- Email: [email protected]
Challenges to Radiology Resident Education in the New Era
Challenges to Radiology Resident Education in the New Era Lori Deitte, MD
Over the past decade, there have been many developments that have changed the practice of radiology and the education of radiology residents. These include workforce issues, the institution of the Accreditation Council for Graduate Medical Education duty-hours restrictions, the increased use of night float systems, and the implementation of picture archiving and communication systems as well as voice recognition. This article reviews the impact on resident education, summarizes potential problems introduced by these changes, and examines proposed solutions. Key Words: Education, PACS, voice recognition, radiology J Am Coll Radiol 2006;3:528-533. Copyright © 2006 American College of Radiology
INTRODUCTION Long gone are the days when the primary role of a radiology resident was to hang films of unread studies with comparisons on an alternator and review the examinations before staffing them out with an attending radiologist. Radiology has undergone tremendous growth and change over the past decade. Some of the physical changes are obvious when entering a reading room. Alternators have been replaced with workstations. Films have been replaced with digital images. Tape-recording units have been replaced with headsets or handheld microphones for voice recognition. However, the impact of these changes on radiology resident education may not be so obvious at first glance. Simultaneously, major changes have occurred in medical education. Some of these have stemmed from the application of adult learning principles. This has resulted in an increased appreciation of the impact of active learning on the development of lifelong learners and critical thinkers empowered to function in the ever-changing medical practice environment [1]. Clearly, there are many factors facing radiology residency educators that were not present a decade ago. What impact have these factors had on radiology resident education? How have residency programs adapted to change? Are there additional measures that could be used to enhance the educational experience of radiology resi-
Department of Radiology, University of Florida–Jacksonville, Jacksonville, Fla. Corresponding author and reprints: Lori Deitte, MD, University of Florida–Jacksonville, Department of Radiology, 655 West Eighth Street, Jacksonville, FL 32209;e-mail: [email protected].
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dents and better prepare them for careers of lifelong learning in this new era? EXAMINING THE CHANGES A variety of forces have come together to significantly change the practice of radiology over the past decade. These factors have had an impact on radiology resident education and are as follows: ●
●
●
●
●
workforce issues, including shortages, decreasing reimbursement, increasing emphasis on clinical productivity, and the use of radiologist extenders; the institution of the Accreditation Council for Graduate Medical Education (ACGME) duty-hours restrictions; the more widespread adaptation of night float systems for resident call coverage and the increasing use of after-hours radiologic services; the implementation of picture archiving and communication systems (PACS) in conjunction with technologic advancements, resulting in the increased complexity of radiologic examinations; and the development of voice recognition for radiology report generation.
The effects of these changes are examined in more detail below. Workforce Issues During the past decade, there has been a fluctuating relationship between the supply of radiologists and the demand for their services. Only a few years ago, there was a severe shortage of radiologists, which seems to be easing of late [2]. This shortage compounded the difficulties that academic centers had already been experiencing in © 2006 American College of Radiology 0091-2182/06/$32.00 ● DOI 10.1016/j.jacr.2006.02.011
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recruiting and retaining faculty members. During the past several decades, there has been a significant increase in the percentage of teaching hospital revenue generated by academic faculty members’ clinical activity. Thus, faculty members must work harder to maintain the same level of earning at the expense of less time available for education and research. Additional factors, including economic fragility, inefficiency, and organizational complexity, led to the prediction of the demise of academic medical centers by some observers in the 1990s [3]. In a discussion of solutions to the financial situation of teaching hospitals, Barach [4] stated that in addition to providing superior training and the dissemination of specialized knowledge, these institutions must deliver the best medical care available and should consider revamping the archaic system of financing medical education in the United States. The ongoing challenge for academic centers is to provide excellent medical care, superior teaching, and cutting-edge research with limited resources and personnel. An additional challenge for radiology departments relates to the significant increase in workload per radiologist that has occurred during the past decade. According to a 2003 survey performed by the Society of Chairmen of Academic Radiology Departments, the average faculty clinical workload, as measured by relative value units per full-time equivalent, increased by 32% compared with 1998 and by 55% compared with 1996 [5]. These factors have resulted in an increased emphasis on the clinical productivity of faculty members. However, in a study evaluating the cost of teaching, Jamadar et al [6] concluded that informal resident teaching significantly reduces clinical throughput. The evaluation of the impact of clinical productivity on the quality of teaching, by nature, is subjective. In this study, teaching quality was assessed by instructing a second-year radiology resident and a radiology research associate to observe faculty readout sessions and independently grade the faculty members on discussions of radiographic signs, differential diagnosis, recommended subsequent tests, and clinical perspectives. The authors concluded that as the quality of teaching increases, the decrease in radiology faculty members’ productivity becomes more pronounced. There is concern that as clinical work demands increase, nonrevenue-generating resident teaching suffers. A potential solution is to employ radiologist extenders to handle duties that do not require the specialized training of a radiologist, freeing up faculty members for resident teaching. Some possibilities include radiologist assistants, physician assistants (PAs), and nurse practitioners [7]. It is generally agreed that the use of extenders will continue to increase, but the impact on radiology resident and fellow training has not yet been systematically studied. In an article discussing the likely effects on radiology training,
Smith and Applegate [8] stated that it is important that radiologist extenders be oriented toward teaching residents as part of their duties. The authors suggested that extenders perform tasks that are necessary for residents’ knowledge base but are otherwise noneducational and repetitive. Examples include venous access placement, the placement of enteric feeding tubes, and the catheterization and performance of voiding cystourethrograms. They noted that residents’ acceptance of extenders’ role as limited instructors is critical. In the University of Washington’s experience at Harborview Medical Center, the acceptance of radiology PAs by residents and fellows has been high. Even though there was initial concern that the PAs would compete with residents and fellows for cases, this was not the situation. Factors considered in determining the PAs’ responsibilities included the type of task, the level of complexity of the task, the educational value to radiology residents, and the difficulty of radiologist coverage with current staffing. Examples of the duties assigned to PAs included consultations, triage, performing less complex procedures and interpretations, and staffing a “line room” to assist with consents and groin compression. This program has been successful in addressing the ongoing radiologist staff shortage issue and freeing up attending radiologists to spend more time teaching residents and fellows [9]. Institution of Resident Duty-Hours Restrictions The ACGME instituted mandatory duty-hours limitations in July 2003. In a review article summarizing the literature regarding the impact on resident education and quality of life, Fletcher et al [10] concluded that the short-term effects on education are mixed and that longer term studies will be needed to understand the impact of this change and determine if there is a link with patient outcome data. They noted that several studies in the literature surveyed residents about perceived rather than objective outcomes and that a valid, reliable survey tool needs to be developed. In an article summarizing the 2004 survey of the American Association of Academic Chief Residents in Radiology, Peterson et al [11] found that 85% responded that the new ACGME requirements had improved their call experience and that 90% felt that their educational experience had been enhanced. They also noted that some programs switched to night float systems to comply with the new duty-hours restrictions. Although the survey results are of interest, there is inherent subjectivity with potential for the introduction of bias when asking a study group to assess the effect of measures resulting in work-hours reduction. Presently, the long-term effect of the ACGME work limitations on resident education has not been deter-
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mined. An additional issue to consider is whether faculty members’ attitudes toward resident education are affected by these regulations. Adaptation of Night Float Systems for Resident Call Coverage According to the 2004 radiology chief resident survey, 60% of the responding programs have implemented night float call systems, up from 42% in 1996 [11]. Although the use of these systems does help circumvent some duty-hours issues, there may be unintended consequences on resident education. One major concern pertains to the difficulty encountered in providing consistent formative feedback to on-call residents. At my institution, the night float resident reads all computed tomographic, ultrasound, and plain radiographic examinations from the trauma center and the emergency department. Even though there is an early-morning attending radiologist to staff out the plain x-rays, it is not unusual for the readout session to be interrupted by calls from the emergency room. We have attempted to improve this situation by building some overlap in resident coverage, with the day resident taking over the pager 30 minutes early. However, in our experience, it takes much longer to review the on-call cases with voice recognition than with traditional dictation and transcription. This is primarily related to inherent system delays and the increase in time demands involved with manually editing the reports, compared with dictating the corrections for transcription. With the institution of duty-hours restrictions, there is not enough time for the on-call resident to staff out cross-sectional imaging studies, which are typically read by attending radiologists in multiple subspecialty areas. We have addressed this issue by having forms available for feedback at the workstations. Examination information is recorded on the forms, which are then placed in the resident’s mailbox for review if there is a discrepancy between the resident’s initial reading and the final report. There are additional concerns regarding the impact of night float rotations on resident education. In a discussion of issues pertaining to residency review committee citations, Rumack [12] noted that there is a risk that night float residents will feel isolated and have very little interaction with faculty members and other radiology residents. One possible solution is the adaptation of alternate work hours for the attending staff. Perhaps an emergency radiology attending radiologist could work an early-morning shift to read out cases with a resident at a time when there are fewer interruptions. With the rapidly increasing on-call radiology workload [13], as well as recent medicolegal and turf-battle issues, there is a trend toward increased attending radiologist–level participation, resulting in 24-hour attending radiologist coverage
in some radiology emergency departments. In addition to improvement in patient care, there is the potential for increased teaching throughout the night. However, there is concern that having an attending radiologist readily available may diminish a resident’s on-call experience because of a decrease in autonomy [14]. Providing “nighthawk” radiology attending coverage necessitates the incurrence of additional faculty salary expenses. Even if funding is available, will academic institutions be able to recruit additional radiologists, considering the ongoing difficulties in recruiting and retaining faculty members in the current job market? The provision of 24-hour coverage has been a challenging issue for the private practice sector. Solutions have included staggered shift scheduling, employing radiologists to provide nighthawk coverage within practices, and outsourcing to established nighthawk services. Another educational concern is that night float residents are unable to attend daytime conferences during the month. One proposal is to rethink conference times to allow attendance by on-call residents [12]. Alternatively, consider videotaping conferences or developing narrated computer-based versions for later viewing. Implementation of PACS Without question, one of the greatest influencing factors on the practice of radiology in the past decade has been the transformation to the filmless department. As computed tomographic and magnetic resonance imaging examinations have increased in complexity and in the total number of images generated, it is no longer feasible to read these examinations on film. There have been multiple studies documenting an improvement in efficiency with PACS [15-17]. In comparison, articles addressing the effect of PACS on radiology resident education are sparse. In a prospective cohort study of the impact of changing from film-based to filmless image interpretation, data were collected on radiographic examinations of patients in the emergency department performed between 9:00 AM and 4:00 PM [18]. With the conversion to a workstation-based system, the authors reported a decrease in the autonomous participation of radiology residents in image interpretation from 38% to 17% and a decrease in the number of reports that the residents dictated from 45% to 4%. Simultaneously, the workload increased by 33%. A tendency toward “group reading” with attending radiologists dictating the reports was observed. These observations are concerning from an educational viewpoint. Adult learning principles emphasize the importance of “active” rather than “passive” learning. Intuitively, it makes sense that we would like to promote a learning environment that encourages residents to “be a radiologist” rather than “watch a radiologist” [18].
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In an October 1999 survey, residents’ perspectives of the impact of PACS on education were addressed [19]. The number of respondents was small (n ⫽ 20), with at least 6 first-year residents, limiting the authors’ ability to draw generalized conclusions. However, they noted that 75% believed that PACS had positively affected their learning experiences and had not negatively affected the quality of education. Most residents responded that PACS was superior to conventional radiography as a teaching tool. Specifically, comparison studies are more readily available, the elimination of time spent hanging films results in more time for teaching, and the increased size of on-screen images is more conducive to group readout sessions. Other advantages of PACS include increased ease of creating teaching files and image use for digital presentations in conferences. Another potential concern is the reported decrease in face-to-face interactions with referring physicians in a PACS environment. These interactions can be of significant educational value in medical training, because they constitute part of the informal curriculum [1]. In an article summarizing their 10-year filmless experience, Siegel et al [20] noted that PACS had a major impact on clinical consultations and communication, resulting in a significant decrease in face-to-face interactions, with an increase in digital communication. Their imaging department has encouraged direct communication by participation in conferences and meetings. Development of Voice Recognition With the use of computer-based voice recognition software, there is increased involvement of radiologists with the transcription process. Motivating factors to implement this system include cost savings associated with the elimination of transcriptionists and a reduction in radiology report turnaround time. However, unlike PACS, which have been demonstrated to result in increased efficiency, there have been reports that voice recognition systems result in decreased radiologist productivity because of the increased time necessary for radiologists to generate and correct reports [21,22]. These sentiments were echoed in a resident survey regarding the impact of PACS and voice recognition on the education of radiology residents. One hundred thirty-four residents were polled, with 42 respondents. Gutierrez et al [23] concluded that residents believe that PACS has positively affected their learning experience and that voice recognition is less reliable and more time consuming than traditional dictation services. Several issues were raised for discussion. Some residents felt that voice recognition was a distraction to education and that it slowed interpretation because they had to view a third monitor. Additionally, although some residents felt that PACS had increased their likelihood of viewing images directly while
they dictated, there still are residents who dictate from notes taken while staffing with attending radiologists rather than viewing the images directly while dictating. In our experience, it takes longer to generate reports with voice recognition, and editing reports on a third monitor can be distracting. However, a unique benefit pertains to the ability of residents to dictate preliminary reports that are immediately available to referring physicians. Our residents have noticed a significant decline in the number of phone calls requesting verbal reports, which helps improve productivity, particularly on call. Another issue that voice recognition raises is that of medical errors in radiology reports. There has been an increase in the public awareness of medical errors, which has resulted in the implementation of various measures to decrease errors. However, in their study, Rana et al [22] found that there were more errors when using voice recognition than traditional dictation and transcription and that this error rate increased with decreasing experience. RESIDENT EDUCATION: POTENTIAL PROBLEMS My department’s experience with PACS and voice recognition parallels the experiences of some of the above authors. We are concerned about potential unintended effects on resident education, including the following: ●
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decreased time available for teaching secondary to greater demands on radiologists when editing and dictating reports, increased passive learning due to the impact of group reading, and decreased feedback secondary to “remote” reading.
Before the development of all-digital radiology departments, the primary role of radiology residents was to hang and preview films, review examinations with attending radiologists, and then dictate reports. This “preview-review-dictate” cycle provided the feedback necessary for active resident learning. With the increased flexibility for viewing images and radiographic reports with PACS and voice recognition, there are multiple ways to conduct readout sessions. In my department, we have observed the following: ●
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Preview-review-dictate: A resident previews images independently and may take notes, dictate a preliminary report, or annotate the images. The images are then reviewed jointly with the attending radiologist. The report is subsequently edited or dictated by the resident or the attending radiologist. Review-dictate: A resident does not preview the images. The resident and attending radiologist view the
532 Journal of the American College of Radiology/ Vol. 3 No. 7 July 2006
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examination jointly, and the report is dictated later by the resident. Group reading: A resident and an attending radiologist view the images jointly while the attending radiologist dictates the report. Parallel reading: A resident and an attending radiologist dictate independently at workstations that are in close physical proximity. The resident previews examinations and dictates preliminary reports. The attending radiologist reviews the examinations and edits the reports at the adjacent workstation. Significant findings and discrepancies can be reviewed jointly. Remote reading: A resident previews the images independently and dictates a preliminary report. An attending radiologist reviews the images and report at a location physically remote from the resident. Reports are edited and released by the attending radiologist without reviewing the images jointly.
In our experience, it can take longer to edit a residentdictated report than to dictate a new report, decreasing the time available for teaching. Consequently, group readout sessions are often more efficient if the attending radiologist assumes the lead role, controlling the computer mouse and dictating reports. However, this process results in a more passive role for the resident. With the advent of voice recognition, it is possible for an attending radiologist to staff out cases at a location remote from the resident who dictated the preliminary report. Unfortunately, this removes the resident from the feedback cycle, thereby diminishing the educational value of previewing cases.
In summary, proposed resident education solutions include the following: ●
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RESIDENT EDUCATION: PROPOSED SOLUTIONS Radiology resident education could benefit from increased emphasis on adult learning principles. It has been determined that adult learners desire clear and achievable goals and objectives and that the learning process should be active, with immediate and specific feedback to affirm or modify behavior [24]. With PACS and voice recognition, there is the potential for resident learning to become more passive and for feedback to be decreased. Because of multiple factors, attending radiologists have less time available to teach than in the past, and self-directed learning should be encouraged. This is representative of the ACGME’s general competency of practice-based learning and improvement and helps prepare residents for careers of lifelong learning. As of July 1, 2006, the ACGME’s requirements for this competency include the documentation of resident conferences and courses attended, as well as the completion of self-assessment modules [25].
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Continue to promote the preview-review-dictate cycle of active learning. With voice recognition, a preliminary report can be dictated and then modified by a resident after review with an attending radiologist. In a high-volume workload situation, it is necessary to have sufficient workstations available so that the attending radiologist can be dictating additional cases while the resident is dictating reviewed cases. Encourage residents to always view images while dictating reports, rather than simply dictating from notes taken during the readout session. Discourage “remote” reading on cases previewed by residents. In situations in which the workload is so high that joint reviews cannot regularly occur, “parallel” reading may be helpful so that residents can still receive immediate and specific feedback on previewed cases. Encourage the adaptation of a system that provides regular feedback to night float or on-call residents. There are several potential solutions to this issue. Feedback can be provided via a form placed in resident’s mailboxes or e-mail. We have requested our PACS manufacturer to develop software that provides a mechanism for the placement of cases in residents’ work queues for review. It is possible that other PACS systems already have this feature available. Evaluate attending physicians’ work schedule options and consider the addition of emergency radiologists with alternate work hours to increase teaching during call. Increase the availability of educational conferences to night float residents by videotaping the conferences or by developing narrated computer-based versions that can be viewed when feasible. Alternatively, consider scheduling conferences when night float residents can attend. Encourage self-directed learning with digital teaching files and computer-based modules such as self-assessment modules. Consider the employment of radiologist extenders to free up faculty members for resident teaching. Promote face-to-face interactions with referring physicians through active participation in multidisciplinary conferences and meetings.
CONCLUSION Over the past decade, there have been many developments that have changed the practice of radiology and the education of radiology residents. Despite these changes, it is imperative to prioritize one of the primary missions of academic radiology departments: the educa-
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tion of residents. As adult learners, residents need to be actively involved in the learning process. All-digital radiology residency programs should be designed so that formative feedback is available to residents, regardless of whether they are on busy clinical rotations or night float. Although there are survey results available addressing the effect of these developments on education, the surveys are subjective and generally assess perceptions rather than objective data. I am not aware of outcomes data that assess the overall impact on radiology resident education in the new era.
12. Rumack CM. Diagnostic Radiology Residency Review Committee program citations and how to avoid them. J Am Coll Radiol 2005;2:617-21.
REFERENCES
17. Redfern RO, Horii SC, Feingold E, Kundel HL. Radiology workflow and patient volume: effect of picture archiving and communication systems on technologists and radiologists. J Digit Imaging 2000;13(2 suppl 1):97100.
1. Stagnard-Green A. Applying adult learning principles to medical education in the United States. Med Teacher 2004;26:79-85. 2. Bhargavan M, Sunshine JH. Workload of radiologists in the United States in 2002-2003 and trends since 1991-1992. Radiology 2005;236:920-31. 3. Moses H, Thier SO, Matheson DH. Why have academic medical centers survived? JAMA 2005;293:1495-500. 4. Barach P. Teaching hospitals in trouble: finding solutions. JAMA 1999; 282:1686. 5. Lu Y, Arenson, RL. The academic radiologist’s clinical productivity. Acad Radiol 2005;12:1211-23. 6. Jamadar DA, Carlos R, Caoili EM, et al. Estimating the effects of informal radiology resident teaching on radiologist productivity: what is the cost of teaching? Acad Radiol 2005;12:123-8. 7. Dunnick NR. ACR Intersociety Conference 2003: radiologist assistants and other radiologist extenders. J Am Coll Radiol 2004;1:386-91.
13. Carroll TJ. Trends in on-call workload in an academic medical center radiology department 1998-2002. Acad Radiol 2003;10:1312-20. 14. Bansal A. Twenty-four-hour attending physician coverage and its impact on resident training. J Am Coll Radiol 2005;2:642-4. 15. Twair AA, Torreggiani WC, Mahmud SM, Ramesh N, Hogan B. Significant savings in radiologic report turnaround time after implementation of a complete picture archiving and communication system (PACS). J Digit Imaging 2000;13:175-7. 16. Mattern CW, King BF, Hangiandreou NJ, et al. Electronic imaging impact on image and report turnaround times. J Digit Imaging 1999;12(2 suppl 1):155-9.
18. Redfern RO, Lowe RA, Kundel HL, et al. From being a radiologist to watching a radiologist: impact of filmless operation on the training of radiology residents. Acad Radiol 2001;8:1154-8. 19. Mullins ME, Mehta A, Patel H, McLoud TC, Novelline RA. Impact of PACS on the education of radiology residents: the residents’ perspective. Acad Radiol 2001;8:67-73. 20. Siegel EL, Reiner BI, Siddiqui. Ten filmless years and ten lessons: a 10th anniversary retrospective for the Baltimore VA Medical Center. J Am Coll Radiol 2004;1:824-33. 21. Gale B, Safriel Y, Lukban A, Kalowitz J, Fleischer J, Gordon D. Radiology report production times: voice recognition vs transcription. Radiol Manage 2001;23:18-22.
8. Smith WL, Applegate KE. The likely effects of radiologist extenders on radiology training. J Am Coll Radiol 2004;1:402-4.
22. Rana DS, Hurst G, Shepstone L, Pilling J, Cockburn J, Crawford M. Voice recognition for radiology reporting: is it good enough? Clin Radiol 2005;60:1205-12.
9. Blackmore CC, Hoffer EK, Albrecht E, Mann FA. Physician assistants in academic radiology: the Harborview experience. J Am Coll Radiol 2004; 1:410-4.
23. Gutierrez AJ, Mullins ME, Novelline RA. Impact of PACS and voice recognition reporting on the education of radiology residents. J Digit Imaging 2005;18:100-8.
10. Fletcher KE, Underwood W, Davis SQ, Mangrulkar RS, McMahon LF, Saint S. Effects of work hour reduction on residents’ lives. JAMA 2005; 294:1088-100.
24. Walker M, Harris D. Principles of adult education. In: Peyton JWR, editor. Teaching and learning in medical practice. Rickmansworth, United Kingdom: Manticore Europe; 1998.
11. Peterson CM, Gerstle R, Bhalla S, Menias CO, Jost RG. Results of the 2004 survey of the American Association of Academic Chief Residents in Radiology. Acad Radiol 2005;12:373-8.
25. Accreditation Council for Graduate Medical Education. Competencies definitions and practice performance measurements. Available at: http:// www.acgme.org/acWebsite/RRC_420/420_compDefsPerfMeas.pdf.
Over the past decade, there have been many developments that have changed the practice of radiology and the education of radiology residents. These include workforce issues, the institution of the Accreditation Council for Graduate Medical Education duty-hours restrictions, the increased use of night float systems, and the implementation of picture archiving and communication systems as well as voice recognition. This article reviews the impact on resident education, summarizes potential problems introduced by these changes, and examines proposed solutions. Key Words: Education, PACS, voice recognition, radiology J Am Coll Radiol 2006;3:528-533. Copyright © 2006 American College of Radiology
INTRODUCTION Long gone are the days when the primary role of a radiology resident was to hang films of unread studies with comparisons on an alternator and review the examinations before staffing them out with an attending radiologist. Radiology has undergone tremendous growth and change over the past decade. Some of the physical changes are obvious when entering a reading room. Alternators have been replaced with workstations. Films have been replaced with digital images. Tape-recording units have been replaced with headsets or handheld microphones for voice recognition. However, the impact of these changes on radiology resident education may not be so obvious at first glance. Simultaneously, major changes have occurred in medical education. Some of these have stemmed from the application of adult learning principles. This has resulted in an increased appreciation of the impact of active learning on the development of lifelong learners and critical thinkers empowered to function in the ever-changing medical practice environment [1]. Clearly, there are many factors facing radiology residency educators that were not present a decade ago. What impact have these factors had on radiology resident education? How have residency programs adapted to change? Are there additional measures that could be used to enhance the educational experience of radiology resi-
Department of Radiology, University of Florida–Jacksonville, Jacksonville, Fla. Corresponding author and reprints: Lori Deitte, MD, University of Florida–Jacksonville, Department of Radiology, 655 West Eighth Street, Jacksonville, FL 32209;e-mail: [email protected].
528
dents and better prepare them for careers of lifelong learning in this new era? EXAMINING THE CHANGES A variety of forces have come together to significantly change the practice of radiology over the past decade. These factors have had an impact on radiology resident education and are as follows: ●
●
●
●
●
workforce issues, including shortages, decreasing reimbursement, increasing emphasis on clinical productivity, and the use of radiologist extenders; the institution of the Accreditation Council for Graduate Medical Education (ACGME) duty-hours restrictions; the more widespread adaptation of night float systems for resident call coverage and the increasing use of after-hours radiologic services; the implementation of picture archiving and communication systems (PACS) in conjunction with technologic advancements, resulting in the increased complexity of radiologic examinations; and the development of voice recognition for radiology report generation.
The effects of these changes are examined in more detail below. Workforce Issues During the past decade, there has been a fluctuating relationship between the supply of radiologists and the demand for their services. Only a few years ago, there was a severe shortage of radiologists, which seems to be easing of late [2]. This shortage compounded the difficulties that academic centers had already been experiencing in © 2006 American College of Radiology 0091-2182/06/$32.00 ● DOI 10.1016/j.jacr.2006.02.011
Deitte/Radiology Resident Education 529
recruiting and retaining faculty members. During the past several decades, there has been a significant increase in the percentage of teaching hospital revenue generated by academic faculty members’ clinical activity. Thus, faculty members must work harder to maintain the same level of earning at the expense of less time available for education and research. Additional factors, including economic fragility, inefficiency, and organizational complexity, led to the prediction of the demise of academic medical centers by some observers in the 1990s [3]. In a discussion of solutions to the financial situation of teaching hospitals, Barach [4] stated that in addition to providing superior training and the dissemination of specialized knowledge, these institutions must deliver the best medical care available and should consider revamping the archaic system of financing medical education in the United States. The ongoing challenge for academic centers is to provide excellent medical care, superior teaching, and cutting-edge research with limited resources and personnel. An additional challenge for radiology departments relates to the significant increase in workload per radiologist that has occurred during the past decade. According to a 2003 survey performed by the Society of Chairmen of Academic Radiology Departments, the average faculty clinical workload, as measured by relative value units per full-time equivalent, increased by 32% compared with 1998 and by 55% compared with 1996 [5]. These factors have resulted in an increased emphasis on the clinical productivity of faculty members. However, in a study evaluating the cost of teaching, Jamadar et al [6] concluded that informal resident teaching significantly reduces clinical throughput. The evaluation of the impact of clinical productivity on the quality of teaching, by nature, is subjective. In this study, teaching quality was assessed by instructing a second-year radiology resident and a radiology research associate to observe faculty readout sessions and independently grade the faculty members on discussions of radiographic signs, differential diagnosis, recommended subsequent tests, and clinical perspectives. The authors concluded that as the quality of teaching increases, the decrease in radiology faculty members’ productivity becomes more pronounced. There is concern that as clinical work demands increase, nonrevenue-generating resident teaching suffers. A potential solution is to employ radiologist extenders to handle duties that do not require the specialized training of a radiologist, freeing up faculty members for resident teaching. Some possibilities include radiologist assistants, physician assistants (PAs), and nurse practitioners [7]. It is generally agreed that the use of extenders will continue to increase, but the impact on radiology resident and fellow training has not yet been systematically studied. In an article discussing the likely effects on radiology training,
Smith and Applegate [8] stated that it is important that radiologist extenders be oriented toward teaching residents as part of their duties. The authors suggested that extenders perform tasks that are necessary for residents’ knowledge base but are otherwise noneducational and repetitive. Examples include venous access placement, the placement of enteric feeding tubes, and the catheterization and performance of voiding cystourethrograms. They noted that residents’ acceptance of extenders’ role as limited instructors is critical. In the University of Washington’s experience at Harborview Medical Center, the acceptance of radiology PAs by residents and fellows has been high. Even though there was initial concern that the PAs would compete with residents and fellows for cases, this was not the situation. Factors considered in determining the PAs’ responsibilities included the type of task, the level of complexity of the task, the educational value to radiology residents, and the difficulty of radiologist coverage with current staffing. Examples of the duties assigned to PAs included consultations, triage, performing less complex procedures and interpretations, and staffing a “line room” to assist with consents and groin compression. This program has been successful in addressing the ongoing radiologist staff shortage issue and freeing up attending radiologists to spend more time teaching residents and fellows [9]. Institution of Resident Duty-Hours Restrictions The ACGME instituted mandatory duty-hours limitations in July 2003. In a review article summarizing the literature regarding the impact on resident education and quality of life, Fletcher et al [10] concluded that the short-term effects on education are mixed and that longer term studies will be needed to understand the impact of this change and determine if there is a link with patient outcome data. They noted that several studies in the literature surveyed residents about perceived rather than objective outcomes and that a valid, reliable survey tool needs to be developed. In an article summarizing the 2004 survey of the American Association of Academic Chief Residents in Radiology, Peterson et al [11] found that 85% responded that the new ACGME requirements had improved their call experience and that 90% felt that their educational experience had been enhanced. They also noted that some programs switched to night float systems to comply with the new duty-hours restrictions. Although the survey results are of interest, there is inherent subjectivity with potential for the introduction of bias when asking a study group to assess the effect of measures resulting in work-hours reduction. Presently, the long-term effect of the ACGME work limitations on resident education has not been deter-
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mined. An additional issue to consider is whether faculty members’ attitudes toward resident education are affected by these regulations. Adaptation of Night Float Systems for Resident Call Coverage According to the 2004 radiology chief resident survey, 60% of the responding programs have implemented night float call systems, up from 42% in 1996 [11]. Although the use of these systems does help circumvent some duty-hours issues, there may be unintended consequences on resident education. One major concern pertains to the difficulty encountered in providing consistent formative feedback to on-call residents. At my institution, the night float resident reads all computed tomographic, ultrasound, and plain radiographic examinations from the trauma center and the emergency department. Even though there is an early-morning attending radiologist to staff out the plain x-rays, it is not unusual for the readout session to be interrupted by calls from the emergency room. We have attempted to improve this situation by building some overlap in resident coverage, with the day resident taking over the pager 30 minutes early. However, in our experience, it takes much longer to review the on-call cases with voice recognition than with traditional dictation and transcription. This is primarily related to inherent system delays and the increase in time demands involved with manually editing the reports, compared with dictating the corrections for transcription. With the institution of duty-hours restrictions, there is not enough time for the on-call resident to staff out cross-sectional imaging studies, which are typically read by attending radiologists in multiple subspecialty areas. We have addressed this issue by having forms available for feedback at the workstations. Examination information is recorded on the forms, which are then placed in the resident’s mailbox for review if there is a discrepancy between the resident’s initial reading and the final report. There are additional concerns regarding the impact of night float rotations on resident education. In a discussion of issues pertaining to residency review committee citations, Rumack [12] noted that there is a risk that night float residents will feel isolated and have very little interaction with faculty members and other radiology residents. One possible solution is the adaptation of alternate work hours for the attending staff. Perhaps an emergency radiology attending radiologist could work an early-morning shift to read out cases with a resident at a time when there are fewer interruptions. With the rapidly increasing on-call radiology workload [13], as well as recent medicolegal and turf-battle issues, there is a trend toward increased attending radiologist–level participation, resulting in 24-hour attending radiologist coverage
in some radiology emergency departments. In addition to improvement in patient care, there is the potential for increased teaching throughout the night. However, there is concern that having an attending radiologist readily available may diminish a resident’s on-call experience because of a decrease in autonomy [14]. Providing “nighthawk” radiology attending coverage necessitates the incurrence of additional faculty salary expenses. Even if funding is available, will academic institutions be able to recruit additional radiologists, considering the ongoing difficulties in recruiting and retaining faculty members in the current job market? The provision of 24-hour coverage has been a challenging issue for the private practice sector. Solutions have included staggered shift scheduling, employing radiologists to provide nighthawk coverage within practices, and outsourcing to established nighthawk services. Another educational concern is that night float residents are unable to attend daytime conferences during the month. One proposal is to rethink conference times to allow attendance by on-call residents [12]. Alternatively, consider videotaping conferences or developing narrated computer-based versions for later viewing. Implementation of PACS Without question, one of the greatest influencing factors on the practice of radiology in the past decade has been the transformation to the filmless department. As computed tomographic and magnetic resonance imaging examinations have increased in complexity and in the total number of images generated, it is no longer feasible to read these examinations on film. There have been multiple studies documenting an improvement in efficiency with PACS [15-17]. In comparison, articles addressing the effect of PACS on radiology resident education are sparse. In a prospective cohort study of the impact of changing from film-based to filmless image interpretation, data were collected on radiographic examinations of patients in the emergency department performed between 9:00 AM and 4:00 PM [18]. With the conversion to a workstation-based system, the authors reported a decrease in the autonomous participation of radiology residents in image interpretation from 38% to 17% and a decrease in the number of reports that the residents dictated from 45% to 4%. Simultaneously, the workload increased by 33%. A tendency toward “group reading” with attending radiologists dictating the reports was observed. These observations are concerning from an educational viewpoint. Adult learning principles emphasize the importance of “active” rather than “passive” learning. Intuitively, it makes sense that we would like to promote a learning environment that encourages residents to “be a radiologist” rather than “watch a radiologist” [18].
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In an October 1999 survey, residents’ perspectives of the impact of PACS on education were addressed [19]. The number of respondents was small (n ⫽ 20), with at least 6 first-year residents, limiting the authors’ ability to draw generalized conclusions. However, they noted that 75% believed that PACS had positively affected their learning experiences and had not negatively affected the quality of education. Most residents responded that PACS was superior to conventional radiography as a teaching tool. Specifically, comparison studies are more readily available, the elimination of time spent hanging films results in more time for teaching, and the increased size of on-screen images is more conducive to group readout sessions. Other advantages of PACS include increased ease of creating teaching files and image use for digital presentations in conferences. Another potential concern is the reported decrease in face-to-face interactions with referring physicians in a PACS environment. These interactions can be of significant educational value in medical training, because they constitute part of the informal curriculum [1]. In an article summarizing their 10-year filmless experience, Siegel et al [20] noted that PACS had a major impact on clinical consultations and communication, resulting in a significant decrease in face-to-face interactions, with an increase in digital communication. Their imaging department has encouraged direct communication by participation in conferences and meetings. Development of Voice Recognition With the use of computer-based voice recognition software, there is increased involvement of radiologists with the transcription process. Motivating factors to implement this system include cost savings associated with the elimination of transcriptionists and a reduction in radiology report turnaround time. However, unlike PACS, which have been demonstrated to result in increased efficiency, there have been reports that voice recognition systems result in decreased radiologist productivity because of the increased time necessary for radiologists to generate and correct reports [21,22]. These sentiments were echoed in a resident survey regarding the impact of PACS and voice recognition on the education of radiology residents. One hundred thirty-four residents were polled, with 42 respondents. Gutierrez et al [23] concluded that residents believe that PACS has positively affected their learning experience and that voice recognition is less reliable and more time consuming than traditional dictation services. Several issues were raised for discussion. Some residents felt that voice recognition was a distraction to education and that it slowed interpretation because they had to view a third monitor. Additionally, although some residents felt that PACS had increased their likelihood of viewing images directly while
they dictated, there still are residents who dictate from notes taken while staffing with attending radiologists rather than viewing the images directly while dictating. In our experience, it takes longer to generate reports with voice recognition, and editing reports on a third monitor can be distracting. However, a unique benefit pertains to the ability of residents to dictate preliminary reports that are immediately available to referring physicians. Our residents have noticed a significant decline in the number of phone calls requesting verbal reports, which helps improve productivity, particularly on call. Another issue that voice recognition raises is that of medical errors in radiology reports. There has been an increase in the public awareness of medical errors, which has resulted in the implementation of various measures to decrease errors. However, in their study, Rana et al [22] found that there were more errors when using voice recognition than traditional dictation and transcription and that this error rate increased with decreasing experience. RESIDENT EDUCATION: POTENTIAL PROBLEMS My department’s experience with PACS and voice recognition parallels the experiences of some of the above authors. We are concerned about potential unintended effects on resident education, including the following: ●
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decreased time available for teaching secondary to greater demands on radiologists when editing and dictating reports, increased passive learning due to the impact of group reading, and decreased feedback secondary to “remote” reading.
Before the development of all-digital radiology departments, the primary role of radiology residents was to hang and preview films, review examinations with attending radiologists, and then dictate reports. This “preview-review-dictate” cycle provided the feedback necessary for active resident learning. With the increased flexibility for viewing images and radiographic reports with PACS and voice recognition, there are multiple ways to conduct readout sessions. In my department, we have observed the following: ●
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Preview-review-dictate: A resident previews images independently and may take notes, dictate a preliminary report, or annotate the images. The images are then reviewed jointly with the attending radiologist. The report is subsequently edited or dictated by the resident or the attending radiologist. Review-dictate: A resident does not preview the images. The resident and attending radiologist view the
532 Journal of the American College of Radiology/ Vol. 3 No. 7 July 2006
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examination jointly, and the report is dictated later by the resident. Group reading: A resident and an attending radiologist view the images jointly while the attending radiologist dictates the report. Parallel reading: A resident and an attending radiologist dictate independently at workstations that are in close physical proximity. The resident previews examinations and dictates preliminary reports. The attending radiologist reviews the examinations and edits the reports at the adjacent workstation. Significant findings and discrepancies can be reviewed jointly. Remote reading: A resident previews the images independently and dictates a preliminary report. An attending radiologist reviews the images and report at a location physically remote from the resident. Reports are edited and released by the attending radiologist without reviewing the images jointly.
In our experience, it can take longer to edit a residentdictated report than to dictate a new report, decreasing the time available for teaching. Consequently, group readout sessions are often more efficient if the attending radiologist assumes the lead role, controlling the computer mouse and dictating reports. However, this process results in a more passive role for the resident. With the advent of voice recognition, it is possible for an attending radiologist to staff out cases at a location remote from the resident who dictated the preliminary report. Unfortunately, this removes the resident from the feedback cycle, thereby diminishing the educational value of previewing cases.
In summary, proposed resident education solutions include the following: ●
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RESIDENT EDUCATION: PROPOSED SOLUTIONS Radiology resident education could benefit from increased emphasis on adult learning principles. It has been determined that adult learners desire clear and achievable goals and objectives and that the learning process should be active, with immediate and specific feedback to affirm or modify behavior [24]. With PACS and voice recognition, there is the potential for resident learning to become more passive and for feedback to be decreased. Because of multiple factors, attending radiologists have less time available to teach than in the past, and self-directed learning should be encouraged. This is representative of the ACGME’s general competency of practice-based learning and improvement and helps prepare residents for careers of lifelong learning. As of July 1, 2006, the ACGME’s requirements for this competency include the documentation of resident conferences and courses attended, as well as the completion of self-assessment modules [25].
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Continue to promote the preview-review-dictate cycle of active learning. With voice recognition, a preliminary report can be dictated and then modified by a resident after review with an attending radiologist. In a high-volume workload situation, it is necessary to have sufficient workstations available so that the attending radiologist can be dictating additional cases while the resident is dictating reviewed cases. Encourage residents to always view images while dictating reports, rather than simply dictating from notes taken during the readout session. Discourage “remote” reading on cases previewed by residents. In situations in which the workload is so high that joint reviews cannot regularly occur, “parallel” reading may be helpful so that residents can still receive immediate and specific feedback on previewed cases. Encourage the adaptation of a system that provides regular feedback to night float or on-call residents. There are several potential solutions to this issue. Feedback can be provided via a form placed in resident’s mailboxes or e-mail. We have requested our PACS manufacturer to develop software that provides a mechanism for the placement of cases in residents’ work queues for review. It is possible that other PACS systems already have this feature available. Evaluate attending physicians’ work schedule options and consider the addition of emergency radiologists with alternate work hours to increase teaching during call. Increase the availability of educational conferences to night float residents by videotaping the conferences or by developing narrated computer-based versions that can be viewed when feasible. Alternatively, consider scheduling conferences when night float residents can attend. Encourage self-directed learning with digital teaching files and computer-based modules such as self-assessment modules. Consider the employment of radiologist extenders to free up faculty members for resident teaching. Promote face-to-face interactions with referring physicians through active participation in multidisciplinary conferences and meetings.
CONCLUSION Over the past decade, there have been many developments that have changed the practice of radiology and the education of radiology residents. Despite these changes, it is imperative to prioritize one of the primary missions of academic radiology departments: the educa-
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tion of residents. As adult learners, residents need to be actively involved in the learning process. All-digital radiology residency programs should be designed so that formative feedback is available to residents, regardless of whether they are on busy clinical rotations or night float. Although there are survey results available addressing the effect of these developments on education, the surveys are subjective and generally assess perceptions rather than objective data. I am not aware of outcomes data that assess the overall impact on radiology resident education in the new era.
12. Rumack CM. Diagnostic Radiology Residency Review Committee program citations and how to avoid them. J Am Coll Radiol 2005;2:617-21.
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