- Email: [email protected]
Radiology Medical Student Education
Radiology Medical Student Education: An Outcome-based Survey of PGY-1 Residents Arnold Saha, MD, R. Andrew Roland, BS, Matthew S. Hartman, MD, Richard H. Daffner, MD Rationale and Objectives: Postgraduate year (PGY)-1 residents are frequently required to order imaging studies and make preliminary interpretations on them. This study determines whether PGY-1 residents feel their radiology education in medical school sufficiently trained them for the clinical responsibilities of internship. Materials and Methods: This multicenter, institutional review board–approved survey asked PGY-1 trainees three categories of questions: 1) extent of medical school training for ordering and interpreting imaging studies, 2) confidence levels in ordering appropriate imaging studies and making common/emergent diagnoses, and 3) rating the importance of radiologic interpretation by interns. Respondents also submitted ideas for medical school teaching topics deemed most useful for interns. Results: A total of 175 questionnaires were returned with good representation across specialties. Although 63.7% of interns were frequently asked to independently preview radiology studies, 12.6% received no formal radiology training in medical school. Participants rated chest radiographs as the most important study for interns to competently interpret (93.4% reporting very or extremely important). However, only 60.2% of interns reported high confidence in recognizing common/emergent pulmonary findings, and 56.3% for evaluating line and tube position. With regard to ordering imaging studies, 81.0% had never used or never heard of the American College of Radiology Appropriateness Criteria. Only 33.1% had high confidence in knowing when to order oral/intravenous contrast. Similar low percentages had high confidence identifying and premedicating contrast allergies (36.4%) and knowing risk factors of nephrogenic systemic fibrosis (13.2%). Conclusions: PGY-1 residents feel that medical school curriculum emphasizing interpretation of chest radiographs and ordering appropriate imaging studies would better prepare students for the responsibilities of internship. Key Words: Medical student education; interpretation; curriculum topic; internship; contrast administration. ªAUR, 2013
I
n the handbook Essentials for Medical Students and PGY-1 Residents, the American College of Surgeons identifies the ability to ‘‘order and interpret appropriate laboratory and imaging studies’’ as integral to the training of postgraduate year (PGY)-1 residents (1). The interpretive skill set expected of interns includes the recognition of common imaging abnormalities such as pneumonia, small bowel obstruction, pneumoperitoneum, and intracranial hematoma, among many others. These expectations are not unique to surgery, but reflect the general consensus that trainees on the front lines of patient care need basic imaging skills in order to provide appropriate and timely patient care. The purpose of this study is to evaluate the perceived preparedness of interns for these clinical responsibilities based on radiology training received in medical school. Acad Radiol 2013; 20:284–289 From Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212 (A.S., R.A.R., M.S.H., R.H.D.); Temple University School of Medicine, Philadelphia, PA (R.A.R.). Received May 15, 2012; accepted October 31, 2012. Address correspondence to: A.S. e-mail: [email protected] ªAUR, 2013 http://dx.doi.org/10.1016/j.acra.2012.10.006
284
MATERIALS AND METHODS A 12-question survey was created using SurveyMonkey (http://www.surveymonkey.com), an online survey and questionnaire tool. Invitations to participate in the survey were emailed to 95 program directors from across the country representing all specialties offering PGY-1 training. The specialties included internal medicine, obstetrics and gynecology, emergency medicine, general surgery, pediatrics, family medicine, psychiatry, transitional year (not going into radiology), and transitional year (going into radiology). Program directors were asked to forward the invitations to their interns, all of whom had at least 6 months of training. The survey begins by asking interns about their medical school training for ordering and interpreting various imaging studies. The effectiveness of this training was determined by then querying participants about their confidence levels in ordering appropriate imaging studies and making common/emergent diagnoses. Based on their experience, residents were also asked to rate how important it is for interns to competently interpret various imaging studies. Finally, participants were asked to submit ideas for teaching topics deemed most useful for rising interns. The list of questions and answer options from the
Academic Radiology, Vol 20, No 3, March 2013
OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
TABLE 1. Electronic Survey Questions Posed to PGY-1 Residents Question 1. 2. 3. 4. 5. 6.
7.
8.
9. 10. 11.
12.
What is your gender? What type of medical school did you attend? What kind of PGY-1 program are you enrolled in? What is the department of your internship program? Describe your radiology training as a medical student. Rate your confidence level in evaluating the following items on chest radiographs: a. Position of lines and tubes b. Pneumonia c. Pneumothorax d. Pulmonary edema Rate your confidence level in evaluating the following items on abdominal radiographs: a. Small bowel obstruction b. Free air Rate your confidence level in the following areas related to ordering radiology studies: a. Choosing the appropriate radiology study for your patient b. Knowing whether to order oral or IV contrast for a CT/MRI c. Knowing if your patient has a true IV contrast allergy by patient history, and how to premedicate d. Knowing the risk factors for developing nephrogenic systemic fibrosis How often do you use the American College of Radiology Appropriateness Criteria? How often are you asked to review radiology images before a radiologist has dictated a report? How important do you think it is for interns to interpret the following studies? a. Bone radiographs b. Chest radiographs c. Abdominal radiographs d. Abdominal CT e. Head CT Is there anything else in radiology you wished you had learned before starting your PGY-1 year?
Answer Option Male; female American/foreign and allopathic/osteopathic Categorical; preliminary; transitional Open-ended Required clerkship; elective; integrated Not confident; somewhat confident; moderately confident; very confident; extremely confident
Not confident; somewhat confident; moderately confident; very confident; extremely confident
Not confident; somewhat confident; moderately confident; very confident; extremely confident
>3x/week; 1–3x/month; 1–3/year; never use it; never heard of it Several times a day, week, month; rarely; never Not important; somewhat important; moderately important; very important; extremely important
Open-ended
CT, computed tomography; IV, intravenous; MRI, magnetic resonance imaging; PGY, postgraduate year.
survey is illustrated in Table 1. A chi-square test was used to compare questionnaire responses according to specialty. A P value less than .05 was considered to indicate a significant difference. The study was approved by our institutional review board. RESULTS A total of 175 questionnaires were returned from all specialties, with baseline demographics detailed in Figure 1. The four largest groups of respondents came from internal medicine (24.6%), obstetrics and gynecology (21.7%), emergency medicine (16.6%), and general surgery (16.0%) programs. A total of 79.6% graduated from American allopathic medical schools, and 84.0% were enrolled in a categorical internship program. Although we did not query the geographic distribution of respondents, we determined the survey results to be
valid based on nearly equal gender participation, good representation of specialties, and other participant characteristics that were comparable to those reported in nationwide data of PGY-1 residents (2). Our method of relying on program directors to disseminate the survey invitations to their trainees precluded us from calculating a response rate. A total of 63.7% of interns were asked by their attending staff several times a day or week to provide preliminary interpretation of imaging studies (Fig 2). Despite this high rate of interpretation, a significant number (12.6%) received no formal radiology training in medical school (ie, no required or elective radiology clerkship, and no training integrated into other clerkships). Elective clerkship was the most frequently cited means of radiology training in medical school (46.9%; Fig 1). Interns rated chest radiographs as the most important study to competently interpret (Fig 3). A total of 93.4% of 285
SAHA ET AL
Academic Radiology, Vol 20, No 3, March 2013
Figure 1. Baseline characteristics.
Figure 2. Frequency that interns are asked to independently preview radiology studies.
Figure 3. Percentage of interns rating high importance for interpretation of various imaging studies.
interns reported that it was very or extremely important to know how to interpret chest radiographs. Interns rated abdominal radiographs as the second most important study (79.3%). Although interns place a high value on interpreting chest radiographs, only 60.2% have very or extremely high confidence in making common or emergent diagnoses such as pneumothorax, pneumonia, and pulmonary edema (Fig 4). Further, only 56.3% of interns reported high confi286
dence in evaluating the position of lines and tubes. Similar lack of confidence was seen with interpretation of abdominal radiographs, with only 52.4% having high confidence in diagnosing small bowel obstruction and pneumoperitoneum. Outcomes were not significantly different across specialties. Additionally, there was no significant difference based on the type of radiology training received in medical school.
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OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
Figure 4. Percentage of interns reporting high confidence in making various imaging diagnoses.
Figure 5. Frequency that interns use the American College of Radiology Appropriateness Criteria.
Figure 6. Percentage of interns reporting high confidence in managing contrast-related issues.
Despite a recent push to educate medical students about the American College of Radiology Appropriateness Criteria (ACR-AC), 81.0% of interns have never heard of, or never used, the ACR-AC (Fig 5). Managing issues related to contrast was cited as an area of perceived weakness (Fig 6). Only 33.1% reported very or extremely high confidence in knowing when to order oral or intravenous (IV) contrast. A similarly low percentage report high confidence for identifying true IV contrast allergy by patient history and knowing how to premedicate (36.4%). Only 13.2% of interns had high confidence in knowing the risk factors for nephrogenic systemic fibrosis. These findings were not significantly difference across specialties.
Free text responses confirmed the survey findings, reiterating the need for more formal radiology training in medical school and especially the need for more teaching on ordering appropriate imaging studies. DISCUSSION The importance of teaching trainees basic radiology is highlighted by the fact that nearly two-thirds of interns in our study are frequently expected to make preliminary interpretations of imaging studies. Although the majority of these interns received formal radiology training in medical school, they also report the need to improve that training. Interns 287
SAHA ET AL
rated chest radiographs as the most important study for them to competently interpret; however, only modest percentages reported high confidence in making basic/emergent diagnoses. Similar confidence levels were seen when evaluating the position of recently placed lines and tubes, a very common indication for imaging. Interns also reported insufficient training for ordering studies correctly with respect to contrast administration, premedication, and contraindications. Although many such questions regarding appropriate use of imaging could be easily answered by referencing the ACR-AC, more than 80% of interns had never heard of or never used this valuable resource. This is in keeping with several other studies in the literature documenting limited use of ACR-AC by residents (3–6). None of our findings were significantly different across specialties. This was expected because responses were based on training received in medical school. To our surprise, however, participants who received formal radiology training (via radiology clerkship or integration with other clinical clerkships) did not report higher confidence identifying basic/ emergent findings compared to participants who received no formal training at all. Overall, these data underscore the need for improving radiology training received by medical students to best equip them for the responsibilities of internship. Our study is unique in that it surveys clinicians (interns), not medical students, about the effectiveness of medical student teaching. Feigin and colleagues assessed the effectiveness of radiology teaching in medical school by means of posttraining given in the preclinical (sophomore) and clinical (senior) years of school (7). Our study takes the assessment another step further by surveying trainees in their first year of residency. Our reasoning is that medical students may perform well on end-of-rotation examinations, but this may not correlate with their preparedness for internship. Confidence in real clinical practice may therefore be a more meaningful indicator of assessing the effectiveness of radiology training in medical school. By surveying PGY-1 residents, we were able to elucidate important information not previously reported in surveys of medical students. The 2006 study by Subramaniam et al surveyed medical students about which curriculum topics they considered most important (8). Like our interns, they also agreed that interpretation of chest radiographs is a top priority. However, the ‘‘real-world’’ clinical experience of our PGY-1 respondents adds the additional finding that medical school curriculum could be practically enriched by educating students about ordering appropriate examinations and managing contrast-related issues. Educating medical students about the use of IV contrast and premedication is not intended to downplay the importance of screening or protocoling by radiology staff. Although we cannot depend on clinicians to do these activities for us, it is nonetheless beneficial for patient safety and efficient throughput to involve clinicians in the process because clinicians may be more knowledgeable about the patient. 288
Academic Radiology, Vol 20, No 3, March 2013
Our findings have several implications for medical student and resident education in the future. First, the high rate of imaging interpretation by interns reinforces the importance of radiology training in medical school curriculum. Maintenance of dedicated radiology clerkships and training integrated within clinical clerkships is vital for ensuring that medical students are prepared for the responsibilities of residency and beyond. Second, programs may consider modifying the content of their medical student curriculum to address the deficiencies reported by interns in this survey. These topics are well covered in curriculum developed by the Alliance of Medical Student Educators in Radiology, and so usage of this curriculum may be a useful remedy (9). At our own institution, we have expanded the number of lectures dedicated to chest radiology and developed completely new lectures related to contrast media and appropriate use of imaging. The changes have been generally well-received by rotating medical students. Along these lines, students may also benefit from early exposure to basic radiographic concepts during their preclinical years. This approach has been previously reported to improve long-term learning by laying a foundation which is built upon by repetition and experience (10,11). Additional benefits cited in the literature include greater understanding of radiology’s importance in the practice of medicine and greater interest in radiology as a career (11,12). Third, additional efforts should be made to increase clinician awareness and utilization of the ACR-AC. Multidisciplinary conferences and trainee didactic forums are excellent opportunities to educate our clinical colleagues, residents and attendings alike, about the ACR-AC (13). Improved accessibility could be obtained by disseminating the criteria into resources already widely used by clinicians, such as specialty journals, MD Consult, UpToDate, and internet search engines (3–5). The recent development of ACR Select (http://www. acrselect.org), a decision support tool integrating ACR-AC into electronic health records, is another significant step in making the criteria available at the point of care. The main limitation of our study concerns the method of determining effectiveness of the participants’ medical school radiology training. We did so by querying their confidence levels in ordering and interpreting studies. It is conceivable that confidence levels do not correlate with actual abilities. A follow-up study could address this issue by presenting respondents with real-life clinical scenarios and performance could be objectively assessed in a multiple-choice question format. Additionally, increasing demands for 24/7 attending radiologist coverage may make the results of this study less relevant in the future. We, however, expect that rural and communitybased training programs may be less well-staffed and thus slower to adopt such change. Regardless, it is clear from the results of our study that the present state of coverage requires most interns to independently interpret basic emergent imaging studies in order to expedite patient care. In conclusion, we feel that basic understanding of radiology is integral to the clinical training of PGY-1 residents. Medical
Academic Radiology, Vol 20, No 3, March 2013
OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
school radiology training that targets practical, high-yield topics will better prepare graduating students for the responsibilities of internship. This will potentially improve patient care as diagnoses are made more quickly and management changed accordingly. REFERENCES 1. Successfully navigating the first year of surgical residency: essentials for medical students and PGY-1 residents. Chicago, IL: Division of Education, American College of Surgeons, 2005. 2. National Resident Matching Program, results and data: 2011 main residency match. Washington, DC: National Resident Matching Program, 2011. 3. Hirschl DA, Ruzal-Shapiro C, Taragin BH. Online survey of radiologic ordering practices by pediatric trainees. J Am Coll Radiol 2010; 7:360–363. 4. Bautista AB, Burgos A, Nickel BJ, et al. Do clinicians use the American College of Radiology Appropriateness Criteria in the management of their patients? AJR Am J Roentgenol 2009; 192:1581–1585. 5. Chiunda AB, Mohammed TL. Knowledge of ACR thoracic imaging Appropriateness Criteria among trainees: one institution’s experience. Acad Radiol 2012; 19:635–639. Epub 2012 Feb 18.
6. Logie CI, Smith SE, Nagy P. Evaluation of resident familiarity and utilization of the ACR musculoskeletal study appropriateness criteria in the context of medical decision support. Acad Radiol 2010; 17:251–254. Epub 2009 Dec 4. 7. Feigin DS, Magid D, Smirniotopoulos JG, et al. Learning and retaining normal radiographic chest anatomy: does preclinical exposure improve student performance? Acad Radiol 2007; 14:1137–1142. 8. Subramaniam RM, Beckley V, Chan M, et al. Curriculum topics for medical students: students’ perspectives. Acad Radiol 2006; 13:880–884. 9. AMSER National Medical Student Curriculum in Radiology. Available at http://www.aur.org/Affiliated_Societies/AMSER/amser_curriculum.cfm. Accessed September 25, 2011. 10. Magid D, Hudson DW, Feigin DS. Chest radiographic anatomy retention: the impact of preclinical groundwork on clinical recall in two schools. Acad Radiol 2009; 16:1443–1447. 11. Branstetter BF, 4th, Faix LE, Humphrey AL, et al. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007; 188:W9–W14. 12. O’Malley L, Athreya S. Awareness and level of knowledge of interventional radiology among medical students at a Canadian Institution. Acad Radiol 2012; 19:894–901. Epub 2012 Apr 21. 13. Naeger DM, Phelps A, Kohi M, et al. Cross-specialty integrated resident conferences: an educational approach to bridging the gap. Acad Radiol 2012; 19:1029–1034. Epub 2012 May 10.
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I
n the handbook Essentials for Medical Students and PGY-1 Residents, the American College of Surgeons identifies the ability to ‘‘order and interpret appropriate laboratory and imaging studies’’ as integral to the training of postgraduate year (PGY)-1 residents (1). The interpretive skill set expected of interns includes the recognition of common imaging abnormalities such as pneumonia, small bowel obstruction, pneumoperitoneum, and intracranial hematoma, among many others. These expectations are not unique to surgery, but reflect the general consensus that trainees on the front lines of patient care need basic imaging skills in order to provide appropriate and timely patient care. The purpose of this study is to evaluate the perceived preparedness of interns for these clinical responsibilities based on radiology training received in medical school. Acad Radiol 2013; 20:284–289 From Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212 (A.S., R.A.R., M.S.H., R.H.D.); Temple University School of Medicine, Philadelphia, PA (R.A.R.). Received May 15, 2012; accepted October 31, 2012. Address correspondence to: A.S. e-mail: [email protected] ªAUR, 2013 http://dx.doi.org/10.1016/j.acra.2012.10.006
284
MATERIALS AND METHODS A 12-question survey was created using SurveyMonkey (http://www.surveymonkey.com), an online survey and questionnaire tool. Invitations to participate in the survey were emailed to 95 program directors from across the country representing all specialties offering PGY-1 training. The specialties included internal medicine, obstetrics and gynecology, emergency medicine, general surgery, pediatrics, family medicine, psychiatry, transitional year (not going into radiology), and transitional year (going into radiology). Program directors were asked to forward the invitations to their interns, all of whom had at least 6 months of training. The survey begins by asking interns about their medical school training for ordering and interpreting various imaging studies. The effectiveness of this training was determined by then querying participants about their confidence levels in ordering appropriate imaging studies and making common/emergent diagnoses. Based on their experience, residents were also asked to rate how important it is for interns to competently interpret various imaging studies. Finally, participants were asked to submit ideas for teaching topics deemed most useful for rising interns. The list of questions and answer options from the
Academic Radiology, Vol 20, No 3, March 2013
OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
TABLE 1. Electronic Survey Questions Posed to PGY-1 Residents Question 1. 2. 3. 4. 5. 6.
7.
8.
9. 10. 11.
12.
What is your gender? What type of medical school did you attend? What kind of PGY-1 program are you enrolled in? What is the department of your internship program? Describe your radiology training as a medical student. Rate your confidence level in evaluating the following items on chest radiographs: a. Position of lines and tubes b. Pneumonia c. Pneumothorax d. Pulmonary edema Rate your confidence level in evaluating the following items on abdominal radiographs: a. Small bowel obstruction b. Free air Rate your confidence level in the following areas related to ordering radiology studies: a. Choosing the appropriate radiology study for your patient b. Knowing whether to order oral or IV contrast for a CT/MRI c. Knowing if your patient has a true IV contrast allergy by patient history, and how to premedicate d. Knowing the risk factors for developing nephrogenic systemic fibrosis How often do you use the American College of Radiology Appropriateness Criteria? How often are you asked to review radiology images before a radiologist has dictated a report? How important do you think it is for interns to interpret the following studies? a. Bone radiographs b. Chest radiographs c. Abdominal radiographs d. Abdominal CT e. Head CT Is there anything else in radiology you wished you had learned before starting your PGY-1 year?
Answer Option Male; female American/foreign and allopathic/osteopathic Categorical; preliminary; transitional Open-ended Required clerkship; elective; integrated Not confident; somewhat confident; moderately confident; very confident; extremely confident
Not confident; somewhat confident; moderately confident; very confident; extremely confident
Not confident; somewhat confident; moderately confident; very confident; extremely confident
>3x/week; 1–3x/month; 1–3/year; never use it; never heard of it Several times a day, week, month; rarely; never Not important; somewhat important; moderately important; very important; extremely important
Open-ended
CT, computed tomography; IV, intravenous; MRI, magnetic resonance imaging; PGY, postgraduate year.
survey is illustrated in Table 1. A chi-square test was used to compare questionnaire responses according to specialty. A P value less than .05 was considered to indicate a significant difference. The study was approved by our institutional review board. RESULTS A total of 175 questionnaires were returned from all specialties, with baseline demographics detailed in Figure 1. The four largest groups of respondents came from internal medicine (24.6%), obstetrics and gynecology (21.7%), emergency medicine (16.6%), and general surgery (16.0%) programs. A total of 79.6% graduated from American allopathic medical schools, and 84.0% were enrolled in a categorical internship program. Although we did not query the geographic distribution of respondents, we determined the survey results to be
valid based on nearly equal gender participation, good representation of specialties, and other participant characteristics that were comparable to those reported in nationwide data of PGY-1 residents (2). Our method of relying on program directors to disseminate the survey invitations to their trainees precluded us from calculating a response rate. A total of 63.7% of interns were asked by their attending staff several times a day or week to provide preliminary interpretation of imaging studies (Fig 2). Despite this high rate of interpretation, a significant number (12.6%) received no formal radiology training in medical school (ie, no required or elective radiology clerkship, and no training integrated into other clerkships). Elective clerkship was the most frequently cited means of radiology training in medical school (46.9%; Fig 1). Interns rated chest radiographs as the most important study to competently interpret (Fig 3). A total of 93.4% of 285
SAHA ET AL
Academic Radiology, Vol 20, No 3, March 2013
Figure 1. Baseline characteristics.
Figure 2. Frequency that interns are asked to independently preview radiology studies.
Figure 3. Percentage of interns rating high importance for interpretation of various imaging studies.
interns reported that it was very or extremely important to know how to interpret chest radiographs. Interns rated abdominal radiographs as the second most important study (79.3%). Although interns place a high value on interpreting chest radiographs, only 60.2% have very or extremely high confidence in making common or emergent diagnoses such as pneumothorax, pneumonia, and pulmonary edema (Fig 4). Further, only 56.3% of interns reported high confi286
dence in evaluating the position of lines and tubes. Similar lack of confidence was seen with interpretation of abdominal radiographs, with only 52.4% having high confidence in diagnosing small bowel obstruction and pneumoperitoneum. Outcomes were not significantly different across specialties. Additionally, there was no significant difference based on the type of radiology training received in medical school.
Academic Radiology, Vol 20, No 3, March 2013
OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
Figure 4. Percentage of interns reporting high confidence in making various imaging diagnoses.
Figure 5. Frequency that interns use the American College of Radiology Appropriateness Criteria.
Figure 6. Percentage of interns reporting high confidence in managing contrast-related issues.
Despite a recent push to educate medical students about the American College of Radiology Appropriateness Criteria (ACR-AC), 81.0% of interns have never heard of, or never used, the ACR-AC (Fig 5). Managing issues related to contrast was cited as an area of perceived weakness (Fig 6). Only 33.1% reported very or extremely high confidence in knowing when to order oral or intravenous (IV) contrast. A similarly low percentage report high confidence for identifying true IV contrast allergy by patient history and knowing how to premedicate (36.4%). Only 13.2% of interns had high confidence in knowing the risk factors for nephrogenic systemic fibrosis. These findings were not significantly difference across specialties.
Free text responses confirmed the survey findings, reiterating the need for more formal radiology training in medical school and especially the need for more teaching on ordering appropriate imaging studies. DISCUSSION The importance of teaching trainees basic radiology is highlighted by the fact that nearly two-thirds of interns in our study are frequently expected to make preliminary interpretations of imaging studies. Although the majority of these interns received formal radiology training in medical school, they also report the need to improve that training. Interns 287
SAHA ET AL
rated chest radiographs as the most important study for them to competently interpret; however, only modest percentages reported high confidence in making basic/emergent diagnoses. Similar confidence levels were seen when evaluating the position of recently placed lines and tubes, a very common indication for imaging. Interns also reported insufficient training for ordering studies correctly with respect to contrast administration, premedication, and contraindications. Although many such questions regarding appropriate use of imaging could be easily answered by referencing the ACR-AC, more than 80% of interns had never heard of or never used this valuable resource. This is in keeping with several other studies in the literature documenting limited use of ACR-AC by residents (3–6). None of our findings were significantly different across specialties. This was expected because responses were based on training received in medical school. To our surprise, however, participants who received formal radiology training (via radiology clerkship or integration with other clinical clerkships) did not report higher confidence identifying basic/ emergent findings compared to participants who received no formal training at all. Overall, these data underscore the need for improving radiology training received by medical students to best equip them for the responsibilities of internship. Our study is unique in that it surveys clinicians (interns), not medical students, about the effectiveness of medical student teaching. Feigin and colleagues assessed the effectiveness of radiology teaching in medical school by means of posttraining given in the preclinical (sophomore) and clinical (senior) years of school (7). Our study takes the assessment another step further by surveying trainees in their first year of residency. Our reasoning is that medical students may perform well on end-of-rotation examinations, but this may not correlate with their preparedness for internship. Confidence in real clinical practice may therefore be a more meaningful indicator of assessing the effectiveness of radiology training in medical school. By surveying PGY-1 residents, we were able to elucidate important information not previously reported in surveys of medical students. The 2006 study by Subramaniam et al surveyed medical students about which curriculum topics they considered most important (8). Like our interns, they also agreed that interpretation of chest radiographs is a top priority. However, the ‘‘real-world’’ clinical experience of our PGY-1 respondents adds the additional finding that medical school curriculum could be practically enriched by educating students about ordering appropriate examinations and managing contrast-related issues. Educating medical students about the use of IV contrast and premedication is not intended to downplay the importance of screening or protocoling by radiology staff. Although we cannot depend on clinicians to do these activities for us, it is nonetheless beneficial for patient safety and efficient throughput to involve clinicians in the process because clinicians may be more knowledgeable about the patient. 288
Academic Radiology, Vol 20, No 3, March 2013
Our findings have several implications for medical student and resident education in the future. First, the high rate of imaging interpretation by interns reinforces the importance of radiology training in medical school curriculum. Maintenance of dedicated radiology clerkships and training integrated within clinical clerkships is vital for ensuring that medical students are prepared for the responsibilities of residency and beyond. Second, programs may consider modifying the content of their medical student curriculum to address the deficiencies reported by interns in this survey. These topics are well covered in curriculum developed by the Alliance of Medical Student Educators in Radiology, and so usage of this curriculum may be a useful remedy (9). At our own institution, we have expanded the number of lectures dedicated to chest radiology and developed completely new lectures related to contrast media and appropriate use of imaging. The changes have been generally well-received by rotating medical students. Along these lines, students may also benefit from early exposure to basic radiographic concepts during their preclinical years. This approach has been previously reported to improve long-term learning by laying a foundation which is built upon by repetition and experience (10,11). Additional benefits cited in the literature include greater understanding of radiology’s importance in the practice of medicine and greater interest in radiology as a career (11,12). Third, additional efforts should be made to increase clinician awareness and utilization of the ACR-AC. Multidisciplinary conferences and trainee didactic forums are excellent opportunities to educate our clinical colleagues, residents and attendings alike, about the ACR-AC (13). Improved accessibility could be obtained by disseminating the criteria into resources already widely used by clinicians, such as specialty journals, MD Consult, UpToDate, and internet search engines (3–5). The recent development of ACR Select (http://www. acrselect.org), a decision support tool integrating ACR-AC into electronic health records, is another significant step in making the criteria available at the point of care. The main limitation of our study concerns the method of determining effectiveness of the participants’ medical school radiology training. We did so by querying their confidence levels in ordering and interpreting studies. It is conceivable that confidence levels do not correlate with actual abilities. A follow-up study could address this issue by presenting respondents with real-life clinical scenarios and performance could be objectively assessed in a multiple-choice question format. Additionally, increasing demands for 24/7 attending radiologist coverage may make the results of this study less relevant in the future. We, however, expect that rural and communitybased training programs may be less well-staffed and thus slower to adopt such change. Regardless, it is clear from the results of our study that the present state of coverage requires most interns to independently interpret basic emergent imaging studies in order to expedite patient care. In conclusion, we feel that basic understanding of radiology is integral to the clinical training of PGY-1 residents. Medical
Academic Radiology, Vol 20, No 3, March 2013
OUTCOMES OF MEDICAL SCHOOL RADIOLOGY EDUCATION
school radiology training that targets practical, high-yield topics will better prepare graduating students for the responsibilities of internship. This will potentially improve patient care as diagnoses are made more quickly and management changed accordingly. REFERENCES 1. Successfully navigating the first year of surgical residency: essentials for medical students and PGY-1 residents. Chicago, IL: Division of Education, American College of Surgeons, 2005. 2. National Resident Matching Program, results and data: 2011 main residency match. Washington, DC: National Resident Matching Program, 2011. 3. Hirschl DA, Ruzal-Shapiro C, Taragin BH. Online survey of radiologic ordering practices by pediatric trainees. J Am Coll Radiol 2010; 7:360–363. 4. Bautista AB, Burgos A, Nickel BJ, et al. Do clinicians use the American College of Radiology Appropriateness Criteria in the management of their patients? AJR Am J Roentgenol 2009; 192:1581–1585. 5. Chiunda AB, Mohammed TL. Knowledge of ACR thoracic imaging Appropriateness Criteria among trainees: one institution’s experience. Acad Radiol 2012; 19:635–639. Epub 2012 Feb 18.
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