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Results from the problem-solving sessions at the 52nd Annual Meeting of the Association of University Radiologists1
Special Report
Results from the Problem-solving Sessions at the 52nd Annual Meeting of the Association of University Radiologists1 Christopher Michael Kay, MD, Madh Krishnan, MD, Wilbur Smith, MD
The education of competent future radiologists is the main goal of radiology residency programs throughout the country. As the field of radiology expands, this goal becomes complex and more difficult to accomplish. At the 52nd Annual Meeting of the Association of University Radiologists (AUR), the American Alliance of Academic Chief Residents in Radiology (A3CR2) hosted problemsolving sessions to discuss two critical educational dilemmas: 1). Ensuring appropriate resident experiences in clinical areas threatened by turf wars, and 2). Achieving the appropriate balance between direct supervision and residents’ independent work. After discussing these issues with radiology residents from across the country, brief position statements were written and presented to members of the Association of Program Directors in Radiology (APDR) and the Association of Program Coordinators in Radiology (APCR) at a joint session. The main objective of this paper is to present the results of this discussion.
ENSURING THE APPROPRIATE RESIDENT EXPERIENCES IN CLINICAL AREAS THREATENED BY TURF WARS As our imaging capabilities continue to expand, the field of radiology now contributes patient information to medical specialties where previously radiology had limited interaction. Increasing evidence of their efficacy has Acad Radiol 2005; 12:526 –528 1 From the Department of Radiology, Wayne State University/Detroit Medical Center, 1135 Beaconsfield, Grosse Pointe Park, MI 48230. Received and accepted January 10, 2005. Address correspondence to C.M.K. e-mail: [email protected]; [email protected]
© AUR, 2005 doi:10.1016/j.acra.2005.01.005
526
added to utilization of these new imaging modalities, often by clinicians and not radiologists. Other medical specialties have trained themselves in these modalities and, in some institutions, have become the primary interpreters (eg, obstetrical imaging, cardiac imaging, and vascular intervention). The accreditation and certification organizations of radiology continue to expect radiology residents to possess knowledge of these modalities, which are threatened by these turf wars. This expectation is not unreasonable because radiology residents should learn these new modalities with the goals of better patient care, furthering research, and advancing imaging. We discussed potential solutions to ensure that the radiology resident receives appropriate experience in clinical areas threatened by turf wars. Organized radiology must establish core curricula concerning these clinical areas of competence. If core curricula are prepared, radiology chairpersons, program directors, and section chiefs will be obligated to find resources for radiology training, and this is a standard approach in medical education. For example, other medical specialties have established imaging requirements for their residents, and they are dependent on our departments to provide such education. By enhancing interdepartmental relationships, a more reciprocal approach to resident training could be developed. Integrated residency training would perhaps allow radiology residents to have better access to rotations outside of the radiology department. Establishing a better defined curriculum will provide incentive for educators to develop novel approaches to resident education. Web-based education has increased dramatically with the proliferation of the Internet and computer applications. This technology could be utilized to develop programs that the resident could access
Academic Radiology, Vol 12, No 4, April 2005
PROBLEM-SOLVING AT THE 52ND ANNUAL MEETING OF THE AUR
whenever he or she had an opportunity. Incentive will exist to establish centers of excellence that utilize these modalities, perhaps as a collaborative effort among the different clinical subspecialties. Radiology residents could spend time at these centers for a more comprehensive educational experience. If not formal rotations, these centers could host shorter, in-depth conferences (eg, one week) where the resident could attend thorough lectures on these modalities. However, residents would have to be given ample time to pursue such educational opportunities. The American College of Radiology (ACR) has dealt effectively with the issue of self-referral. Since radiologists typically do not have a patient base from which to draw, self-referral has the potential to limit the number of patients coming through our departments, especially as the owning and referring clinician may be more prone to order a test that will increase the likelihood of their own reimbursement. Through the ACR’s continued efforts to limit self-referral, radiology will have enhanced opportunities to participate in quality patient care. By maintaining the number of imaging examinations within the department of radiology, combating self-referral will provide radiology residents with ample opportunity to learn the new imaging modalities. Finally, radiology must make its “value added” more apparent to the referring clinicians, the insurance industry, and the general public. People need to know that multiple options exist, and we need to convince these people that radiology can provide them with better service and more comprehensive evaluation at lower cost. We need to show that these clinical areas at risk require a certain level of expertise and that our certification truly contributes expertise and health care value. To do this, we must participate in more direct communication with the referring clinicians. For instance, after performing and interpreting magnetic resonance angiography of the lower extremity, the radiologist could directly communicate with the ordering clinician as to what options exist for possible intervention. Radiology must be more interactive with the patients as well, and this could be accomplished by developing our own clinics, especially in interventional radiology. These efforts will help maintain the number of exams that we perform and interpret, and again, through this volume, radiology residents will have an appropriate amount of experience in these clinical areas.
ACHIEVING THE APPROPRIATE BALANCE BETWEEN DIRECT SUPERVISION AND RESIDENTS’ INDEPENDENT WORK As the role of imaging in patient care increases, enhanced availability of radiologists to provide primary interpretation has been requested by many departments within the hospital (eg, the emergency department). Functioning as the primary imaging consultant, residents develop invaluable skills in interpretation, diagnosis, and communication. Our objective was to find solutions to protect this resident autonomy. Nationally, it appears that the majority of overnight call in facilities with residency programs is taken by the residents. However, there has been institutional pressure to provide 24-hour attending coverage. Radiology residents believe that call is a critical component of their training, providing them with an opportunity to be the primary interpreter of imaging examinations. Residents strongly believe that their growth will be stunted without this experience. As an alternative to complete attending coverage, we proposed developing a system of teleradiology where the radiology resident can act as a gatekeeper. After providing an initial reading, the resident could decide whether he or she needs to contact the attending. In addition, there could be other established criteria where the referring clinician could request an attending interpretation. These criteria must be documented and agreed upon by the different departments within the hospital. With this compromise, the radiology resident remains on the front line, while the referring clinician has the opportunity to receive an attending’s interpretation. A possible alternative is to have a more senior radiology resident available for consultation by the more junior radiology resident. Not only would this maintain the resident as the primary interpreter, this would also encourage a more team-based approach to patient care. In addition, this will provide the senior resident a chance to improve his or her teaching skills. Unfortunately, an immediate realization is that this option is only applicable to residency programs with a large group of residents. Once again, an increased effort must be made to enhance relationships with other departments within the hospital. By doing this, a certain sense of confidence and collaboration can be developed. Since rapport builds trust, the radiology resident must also participate in this effort. By being more available and more open to consultation within the emergency department, the radiology resident
527
KAY
can be utilized as a primary resource by the referring clinician. Finally, if we can prove to the referring physician that radiology residents provide a reasonable level of service, we can alleviate the concerns of these physicians. Despite the fact that the literature already indicates resident proficiency, the development of consistent and reliable institutional quality assurance will provide the referring clinicians with site-specific data. By hosting regularly scheduled quality assurance conferences (ie,. morbidity and mortality) and allowing the referring clinicians to either participate or to offer input, we will not only educate ourselves but also provide the clinicians with the information
528
Academic Radiology, Vol 12, No 4, April 2005
that they need to feel confident with the radiology resident’s interpretation.
CONCLUSION Two conflicts have been presented that have the potential to alter radiology residency education. Utilizing input from the A3CR2, APDR, and APCR, potential solutions have been developed. With the continued efforts of all concerned parties (eg, radiology residents, program directors, and the ACR), the education of radiology residents can be preserved.
Results from the Problem-solving Sessions at the 52nd Annual Meeting of the Association of University Radiologists1 Christopher Michael Kay, MD, Madh Krishnan, MD, Wilbur Smith, MD
The education of competent future radiologists is the main goal of radiology residency programs throughout the country. As the field of radiology expands, this goal becomes complex and more difficult to accomplish. At the 52nd Annual Meeting of the Association of University Radiologists (AUR), the American Alliance of Academic Chief Residents in Radiology (A3CR2) hosted problemsolving sessions to discuss two critical educational dilemmas: 1). Ensuring appropriate resident experiences in clinical areas threatened by turf wars, and 2). Achieving the appropriate balance between direct supervision and residents’ independent work. After discussing these issues with radiology residents from across the country, brief position statements were written and presented to members of the Association of Program Directors in Radiology (APDR) and the Association of Program Coordinators in Radiology (APCR) at a joint session. The main objective of this paper is to present the results of this discussion.
ENSURING THE APPROPRIATE RESIDENT EXPERIENCES IN CLINICAL AREAS THREATENED BY TURF WARS As our imaging capabilities continue to expand, the field of radiology now contributes patient information to medical specialties where previously radiology had limited interaction. Increasing evidence of their efficacy has Acad Radiol 2005; 12:526 –528 1 From the Department of Radiology, Wayne State University/Detroit Medical Center, 1135 Beaconsfield, Grosse Pointe Park, MI 48230. Received and accepted January 10, 2005. Address correspondence to C.M.K. e-mail: [email protected]; [email protected]
© AUR, 2005 doi:10.1016/j.acra.2005.01.005
526
added to utilization of these new imaging modalities, often by clinicians and not radiologists. Other medical specialties have trained themselves in these modalities and, in some institutions, have become the primary interpreters (eg, obstetrical imaging, cardiac imaging, and vascular intervention). The accreditation and certification organizations of radiology continue to expect radiology residents to possess knowledge of these modalities, which are threatened by these turf wars. This expectation is not unreasonable because radiology residents should learn these new modalities with the goals of better patient care, furthering research, and advancing imaging. We discussed potential solutions to ensure that the radiology resident receives appropriate experience in clinical areas threatened by turf wars. Organized radiology must establish core curricula concerning these clinical areas of competence. If core curricula are prepared, radiology chairpersons, program directors, and section chiefs will be obligated to find resources for radiology training, and this is a standard approach in medical education. For example, other medical specialties have established imaging requirements for their residents, and they are dependent on our departments to provide such education. By enhancing interdepartmental relationships, a more reciprocal approach to resident training could be developed. Integrated residency training would perhaps allow radiology residents to have better access to rotations outside of the radiology department. Establishing a better defined curriculum will provide incentive for educators to develop novel approaches to resident education. Web-based education has increased dramatically with the proliferation of the Internet and computer applications. This technology could be utilized to develop programs that the resident could access
Academic Radiology, Vol 12, No 4, April 2005
PROBLEM-SOLVING AT THE 52ND ANNUAL MEETING OF THE AUR
whenever he or she had an opportunity. Incentive will exist to establish centers of excellence that utilize these modalities, perhaps as a collaborative effort among the different clinical subspecialties. Radiology residents could spend time at these centers for a more comprehensive educational experience. If not formal rotations, these centers could host shorter, in-depth conferences (eg, one week) where the resident could attend thorough lectures on these modalities. However, residents would have to be given ample time to pursue such educational opportunities. The American College of Radiology (ACR) has dealt effectively with the issue of self-referral. Since radiologists typically do not have a patient base from which to draw, self-referral has the potential to limit the number of patients coming through our departments, especially as the owning and referring clinician may be more prone to order a test that will increase the likelihood of their own reimbursement. Through the ACR’s continued efforts to limit self-referral, radiology will have enhanced opportunities to participate in quality patient care. By maintaining the number of imaging examinations within the department of radiology, combating self-referral will provide radiology residents with ample opportunity to learn the new imaging modalities. Finally, radiology must make its “value added” more apparent to the referring clinicians, the insurance industry, and the general public. People need to know that multiple options exist, and we need to convince these people that radiology can provide them with better service and more comprehensive evaluation at lower cost. We need to show that these clinical areas at risk require a certain level of expertise and that our certification truly contributes expertise and health care value. To do this, we must participate in more direct communication with the referring clinicians. For instance, after performing and interpreting magnetic resonance angiography of the lower extremity, the radiologist could directly communicate with the ordering clinician as to what options exist for possible intervention. Radiology must be more interactive with the patients as well, and this could be accomplished by developing our own clinics, especially in interventional radiology. These efforts will help maintain the number of exams that we perform and interpret, and again, through this volume, radiology residents will have an appropriate amount of experience in these clinical areas.
ACHIEVING THE APPROPRIATE BALANCE BETWEEN DIRECT SUPERVISION AND RESIDENTS’ INDEPENDENT WORK As the role of imaging in patient care increases, enhanced availability of radiologists to provide primary interpretation has been requested by many departments within the hospital (eg, the emergency department). Functioning as the primary imaging consultant, residents develop invaluable skills in interpretation, diagnosis, and communication. Our objective was to find solutions to protect this resident autonomy. Nationally, it appears that the majority of overnight call in facilities with residency programs is taken by the residents. However, there has been institutional pressure to provide 24-hour attending coverage. Radiology residents believe that call is a critical component of their training, providing them with an opportunity to be the primary interpreter of imaging examinations. Residents strongly believe that their growth will be stunted without this experience. As an alternative to complete attending coverage, we proposed developing a system of teleradiology where the radiology resident can act as a gatekeeper. After providing an initial reading, the resident could decide whether he or she needs to contact the attending. In addition, there could be other established criteria where the referring clinician could request an attending interpretation. These criteria must be documented and agreed upon by the different departments within the hospital. With this compromise, the radiology resident remains on the front line, while the referring clinician has the opportunity to receive an attending’s interpretation. A possible alternative is to have a more senior radiology resident available for consultation by the more junior radiology resident. Not only would this maintain the resident as the primary interpreter, this would also encourage a more team-based approach to patient care. In addition, this will provide the senior resident a chance to improve his or her teaching skills. Unfortunately, an immediate realization is that this option is only applicable to residency programs with a large group of residents. Once again, an increased effort must be made to enhance relationships with other departments within the hospital. By doing this, a certain sense of confidence and collaboration can be developed. Since rapport builds trust, the radiology resident must also participate in this effort. By being more available and more open to consultation within the emergency department, the radiology resident
527
KAY
can be utilized as a primary resource by the referring clinician. Finally, if we can prove to the referring physician that radiology residents provide a reasonable level of service, we can alleviate the concerns of these physicians. Despite the fact that the literature already indicates resident proficiency, the development of consistent and reliable institutional quality assurance will provide the referring clinicians with site-specific data. By hosting regularly scheduled quality assurance conferences (ie,. morbidity and mortality) and allowing the referring clinicians to either participate or to offer input, we will not only educate ourselves but also provide the clinicians with the information
528
Academic Radiology, Vol 12, No 4, April 2005
that they need to feel confident with the radiology resident’s interpretation.
CONCLUSION Two conflicts have been presented that have the potential to alter radiology residency education. Utilizing input from the A3CR2, APDR, and APCR, potential solutions have been developed. With the continued efforts of all concerned parties (eg, radiology residents, program directors, and the ACR), the education of radiology residents can be preserved.