- Email: [email protected]
Awareness and Level of Knowledge of Interventional Radiology among Medical Students at a Canadian Institution
Radiology Resident Education
Awareness and Level of Knowledge of Interventional Radiology among Medical Students at a Canadian Institution Lauren O’Malley, MD, MA, BASc, Sriharsha Athreya, MS, FRCS, FRCR Purpose: To assess the awareness and level of exposure of interventional radiology (IR) among medical students at a Canadian medical school. To understand how IR can be better described and introduced to medical students. Materials and Methods: Electronic anonymous surveys were sent to 542 medical students in their first, second, and third years at a Canadian 3-year medical school. A total of 103 students (19%) responded. Each survey contained 17 questions assessing knowledge, interest, and perception of IR. Results: Fifty-three percent (55/103) of respondents reported ‘‘poor’’ knowledge of IR and only 18% (19/103) said they would consider a career in IR. Respondents cited lack of knowledge (48%, 37/77) or lack of interest (43%, 33/77) as the main reasons why they would not consider IR as a career. Although 92% (95/103) of respondents could name at least one IR procedure, many (54%, 56/103) were unclear as to the duties of an interventional radiologist within the hospital. Seventy-four percent (76/103) of students stated that a mandatory 2-week rotation in radiology during clerkship would be beneficial, whereas 71% (73/103) stated that they would be interested in a 2-week IR selective during their mandatory core surgery rotation. Conclusions: The knowledge and exposure to IR in medical school is limited. Students were eager to learn more about IR and expressed a desire for more exposure. Early exposure of medical students to IR should be introduced to attract future interventional radiologists as well as increase awareness among future referring physicians. Key Words: Medical students; education; interventional radiology. ªAUR, 2012
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ith the continuing introduction of novel minimally invasive treatments, the field of interventional radiology (IR) is rapidly developing and expanding (1). However, as it continues to grow, it faces many challenges, including a worsening personnel shortage, turf issues with other specialties, limited funding, lack of referral support, and lack of awareness among other specialists, family physicians (2), and medical students (1,3). To address many of the issues faced by the field of IR, awareness among other practicing physicians as well as future physicians is vital (1). The purpose of this study is to assess the awareness and level of knowledge of IR among medical students at a Canadian medical school. We also assess the methods of dissemination Acad Radiol 2012; 19:894–901 From the Michael G. Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada (L.O.’M.); Faculty of Health Sciences, St. Joseph’s Healthcare Hamilton, 50 Charlton Ave. E., Room T0112, Hamilton ON L8N 4A6 (S.A.). Received November 29, 2011; accepted March 3, 2012. Conflict of interest: None. Address correspondence to: S.A. e-mail: [email protected] ªAUR, 2012 doi:10.1016/j.acra.2012.03.009
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of this information in an attempt to understand how this rapidly expanding field can be better described and introduced to our future physicians. This could have important implications for the future of IR, both in attracting more talented medical students to the field and in increasing awareness among future referring physicians. Although similar studies have been performed in Europe (1) and the United States (4), data concerning Canadian medical students’ exposure to IR are sparse in the literature and we hope to address this deficit.
MATERIALS AND METHODS Ethics approval for this study was obtained at our institution. An electronic survey created through Survey Monkey was sent to 542 medical students in their first, second, and third years at a 3-year medical school. The students at this institution have full-time clinical exposure in their second and third years of study and have the opportunity to complete horizontal clinical electives during their first year of study. A total of 103 students (19%) responded to the survey. All questions were completed and submitted through the online software
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TABLE 1. Demographics of Respondents as they Pertain to Knowledge and General Interest in Diagnostic and Interventional Radiology (IR)
Year of medical school
Self-reported knowledge of IR as compared with other subjects
Respondents who have completed or plan to complete an elective in radiology Respondents who would consider a career in radiology Respondents who would consider a career in IR
Reasons respondents would not consider a career in IR or are not sure
Respondents who have seen patients who were treated by an interventional radiologist
Possible Responses
Response Count (n = 103)
%
1 2 3 Excellent Good Adequate Poor No knowledge Yes No Yes No Not sure Yes No Not sure Lack of interest Lack of knowledge Lifestyle Radiation exposure Other Yes No Not sure
47 40 16 3 9 26 55 10 61 42 23 50 30 19 46 38 33/77 37/77 5/77 2/77 13/77 57 31 15
46 39 16 3 9 25 53 10 59 41 22 49 29 18 45 37 43 48 7 3 17 55 30 15
and submissions were anonymous. The survey consisted of 17 questions (Appendix). Students were given 4 weeks to provide an electronic reply. Over the course of the 4 weeks, students received 2 reminder emails about the survey. A link to the survey with an invitation to take part was also posted on the online message board for students. The survey comprised questions in various categories, including knowledge of IR procedures, training, and hospital duties. Respondents were asked to rate their knowledge of IR compared to other subjects, their level of interest in IR, and their desire for future education on this topic. Respondents were asked to recall how they have acquired their knowledge of IR to date and to rank their preferred methods for learning about IR in the future. Respondents were also asked whether they would be interested in taking part in potential mandatory rotations in radiology as well as a possible 2-week selective in IR during the clerkship curriculum. RESULTS There were respondents from each year of a 3-year medical program at a Canadian university: 46% (47/103) were in their first year, 39% (40/103) in their second, and 16% (16/103) of respondents were in their third year (Table 1). Only 59% (61/ 103) had completed or were planning to complete an elective in radiology (Table 1). The majority of respondents (53%, 55/ 103) rated their knowledge of IR as poor (Table 1). Ten percent (10/103) said they had ‘‘no knowledge’’ of IR
(Table 1). Only a few students (12) rated their knowledge of IR as excellent (3%, 3/103), good (9%, 9/103), or adequate (25%, 26/103) (Table 1). Although 18% (19/103) of students said they would consider a career in IR, 45% (46/103) said they would not consider it as a career choice, and 37% (38/103) were unsure (Table 1). The most common reasons for not considering IR as a career or for being unsure was lack of knowledge (48%, 37/77) and lack of interest (43%, 33/77) (Table 1). During clinical rotations, 55% (57/103) of respondents had seen patients who had undergone IR procedures, whereas 30% (31/103) said they had never seen a patient who was treated by an interventional radiologist (Table 1). When asked to list three IR procedures, the most commonly mentioned procedures were: image-guided biopsies (25%, 26/103), line insertion (21%, 22/103), angiography (19%, 20/103), balloon angioplasty (17%, 18/103), and embolization (16%, 16/103) (Table 2). A total of 8% (8/103) could not mention a single IR procedure and 4% (4/103) incorrectly stated that interventional radiologists perform radiation treatment for cancer. Eighty-five percent (88/103) of respondents thought that interventional radiologists must complete a residency in radiology, 13% (13/103) thought that interventional radiologists must complete a residency in both surgery and radiology, and 2% (2/103) thought that interventional radiologists must complete a residency in surgery only (Table 3). When asked about IR clinical duties, 64% (66/103) thought that interventional radiologists have outpatient clinics, 36% (52/103) 895
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TABLE 2. Most Commonly Known IR Procedures among Respondents
Procedure Ultrasound- or computed tomography–guided biopsy Line insertion Angiography Balloon angioplasty Embolization (includes uterine fibroids) Stent placement Feeding tube insertion Inferior vena cava filter placement Thoracentesis/chest tube placement Abscess drains Coiling aneurysms
Number of Respondents Who Mentioned the Procedure % of (n = 103) Respondents 26
25
22 20 18 16
21 19 17 16
15 10 8
15 10 8
7
7
6 6
6 6
thought interventional radiologists did ward rounds in the hospital, and only 27% (28/103) thought they had admitting privileges (Table 3). When asked about where they received their information about IR, the most common responses were radiology electives (27%, 28/103), IR lectures (13%, 13/103), ward rounds (11%, 11/103), self-directed research on the specialty (10%, 10/103), problem-based learning tutorials (4%, 4/103), and multidisciplinary meetings (3%, 3/103) (Table 4). A total of 33% (34/103) had no exposure to IR. Respondents were also asked to indicate their preferred methods for learning about IR. The most common responses were radiology electives and lectures given by interventional radiologists. Fifty-five respondents out of 103 selected radiology electives as the best method for gaining exposure to IR and 19 respondents of 103 selected lectures as the best method for gaining exposure to IR (Table 5). An overwhelming 74% (76/103) of respondents stated that a 2-week mandatory radiology rotation during clerkship would be beneficial and 71% (73/103) indicated that they would be interested in taking part in a 2-week IR selective during the 6-week clerkship surgery rotation (Table 6). DISCUSSION Although IR is a rapidly expanding field worldwide (5), Canada is reported to be the slowest to adopt IR procedures among G7 nations, performing the fewest number of IR procedures per million population (6). A 2006 report by the Millennium research group (commissioned by the Canadian Association of Radiologists and the Canadian Interventional Radiology Association) speaks to the fact that better establishing the field of IR in Canada may lead to mortality and 896
monetary benefit (6). It suggests that if existing surgical procedures for 8 diseases were replaced with IR procedures, the resulting savings could be estimated at $180.3 million (CAD) in direct health care costs and 402 Canadian lives saved annually (6). The growth of IR in Canada is limited by a number of factors, including funding, personnel shortage, and lack of referral support (5). Previous studies have supported the need for a concerted effort in increasing public exposure to IR to advance the field of IR (5). Undergraduate medical students play an important part in this advancement, as they represent future medical professionals who could be radiologists and potential referring physicians. To assess the level of knowledge of IR among medical students, we created our survey based on a similar survey implemented by Leong et al in their study of IR awareness among medical students in a European medical school (1). Studies of education in diagnostic radiology have shown that exposing students to radiology in the first year of medical school improves their opinion of radiology as a specialty and increases their interest in radiology as a career (7). Similar studies in vascular surgery have shown that extensive exposure to vascular surgery in medical school increases knowledge and may positively influence choice of vascular surgery as a career among medical students (8–10). In the survey performed by Ghatan et al at an American institution, nearly two thirds of respondents reported no exposure to IR during their medical school training (4). Respondents to our survey did somewhat better with only 33% (34/103) of respondents reporting no exposure to IR (including 13% of respondents who were in their final year [2/16]) (Table 1). However, 33% is still a significant number and thus there appears to be a lack of organized educational exposure within the medical school curriculum. It is not surprising, then, that we found a paucity of knowledge of IR among respondents to our survey. Many students reported little or no knowledge of IR. In our study, 63% (65/103) of respondents reported poor or no knowledge of IR. This was similar to the 66% of respondents reporting poor or no knowledge of IR in the survey performed by Leong et al in Europe (1). Nearly half of respondents to our survey reported a lack of interest in the field. Currently, there are no required rotations in diagnostic radiology or IR in the curriculum at the Canadian medical school surveyed. In attempting to increase exposure to IR in Canada, it will be important to address this crucial audience. As seen in the specialty of vascular surgery, implementation of programs designed to give early, extensive exposure of the specialty to medical students can have a positive influence on the choice of this specialty as a career (8). As well, the study performed by Ghatan et al in a US institution in which students were surveyed before and after an introductory lecture to IR suggested that exposure to IR may significantly increase interest in the field, influence career choice, and simply increase understanding and impression of the field (4). Forty-five percent (46/103) of students in our study said they would not consider IR as a career choice, citing lack of
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TABLE 3. Respondents’ Knowledge of Tasks Performed by Interventional Radiologists Statement Presented in Survey An interventional radiologists must complete a residency in:
Interventional radiologists have outpatient clinics. Interventional radiologists do ward rounds in the hospital. Interventional radiologists admit patients to hospital.
TABLE 4. Methods of Learning that Provided Respondents with the Most Information about Interventional Radiology (IR)
Methods of Exposure to IR Radiology elective Lectures from interventional radiologists Ward rounds in hospital Self-directed research Problem-based learning tutorials Multidisciplinary meetings Other Respondents with no exposure to IR
Response Count Percentage of (n = 103) Respondents 28 13
27 13
11 10 4 3 12 34
11 10 4 3 12 33
knowledge (48%, 37/77) and lack of interest (43%, 33/77) (Table 1) as the two major reasons why they would not consider it or were unsure. Only 18% (19/103) of respondents said that they would consider a career in IR, whereas 22% (23/103) said they would consider a career in Radiology. Similarly, in the American study by Ghatan et al, 19% of respondents ranked IR and 22% of respondents ranked radiology as one of their top two career choices (before intervention with a 1-hour lecture on the topic of IR) (4). It is interesting to note that in the European study by Leong et al, 41% of those surveyed said they would consider radiology as a career choice, which is quite a bit higher than in their North American counterparts (1). Studies regarding career choice among medical students show that the ultimate choice results from interplay of several factors (11–13). Some important factors cited by students in one study were: exposure to interesting diseases, patient contact, quality of life, intellectual challenge, knowledge, and income (11). With the implementation of programs to expose students to IR, it will be important to address these factors within the profession and determine how they are viewed among medical students. What aspects of IR are particularly appealing among medical students and what draws physicians to the profession? These questions might be answered in future studies and will be important to consider as we strive to introduce medical students to this potential career choice.
Possible Responses
Response Count (n = 103)
%
Surgery Radiology Both surgery and radiology Other True False True False True False
2 88 13 2 66 37 52 51 28 75
2 85 13 2 64 36 51 49 27 73
When asked about their preferred methods for learning about IR, we found that respondents in our study responded almost identically to those in both the European (1) and American (4) studies. That is, most preferred to learn by elective placements in IR and by didactic lectures. While 53% (55/103) of students listed radiology electives as their preferred method of learning about IR, only 27% (28/103) cited radiology electives as their primary source of information (Tables 4 and 5). Only 13% (13/103) of respondents to our survey cited lectures from interventional radiologists as their primary source of information about IR (Table 4). Evidently, there is a lack of involvement of interventional radiologists in the undergraduate curriculum and a need for the development of educational and clinical programs that promote excitement and interest around the field. Overwhelmingly, nearly three quarters of students surveyed (76/103) agreed that a mandatory 2-week rotation in radiology would be beneficial, whether they were interested in radiology as a career or not (Table 6). Given the fact that radiology plays an important role in almost any clinical service, it seems logical to expose students to the field. Seventy-one percent (73/103) of respondents were interested in pursuing a 2-week IR selective if it was made available during the surgery rotation in clerkship (Table 6). Clearly, there is a demand for more knowledge among students that is not currently being met. Although most students correctly indicated that interventional radiologists required residency training in radiology, there was misinformation about the day-to-day responsibilities of an interventional radiologist. Thirty-six percent (37/ 103) of respondents said that interventional radiologists do not have outpatient clinics. Only 51% (52/103) of respondents said that interventional radiologists do ward rounds in hospital. Seventy-three percent (75/103) of students said that interventional radiologists are not able to admit patients to the hospital (Table 3). Because the practices of interventional radiologists vary from institution to institution, this may speak more to the particular exposures that these students have had within the hospitals of this teaching institution. However, the potential roles for the interventional radiologist need to be considered and understood as IR continues to establish itself as a field with growing importance in Canada. 897
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TABLE 5. Student Ratings of the Various Teaching Methods in Interventional Radiology, Ranging from 1 (Best) to 7 (Worst)
Ward rounds Radiology department electives Lectures from interventional radiologists Multidisciplinary meetings Self-directed learning websites Problem-based learning tutorials Clinical research projects
1 (best), number
2, number
3, number
4, number
5, number
6, number
7 (worst), number
10 55 19 2 5 7 0
21 22 33 6 7 8 3
11 7 24 16 17 17 7
16 8 11 17 19 21 8
13 2 4 25 15 24 15
11 3 1 21 27 19 16
12 3 3 10 7 5 53
TABLE 6. Respondents’ Interest in Making Diagnostic Radiology and Interventional Radiology a Part of the Medical School Clerkship Curriculum Question Do you think a mandatory 2-week radiology rotation during clerkship would be beneficial? Would you be interested in doing a 2-week interventional radiology selective if it was offered during the 6-week surgery rotation in clerkship?
There are several limitations to this study. Given the voluntary nature of the survey online, we were only able to elicit replies from 19% (103/542) of the student population. There are many factors that may have contributed to the low response rate, including lack of interest in the subject. We also recognize that there may be a response bias toward medical students who have an interest in radiology. We also acknowledge that the results only apply to the medical teaching in Canada. Although our study was limited to one medical school, we recognize that there is no defined IR curriculum in medical schools across Canada. Ideally, we would like to extend this study and perform further surveys of other medical schools in Canada. Further, it should be noted that there are many methods that might be used to introduce medical students to IR. As mentioned previously, clerkship rotations in radiology and IR would be beneficial, as would introductory lectures by interventional radiologists. Currently, the clerkship program in this medical school does require a 2-week selective rotation in one of a variety of subspecialties during the 6-week surgical rotation. Offering IR as a potential selective option would be one way of introducing IR to medical students. Some medical students commented that often radiology electives do not provide an ideal learning environment and perhaps a concerted effort to offer teaching to students during elective time would be in order. Other options for exposure would include e-learning modules that students could complete on their own time. In conclusion, the results of our survey suggest that medical students’ exposure to IR teaching in the undergraduate medical curriculum is quite poor. This can only be amelio898
Possible Response
Response Count (n = 103)
%
Yes No Not sure Yes No Not sure
76 11 16 73 16 14
74 11 15 71 15 14
rated by direct involvement of interventional radiologists in the medical school curriculum. To strive for the continued growth of the field of IR and increase awareness among future referring physicians, early exposure of medical students to IR should be introduced. To this end, various interventional radiological societies would have to interact with medical school boards to develop a comprehensive IR curriculum. ACKNOWLEDGMENTS We thank Philip Mok for his advice and help with the survey. We thank all the medical students who completed the survey. We also thank Prof. M. J. Lee for agreeing to the use of part of the questions from the survey in their study. REFERENCES 1. 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. 2. Mok PS, Tan EY, Baerlocher MO, et al. What do family physicians know about interventional radiology? A survey of family physicians at a large Canadian annual scientific assembly. J Vasc Interv Radiol 2010; 21: 1250–1254. 3. Sunshine JH, Cypel YS, Schepps B. Diagnostic radiologists in 2000: basic characteristics, practices, and issues related to the radiologist shortage. AJR Am J Roengenol 2002; 178:291–301. 4. Ghatan CE, Kuo WT, Hofmann LV, et al. Making the case for early medical student education in interventional radiology: a survey of 2nd-year students in a single U.S. institution. J Vasc Interv Radiol 2010; 21:549–553. 5. O’Brien, Baerlocher MO, Asch MR, et al. Limitations influencing interventional radiology in Canada: results of a national survey by the Canadian Interventional Radiology Association (CIRA). Cardiovasc Intervent Radiol 2007; 30:847–853. 6. Baerlocher MO. Canada’s slow adoption of new technologies adds burden to health care system. CMAJ 2007; 176:616.
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7. Brantstetter BF 4th, Faix LE, Humphrey AL, et al. Preclinical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007; 188(1):9–14. 8. Malikova MA, Doros G, Joglar F, et al. A third-year 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. 9. Singh N, Causey W, Brounts L, et al. Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions. J. Vasc Surg 2010 Jan; 51:252–258.
10. Godshall CJ, Moore PS, Fleming SH, et al. A vascular disease educational program in the preclinical years of medical school increases student interest in vascular disease. J Vasc Surg 2010; 52:775–780. 11. Lefevre JH, Roupret M, Kerneis S, et al. Career choices of medical students: a national survey of 1780 students. Med Educ 2010; 44:603–612. 12. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two U.S. medical schools, 1998–2004. Acad Med 2005; 80:809–814. 13. Teitelbaum HS, Ehrlich N, Travis L. Factors affecting specialty choice among osteopathic medical students. Acad Med 2009; 84:718–723.
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APPENDIX. SURVEY
T
his survey was created at the St. Joseph’s Healthcare Hamilton Radiology Department to assess the level of knowledge that medical students have regarding interventional radiology. It was created in the hopes of understanding the level of exposure that medical students have to interventional radiology so that we may assess the need for further education in this field. The survey is completely anonymous. Participants cannot be identified. By taking the survey you are consenting to let us, the investigators, use the data compiled. You will be asked a series of 17 questions, most of which are multiple choice format or true/false. Thank you for taking the time to fill out this survey! 1. Year of medical school 1 2 3 2. How would you rate your knowledge of interventional radiology as compared to other subjects? Excellent/good/adequate/poor/no knowledge 3. Have you completed or do you plan to complete an elective in radiology (diagnostic or interventional)? Yes No 4. Would you consider a career in diagnostic radiology? Yes No Not sure 5. Would you consider a career in interventional radiology? Yes No
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9. An interventional radiologist must complete a residency in: Radiology surgery Both radiology and surgery Internal medicine Other (please specify):_____________________ 10. Interventional radiologists have outpatient clinics. True False 11. Interventional radiologists do ward rounds in the hospital. True False 12. Interventional radiologists admit patients to the hospital. True False 13. What has provided you with the most information about interventional radiology? Radiology elective Lectures from interventional radiologists Problem-based learning tutorials Self-directed research Ward rounds in the hospital Multidisciplinary meetings I have had no exposure to interventional radiology. Other (please specify):______________________ 14. How would you prefer to gain exposure to interventional radiology? Please rank the following methods for learning (rank 1 [best] to 8 [worst]).
Not sure 6. If you answered no or not sure to the previous question, please choose the most appropriate reason why. I don’t find it interesting I don’t know enough about it The lifestyle is not for me Radiation exposure Other (please specify):_____________________ 7. Have you seen patients who were treated by an interventional radiologist? Yes No
1(best) 2 3 4 5 6 7 (worst) Ward rounds Radiology department electives Lectures from interventional radiologists Multidisciplinary meetings Self-directed learning websites Problem-based learning tutorials Clinical research projects
Not sure 8. Please list three interventional radiology procedures that you are aware of: 1. ____________________ 2. ____________________ 3. ____________________
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15. Do you think a mandatory 2-week radiology rotation during clerkship would be beneficial? Yes No Not sure
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16. Would you be interested in doing a 2-week interventional radiology selective if it was offered during the 6-week surgery rotation in clerkship? Yes
17. Do you have any comments about interventional radiology in the medical school curriculum?
No Not sure
901
Awareness and Level of Knowledge of Interventional Radiology among Medical Students at a Canadian Institution Lauren O’Malley, MD, MA, BASc, Sriharsha Athreya, MS, FRCS, FRCR Purpose: To assess the awareness and level of exposure of interventional radiology (IR) among medical students at a Canadian medical school. To understand how IR can be better described and introduced to medical students. Materials and Methods: Electronic anonymous surveys were sent to 542 medical students in their first, second, and third years at a Canadian 3-year medical school. A total of 103 students (19%) responded. Each survey contained 17 questions assessing knowledge, interest, and perception of IR. Results: Fifty-three percent (55/103) of respondents reported ‘‘poor’’ knowledge of IR and only 18% (19/103) said they would consider a career in IR. Respondents cited lack of knowledge (48%, 37/77) or lack of interest (43%, 33/77) as the main reasons why they would not consider IR as a career. Although 92% (95/103) of respondents could name at least one IR procedure, many (54%, 56/103) were unclear as to the duties of an interventional radiologist within the hospital. Seventy-four percent (76/103) of students stated that a mandatory 2-week rotation in radiology during clerkship would be beneficial, whereas 71% (73/103) stated that they would be interested in a 2-week IR selective during their mandatory core surgery rotation. Conclusions: The knowledge and exposure to IR in medical school is limited. Students were eager to learn more about IR and expressed a desire for more exposure. Early exposure of medical students to IR should be introduced to attract future interventional radiologists as well as increase awareness among future referring physicians. Key Words: Medical students; education; interventional radiology. ªAUR, 2012
W
ith the continuing introduction of novel minimally invasive treatments, the field of interventional radiology (IR) is rapidly developing and expanding (1). However, as it continues to grow, it faces many challenges, including a worsening personnel shortage, turf issues with other specialties, limited funding, lack of referral support, and lack of awareness among other specialists, family physicians (2), and medical students (1,3). To address many of the issues faced by the field of IR, awareness among other practicing physicians as well as future physicians is vital (1). The purpose of this study is to assess the awareness and level of knowledge of IR among medical students at a Canadian medical school. We also assess the methods of dissemination Acad Radiol 2012; 19:894–901 From the Michael G. Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada (L.O.’M.); Faculty of Health Sciences, St. Joseph’s Healthcare Hamilton, 50 Charlton Ave. E., Room T0112, Hamilton ON L8N 4A6 (S.A.). Received November 29, 2011; accepted March 3, 2012. Conflict of interest: None. Address correspondence to: S.A. e-mail: [email protected] ªAUR, 2012 doi:10.1016/j.acra.2012.03.009
894
of this information in an attempt to understand how this rapidly expanding field can be better described and introduced to our future physicians. This could have important implications for the future of IR, both in attracting more talented medical students to the field and in increasing awareness among future referring physicians. Although similar studies have been performed in Europe (1) and the United States (4), data concerning Canadian medical students’ exposure to IR are sparse in the literature and we hope to address this deficit.
MATERIALS AND METHODS Ethics approval for this study was obtained at our institution. An electronic survey created through Survey Monkey was sent to 542 medical students in their first, second, and third years at a 3-year medical school. The students at this institution have full-time clinical exposure in their second and third years of study and have the opportunity to complete horizontal clinical electives during their first year of study. A total of 103 students (19%) responded to the survey. All questions were completed and submitted through the online software
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TABLE 1. Demographics of Respondents as they Pertain to Knowledge and General Interest in Diagnostic and Interventional Radiology (IR)
Year of medical school
Self-reported knowledge of IR as compared with other subjects
Respondents who have completed or plan to complete an elective in radiology Respondents who would consider a career in radiology Respondents who would consider a career in IR
Reasons respondents would not consider a career in IR or are not sure
Respondents who have seen patients who were treated by an interventional radiologist
Possible Responses
Response Count (n = 103)
%
1 2 3 Excellent Good Adequate Poor No knowledge Yes No Yes No Not sure Yes No Not sure Lack of interest Lack of knowledge Lifestyle Radiation exposure Other Yes No Not sure
47 40 16 3 9 26 55 10 61 42 23 50 30 19 46 38 33/77 37/77 5/77 2/77 13/77 57 31 15
46 39 16 3 9 25 53 10 59 41 22 49 29 18 45 37 43 48 7 3 17 55 30 15
and submissions were anonymous. The survey consisted of 17 questions (Appendix). Students were given 4 weeks to provide an electronic reply. Over the course of the 4 weeks, students received 2 reminder emails about the survey. A link to the survey with an invitation to take part was also posted on the online message board for students. The survey comprised questions in various categories, including knowledge of IR procedures, training, and hospital duties. Respondents were asked to rate their knowledge of IR compared to other subjects, their level of interest in IR, and their desire for future education on this topic. Respondents were asked to recall how they have acquired their knowledge of IR to date and to rank their preferred methods for learning about IR in the future. Respondents were also asked whether they would be interested in taking part in potential mandatory rotations in radiology as well as a possible 2-week selective in IR during the clerkship curriculum. RESULTS There were respondents from each year of a 3-year medical program at a Canadian university: 46% (47/103) were in their first year, 39% (40/103) in their second, and 16% (16/103) of respondents were in their third year (Table 1). Only 59% (61/ 103) had completed or were planning to complete an elective in radiology (Table 1). The majority of respondents (53%, 55/ 103) rated their knowledge of IR as poor (Table 1). Ten percent (10/103) said they had ‘‘no knowledge’’ of IR
(Table 1). Only a few students (12) rated their knowledge of IR as excellent (3%, 3/103), good (9%, 9/103), or adequate (25%, 26/103) (Table 1). Although 18% (19/103) of students said they would consider a career in IR, 45% (46/103) said they would not consider it as a career choice, and 37% (38/103) were unsure (Table 1). The most common reasons for not considering IR as a career or for being unsure was lack of knowledge (48%, 37/77) and lack of interest (43%, 33/77) (Table 1). During clinical rotations, 55% (57/103) of respondents had seen patients who had undergone IR procedures, whereas 30% (31/103) said they had never seen a patient who was treated by an interventional radiologist (Table 1). When asked to list three IR procedures, the most commonly mentioned procedures were: image-guided biopsies (25%, 26/103), line insertion (21%, 22/103), angiography (19%, 20/103), balloon angioplasty (17%, 18/103), and embolization (16%, 16/103) (Table 2). A total of 8% (8/103) could not mention a single IR procedure and 4% (4/103) incorrectly stated that interventional radiologists perform radiation treatment for cancer. Eighty-five percent (88/103) of respondents thought that interventional radiologists must complete a residency in radiology, 13% (13/103) thought that interventional radiologists must complete a residency in both surgery and radiology, and 2% (2/103) thought that interventional radiologists must complete a residency in surgery only (Table 3). When asked about IR clinical duties, 64% (66/103) thought that interventional radiologists have outpatient clinics, 36% (52/103) 895
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TABLE 2. Most Commonly Known IR Procedures among Respondents
Procedure Ultrasound- or computed tomography–guided biopsy Line insertion Angiography Balloon angioplasty Embolization (includes uterine fibroids) Stent placement Feeding tube insertion Inferior vena cava filter placement Thoracentesis/chest tube placement Abscess drains Coiling aneurysms
Number of Respondents Who Mentioned the Procedure % of (n = 103) Respondents 26
25
22 20 18 16
21 19 17 16
15 10 8
15 10 8
7
7
6 6
6 6
thought interventional radiologists did ward rounds in the hospital, and only 27% (28/103) thought they had admitting privileges (Table 3). When asked about where they received their information about IR, the most common responses were radiology electives (27%, 28/103), IR lectures (13%, 13/103), ward rounds (11%, 11/103), self-directed research on the specialty (10%, 10/103), problem-based learning tutorials (4%, 4/103), and multidisciplinary meetings (3%, 3/103) (Table 4). A total of 33% (34/103) had no exposure to IR. Respondents were also asked to indicate their preferred methods for learning about IR. The most common responses were radiology electives and lectures given by interventional radiologists. Fifty-five respondents out of 103 selected radiology electives as the best method for gaining exposure to IR and 19 respondents of 103 selected lectures as the best method for gaining exposure to IR (Table 5). An overwhelming 74% (76/103) of respondents stated that a 2-week mandatory radiology rotation during clerkship would be beneficial and 71% (73/103) indicated that they would be interested in taking part in a 2-week IR selective during the 6-week clerkship surgery rotation (Table 6). DISCUSSION Although IR is a rapidly expanding field worldwide (5), Canada is reported to be the slowest to adopt IR procedures among G7 nations, performing the fewest number of IR procedures per million population (6). A 2006 report by the Millennium research group (commissioned by the Canadian Association of Radiologists and the Canadian Interventional Radiology Association) speaks to the fact that better establishing the field of IR in Canada may lead to mortality and 896
monetary benefit (6). It suggests that if existing surgical procedures for 8 diseases were replaced with IR procedures, the resulting savings could be estimated at $180.3 million (CAD) in direct health care costs and 402 Canadian lives saved annually (6). The growth of IR in Canada is limited by a number of factors, including funding, personnel shortage, and lack of referral support (5). Previous studies have supported the need for a concerted effort in increasing public exposure to IR to advance the field of IR (5). Undergraduate medical students play an important part in this advancement, as they represent future medical professionals who could be radiologists and potential referring physicians. To assess the level of knowledge of IR among medical students, we created our survey based on a similar survey implemented by Leong et al in their study of IR awareness among medical students in a European medical school (1). Studies of education in diagnostic radiology have shown that exposing students to radiology in the first year of medical school improves their opinion of radiology as a specialty and increases their interest in radiology as a career (7). Similar studies in vascular surgery have shown that extensive exposure to vascular surgery in medical school increases knowledge and may positively influence choice of vascular surgery as a career among medical students (8–10). In the survey performed by Ghatan et al at an American institution, nearly two thirds of respondents reported no exposure to IR during their medical school training (4). Respondents to our survey did somewhat better with only 33% (34/103) of respondents reporting no exposure to IR (including 13% of respondents who were in their final year [2/16]) (Table 1). However, 33% is still a significant number and thus there appears to be a lack of organized educational exposure within the medical school curriculum. It is not surprising, then, that we found a paucity of knowledge of IR among respondents to our survey. Many students reported little or no knowledge of IR. In our study, 63% (65/103) of respondents reported poor or no knowledge of IR. This was similar to the 66% of respondents reporting poor or no knowledge of IR in the survey performed by Leong et al in Europe (1). Nearly half of respondents to our survey reported a lack of interest in the field. Currently, there are no required rotations in diagnostic radiology or IR in the curriculum at the Canadian medical school surveyed. In attempting to increase exposure to IR in Canada, it will be important to address this crucial audience. As seen in the specialty of vascular surgery, implementation of programs designed to give early, extensive exposure of the specialty to medical students can have a positive influence on the choice of this specialty as a career (8). As well, the study performed by Ghatan et al in a US institution in which students were surveyed before and after an introductory lecture to IR suggested that exposure to IR may significantly increase interest in the field, influence career choice, and simply increase understanding and impression of the field (4). Forty-five percent (46/103) of students in our study said they would not consider IR as a career choice, citing lack of
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TABLE 3. Respondents’ Knowledge of Tasks Performed by Interventional Radiologists Statement Presented in Survey An interventional radiologists must complete a residency in:
Interventional radiologists have outpatient clinics. Interventional radiologists do ward rounds in the hospital. Interventional radiologists admit patients to hospital.
TABLE 4. Methods of Learning that Provided Respondents with the Most Information about Interventional Radiology (IR)
Methods of Exposure to IR Radiology elective Lectures from interventional radiologists Ward rounds in hospital Self-directed research Problem-based learning tutorials Multidisciplinary meetings Other Respondents with no exposure to IR
Response Count Percentage of (n = 103) Respondents 28 13
27 13
11 10 4 3 12 34
11 10 4 3 12 33
knowledge (48%, 37/77) and lack of interest (43%, 33/77) (Table 1) as the two major reasons why they would not consider it or were unsure. Only 18% (19/103) of respondents said that they would consider a career in IR, whereas 22% (23/103) said they would consider a career in Radiology. Similarly, in the American study by Ghatan et al, 19% of respondents ranked IR and 22% of respondents ranked radiology as one of their top two career choices (before intervention with a 1-hour lecture on the topic of IR) (4). It is interesting to note that in the European study by Leong et al, 41% of those surveyed said they would consider radiology as a career choice, which is quite a bit higher than in their North American counterparts (1). Studies regarding career choice among medical students show that the ultimate choice results from interplay of several factors (11–13). Some important factors cited by students in one study were: exposure to interesting diseases, patient contact, quality of life, intellectual challenge, knowledge, and income (11). With the implementation of programs to expose students to IR, it will be important to address these factors within the profession and determine how they are viewed among medical students. What aspects of IR are particularly appealing among medical students and what draws physicians to the profession? These questions might be answered in future studies and will be important to consider as we strive to introduce medical students to this potential career choice.
Possible Responses
Response Count (n = 103)
%
Surgery Radiology Both surgery and radiology Other True False True False True False
2 88 13 2 66 37 52 51 28 75
2 85 13 2 64 36 51 49 27 73
When asked about their preferred methods for learning about IR, we found that respondents in our study responded almost identically to those in both the European (1) and American (4) studies. That is, most preferred to learn by elective placements in IR and by didactic lectures. While 53% (55/103) of students listed radiology electives as their preferred method of learning about IR, only 27% (28/103) cited radiology electives as their primary source of information (Tables 4 and 5). Only 13% (13/103) of respondents to our survey cited lectures from interventional radiologists as their primary source of information about IR (Table 4). Evidently, there is a lack of involvement of interventional radiologists in the undergraduate curriculum and a need for the development of educational and clinical programs that promote excitement and interest around the field. Overwhelmingly, nearly three quarters of students surveyed (76/103) agreed that a mandatory 2-week rotation in radiology would be beneficial, whether they were interested in radiology as a career or not (Table 6). Given the fact that radiology plays an important role in almost any clinical service, it seems logical to expose students to the field. Seventy-one percent (73/103) of respondents were interested in pursuing a 2-week IR selective if it was made available during the surgery rotation in clerkship (Table 6). Clearly, there is a demand for more knowledge among students that is not currently being met. Although most students correctly indicated that interventional radiologists required residency training in radiology, there was misinformation about the day-to-day responsibilities of an interventional radiologist. Thirty-six percent (37/ 103) of respondents said that interventional radiologists do not have outpatient clinics. Only 51% (52/103) of respondents said that interventional radiologists do ward rounds in hospital. Seventy-three percent (75/103) of students said that interventional radiologists are not able to admit patients to the hospital (Table 3). Because the practices of interventional radiologists vary from institution to institution, this may speak more to the particular exposures that these students have had within the hospitals of this teaching institution. However, the potential roles for the interventional radiologist need to be considered and understood as IR continues to establish itself as a field with growing importance in Canada. 897
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TABLE 5. Student Ratings of the Various Teaching Methods in Interventional Radiology, Ranging from 1 (Best) to 7 (Worst)
Ward rounds Radiology department electives Lectures from interventional radiologists Multidisciplinary meetings Self-directed learning websites Problem-based learning tutorials Clinical research projects
1 (best), number
2, number
3, number
4, number
5, number
6, number
7 (worst), number
10 55 19 2 5 7 0
21 22 33 6 7 8 3
11 7 24 16 17 17 7
16 8 11 17 19 21 8
13 2 4 25 15 24 15
11 3 1 21 27 19 16
12 3 3 10 7 5 53
TABLE 6. Respondents’ Interest in Making Diagnostic Radiology and Interventional Radiology a Part of the Medical School Clerkship Curriculum Question Do you think a mandatory 2-week radiology rotation during clerkship would be beneficial? Would you be interested in doing a 2-week interventional radiology selective if it was offered during the 6-week surgery rotation in clerkship?
There are several limitations to this study. Given the voluntary nature of the survey online, we were only able to elicit replies from 19% (103/542) of the student population. There are many factors that may have contributed to the low response rate, including lack of interest in the subject. We also recognize that there may be a response bias toward medical students who have an interest in radiology. We also acknowledge that the results only apply to the medical teaching in Canada. Although our study was limited to one medical school, we recognize that there is no defined IR curriculum in medical schools across Canada. Ideally, we would like to extend this study and perform further surveys of other medical schools in Canada. Further, it should be noted that there are many methods that might be used to introduce medical students to IR. As mentioned previously, clerkship rotations in radiology and IR would be beneficial, as would introductory lectures by interventional radiologists. Currently, the clerkship program in this medical school does require a 2-week selective rotation in one of a variety of subspecialties during the 6-week surgical rotation. Offering IR as a potential selective option would be one way of introducing IR to medical students. Some medical students commented that often radiology electives do not provide an ideal learning environment and perhaps a concerted effort to offer teaching to students during elective time would be in order. Other options for exposure would include e-learning modules that students could complete on their own time. In conclusion, the results of our survey suggest that medical students’ exposure to IR teaching in the undergraduate medical curriculum is quite poor. This can only be amelio898
Possible Response
Response Count (n = 103)
%
Yes No Not sure Yes No Not sure
76 11 16 73 16 14
74 11 15 71 15 14
rated by direct involvement of interventional radiologists in the medical school curriculum. To strive for the continued growth of the field of IR and increase awareness among future referring physicians, early exposure of medical students to IR should be introduced. To this end, various interventional radiological societies would have to interact with medical school boards to develop a comprehensive IR curriculum. ACKNOWLEDGMENTS We thank Philip Mok for his advice and help with the survey. We thank all the medical students who completed the survey. We also thank Prof. M. J. Lee for agreeing to the use of part of the questions from the survey in their study. REFERENCES 1. 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. 2. Mok PS, Tan EY, Baerlocher MO, et al. What do family physicians know about interventional radiology? A survey of family physicians at a large Canadian annual scientific assembly. J Vasc Interv Radiol 2010; 21: 1250–1254. 3. Sunshine JH, Cypel YS, Schepps B. Diagnostic radiologists in 2000: basic characteristics, practices, and issues related to the radiologist shortage. AJR Am J Roengenol 2002; 178:291–301. 4. Ghatan CE, Kuo WT, Hofmann LV, et al. Making the case for early medical student education in interventional radiology: a survey of 2nd-year students in a single U.S. institution. J Vasc Interv Radiol 2010; 21:549–553. 5. O’Brien, Baerlocher MO, Asch MR, et al. Limitations influencing interventional radiology in Canada: results of a national survey by the Canadian Interventional Radiology Association (CIRA). Cardiovasc Intervent Radiol 2007; 30:847–853. 6. Baerlocher MO. Canada’s slow adoption of new technologies adds burden to health care system. CMAJ 2007; 176:616.
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7. Brantstetter BF 4th, Faix LE, Humphrey AL, et al. Preclinical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007; 188(1):9–14. 8. Malikova MA, Doros G, Joglar F, et al. A third-year 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. 9. Singh N, Causey W, Brounts L, et al. Vascular surgery knowledge and exposure obtained during medical school and the potential impact on career decisions. J. Vasc Surg 2010 Jan; 51:252–258.
10. Godshall CJ, Moore PS, Fleming SH, et al. A vascular disease educational program in the preclinical years of medical school increases student interest in vascular disease. J Vasc Surg 2010; 52:775–780. 11. Lefevre JH, Roupret M, Kerneis S, et al. Career choices of medical students: a national survey of 1780 students. Med Educ 2010; 44:603–612. 12. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two U.S. medical schools, 1998–2004. Acad Med 2005; 80:809–814. 13. Teitelbaum HS, Ehrlich N, Travis L. Factors affecting specialty choice among osteopathic medical students. Acad Med 2009; 84:718–723.
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APPENDIX. SURVEY
T
his survey was created at the St. Joseph’s Healthcare Hamilton Radiology Department to assess the level of knowledge that medical students have regarding interventional radiology. It was created in the hopes of understanding the level of exposure that medical students have to interventional radiology so that we may assess the need for further education in this field. The survey is completely anonymous. Participants cannot be identified. By taking the survey you are consenting to let us, the investigators, use the data compiled. You will be asked a series of 17 questions, most of which are multiple choice format or true/false. Thank you for taking the time to fill out this survey! 1. Year of medical school 1 2 3 2. How would you rate your knowledge of interventional radiology as compared to other subjects? Excellent/good/adequate/poor/no knowledge 3. Have you completed or do you plan to complete an elective in radiology (diagnostic or interventional)? Yes No 4. Would you consider a career in diagnostic radiology? Yes No Not sure 5. Would you consider a career in interventional radiology? Yes No
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9. An interventional radiologist must complete a residency in: Radiology surgery Both radiology and surgery Internal medicine Other (please specify):_____________________ 10. Interventional radiologists have outpatient clinics. True False 11. Interventional radiologists do ward rounds in the hospital. True False 12. Interventional radiologists admit patients to the hospital. True False 13. What has provided you with the most information about interventional radiology? Radiology elective Lectures from interventional radiologists Problem-based learning tutorials Self-directed research Ward rounds in the hospital Multidisciplinary meetings I have had no exposure to interventional radiology. Other (please specify):______________________ 14. How would you prefer to gain exposure to interventional radiology? Please rank the following methods for learning (rank 1 [best] to 8 [worst]).
Not sure 6. If you answered no or not sure to the previous question, please choose the most appropriate reason why. I don’t find it interesting I don’t know enough about it The lifestyle is not for me Radiation exposure Other (please specify):_____________________ 7. Have you seen patients who were treated by an interventional radiologist? Yes No
1(best) 2 3 4 5 6 7 (worst) Ward rounds Radiology department electives Lectures from interventional radiologists Multidisciplinary meetings Self-directed learning websites Problem-based learning tutorials Clinical research projects
Not sure 8. Please list three interventional radiology procedures that you are aware of: 1. ____________________ 2. ____________________ 3. ____________________
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15. Do you think a mandatory 2-week radiology rotation during clerkship would be beneficial? Yes No Not sure
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16. Would you be interested in doing a 2-week interventional radiology selective if it was offered during the 6-week surgery rotation in clerkship? Yes
17. Do you have any comments about interventional radiology in the medical school curriculum?
No Not sure
901