.3%)
2 (3.6%)
No Yes
63 (40.9%) 106 (69.2%)
9 (7.8%) 79 (68.1%)
35 (39.3%) —
2 (3.6%) —
Interested in 2-week IR experience during surgery rotation
Not sure
37 (24.2%)
25 (21.6%)
—
—
No
10 (6.5%)
12 (10.3%)
—
—
DR ¼ diagnostic radiology; IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component.
MSR students rated their knowledge as either “excellent” or “very good” compared with 5% (n ¼ 6 of 117) MSE students (P ¼ .017). Clinical students at both institutions reported significantly greater knowledge of IR than preclinical students (P ¼ .036 MSE; P o .001 MSR; P o .001 combined) (Table 1). When asked about IR as a potential career choice, 63% (n ¼ 163) of preclinical students were either considering or unsure compared with 16% (n ¼ 29) of students in their clinical years (P o .001 MSE; P o .001 MSR; P o .001 combined). However, when the responses from the two schools were compared, 54% (n ¼ 88) of students from the MSR were either considering a career in IR or were unsure compared with 38% (n ¼ 104) of students at the MSE (P ¼ .003). Of the students who were unsure (n ¼ 136), 82% reported that they did not know enough about the specialty to consider it (Table 1). Answers to questions regarding required training pathways for interventional radiologists are listed in Table E1 (available online at www.jvir.org). When asked what had provided the most knowledge about IR, most clinical students (51%) at the MSE
indicated that it was through exposure during nonradiology clerkships. At the MSR, 77% (n ¼ 47) of clinical students reported learning about IR during the required radiology elective (P o .001) (Table 2). At the MSE, 31% (n ¼ 47) of preclinical students indicated they have had no exposure to IR, with 18% (n ¼ 27) reporting knowledge via self-directed learning. Similarly, 51% (n ¼ 18) of preclinical students at the MSR reported no exposure to IR, with 17% (n ¼ 6) reporting knowledge via self-directed learning (Table 2). As a means of learning about IR, both preclinical and clinical students at the MSE overwhelmingly preferred to hear lectures from IR faculty during preclinical training and to rotate through the division during the clinical years as opposed to self-directed learning, multidisciplinary meetings, small group exercises during the preclinical years, or the radiology interest group (Table E2 [available online at www.jvir.org]). At the MSE, 47% (n ¼ 55) of clinical students and 37% (n ¼ 56) of preclinical students thought a required rotation would be beneficial. In contrast, 69% of all students at the MSE (68%, n ¼ 106 preclinical;
1804
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
Table 2 . Respondents’ Means of Primary Exposure to IR MSE*
MSR*
Preclinical, n ¼ 153
Clinical, n ¼ 116
Preclinical, n ¼ 35
Clinical, n ¼ 61
Radiology elective Lectures from IR faculty
1 (1%) 16 (10%)
3 (3%) 6 (5%)
0 (0%) 3 (9%)
47 (77%) 0 (0%)
Preclinical small group exercises Rotations other than radiology
27 (18%) 0 (0%)
2 (2%) 59 (51%)
2 (6%) 0 (0%)
0 (0%) 1 (2%)
Radiology interest group
12 (8%)
1 (1%)
1 (3%)
0 (0%)
Multidisciplinary meetings Self-directed learning
8 (5%) 27 (18%)
4 (3%) 12 (10%)
1 (3%) 6 (17%)
1 (2%) 3 (5%)
No exposure
47 (31%)
21 (18%)
18 (51%)
5 (8%)
Other
15 (10%)
8 (7%)
4 (11%)
4 (8%)
Exposure
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component. *P o .001.
69%, n ¼ 79 clinical) indicated an interest in taking a 2week elective in IR if it were offered during the 8-week surgery clerkship (P ¼ .5). Students at both institutions were asked to name procedures performed by interventionalists. At the MSE, 69% (n ¼ 190) of students listed at least one procedure performed by interventional radiologists (Table E3 [available online at www.jvir.org]); 48% (n ¼ 131) named three procedures, 12% (n ¼ 33) named two procedures, and 9% (n ¼ 26) named one procedure. At the MSR, 53% (n ¼ 87) of students named at least one procedure performed by interventional radiologists; 76% (n ¼ 66) named three procedures, 14% (n ¼ 12) named two procedures, and 10% (n ¼ 9) named one procedure. The most commonly named procedure was “stent placement,” which was identified by 22% of all respondents (n ¼ 61). Other commonly identified procedures are listed in Table E3 (available online at www.jvir.org).
DISCUSSION Although clinical applications of IR are increasing worldwide (1,4,5) and graduate medical education for the specialty is evolving (2,8), IR education has not yet established a formal role in most medical school curricula. Given the recent distinction of IR as a primary specialty by the American Board of Medical Specialties (9), the need to expose medical students to IR early in their education is important so that they can make informed career decisions. Investigations into the impact of early exposure to specific specialties have shown that students have more favorable opinions of specialties with which they are familiar and are more likely to consider them for a future elective or as a career (10,15–18). The opposite also holds true: lack of knowledge and lack of early exposure in medical school contribute to fewer applicants (19,20). It has also been argued that increasing exposure to radiology early in
medical training is beneficial for the field even if students do not go on to become radiologists because they will be more knowledgeable as the future referral base (21). The results of this study underscore the perceived lack of knowledge of IR reported by preclinical medical students. In this study, 76% of all students rated their knowledge as either “fair” (38%) or “poor” (37%), with 84% of preclinical students reporting this level of knowledge compared with 62% of clinical students (P o .001) (Table 1). These results are similar to European (22) and Canadian (12) studies, in which 66% and 63% of respondents had “poor” or “no” knowledge of IR, respectively. Additionally, our study found that 25% of all respondents reported no exposure to IR. Preclinical students fared worse in this category with 35% reporting no exposure compared with 15% of clinical students (Table 2). This percentage is lower overall than percentages reported in previous studies, which identified 33%–66% of students reporting no exposure to the field (10,12). This difference may be due to differences in the levels of organized educational exposure in the institutions of prior studies (2) compared with the institutions in this study. An interesting finding is the large difference between preclinical and clinical student interest in pursuing IR as a career. The data suggest that preclinical students consider IR more so than clinical students; this could be due to the knowledge gap between preclinical and clinical students and the narrowing of interests as students enter the clinical years of training. Given the impact of early awareness, this information could be used by educators and interventionalists who are involved in the development and restructuring of medical school curricula. One solution is for IR faculty to become more involved in preclinical instruction, including giving lectures and leading small group exercises, as affirmed by the results of this study (Table E2 [available online at www.jvir.org]). Lectures could be
Volume 25
’
Number 11
’
November
’
2014
given on interventions that coincide with the pathophysiology of the organ system being studied. For example, indications, techniques, and complications of nephrostomy tube and ureteral stent placement could be described during the genitourinary section. Similarly, a radiologist could be added to small group discussions in the preclinical years, which should not negatively impact other specialties. At the MSE, preclinical small group sections always include a pathologist and a clinician. It is a natural extension to include a radiologist to review imaging findings relevant to the case. Finally, interventional radiologists could be involved in gross anatomy instruction describing the location of the vasculature and other anatomic structures relevant to various procedures. Another important conclusion demonstrated by this study is the increased awareness of IR by the clinical students at the MSR with a mandatory radiology clerkship compared with students without one at the MSE. It is suggested that integrating dedicated radiology clerkships into the medical school curriculum would have a positive impact on medical students’ awareness of IR and, by extension, have a positive impact on interest in IR as a career. However, most U.S. medical schools do not have a required radiology clerkship. In a survey of medical students in the United States, only 1.7% reported that their school had a required diagnostic radiology rotation, and only 0.4% (n ¼ 3 of 723) indicated that their curriculum included a required rotation in IR (11). As patient contact has been demonstrated to be important to students rotating in radiology (23,24), a required radiology rotation would demonstrate the amount of patient contact involved in IR, allowing programs to capitalize on this facet of patient care as the specialty continues to evolve (25). The students in the present study expressed the desire to have a 2-week IR rotation as part of their surgical clerkship (Table 1). This IR rotation would allow students to explore the field, meet faculty, and develop relationships. Interested students could take a dedicated elective in their senior year and continue to foster a relationship with a mentor and career goals advisor. When considering such changes to curricula, one must consider what might be sacrificed for IR to have increased exposure. At both schools surveyed, during the core surgery rotation, students spend 4 weeks on a general surgery service (eg, trauma and acute care, oncologic surgery, colorectal surgery) and then have two 2-week experiences on specialty services (eg, neurosurgery, orthopedics, vascular, urology) that are selected by the student. Integrating a 2-week IR elective into this type of curriculum would be well received by students. It would allow the students to work on the vascular IR consultation service, performing histories and physical examinations before procedures, assisting with the procedures, and making ward rounds on patients with complex conditions in subsequent days.
1805
The present study has several limitations. As with all voluntary surveys, response bias is a possibility, with students more interested in radiology and IR more likely to respond. However, the self-reported level of knowledge about IR was similar to prior studies (11,12,22). Also, the question regarding self-reported knowledge of IR did not include “no knowledge” as an answer choice as in prior studies, limiting a direct comparison (7,18). In addition, the decision to exclude the third-year research group at the MSR from the survey could have excluded students who might have learned about IR through the research project. However, this exclusion is thought to have had little impact on the overall results because very few students historically are involved in IR research at this level of training in the MSR, and no students were involved in IR research at the time of this study. Finally, the students surveyed are from schools that are in close geographic proximity. It is possible that there is regional bias and that respondents’ attitudes about radiology and IR are not generalizable across the United States. In conclusion, IR is an enigmatic specialty to most medical students. This study shows that preclinical medical students have less knowledge and awareness than clinical students at two medical schools in the United States. In addition, the MSR students had more knowledge than the MSE students, suggesting that a required radiology rotation in the clinical years is one way to increase awareness. Additional solutions include increased IR faculty involvement in preclinical instruction and a 2-week elective during the surgery rotation. Further research is needed to assess more fully strategies for providing increased IR education to medical students. Additionally, exposure to IR by clinical students should be studied more carefully to determine why students ceased considering IR as a career. As medical curricula evolve, incorporating IR into preclinical and clinical training serves not only to attract interested students early but also to improve the overall level of knowledge for all students, including students who will ultimately pursue other specialties that rely on the services provided by interventionalists.
ACKNOWLEDGMENT Funding for this study was provided from the Department of Radiology, University of North Carolina.
REFERENCES 1. Sunshine JH, Lewis RS, Bhargavan M. A portrait of interventional radiologists in the United States. AJR Am J Roentgenol 2005; 185: 1103–1112. 2. Kaufman J. Primary certificate in vascular and interventional radiology. J Vasc Interv Radiol 2006; 17:S183–S186. 3. Becker GJ. 2000 RSNA annual oration in diagnostic radiology: the future of interventional radiology. Radiology 2001; 220:281–292. 4. Becker GJ. Interventional oncology: perspectives on current scholarly productivity and potential for future growth. Radiology 2010; 257: 309–312.
1806
’
Commentary: Demystifying the “Black Box” of IR
5. Goldberg SN, Bonn J, Dodd G, et al. Society of Interventional Radiology Interventional Oncology Task Force: interventional oncology research vision statement and critical assessment of the state of research affairs. J Vasc Interv Radiol 2005; 16:1287–1294. 6. National Resident Matching Program, Results and Data. Specialties matching service 2009 appointment year. 2009. Available at: http://www. nrmp.org/match-data/nrmp-historical-reports/. Accessed March 19, 2014. 7. National Resident Matching Program, Results and Data. Specialties matching service 2013 appointment year. 2013. Available at: http:// www.nrmp.org/match-data/nrmp-historical-reports/. Accessed March 19, 2014. 8. Siragusa DA, Cardella JF, Hieb RA, et al. Requirements for training in interventional radiology. J Vasc Interv Radiol 2013; 24:1609–1612. 9. American Board of Radiology. Interventional radiology/diagnostic radiology (IR/DR)—latest information. 2014. Available at: http://www.theabr.org/sites/ all/themes/abr-media/pdf/ABR-IR-DR-FAQ.pdf. Accessed May 18, 2014. 10. Ghatan CE, Kuo WT, Hofmann LV, Kothary N. Making the case for early medical student education in interventional radiology: a survey of 2ndyear students in a single U.S. institution. J Vasc Interv Radiol 2010; 21: 549–553. 11. Nissim L, Krupinski E, Hunter T, Taljanovic M. Exposure to, understanding of, and interest in interventional radiology in American medical students. Acad Radiol 2013; 20:493–499. 12. O’Malley L, Athreya S. Awareness and level of knowledge of interventional radiology among medical students at a Canadian institution. Acad Radiol 2012; 19:894–901. 13. Likert R. A technique for the measurement of attitudes. Arch Psychol 1932; 22:55. 14. Fisher RA. Statistical Methods for Research Workers. Edinburgh: Oliver and Boyd; 1925. 15. Branstetter BF 4th, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007; 188:W9–W14.
Funaki and Siragusa
’
JVIR
16. Donnelly LF, Racadio JM, Strife JL. Exposure of first-year medical students to a pediatric radiology research program: is there an influence on career choice? Pediatr Radiol 2007; 37:876–878 17. Branstetter BF 4th, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinions about radiology. Acad Radiol 2008; 15:1331–1339. 18. Gunderman RB, Alexander S, Jackson VP, Lane KA, Siddiqui AR, Tarver RD. The value of good medical student teaching: increasing the number of radiology residency applicants. Acad Radiol 2000; 7:960–964. 19. Singh N, Causey W, Brounts L, Clouse WD, Curry T, Andersen C. Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions. J Vasc Surg 2010; 51:252–258. 20. Malikova MA, Doros G, Joglar F, Rybin D, Petros JG, Farber A. A thirdyear surgery clerkship with extensive exposure to vascular surgery improves knowledge about vascular disease and the role of vascular surgeons in its management. Vasc Endovasc Surg 2010; 44:361–367. 21. Rogers LF. Imaging literacy: a laudable goal in the education of medical students. AJR Am J Roentgenol 2003; 180:1201. 22. Leong S, Keeling AN, Lee MJ. A survey of interventional radiology awareness among final-year medical students in a European country. Cardiovasc Intervent Radiol 2009; 32:623–629. 23. Fielding JR, Major NM, Mullan BF, et al. Choosing a specialty in medicine: female medical students and radiology. AJR Am J Roentgenol 2007; 188:897–900. 24. Schlesinger AE, Blane CE, Vydareny KH. First-year medical students’ attitudes toward radiology. Invest Radiol 1992; 27:175–178. 25. Baerlocher MO, Asch M. Protecting the future: attracting interventional radiology trainees–a medical student’s perspective. Can Assoc Radiol J 2006; 57:147–151.
INVITED COMMENTARY
IR—Demystifying the “Black Box” Brian Funaki, MD, and Daniel Siragusa, MD Any important decision should be an informed one. To make an informed decision, one must first have a working understanding of the facts, implications, and future consequences of the decision being considered (1). For example, as medicine is a “black box” for most laypeople, a critical component of a physician’s responsibility consists of educating patients on the pros, cons, and alternatives to any treatment so that an informed decision can be made. As interventional radiologists, we obtain informed consent daily from all patients before any invasive therapy we perform.
From the Department of Vascular and Interventional Radiology (B.F.), University of Chicago, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637; and Division of Vascular and Interventional Radiology (D.S.), University of Florida, Gainesville, Florida. Received July 16, 2014 accepted July 16, 2014. Address correspondence to B.F.; E-mail: [email protected] Neither of the authors has identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1806–1807 http://dx.doi.org/10.1016/j.jvir.2014.07.019
As medicine is a black box for patients, it appears that interventional radiology is a black box for medical students. Commander et al (2) evaluated the level of knowledge of interventional radiology in preclinical and clinical medical students in two different institutions and found that 84% of preclinical students reported their own knowledge as “poor” or “fair.” More disturbing was that 62% of clinical students reported the same. Students at a second institution, which had a required radiology rotation, reported significantly better awareness of interventional radiology compared with the first one. However, overall, it appears that our profession still remains nebulous to many students. Why is this important? First, with the advent of the new interventional radiology residency, we are entering an era of training in which future interventional radiologists must choose the specialty while in medical school, rather than after 2 years of a radiology residency. The fact that few training institutions currently have structured, robust interventional radiology experiences for medical students is problematic. Interventional radiologists of the near future will be asked to commit to
1807e.1
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
APPENDIX A Survey Administered at the Public Medical School (MSE) 1. What is your current year of medical school? a. MS1 (class of 2016) b. MS2 (class of 2015) c. MS3 (class of 2014) 2. How would you rate your knowledge of interventional radiology compared with other medical specialties? a. b. c. d. e.
Excellent Very good Good Fair Poor
3. Have you completed or do you plan to complete an elective in radiology a. Yes b. Not sure c. No 4. Are you considering a career in diagnostic radiology? a. Yes b. Not sure c. No 5. Are you considering a career in interventional radiology? a. Yes b. Not sure c. No 6. Please choose the most appropriate reason why you chose “No” or “Not sure” in answer to the previous question. a. I don’t find it interesting. b. I don’t know enough about it. c. I don’t like the lifestyle. d. Radiation exposure concerns. e. Other (please specify) ____________________ 7. An interventional radiologist must complete a residency in: a. b. c. d. e.
Radiology Surgery Internal medicine Both radiology and surgery Other (please specify) ____________________
8. Are you familiar with the combined diagnostic radiology/interventional radiology pathway? a. Yes b. No 9. Have you seen patients who were treated by an interventional radiologist? a. Yes b. Not sure c. No 10. Please list three interventional radiology procedures. a. _______________ b. _______________ c. _______________
Volume 25
’
Number 11
’
November
’
2014
1807.e2
11. Interventional radiologists can admit patients to the hospital. a. True b. False 12. What has provided you with the most knowledge of interventional radiology? a. b. c. d. e. f. g. h. i.
Radiology elective Lectures from interventional radiologists MS1 or MS2 small group exercises MS3 rotations (other than radiology) Radiology interest group Multidisciplinary meetings (eg, careers lunches) Self-directed learning I have no exposure to interventional radiology Other (please specify) ____________________
13. How would you prefer to gain more exposure to interventional radiology? a. Radiology elective b. Lectures from interventional radiologists c. Multidisciplinary meetings d. MS1 or MS2 small group exercises e. Self-directed learning f. Radiology interest group
Strongly Avoid (1) Avoid (2) Indifferent (3) Prefer (4) Strongly Prefer (5) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
14. Do you think a mandatory radiology rotation would be beneficial? a. Yes b. Not sure c. No 15. How many weeks should this clerkship last? a. b. c. d.
1 week 2 weeks 4 weeks Other (please specify) ____________________
16. Would you be interested in doing a 2-week interventional radiology elective if it was offered during the 8-week surgery clerkship? a. Yes b. Not sure c. No 17. Do you have any additional comments about the role of interventional radiology in the medical school curriculum? MSE ¼ medical school with elective radiology component.
APPENDIX B Survey Administered at the Private Medical School (MSR) 1. How would you rate your knowledge of interventional radiology compared with other medical specialties? a. Excellent b. Very good c. Good d. Fair e. Poor
1807e.3
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
2. Are you considering a career in diagnostic radiology? a. Yes b. Not sure c. No 3. Are you considering a career in interventional radiology? a. Yes b. Not sure c. No 4. Please choose the most appropriate reason why you chose “No” or “Not sure” in answer to the previous question. a. I don’t find it interesting b. I don’t know enough about it c. I don’t like the lifestyle d. Radiation exposure concerns e. Other (please specify) ____________________ 5. Did you complete a fourth-year interventional radiology elective? a. Yes b. No 6. Traditionally, an interventional radiologist must complete an internship in: a. Radiology b. Surgery c. Internal medicine d. Transitional year e. Don’t know f. Other (please specify) ___________________ 7. Traditionally, an interventional radiologist must complete a residency in: a. Radiology b. Surgery c. Internal medicine d. Both radiology and surgery e. Don’t know f. Other (please specify) ___________________ 8. Are you familiar with the combined diagnostic radiology/interventional radiology (“direct”) pathway? a. Yes b. No 9. Have you heard about the new interventional radiology residency? a. Yes b. No 10. Have you heard about the new American Board of Medical Specialties dual certificate in diagnostic radiology and interventional radiology?
a. Yes b. No 11. Have you seen patients who were treated by an interventional radiologist? a. Yes b. Not sure c. No 12. Please list three interventional radiology procedures. a. __________________________ b. __________________________ c. __________________________
Volume 25
’
Number 11
’
November
’
2014
1807.e4
13. Can interventional radiologists admit patients to the hospital? a. Yes b. No 14. What has provided you with the most knowledge of interventional radiology? a. Second-year radiology clerkship b. Fourth-year interventional radiology elective c. Lectures from interventional radiologists d. MS1 or MS2 small group exercises e. MS3 research project f. Radiology interest group g. Multidisciplinary meetings h. Self-directed learning i. I have had no exposure to interventional radiology j. Other (please specify) _________________________ 15. How would you have preferred to gain more exposure to interventional radiology? Please rank the following from 1 (most interested) to 5 (least interested).
a. b. c. d. e. f. g. h. i.
First-year lectures by interventional radiologists More days in interventional radiology during the second-year required radiology clerkship Third-year research project Fourth-year interventional radiology elective Multidisciplinary meetings MS1 or MS2 small group exercises Radiology interest group Interventional radiology interest group Self-directed learning
MSR ¼ medical school with required radiology component.
Table E1 . Respondents’ Knowledge of IR Training and Privileges MSE (n ¼ 274)
MSR (n ¼ 162)
Preclinical,
Clinical,
Preclinical,
Clinical,
Question
Answer Options
n ¼ 157 (57.3%)
n ¼ 117 (42.7%)
n ¼ 102 (63.0%)
n ¼ 60 (37.0%)
Traditionally, an interventional
Radiology
101 (65.6%)
97 (83.6%)
57 (62.6%)
53 (96.4%)
Surgery Radiology and
5 (3.25%) 44 (28.6%)
3 (2.6%) 13 (11.2%)
0 (0.0%) 6 (6.6%)
0 (0.0%) 1 (1.8%)
Internal medicine Other
1 (0.7%) 3 (2.0%)
0 (0.0%) 3 (2.6%)
0 (0.0%) 0 (0.0%)
0 (0.0%) 0 (0.0%)
Yes
112 (72.7%)
80 (69.0%)
57 (64.8%)
39 (70.9%)
No
42 (27.3%)
36 (31.0%)
31 (35.2%)
16 (29.1%)
radiologist must complete a residency in:
surgery
Interventional radiologists can admit patients to the hospital
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component.
1807e.5
’
Medical Students’ Knowledge of IR
Commander et al
’
JVIR
Table E2 . Respondents’ Preferred Method of Learning More about IR
Answer Choice Radiology elective*
Lectures from IR faculty during preclinical training Small group exercises
Level of
Strongly
Avoid,
Indifferent,
Prefer,
Strongly
Institution
Training
Avoid, n (%)
n (%)
n (%)
n (%)
Prefer, n (%)
MSE†
Preclinical
9 (6%)
7 (5%)
42 (28%)
71 (47%)
23 (15%)
MSR‡
Clinical Preclinical
1 (1%) 0 (0%)
6 (5%) 0 (0%)
23 (20%) 5 (14%)
51 (45%) 11 (31%)
32 (28%) 20 (56%)
Clinical
2 (4%)
3 (6%)
10 (21%)
11 (23%)
22 (46%)
MSE
Preclinical Clinical
1 (1%) 0 (0%)
7 (5%) 4 (4%)
28 (18%) 25 (22%)
92 (60%) 66 (58%)
25 (16%) 19 (17%)
MSR
Preclinical
0 (0%)
1 (3%)
15 (42%)
14 (39%)
6 (17%)
MSE‡
Clinical Preclinical
4 (9%) 8 (5%)
3 (6%) 15 (10%)
11 (23%) 46 (30%)
20 (43%) 65 (42%)
9 (19%) 19 (12%)
Clinical
6 (5%)
20 (18%)
41 (37%)
34 (30%)
11 (10%)
MSR
Preclinical Clinical
0 (0%) 4 (9%)
7 (21%) 9 (20%)
12 (36%) 12 (27%)
10 (30%) 15 (33%)
4 (12%) 5 (11%)
MSE
Preclinical
1 (1%)
18 (12%)
58 (38%)
61 (40%)
13 (9%)
MSR
Clinical Preclinical
4 (4%) 1 (3%)
16 (14%) 4 (12%)
45 (39%) 10 (56%)
39 (34%) 8 (24%)
10 (9%) 2 (6%)
incorporating IR during preclinical training Multidisciplinary meetings
Self-directed learning
Radiology interest group
Clinical
4 (9%)
4 (9%)
15 (34%)
19 (43%)
2 (5%)
MSE
Preclinical Clinical
10 (7%) 5 (4%)
38 (25%) 21 (18%)
56 (37%) 53 (46%)
40 (26%) 30 (26%)
7 (5%) 5 (4%)
MSR
Preclinical
3 (9%)
8 (23%)
17 (49%)
6 (17%)
1 (3%)
MSE
Clinical Preclinical
5 (11%) 8 (5%)
4 (9%) 23 (15%)
25 (56%) 58 (39%)
8 (18%) 53 (35%)
3 (7%) 8 (5%)
Clinical
3 (3%)
16 (14%)
52 (46%)
31 (27%)
11 (10%)
Preclinical Clinical
4 (12%) 9 (20%)
2 (6%) 5 (11%)
13 (38%) 19 (42%)
9 (26%) 10 (22%)
6 (18%) 2 (4%)
MSR
IR ¼ interventional radiology; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component. *Combined P o .05. † Wilcoxon-Mann-Whitney P o .01. ‡ Wilcoxon-Mann-Whitney P o .05.
Table E3 . Ten Most Common IR Procedures Named by Respondents No. Respondents (Preclinical, Clinical),
% All Respondents (Preclinical, Clinical),
% MSE Respondents (Preclinical, Clinical),
% MSR Respondents (Preclinical, Clinical),
n ¼ 178 (132, 146)
n ¼ 178 (132, 146)
n ¼ 190 (95, 95)
n ¼ 87 (36, 51)
61 (27, 34) 57 (11, 46)
22 (20, 23) 21 (8, 32)
21 (15, 28) 16 (8, 24)
23 (25, 14) 30 (6, 45)
fibroids) Angiography
54 (19, 35)
19 (14, 24)
21 (11, 32)
15 (16, 10)
TIPS
50 (3, 45)
18 (2, 31)
12 (0, 23)
32 (6, 45)
Drain placement IVC filter placement
40 (4, 36) 35 (4, 31)
14 (3, 25) 13 (3, 21)
17 (1, 34) 8 (1, 15)
8 (6, 8) 23 (6, 33)
Image-guided biopsy
33 (11, 22)
12 (8, 15)
13 (6, 20)
9 (10, 6)
Central line placement Thrombolysis
33 (10, 23) 22 (8, 14)
12 (8, 16) 8 (6, 10)
12 (5, 19) 7 (3, 12)
11 (10, 10) 9 (10, 6)
Angioplasty
21 (15, 6)
8 (11, 4)
7 (13, 2)
Procedure Stent placement Embolization (including uterine
8 (6,8)
IR ¼ interventional radiology; IVC ¼ inferior vena cava; MSE ¼ medical school with elective radiology component; MSR ¼ medical school with required radiology component; TIPS ¼ transjugular intrahepatic portosystemic shunt.