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Developing Tomorrow's Academic Radiologists
Radiology Resident Education
2003 AUR Joseph E. and Nancy O. Whitley Award
Developing Tomorrow’s Academic Radiologists: A 3-month Residency Elective in Education1 Richard B. Gunderman, MD, PhD, Darel E. Heitkamp, MD, Hal D. Kipfer, MD Mark S. Frank, MD, Valerie P. Jackson, MD, Ken B. Williamson, PhD
Rationale and Objectives. The shortage of academic radiologists reveals an urgent need to attract more residents into academic careers. A great deal of attention has been focused on research, but few programmatic initiatives have addressed the development of the next generation of radiology educators. The purpose of this study was to develop and test a new 3-month residency elective in education. Materials and Methods. A large academic radiology department developed a 3-month education elective, during which two residents would be relieved of clinical duties and focus full-time on tasks related to their development as educators, including the completion of a major educational project. Results. Two residents, in their 3rd year and 4th year of residency, respectively, proposed to collaborate in developing a Web-delivered tutorial for the department’s senior medical student clerkship. At the end of 3 months, their radiology tutorial was introduced. In its 1st month, it received a mean rating of 4.3 on a five-point scale. The residents stated that the elective had enabled them to develop important skills in instructional technology, put into practice their enhanced understanding of learning psychology, and substantially strengthened their overall commitment to academic careers. Conclusion. It is vital that residency programs focus on developing the next generation of radiology educators. This ongoing education elective represents one successful model. Key Word. Education. ©
AUR, 2003
The direction in which education starts a man will determine his future life. Plato, Republic IV
A number of observations indicate that the future of academic radiology is in peril. Most academic radiology departments are understaffed. Academic radiologists are being asked to perform more clinical work than ever before, eroding their time for distinctively academic activiAcad Radiol 2003; 10:650 – 656 1 From the Education Division, Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 462025200. Received February 14, 2003; accepted March 6. Address correspondence to R.B.G.
©
AUR, 2003
650
ties such as research, teaching, and professional service. The financial incentives for residents to choose private practice careers have never been greater. This situation represents a profound threat to the future of radiology (1). Today’s research will determine what tomorrow’s radiologists practice, today’s education will determine what tomorrow’s radiologists know, and today’s service will determine the professional standing of radiology for years to come. Academicians play a disproportionately large role in research, teaching, and professional service. If radiology does not manage to attract a sufficient number of residents to academic careers, everyone will suffer. It is vital that radiology residency programs make substantial investments in the development of future academic radiologists (2).
Academic Radiology, Vol 10, No 6, June 2003
In so doing, academic radiology departments might pursue a number of strategies. One strategy would be to increase the financial incentives for residents to choose academic careers. Unfortunately, such an approach would rapidly prove counterproductive. Before long, it would force academic departments to generate more clinical revenue to fund this increase in compensation, thereby reducing the faculty’s time for nonclinical pursuits. A second strategy would be to require certain residency and fellowship applicants to commit to an academic appointment at the conclusion of their training. Unfortunately, this would do nothing to enhance the intrinsic appeal of an academic career, and such agreements might, in any case, be difficult to enforce (3). A third strategy would be to develop opportunities for residents to experience firsthand the professional challenges and rewards of academic radiology. New competencies required of residents by the Accreditation Council for Graduate Medical Education provide implicit support for moving residency curricula toward a more academic orientation (4). A number of initiatives are beginning to move radiology in this direction. By reducing the amount of time that selected residents must devote to clinical training, the Holman pathway of the American Board of Radiology provides an intensive exposure to research without increasing the overall length of residency. Some institutions are now requiring a full year of research experience in addition to the 4 years their residents devote to clinical training in radiology. Other programs are providing substantial training in research methods and critical thinking. These important steps reflect an important recognition that sending the brightest and best radiology residents into lucrative private practice careers is not a viable long-term strategy for the profession. They show promise as means of improving the future quality of radiologic research (5). Unfortunately, these measures do little to develop the next generation of radiology educators. For several reasons, education tends to rank below clinical care and research as a priority for many academic radiology departments (6). First, taking on new education responsibilities or improving existing teaching programs generates little new revenue for an academic department, and therefore such activities may not appeal to departmental leaders. Moreover, the academic system tends to assign a lower value to teaching than to research as a means of obtaining promotion and tenure. Medical school deans and department chairs are frequently graded for their ability to attract extramural funding, and the funding available in education pales by comparison to that in research. Finally,
DEVELOPING TOMORROW’S ACADEMIC RADIOLOGISTS
many radiology leaders operate from a mistaken presumption that good educators are born, not made. Therefore, they may think, there is little point in devoting scarce resources to the promotion of educational excellence. Yet, education is every bit as vital to the future of radiology as research (7). Radiology programs must provide high-quality education to residents, who will use what they learn in residency as the basis for their practice for decades to come. Providing high-quality medical student education is equally important. Medical students choose their careers partly on the basis of the quality of teaching they receive, and radiology needs the highest-quality medical students it can attract. Even medical students who choose other fields are vital to a referral-based specialty such as radiology, since their familiarity with radiology will influence the number and quality of referrals they provide once they enter practice. Other vital but frequently underappreciated missions for radiology education include continuing education for radiologists and nonradiologist physicians, technologists, nurses, health care administrators, and others whose perceptions and practices influence the quality of radiology practice. For these reasons, it is vital that radiology residency programs make substantial investments in the development of the next generation of radiology educators. The purpose of this study was to develop and test the implementation of a new 3-month elective for radiology residents in education. To our knowledge, no other full-time educational opportunity of this type and magnitude has ever been developed for radiology residents (8). The intent of this educational innovation was threefold. First, we sought to provide selected residents a high-quality exposure to the theory and methods of education, thereby enabling them to benefit from an important knowledge base about which many radiologists know little. Second, we wanted them to develop expertise with cutting-edge educational technologies that they could use throughout their careers. Finally, we aimed to provide a deep immersion in the challenges and rewards of teaching radiology, with the hope that participating residents would find education so interesting that it would attract them to academic careers. The best way to interest people in a career track is not to bribe or coerce them, but to give them a first-rate opportunity to try it out and succeed for themselves. MATERIALS AND METHODS Having identified the need to develop radiology residents as educators, the education committee of a large
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academic radiology department met multiple times to discuss appropriate strategies for achieving this objective. After extensive discussion, it was determined that, in order to be successful, the program would have to provide (a) opportunities to participate in active, hands-on education that turns residents into teachers as opposed to passive observers of education, (b) substantial release time from clinical responsibilities so that residents can focus their attention on their educational endeavors, (c) exposure of sufficient duration to permit participants to develop confidence as educators, (d) a serious commitment of technical instruction and support, and (e) effective mentoring to ensure that participants receive the supervision and guidance they need to succeed. With these priorities in mind, the department faculty instituted a 3-month elective in radiology education, making it available to residents who have completed at least 1 year of residency. On the basis of clinical needs, it was decided that a maximum of two residents could participate in the education elective each year. During this period, selected residents would be removed from the regular monthly clinical rotation schedule. However, they would continue to attend the department’s daily teaching conferences, occasional visiting professor lectures, and weekly teaching sessions of a clinical section of their choice, and their night and weekend call duties would continue. Participants could use vacation time for the elective; otherwise, they would be expected to maintain regular work hours 5 days per week. The elective would be organized around a major project, to be outlined and approved prior to commencing work and completed during the 3-month period. A variety of potential resident projects were identified, including assuming major responsibility for teaching one of the department’s medical student or radiologic technology courses, carrying out a major research project in radiology education, or developing a new educational resource, such as an electronic tutorial for medical students or residents or new teaching tools for radiology faculty members (9). A faculty mentor or mentors would be designated for each resident, and residents would be given office space in the department’s education division. There they would have access to personnel with expertise in such areas as curriculum design, evaluation methods, and instructional technology, as well as necessary equipment and secretarial support. Weekly progress updates would take place at divisional meetings, where unexpected problems and opportunities could be identified and addressed promptly.
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Selection of residents for participation in the elective would be based on four criteria. The first is the resident’s prior level of commitment to radiology education. The second is a strong record of clinical performance during the residency—a criterion that is designed to avoid depriving a struggling resident of 3 important months of clinical training. The third is a strong commitment to an academic career. Finally, residents would be selected on the basis of the quality of their project proposal. RESULTS During the 1st year of the education elective, two residents were selected for participation— one in the 3rd year and the other in the 4th year of postgraduate training. Both residents had voiced strong interest in education since the time they interviewed for a residency position, and both had been active contributors to the department’s educational programs, particularly in the area of medical student education. Both residents proposed to work on the same project concurrently, with the expectation that they would be able to collaborate and spur one another on, making for a more enjoyable and productive experience. Their project focused on the development of an electronic learning resource for the department’s 4th-year medical student clerkship (10). The school’s senior students are enrolled in this required clerkship for a period of 1 month, each group consisting of 20 –30 students. Because faculty time available for basic monthly lectures to such groups is steadily decreasing, the residents proposed to relieve some of this demand on faculty members’ time by developing an interactive Web-delivered radiology tutorial (11). The tutorial was designed to enable students to develop basic radiologic competencies through independent and small-group study, while freeing faculty to reallocate valuable teaching time to more advanced use of imaging for the solution of higher-level clinical problems. Students would be able to spend more of their in-class time with faculty members, solving the sorts of problems they would soon encounter in clinical practice as interns and residents. The tutorial would consist of modules in each of 10 major radiologic subspecialties. The chest radiography module provides an example of how some of this basic material would be covered (Fig 1). A portion of the module included interactive discussions of technical factors in radiographic interpretation, such as inspiration, penetration, and rotation, with multiple examples of technically adequate and inadequate examinations according to each parameter. The residents proposed to complete
Academic Radiology, Vol 10, No 6, June 2003
DEVELOPING TOMORROW’S ACADEMIC RADIOLOGISTS
Figure 1. Sample page from the chest radiography module in the tutorial designed by radiology residents participating in a 3-month education elective.
basic versions of all 10 modules during the 3-month elective. As it turned out, this goal was too ambitious, and 3 months was insufficient time to complete all 10. However, the residents were able to complete three of the 10 modules, in thoracic radiology, abdominal radiology, and neuroradiology. During the 3 months, one of the residents took 2 weeks of night call, and the other took 1 week of vacation. Figure 2 provides an overview of how their time was allocated during the elective. The residents made extensive use of the department’s educational resources. A faculty member’s previously developed knowledge management and delivery software system provided the latticework for the development of the Web-delivered modules (12). The residents spent most of their time during the first few weeks becoming proficient with this software but reaped large rewards throughout the remainder of the elective. Another faculty member provided expertise in instructional design and evaluation, helping to design interactive questions for the tutorial and to incorporate the new material into the final examination for the clerkship. The residents were able to draw on the
department’s electronic teaching file for much of their case material, although they still found it necessary to spend the equivalent of 1 day per week on a search for images. A production assistant in the department’s education division helped digitize radiographs for storage in an image database accessible to the residents. They drew on the university’s center for teaching and learning for insights into adult learning principles, problem-based learning, and just-in-time teaching. As planned, they met weekly with the education working group, which proved an effective forum for monitoring progress and responding to challenges and opportunities. The residents found that their individual interests were complementary. One focused almost entirely on securing images and developing the Web-delivered modules, including designing the format, selecting images, and writing the interactive text. The other resident also spent most of the 3 months creating the tutorial but focused to a greater degree on the theoretical aspects of education, especially on how principles of human cognition and learning could be incorporated into the project. Both believed strongly that the Web-delivered tutorial should not
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Academic Radiology, Vol 10, No 6, June 2003
Figure 2. Graph shows allocation of residents’ time during the 3-month elective.
be a mere “textbook on a computer,” but should be as interactive, challenging, and engaging as possible for the medical students who would be using it. Dynamic, interactive questions with immediate and sometimes humorous confirmatory or corrective feedback were therefore interspersed liberally throughout the modules. The residents found their relatively recent tenure as medical students very helpful in orienting the tutorial to the students’ knowledge level and motivation for learning radiology. Basing their approach on the work of a faculty member with extensive experience in medical student teaching, the residents designed the tutorial to focus on principles that medical students must understand to perform optimally as interns and residents, particularly in the emergency room and on night call. Because students give formal presentations on radiology topics at the conclusion of the clerkship, the residents also developed a module on making effective presentations, by using a popular offthe-shelf commercial software package for manipulating text and images. The Web-delivered clerkship tutorial was highly rated by students, receiving a mean rating of 4.3 on a five-point scale for educational value in the 1st month after its introduction. Students almost uniformly praised it, and one asserted that it was the best aspect of the entire clerkship. A nearly unanimous request was made that other modules in the tutorial be completed as soon as possible. In addition to developing their Web-delivered tutorial for the department’s radiology clerkship, the residents also used the elective to gain more hands-on teaching experience. Each taught 2-hour in-class clerkship sessions on selected topics and received high marks from the students. The residents’ educational experience did not end at the conclusion of the elective. Citing the success they had
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enjoyed, they requested ongoing academic time (a halfday per week) to enable them to complete the other modules in the Web-delivered clerkship tutorial. However, scheduling hurdles and concerns that such time might impede their development as clinical radiologists led to a tabling of this motion, with a plan to revisit the issue in several months. To sustain their activity in radiology education and to enable them to complete more of the tutorial, the department successfully applied for an extramural educational technology grant of $15,000, which will compensate the residents for continued off-hours work on the project. Both also will continue teaching one or two clerkship sessions per month throughout the remainder of their residency training, helping to ensure that preoccupations such as preparation for the board examinations do not completely overwhelm their academic aspirations. In their evaluation of the elective, the residents described lessons they had learned. Both stated that the experience strongly reinforced their desire to pursue careers in academic radiology, and particularly in education. They also pointed to important lessons about curriculum design and instructional technology. For example, they found that the availability of an enabling technologic infrastructure was only a part of the solution. The effort involved in meticulously mapping what one would teach and how one would electronically teach it at times paled in comparison to amassing the materials necessary to transform concepts into digital curricula. Said one, “I was surprised by how much time it takes to develop high-quality educational material (13). Research, planning, finding images, digitizing images, achieving stylistic consistency, and proofreading and revision were all considerable investments. In the end, though, I was really proud of the work we did, and how well it was received by the students.”
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DEVELOPING TOMORROW’S ACADEMIC RADIOLOGISTS
Figure 3. Model of a successful program of instruction in education.
The other resident was especially impressed by what they had learned about learning: “It was amazing to learn something about cognitive psychology and learning theory and see how it could be put to use in actually teaching students (14). If you know what you are doing, you can transform what would have been inert knowledge into knowledge that students can readily access and put to use.” CONCLUSION At a time when a number of residency programs are rightly expanding their trainees’ exposure to research, in some cases adding an entire year of research to residency training, it is vital that radiology departments around the country not overlook education. How well we teach the radiologists and physicians of tomorrow is no less vital to the quality of future radiologic practice than the fruits of research that determine the content of that instruction. Just as radiology leaders seek to develop national centers of excellence in radiology research training, they also should look for opportunities to develop national centers of excellence in radiology education. As radiologists seek to become more important contributors to medical research, they also should seek to make a greater contribution to medical education—an investment from which radiology could reap substantial rewards. One practical means of fostering such educational excellence is the de-
velopment of formal training opportunities for radiology residents in education. Just as some residency programs lack the resources to provide first-rate training in research, some also lack the capacity to undertake such educational initiatives. However, it is imperative that residency programs with the departmental and institutional resources to mount such programs do so soon and successfully. As other departments around the country examine this challenge, it is important that they bear in mind the key ingredients of success. These include the availability of faculty members with personal educational expertise and a strong commitment to the development of residents as educators; a program of sufficient size that it can afford to excuse residents from clinical rotations for a sufficient period; institutional resources, such as a school or department of education; technical resources of equipment and personnel; a strong knowledge management and delivery infrastructure to enhance educational productivity; and a department-wide commitment to the development of the next generation of radiology educators. In our experience, a successful program of instruction in education also requires the integration of three groups of contributors: clinical radiologists who understand what needs to be taught, education specialists who understand how best to teach it, and technology specialists who understand how to exploit instructional technology (Fig 3). Another essential ingre-
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dient is a high level of commitment by the faculty members and residents involved. As a number of such programs have been developed at different institutions, there is no reason why residents in departments that do not offer such opportunities cannot gain such experience by taking electives in departments that do. In addition to developing a cadre of excellent educators among the next generation of academic radiologists, such programs offer side benefits. First, they show all residents at an institution that their department takes education very seriously and is prepared to invest in the residents’ development as educators. Even residents who do not participate in the elective will benefit from a general elevation of education’s profile, and participating residents’ enthusiasm for education can be infectious. Second, the development of such electives enables radiology to establish itself as a leader in medical education, a strategically important position to occupy at any time, but especially when the field is understaffed. By excelling in education, radiology programs can help ensure that a large number of highly qualified applicants are attracted to the field. Finally, education is one of the most challenging and rewarding activities in which physicians can participate. By helping radiologists-in-training to excel as teachers, academic radiologists will enrich their field.
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REFERENCES 1. Gunderman RB. Today’s radiology resident and tomorrow’s academic radiologist. AJR Am J Roentgenol 2001; 177:1277–1280. 2. Maynard CD. Academic radiology: time for action. Acad Radiol 1995; 2:1097–1103. 3. Cohen MD, Gunderman RB. Academic radiology: sustaining the mission. Radiology 2002; 224:1– 4. 4. Collins J, Hyde C, Gray L, et al. Radiology resident evaluation: a form that addresses the six competencies of the Accreditation Council for Graduate Medical Education. Acad Radiol 2002; 9:815– 816. 5. Gay SB, Hillman BJ. Evaluation of a mandatory radiology resident research rotation. Acad Radiol 2000; 7:172–175. 6. Gunderman RB. The fight for education. AJR Am J Roentgenol 2001; 176:23–26. 7. Gunderman RB. Why teaching should be recognized as an essential component of radiology residency training. Acad Radiol 2000; 7:1123– 1125. 8. Troupin RH. The mini-fellowship in teaching: a senior resident elective. Invest Radiol 1990; 25:751–753. 9. Collins J. Academic opportunities in radiology education and education research. Acad Radiol 2002; 9:753–755. 10. Collins J, Dotti SL, Albanese MA. Teaching radiology to medical students: an integrated approach. Acad Radiol 2002; 9:1046 –1053. 11. Lieberman G, Abramson R, Volkan K, McArdle PJ. Tutor versus computer: a prospective comparison of interactive tutorial and computer-assisted instruction in radiology. Acad Radiol 2002; 9:40 – 49. 12. Frank MS, Dreyer KJ. Beyond the electronic-textbook model: software techniques to make on-line educational content dynamic. J Digit Imaging 2001; 14:108 –112. 13. Schank RC. Designing world-class e-learning. New York, NY: McGraw-Hill, 2002. 14. Bransford J, Brown AL, Cocking RR, eds. How people learn: mind, brain, experience, and school. Washington, DC: National Academy Press, 2000.
2003 AUR Joseph E. and Nancy O. Whitley Award
Developing Tomorrow’s Academic Radiologists: A 3-month Residency Elective in Education1 Richard B. Gunderman, MD, PhD, Darel E. Heitkamp, MD, Hal D. Kipfer, MD Mark S. Frank, MD, Valerie P. Jackson, MD, Ken B. Williamson, PhD
Rationale and Objectives. The shortage of academic radiologists reveals an urgent need to attract more residents into academic careers. A great deal of attention has been focused on research, but few programmatic initiatives have addressed the development of the next generation of radiology educators. The purpose of this study was to develop and test a new 3-month residency elective in education. Materials and Methods. A large academic radiology department developed a 3-month education elective, during which two residents would be relieved of clinical duties and focus full-time on tasks related to their development as educators, including the completion of a major educational project. Results. Two residents, in their 3rd year and 4th year of residency, respectively, proposed to collaborate in developing a Web-delivered tutorial for the department’s senior medical student clerkship. At the end of 3 months, their radiology tutorial was introduced. In its 1st month, it received a mean rating of 4.3 on a five-point scale. The residents stated that the elective had enabled them to develop important skills in instructional technology, put into practice their enhanced understanding of learning psychology, and substantially strengthened their overall commitment to academic careers. Conclusion. It is vital that residency programs focus on developing the next generation of radiology educators. This ongoing education elective represents one successful model. Key Word. Education. ©
AUR, 2003
The direction in which education starts a man will determine his future life. Plato, Republic IV
A number of observations indicate that the future of academic radiology is in peril. Most academic radiology departments are understaffed. Academic radiologists are being asked to perform more clinical work than ever before, eroding their time for distinctively academic activiAcad Radiol 2003; 10:650 – 656 1 From the Education Division, Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 462025200. Received February 14, 2003; accepted March 6. Address correspondence to R.B.G.
©
AUR, 2003
650
ties such as research, teaching, and professional service. The financial incentives for residents to choose private practice careers have never been greater. This situation represents a profound threat to the future of radiology (1). Today’s research will determine what tomorrow’s radiologists practice, today’s education will determine what tomorrow’s radiologists know, and today’s service will determine the professional standing of radiology for years to come. Academicians play a disproportionately large role in research, teaching, and professional service. If radiology does not manage to attract a sufficient number of residents to academic careers, everyone will suffer. It is vital that radiology residency programs make substantial investments in the development of future academic radiologists (2).
Academic Radiology, Vol 10, No 6, June 2003
In so doing, academic radiology departments might pursue a number of strategies. One strategy would be to increase the financial incentives for residents to choose academic careers. Unfortunately, such an approach would rapidly prove counterproductive. Before long, it would force academic departments to generate more clinical revenue to fund this increase in compensation, thereby reducing the faculty’s time for nonclinical pursuits. A second strategy would be to require certain residency and fellowship applicants to commit to an academic appointment at the conclusion of their training. Unfortunately, this would do nothing to enhance the intrinsic appeal of an academic career, and such agreements might, in any case, be difficult to enforce (3). A third strategy would be to develop opportunities for residents to experience firsthand the professional challenges and rewards of academic radiology. New competencies required of residents by the Accreditation Council for Graduate Medical Education provide implicit support for moving residency curricula toward a more academic orientation (4). A number of initiatives are beginning to move radiology in this direction. By reducing the amount of time that selected residents must devote to clinical training, the Holman pathway of the American Board of Radiology provides an intensive exposure to research without increasing the overall length of residency. Some institutions are now requiring a full year of research experience in addition to the 4 years their residents devote to clinical training in radiology. Other programs are providing substantial training in research methods and critical thinking. These important steps reflect an important recognition that sending the brightest and best radiology residents into lucrative private practice careers is not a viable long-term strategy for the profession. They show promise as means of improving the future quality of radiologic research (5). Unfortunately, these measures do little to develop the next generation of radiology educators. For several reasons, education tends to rank below clinical care and research as a priority for many academic radiology departments (6). First, taking on new education responsibilities or improving existing teaching programs generates little new revenue for an academic department, and therefore such activities may not appeal to departmental leaders. Moreover, the academic system tends to assign a lower value to teaching than to research as a means of obtaining promotion and tenure. Medical school deans and department chairs are frequently graded for their ability to attract extramural funding, and the funding available in education pales by comparison to that in research. Finally,
DEVELOPING TOMORROW’S ACADEMIC RADIOLOGISTS
many radiology leaders operate from a mistaken presumption that good educators are born, not made. Therefore, they may think, there is little point in devoting scarce resources to the promotion of educational excellence. Yet, education is every bit as vital to the future of radiology as research (7). Radiology programs must provide high-quality education to residents, who will use what they learn in residency as the basis for their practice for decades to come. Providing high-quality medical student education is equally important. Medical students choose their careers partly on the basis of the quality of teaching they receive, and radiology needs the highest-quality medical students it can attract. Even medical students who choose other fields are vital to a referral-based specialty such as radiology, since their familiarity with radiology will influence the number and quality of referrals they provide once they enter practice. Other vital but frequently underappreciated missions for radiology education include continuing education for radiologists and nonradiologist physicians, technologists, nurses, health care administrators, and others whose perceptions and practices influence the quality of radiology practice. For these reasons, it is vital that radiology residency programs make substantial investments in the development of the next generation of radiology educators. The purpose of this study was to develop and test the implementation of a new 3-month elective for radiology residents in education. To our knowledge, no other full-time educational opportunity of this type and magnitude has ever been developed for radiology residents (8). The intent of this educational innovation was threefold. First, we sought to provide selected residents a high-quality exposure to the theory and methods of education, thereby enabling them to benefit from an important knowledge base about which many radiologists know little. Second, we wanted them to develop expertise with cutting-edge educational technologies that they could use throughout their careers. Finally, we aimed to provide a deep immersion in the challenges and rewards of teaching radiology, with the hope that participating residents would find education so interesting that it would attract them to academic careers. The best way to interest people in a career track is not to bribe or coerce them, but to give them a first-rate opportunity to try it out and succeed for themselves. MATERIALS AND METHODS Having identified the need to develop radiology residents as educators, the education committee of a large
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academic radiology department met multiple times to discuss appropriate strategies for achieving this objective. After extensive discussion, it was determined that, in order to be successful, the program would have to provide (a) opportunities to participate in active, hands-on education that turns residents into teachers as opposed to passive observers of education, (b) substantial release time from clinical responsibilities so that residents can focus their attention on their educational endeavors, (c) exposure of sufficient duration to permit participants to develop confidence as educators, (d) a serious commitment of technical instruction and support, and (e) effective mentoring to ensure that participants receive the supervision and guidance they need to succeed. With these priorities in mind, the department faculty instituted a 3-month elective in radiology education, making it available to residents who have completed at least 1 year of residency. On the basis of clinical needs, it was decided that a maximum of two residents could participate in the education elective each year. During this period, selected residents would be removed from the regular monthly clinical rotation schedule. However, they would continue to attend the department’s daily teaching conferences, occasional visiting professor lectures, and weekly teaching sessions of a clinical section of their choice, and their night and weekend call duties would continue. Participants could use vacation time for the elective; otherwise, they would be expected to maintain regular work hours 5 days per week. The elective would be organized around a major project, to be outlined and approved prior to commencing work and completed during the 3-month period. A variety of potential resident projects were identified, including assuming major responsibility for teaching one of the department’s medical student or radiologic technology courses, carrying out a major research project in radiology education, or developing a new educational resource, such as an electronic tutorial for medical students or residents or new teaching tools for radiology faculty members (9). A faculty mentor or mentors would be designated for each resident, and residents would be given office space in the department’s education division. There they would have access to personnel with expertise in such areas as curriculum design, evaluation methods, and instructional technology, as well as necessary equipment and secretarial support. Weekly progress updates would take place at divisional meetings, where unexpected problems and opportunities could be identified and addressed promptly.
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Selection of residents for participation in the elective would be based on four criteria. The first is the resident’s prior level of commitment to radiology education. The second is a strong record of clinical performance during the residency—a criterion that is designed to avoid depriving a struggling resident of 3 important months of clinical training. The third is a strong commitment to an academic career. Finally, residents would be selected on the basis of the quality of their project proposal. RESULTS During the 1st year of the education elective, two residents were selected for participation— one in the 3rd year and the other in the 4th year of postgraduate training. Both residents had voiced strong interest in education since the time they interviewed for a residency position, and both had been active contributors to the department’s educational programs, particularly in the area of medical student education. Both residents proposed to work on the same project concurrently, with the expectation that they would be able to collaborate and spur one another on, making for a more enjoyable and productive experience. Their project focused on the development of an electronic learning resource for the department’s 4th-year medical student clerkship (10). The school’s senior students are enrolled in this required clerkship for a period of 1 month, each group consisting of 20 –30 students. Because faculty time available for basic monthly lectures to such groups is steadily decreasing, the residents proposed to relieve some of this demand on faculty members’ time by developing an interactive Web-delivered radiology tutorial (11). The tutorial was designed to enable students to develop basic radiologic competencies through independent and small-group study, while freeing faculty to reallocate valuable teaching time to more advanced use of imaging for the solution of higher-level clinical problems. Students would be able to spend more of their in-class time with faculty members, solving the sorts of problems they would soon encounter in clinical practice as interns and residents. The tutorial would consist of modules in each of 10 major radiologic subspecialties. The chest radiography module provides an example of how some of this basic material would be covered (Fig 1). A portion of the module included interactive discussions of technical factors in radiographic interpretation, such as inspiration, penetration, and rotation, with multiple examples of technically adequate and inadequate examinations according to each parameter. The residents proposed to complete
Academic Radiology, Vol 10, No 6, June 2003
DEVELOPING TOMORROW’S ACADEMIC RADIOLOGISTS
Figure 1. Sample page from the chest radiography module in the tutorial designed by radiology residents participating in a 3-month education elective.
basic versions of all 10 modules during the 3-month elective. As it turned out, this goal was too ambitious, and 3 months was insufficient time to complete all 10. However, the residents were able to complete three of the 10 modules, in thoracic radiology, abdominal radiology, and neuroradiology. During the 3 months, one of the residents took 2 weeks of night call, and the other took 1 week of vacation. Figure 2 provides an overview of how their time was allocated during the elective. The residents made extensive use of the department’s educational resources. A faculty member’s previously developed knowledge management and delivery software system provided the latticework for the development of the Web-delivered modules (12). The residents spent most of their time during the first few weeks becoming proficient with this software but reaped large rewards throughout the remainder of the elective. Another faculty member provided expertise in instructional design and evaluation, helping to design interactive questions for the tutorial and to incorporate the new material into the final examination for the clerkship. The residents were able to draw on the
department’s electronic teaching file for much of their case material, although they still found it necessary to spend the equivalent of 1 day per week on a search for images. A production assistant in the department’s education division helped digitize radiographs for storage in an image database accessible to the residents. They drew on the university’s center for teaching and learning for insights into adult learning principles, problem-based learning, and just-in-time teaching. As planned, they met weekly with the education working group, which proved an effective forum for monitoring progress and responding to challenges and opportunities. The residents found that their individual interests were complementary. One focused almost entirely on securing images and developing the Web-delivered modules, including designing the format, selecting images, and writing the interactive text. The other resident also spent most of the 3 months creating the tutorial but focused to a greater degree on the theoretical aspects of education, especially on how principles of human cognition and learning could be incorporated into the project. Both believed strongly that the Web-delivered tutorial should not
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Figure 2. Graph shows allocation of residents’ time during the 3-month elective.
be a mere “textbook on a computer,” but should be as interactive, challenging, and engaging as possible for the medical students who would be using it. Dynamic, interactive questions with immediate and sometimes humorous confirmatory or corrective feedback were therefore interspersed liberally throughout the modules. The residents found their relatively recent tenure as medical students very helpful in orienting the tutorial to the students’ knowledge level and motivation for learning radiology. Basing their approach on the work of a faculty member with extensive experience in medical student teaching, the residents designed the tutorial to focus on principles that medical students must understand to perform optimally as interns and residents, particularly in the emergency room and on night call. Because students give formal presentations on radiology topics at the conclusion of the clerkship, the residents also developed a module on making effective presentations, by using a popular offthe-shelf commercial software package for manipulating text and images. The Web-delivered clerkship tutorial was highly rated by students, receiving a mean rating of 4.3 on a five-point scale for educational value in the 1st month after its introduction. Students almost uniformly praised it, and one asserted that it was the best aspect of the entire clerkship. A nearly unanimous request was made that other modules in the tutorial be completed as soon as possible. In addition to developing their Web-delivered tutorial for the department’s radiology clerkship, the residents also used the elective to gain more hands-on teaching experience. Each taught 2-hour in-class clerkship sessions on selected topics and received high marks from the students. The residents’ educational experience did not end at the conclusion of the elective. Citing the success they had
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enjoyed, they requested ongoing academic time (a halfday per week) to enable them to complete the other modules in the Web-delivered clerkship tutorial. However, scheduling hurdles and concerns that such time might impede their development as clinical radiologists led to a tabling of this motion, with a plan to revisit the issue in several months. To sustain their activity in radiology education and to enable them to complete more of the tutorial, the department successfully applied for an extramural educational technology grant of $15,000, which will compensate the residents for continued off-hours work on the project. Both also will continue teaching one or two clerkship sessions per month throughout the remainder of their residency training, helping to ensure that preoccupations such as preparation for the board examinations do not completely overwhelm their academic aspirations. In their evaluation of the elective, the residents described lessons they had learned. Both stated that the experience strongly reinforced their desire to pursue careers in academic radiology, and particularly in education. They also pointed to important lessons about curriculum design and instructional technology. For example, they found that the availability of an enabling technologic infrastructure was only a part of the solution. The effort involved in meticulously mapping what one would teach and how one would electronically teach it at times paled in comparison to amassing the materials necessary to transform concepts into digital curricula. Said one, “I was surprised by how much time it takes to develop high-quality educational material (13). Research, planning, finding images, digitizing images, achieving stylistic consistency, and proofreading and revision were all considerable investments. In the end, though, I was really proud of the work we did, and how well it was received by the students.”
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Figure 3. Model of a successful program of instruction in education.
The other resident was especially impressed by what they had learned about learning: “It was amazing to learn something about cognitive psychology and learning theory and see how it could be put to use in actually teaching students (14). If you know what you are doing, you can transform what would have been inert knowledge into knowledge that students can readily access and put to use.” CONCLUSION At a time when a number of residency programs are rightly expanding their trainees’ exposure to research, in some cases adding an entire year of research to residency training, it is vital that radiology departments around the country not overlook education. How well we teach the radiologists and physicians of tomorrow is no less vital to the quality of future radiologic practice than the fruits of research that determine the content of that instruction. Just as radiology leaders seek to develop national centers of excellence in radiology research training, they also should look for opportunities to develop national centers of excellence in radiology education. As radiologists seek to become more important contributors to medical research, they also should seek to make a greater contribution to medical education—an investment from which radiology could reap substantial rewards. One practical means of fostering such educational excellence is the de-
velopment of formal training opportunities for radiology residents in education. Just as some residency programs lack the resources to provide first-rate training in research, some also lack the capacity to undertake such educational initiatives. However, it is imperative that residency programs with the departmental and institutional resources to mount such programs do so soon and successfully. As other departments around the country examine this challenge, it is important that they bear in mind the key ingredients of success. These include the availability of faculty members with personal educational expertise and a strong commitment to the development of residents as educators; a program of sufficient size that it can afford to excuse residents from clinical rotations for a sufficient period; institutional resources, such as a school or department of education; technical resources of equipment and personnel; a strong knowledge management and delivery infrastructure to enhance educational productivity; and a department-wide commitment to the development of the next generation of radiology educators. In our experience, a successful program of instruction in education also requires the integration of three groups of contributors: clinical radiologists who understand what needs to be taught, education specialists who understand how best to teach it, and technology specialists who understand how to exploit instructional technology (Fig 3). Another essential ingre-
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dient is a high level of commitment by the faculty members and residents involved. As a number of such programs have been developed at different institutions, there is no reason why residents in departments that do not offer such opportunities cannot gain such experience by taking electives in departments that do. In addition to developing a cadre of excellent educators among the next generation of academic radiologists, such programs offer side benefits. First, they show all residents at an institution that their department takes education very seriously and is prepared to invest in the residents’ development as educators. Even residents who do not participate in the elective will benefit from a general elevation of education’s profile, and participating residents’ enthusiasm for education can be infectious. Second, the development of such electives enables radiology to establish itself as a leader in medical education, a strategically important position to occupy at any time, but especially when the field is understaffed. By excelling in education, radiology programs can help ensure that a large number of highly qualified applicants are attracted to the field. Finally, education is one of the most challenging and rewarding activities in which physicians can participate. By helping radiologists-in-training to excel as teachers, academic radiologists will enrich their field.
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REFERENCES 1. Gunderman RB. Today’s radiology resident and tomorrow’s academic radiologist. AJR Am J Roentgenol 2001; 177:1277–1280. 2. Maynard CD. Academic radiology: time for action. Acad Radiol 1995; 2:1097–1103. 3. Cohen MD, Gunderman RB. Academic radiology: sustaining the mission. Radiology 2002; 224:1– 4. 4. Collins J, Hyde C, Gray L, et al. Radiology resident evaluation: a form that addresses the six competencies of the Accreditation Council for Graduate Medical Education. Acad Radiol 2002; 9:815– 816. 5. Gay SB, Hillman BJ. Evaluation of a mandatory radiology resident research rotation. Acad Radiol 2000; 7:172–175. 6. Gunderman RB. The fight for education. AJR Am J Roentgenol 2001; 176:23–26. 7. Gunderman RB. Why teaching should be recognized as an essential component of radiology residency training. Acad Radiol 2000; 7:1123– 1125. 8. Troupin RH. The mini-fellowship in teaching: a senior resident elective. Invest Radiol 1990; 25:751–753. 9. Collins J. Academic opportunities in radiology education and education research. Acad Radiol 2002; 9:753–755. 10. Collins J, Dotti SL, Albanese MA. Teaching radiology to medical students: an integrated approach. Acad Radiol 2002; 9:1046 –1053. 11. Lieberman G, Abramson R, Volkan K, McArdle PJ. Tutor versus computer: a prospective comparison of interactive tutorial and computer-assisted instruction in radiology. Acad Radiol 2002; 9:40 – 49. 12. Frank MS, Dreyer KJ. Beyond the electronic-textbook model: software techniques to make on-line educational content dynamic. J Digit Imaging 2001; 14:108 –112. 13. Schank RC. Designing world-class e-learning. New York, NY: McGraw-Hill, 2002. 14. Bransford J, Brown AL, Cocking RR, eds. How people learn: mind, brain, experience, and school. Washington, DC: National Academy Press, 2000.