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The Exposure Dilemma: Qualitative Study of Medical Student Opinions and Perceptions of Radiology
Canadian Association of Radiologists Journal 66 (2015) 291e297 www.carjonline.org
Education and Training / Formation et perfectionnement professionnel
The Exposure Dilemma: Qualitative Study of Medical Student Opinions and Perceptions of Radiology Kari L. Visscher, MD, MScBMCa,*, Georges Nassrallah, BSc, MDb, Lisa Faden, PhDc, Daniele Wiseman, MD, FRCPCa a
Department of Medical Imaging, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada b Department of Medicine, Schulich School of Medicine & Dentistry, London, Ontario, Canada c Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
Abstract Purpose: According to a national survey of over 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists. The purpose of this study is to use qualitative methods to explore the ways exposure to radiology in medical school impacts students’ opinions and perceptions of radiology and radiologists. Methods: After receiving ethics approval, 4 focus groups were conducted, 1 per year of undergraduate medical training at Western University. The transcribed audio recordings and accompanying field notes, together with the open-ended questions obtained from the national survey, were analyzed using thematic analysis. Results: Five hundred sixty students in medical school years 1 and 2 (preclerkship) participated in the national survey and 18 in the focus groups; 336 students in years 3 and 4 [clerkship] participated in the national survey and 10 in the focus groups. Three major findings emerged from the analysis of the data. First, stereotypes are perpetuated mainly through informal interactions. Second, there is limited exposure to radiology and radiologists in medical school, especially in preclerkship. Third, students want to know what to expect if they choose a career in radiology. Conclusions: Medical students, especially those in preclerkship, are seeking accurate information to modify or reinforce radiology stereotypes. Limited exposure makes interactions with students impactful and mentorship essential. Students want meaningful interactions with radiologists and radiology residents. Resume Objectif : Un sondage national mene aupres de plus de 900 etudiants en medecine canadiens revele que le stereotype du radiologiste travaillant seul dans une chambre noire persiste. Cette etude a pour objectif d’utiliser des methodes qualitatives pour explorer la fac¸on dont l’exposition a la radiologie pendant les etudes en medecine influe sur l’opinion et les perceptions des etudiants a l’egard de la radiologie et des radiologistes. Methodes : Une fois le projet approuve par le comite d’ethique, quatre groupes de discussion ont ete reunis, soit un a l’intention des etudiants de chaque annee d’etudes de premier cycle en medecine a la Western University. La transcription des enregistrements sonores et les notes prises sur le vif, ainsi que les reponses aux questions ouvertes recueillies dans le cadre du sondage national ont fait l’objet d’une analyse thematique. Resultats : Cinq cent soixante etudiants de premiere et de deuxieme annees de medecine (avant le debut du stage clinique) ont participe au sondage national et 18, aux groupes de discussion, alors que 336 etudiants de troisieme et de quatrieme annees (stage clinique) ont participe au sondage national et 10, aux groupes de discussion. L’analyse des donnees a permis trois grandes observations. D’abord, les stereotypes sont principalement perpetues dans le cadre d’echanges informels. Ensuite, les etudiants en medecine sont peu exposes a la radiologie et aux radiologistes, surtout s’ils n’ont pas encore fait de stage clinique. Enfin, les etudiants veulent savoir ce qui les attend s’ils choisissent de poursuivre une carriere en radiologie. Conclusions : Les etudiants en medecine, en particulier ceux qui n’ont pas encore effectue de stage clinique, veulent obtenir des renseignements exacts qui permettront de briser ou de confirmer les stereotypes associes a la radiologie. Cette exposition limitee a la * Address for correspondence: Kari L. Visscher, MD, MScBMC, Department of Medical Imaging, C/O London Health Sciences Centre, Victoria
Hospital, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada. E-mail address: [email protected] (K. L. Visscher).
0846-5371/$ - see front matter Ó 2015 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2014.12.008
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radiologie donne un caractere percutant aux interactions avec les etudiants et un caractere essentiel au mentorat. Les etudiants veulent avoir des interactions concretes avec les radiologistes et les residents en radiologie. Ó 2015 Canadian Association of Radiologists. All rights reserved. Key Words: Education; Medical students; Radiology and radiologists; Qualitative research; Undergraduate medical education
According to a national survey (NS) of more than 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists [1]. This study also found that one of the most cited factors deterring medical students from pursuing a career in radiology is lack of previous exposure or mentorship in the field. Furthermore, lack of exposure to research and observerships was offered as a possible factor contributing to the persistently low number of females pursuing a career in radiology. These findings reflect a problem for the future of radiology. With a trend towards decreasing applications for radiology resident programs, it is of interest to explore new possibilities for promoting the profession. Although more studies are needed to better assess this association, the question remainsdhow does exposure to radiology in medical school shape students’ opinions and perceptions of radiology and radiologists? Previous studies have found that exposure to radiology in preclinical years has a positive and long-lasting impact on medical students’ attitudes towards radiology. Also, early exposure reduced the prevalence of negative stereotypes about radiologists among graduating medical students [2,3]. Furthermore, a study that involved the development of a radiology medical student society with active staff involvement demonstrated a 5-fold increase in the number of students applying to radiology as a career [4]. The methodology of the aforementioned studies used quantitative methods, primarily surveys with closed-ended questions. Although valuable, there has been a growing recognition in medical education literature that some of the relevant and pressing questions in the field cannot be satisfactory explored with this approach [5]. As such, a valuable complementary approach is the application of qualitative methods to gain new insights into the experiences and perspectives of medical students [6]. In radiology education literature, there is a salient deficit of qualitative studies that endeavor to better understand how medical students develop their perceptions of radiology and radiologists, as well as how these perceptions may impact the profession. The purpose of this study was 2-fold and will be presented in 2 papers. For this paper, we used qualitative methods to explore how exposure to radiology during medical school impacts medical students’ opinions and perceptions of radiology and radiologists. To do this, we used student comments collected by the NS combined with data from focus groups (FG) of medical students at 1 medical school to further explore 2 main questions:
1. What are the perceptions that medical students have of radiology and of radiologists? 2. How does formal and informal exposure to radiology in medical school shape these perceptions? After presenting our findings, we discuss the potential implications of these perceptions on the future of the profession. Methods Rationale Qualitative methodology was chosen for its potential to interpret human experience in order to identify problems and form theories [7]. Of the various qualitative methods, FGs were deemed most appropriate for several reasons. FGs allow for a discussion of complex topics and emphasize the interactions among participants to generate data and explore multiple perspectives on a topic. In theory, the group setting provides a safe environment that enables participants to share experiences and perceptions and to discuss difficulties or suboptimal practices. Also, interactions among participants can provide valuable information regarding group norms and less easily articulated attitudes [6,8]. Design Following institutional ethics approval, between September 2012 and April 2013, students in each of the 4 years of undergraduate medical education from Western University, London, Ontario, Canada were invited to participate in FGs. Participation was voluntary and written informed consent was attained. To protect anonymity and confidentiality no personally identifiable data was collected. For this reason, we are unable to attribute comments to specific participants. Data were collected by way of semi-structured FGs utilizing a moderator guide (Appendix 1) developed from the literature [9] and through discussion among the authors about the purpose of the study and the findings of the previous (NS) study. Each session was 1.5-2 hours in length and moderated by the primary investigator (K.L.V.). Sessions were recorded using a voice recorder and transcribed verbatim. Field notes were taken by the coauthor (G.N.) to document interactions, expression and events that would not have been captured on the voice recordings.
Student opinions and perceptions of radiology / Canadian Association of Radiologists Journal 66 (2015) 291e297
As in most groups, there were people who naturally spoke more often. Full effort was made to include all participants in the discussion. This was achieved with directed questions. For example, the moderator was intentional about asking the less vocal participants how they felt about a discussion topic or if they had any comments. Field notes captured the nonverbal participation of quieter participants, such as head nods or softly spoken words of agreement or disagreement. This was taken into consideration during the analysis. Data Analysis Data sources for the thematic analysis included: 1) transcribed audio recordings of the 4 FGs, 2) field notes from the FGs, and 3) responses from open-ended questions on the NS. These sources were analyzed using modified thematic analysis (Table 1). Modifications involved independent initial analysis by the authors K.L.V. and G.N. The authors then met to compare and contrast coding, and to clarify and resolve variations in understanding and coding. The final analysis was then independently reviewed by the coauthor L.F. to ensure that the analysis provided a reasonable account of the data without gaps or leaps of logic. Any differences identified were discussed until agreement by all 3 authors was reached. This strategy is referred to as investigator triangulation [10,11], and is accepted as a means of increasing the strength (or validity) of qualitative data analysis [12].
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Finding 1: The Stereotype of the Isolated and Sedentary Radiologist is Perpetuated Mainly Through Informal Interactions For this study, informal interactions included what family, friends, colleagues, and other services said or did to convey an opinion about radiology. Despite having a limited understanding of what a radiologist is or does, most students expressed skepticism that the stereotypes could be false. However, students were interested in obtaining accurate information from radiologists or radiology residents in order to refute or support these perceptions. ‘‘[Interest groups] are our first exposure to what it’s actually like, because you hear all these rumors about what happens in radiology and we get these ideas that you’re stuck in a dark room, looking at a computer screen all day. Then you have these interest groups and you [radiologists] come and say ‘No, it’s not like that. This is what I do day-to-day. This is how I set up my practice.’’’ [FG Y1] The motivation to seek out information and openness to modify beliefs was strongest in first year students and tapered noticeably by fourth year. Finding 2: There is Limited Formal (Curricular) and Informal (Extracurricular) Exposure to Radiology and Radiologists, Especially in Preclerkship
Results Participants in the NS portion of the study included 917 medical students from 14 English-speaking accredited medical schools across Canada. Of the 917 respondents, 21 were excluded because they were not medical students. Participants in the FG portion of the study included 28 medical students from the University of Western Ontario. Of those, 560 students in the NS and 18 in the FG were in preclerkship, and 336 students in the NS and 10 in the FG were in clerkship. Within the FGs, 9 were female and 19 male, of which 2 females and 6 males were considering a career in radiology. Specific to the focus of this paper, that data revealed 3 major findings.
Students noted that they rarely heard from radiologists throughout their formal curriculum. When diagnostic imaging was presented or taught, it was often given only cursory attention, and was most often presented by nonradiologists. Students in the second-year FG commented: ‘‘We don’t get many radiology lectures so I don’t really know who the radiologists are,’’ and, ‘‘Given the way out curriculum is structured I am not sure it is conducive to exploring radiology because it is not given its own dedicated time and is more interspersed into whatever we are looking at.’’ The majority of the students stated that they did not have enough information about radiology to consider it as a career option. One student said, ‘‘Had I been told it were more accessible in my early years, or had I obtained more
Table 1 Phases of thematic analysis [8] Phases
Description of process
Data familiarization Generating codes Searching for themes Reviewing themes
Reading and rereading the data, noting down initial ideas Coding interesting features of data in systematic fashion across entire data set. Then collating relevant data under each code. Collating codes into potential themes. Then gathering data relevant to each potential theme Checking if themes work in relation to the codes and to the entire data set. Then generating a thematic ‘‘map’’ of the analysis Ongoing analysis to refine the specifics of each theme, and the overall story the analysis tells, generating clear definitions and names for each theme. Selection of compelling extract examples, final analysis of the selected extracts, relation back of the analysis to the research question and literature, producing a scholarly report of the analysis
Defining and naming themes Produce the report
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exposure to it in my pre-clinical years, things may currently be different as I could have started to build a portfolio towards applying for a radiology residency’’ [NS Y3]. In all of the FGs, students expressed disappointment that they rarely encountered radiologists who promoted radiology as a profession. When interaction did occur, students had mixed experiences. For example, a fourth year student from the FG shared a positive interaction: ‘‘I had a really good experience in first year. You had a department introduction day. It was . very focused on what it is that you do, and why it is exciting.’’ However, a fourth-year student from the NS shared a negative impression: ‘‘Many of the staff, residents, and fellows were the worst people to work with. Consistently dismissing me, terrible teaching, negative attitudes and comments about their own careers, patients, colleagues and life in general.’’ Overall, students wanted to know that the radiologists valued them as learners. In particular, they were looking to see if the radiologists wanted them around and were interested in their education and well-being. They were looking to make some degree of a personal connection. This goes for both staff and residents. One fourth year medical student commented that it is ‘‘not just the staff, but the residents in the program that can be good mentors.’’ Although some students had positive experiences interacting with radiology departments, the majority expressed frustration and disappointment because they felt ignored. These students commented, ‘‘The organization of [the radiology selective] I think reinforces the radiology stereotype that nobody actually wants to talk to you’’ [FG Y3], and, ‘‘You establish no relationship with anyone. No one ever gives you meaningful feedback.’’ [FG Y4]. Many participants viewed their interactions with radiologists as unrealized learning opportunities. Finding 3: Students, Especially Those in Preclerkship, Want to Have the Information That They Need to Make a Decision About a Career in Radiology Students recognized that radiology is an integral part of the health care team. In particular, they wanted to know more about the specific rewards of a career in radiology and whether radiologists enjoy their jobs and want to come to work each day: ‘‘When a staff physician is exciting and enthusiastic and loves their job and makes you interested in something, for me that is top priority for making my career choice’’ [FG Y4]. Students wanted to know more about the clinical value and impact of the profession. One fourth year student commented, ‘‘[Radiologists get] exposure to most, if not all, of the interesting cases that come into the hospital.’’ [FG Y4]. Furthermore, students expressed that before they could consider a career in radiology, they needed more information. In particular, they wanted to learn more about lifestyle, research and observership opportunities, Canadian Residency Matching Service (CaRMS) applications and competitiveness, residency difficulty, the need for
fellowships, job availability, and the impact that outsourcing and teleradiology will have on the job market. Also, to a lesser extent, they wanted to know about radiation exposure and earning potential. Discussion Medical Students, Especially Those in Preclerkship, Want Accurate Information to Modify or Reinforce Radiology Stereotypes The stereotype of the isolated, sedentary radiologist persists, limiting the pool of medical students who consider a career in radiology. Although this finding is similar to other studies [1,3,13,14] our results suggest stereotypes persist mainly through informal interactions and the dearth of accurate information presented by radiologists or radiology residents. This concept of informal interactions or the ‘‘hidden curriculum’’ is important, having been recognized by the Association of Faculties of Medicine of Canada in its report ‘‘The Future of Medical Education in Canada [FMEC].’’ The FMEC defines the hidden curriculum as ‘‘a set of influences that function at the level of organizational structure and culture, affecting the nature of learning, professional interactions, and clinical practice.’’ One of its goals is to ‘‘ensure that the hidden curriculum is regularly identified and addressed by students, educators, and faculty throughout all stages of learning’’ [13]. Similarly several authors agree that student observations of behaviors are a much greater influence than the professionalism taught in the classroom [13,15,16]. As such, those involved with undergraduate medical training need to pay particular attention to educator professionalism, not only with direct medical student interaction but also with colleague interactions being observed by medical students. As Dixie Anderson, a radiologist at Washington University recognized more than 20 years ago, ‘‘Our teachings reflect our attitudes, prejudices, honesty, and humility. It is our example that will be remembered long after the differential diagnoses are forgotten. Our example, our hidden curriculum, must be considered, guarded, and used wisely’’ [17]. Furthermore, our results demonstrate that preclerkship students, especially those in first year, are the most open minded to using the information presented to modify or reinforce these beliefs. This finding is not uncommon, as Inui [18] noted, As they move through their undergraduate medical education experience, our students also move from being open-minded to being fact-surfeited, from being intellectually curious to being increasingly focused on just that set of knowledge and skills that must be acquired to pass examinations, from being open-hearted and empathetic to being emotionally well-defended, from idealistic to cynical about medicine, medical practice, and the life of medicine.
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In radiology literature, this finding has been seen indirectly through previous work demonstrating that radiology education early in medical school improves the impression of radiology as a specialty and increases interest in radiology as a career [2,3]. For example, in a survey of 64 second-year medical students at a single U.S. institution after an 1-hour, case-based introductory interventional radiology lecture, 29% said their impressions of and interest in the practice of Interventional Radiology had significantly improved and 46% had a better impression [19]. Accordingly, recruitment efforts are likely to be most effective if concentrated in year one of medical school. The method by which accurate information is conveyed may vary depending on the institution, but it is important that there be an intentional and thoughtful effort to provide enough information so that a reasonable medical student could make an informed career choice. Also, for those not interested in radiology as a career, the information provided may serve as the groundwork necessary for positive working relationships across specialties [14]. Limited Exposure to Radiology and Radiologist Makes Interactions With Students Impactful and Mentorship Essential Medical students felt that they were lacking formal (curricular) and informal (extracurricular) opportunities to learn radiology. As a result, interactions with radiology and radiologists seem to have a sizeable impact on the students’ opinions and perceptions. In other words, there appears to be a high impact to interaction ratio. This is partially extrapolated from the fact that there were polar opinions about radiology stemming from a single or small number of interactions. Although there are likely many confounding variables contributing to the strong opinions expressed by some of the students, it is sensible to consider that by providing more neutral or positive experiences, the negative experiences may be less impactful. As with statistics, by increasing the sample size of experiences the students’ perceptions will more accurately reflect the realty of what a radiologist is and does. Another possible outcome associated with limited exposure is that without extracurricular mentorship from radiologists or radiology residents, students may be overlooking radiology as a career option. For example, one third-year student from the NS commented, ‘‘Unless you know early on that [radiology is] a strong consideration you [will] not search for early exposure [which] is difficult to obtain unless you have a mentor.’’ Furthermore, students recognize radiology as a competitive specialty and those considering it as a career option expressed a need to have more extracurricular opportunities such as mentorship, observerships, and research. Also, there was confusion and lack of awareness about where one might go to find information about obtaining such opportunities. Although mentorship, research and observerships were cited as being important for developing a competitive resume
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for CaRMS application, only mentorship was mentioned as being paramount in making career decisions: ‘‘It [good mentorship] weights much more highly then you would think it would in the decision making process. Having someone you look up to, even though it is just one sample out of one hundred thousand others, it is really influential’’ [FG Y4]. This finding is supported by a systematic review of the literature that found mentorship is influential on personal development, career guidance, and career choice [20]. Students Want Meaningful Interactions With Radiologists and Radiology Residents Although what defines a meaningful interaction may vary depending on the population in consideration, some generalities exist [21,22]. As a starting point and memory aid consider these 4 words when interacting with medical students: engage, explain, converse, and offer. Engage Take a moment to engage and include the medical student in what you are doing. Ask what he or she is interested in learning, and try to demonstrate how radiology is used in their area of interest, or discuss what they will need to know about radiology to be a better resident or clerk in that specialty. Explain Make explicit your mental process when examining a study. Explain what you find interesting or how your finding(s) may impact patient care. Converse Be open to discussing the practical side of radiology including what your day-to-day work is like. Share your perspectives and insights about lifestyle, research and observership opportunities, CaRMS applications and competitiveness, residency difficulty and need for fellowships, job availability including the impact that outsourcing and teleradiology has on the job market, and to a lesser extent radiation exposure and earning potential. Offer Offer opportunities to ‘‘stand out’’ for those expressing interest, such as by giving them a role in research, case reports, lunchtime or grand round presentations. Limitations While the survey component of this study included a large sample of responses from medical schools across Canada, the FG component of this study involved a convenience sample of 28 medical students from a single institution. Although this would be a limitation in quantitative research methodology, in qualitative research it is less of a concern as the goal of this work is to produce ‘‘better ways of thinking about problems that we face,’’ as well as support creative
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problem solving [23]. The strength of qualitative research is measured in the transferability of its discoveries, not in their generalizability [24]. In summary, the data from this study suggests that medical students experience a deficit of quality exposure to radiology. To varying amounts, this deficit impacts their interest in radiology as a career, perpetuates the negative radiology stereotypes, and contributes to a lack of positive relations with physicians in other fields. Being cognizant of how medical students perceive radiology is an important first step in capitalizing on the rich opportunities for change that exist in undergraduate medical education. Especially in a time when radiologists are redefining their ‘‘value added’’ roles in academic medicine, involvement in undergraduate medical education is a prime target [25]. Going forward, the second part of this study will involve examining how the medical students at Western University assess quality when evaluating radiology exposure during medical school. Moreover, important insights will be revealed on how to increase interest in radiology as a career; develop those who are interested into competitive CaRMS applicants; and educate those not interested on how to be more effective radiology collaborators. References [1] Zener R, Visscher KL, Lee S, Richetts M, Spear S, Wiseman D. Why are fewer women selecting a career in radiology? Paper presented at: European Congress of Radiology. March 7-11, 2013; Vienna, Austria. [2] Branstetter 4th BF, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: The effect of early exposure. AJR Am J Roentgenol 2007;188:W9e14. [3] Branstetter 4th BF, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinions about radiology. Acad Radiol 2008;15:1331e9. [4] Murphy KD, Yu JN, Heitzman ER, Groskin SA, Wasenko JJ, Wilfred C. The impact of a radiology medical student society on student interest and career choice in radiology. Acad Radiol 1997;4:855. [5] Watling CJ, Lingard L. Grounded theory in medical education research: AMEE guide no. 70. Med Teach 2012;34:850e61. [6] Khan ME, Anker M, Patel BC, Barge S, Sadhwani H, Kohle R. The use of focus groups in social and behavioural research: Some methodological issues. World Health Stat Quart 1991;44:145e9.
[7] Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description - the poor cousin of health research? BMC 2009;9:52. [8] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psych 2006;3:77e101. [9] Greenbaum TL. The Practical Handbook and Guide to Focus Group Research. Lexington, MA: D.C. Heath; 1988. [10] Mitchell ES. Multiple triangulation: A methodlogy for nursing science. Adv Nurs Sci 1986;8:18e26. [11] Thurmond VA. The point of triangulation. J Nurs Scholarsh 2001;33: 253e8. [12] Burnard P, Gill P, Stewart K, Treasure E, Chadwick B. Analysing and presenting qualitative data. Br Dent J 2008;204:429e32. [13] Van Deven T, Hibbert K, Faden L, Chhem RK. The hidden curriculum in radiology residency programs: A path to isolation or integration? Eur J Radiol 2013;82:883e7. [14] Gunderman RB, Hill DV. Student concerns and misconceptions about a career in radiology. Acad Radiol 2012;19:366e8. [15] Glicken AD, Merenstein GB. Addressing the hidden curriculum: Understanding educator professionalism. Med Teach 2007;29:54e7. [16] Gunderman RB. Why teaching should be recognized as an essential component of radiology residency training. Acad Radiol 2000;7: 1123e5. [17] Anderson DJ. The hidden curriculum. AJR Am J Roentgenol 1992;159: 21e2. [18] Inui TA. Flag in the Wind: Educating From Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. [19] Ghatan CE, Kuo WT, Hofman LV, Kothary N. Making the case for early medical student education in interventional radiology: a survey of 2nd-year students in a single U.S. institution. J Vasc Interv Radiol 2010;21:549e53. [20] Melnyk BM. Mentoring in academic medicine. A systematic review. Worldviews Evidence-Based Nurs 2007;4:170e1. [21] Department for Communities and Local Government. The Benefits of Meaningful Interaction. Rapid Evidence Assessment of Existing Literature. London, England: Queen’s Printer and Controller of Her Majesty’s Stationery Office; 2011. [22] Department for Communities and Local Government. Guidance on Meaningful Interaction. How Encouraging Positive Relationships Between People Can Help Build Community Cohesion. Wetherby, England: Communities and Local Government; 2008. [23] Regehr G. It’s NOT rocket science: Rethinking our metaphors for research in health professions education. Med Educ 2010;44: 31e9. [24] Merriam SB, editor. Qualitative Research: A Guide to Design and Implementation. 1st edition. San Francisco, CA: Jossey-Bass; 2009. [25] Gunderman RB. Medical students are our future. J Am Coll Radiol 2005;2:795e7.
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Appendix 1. Moderator Guide This moderator guide was created at the London Health Sciences Centre, Victoria Hospital Radiology Department in conjunction with the Center for Education Research and Innovation at Western University. The guide is meant to be a loose framework that the moderator can use to organize the focus group discussions around certain topics of interest. The aim is to stimulate discussion that can be used to better understanding how exposures to radiology in medical school impacts students’ perceptions and opinions of radiology. Agenda 1. Introduction of the research team. 2. Review of the study purpose and goals. 3. Discussion about confidentiality and risks of participation. 4. Answering questions and obtaining voluntary consent. 5. General rules of conduct for the session. 6. Begin discussion using the question guide below as framework. 7. Conclusion. Questions 1. First of all, I am interested in knowing what opportunities you have had to learn about radiology while in medical school. Alternative wording: (A) tell me about any of your experiences that have contributed to your understanding of what a radiologist does? (B) What opportunities have you had in medical school to learn about what radiologists do? 2. If you were trying to balance the pros and cons of a career in radiology, what would you put on your list? Alterative wording: (A) What do you consider the most attractive and least attractive aspects of a career in radiology? (B) What is it about radiology that is attractive or unattractive to you? Possible probes: (A) Radiology is perceived by some medical students as a very competitive field to get into. Does that influence your decision-making? (B) How does salary fit into your thinking about radiology? (C) Some see radiology as a male-dominated field. Does that affect your thinking? (D) Some people view radiology work as isolated or lacking in patient contact. What do you think about that? (E) Some people see the rapid changes in technology as making the future of radiology work uncertain. Is this part of your thinking? (F) Some medical students have reported that they hear negative comments about radiology from doctors in other specialties. Do those comments impact your thinking about radiology? 3. Can you share with me your opinions about what you need to learn about radiology in medical school to be a good doctor in any specialty?
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Alternative wording: (A) Regardless of what field of medicine you choose as a career, can you tell me what you think you need to know about radiology to be a good doctor? (B) In essence medical school is about learning the essentials of general medicine, what do you think is essential to know about radiology? 4a. When I was in medical school, I was unaware of all the subspecialties within radiology. Let’s work together to list each subspecialty and briefly discuss what each role entails. Alternative wording: (A) Radiology consists of several subspecialties, can you help me make a list and describe briefly what each of the specialties do? (B) Can you share with me your understanding of the different subspecialties in radiology? Let’s start by making a list and discuss what each subspecialty does. 4b. With this information about the different subspecialties, would you reconsider any of the factors on the pro and con lists? Alternative wording: (A) Now that you have a more comprehensive list of what a radiologist does, do you still think the factors you listed as attractors or dissuaders are accurate? (B) Considering the information of all the different subspecialties, are there any changes you would make to the list of attractors or dissuaders? 5. What resources would you use to improve your understanding of or exposure to radiology? Alternative wording: (A) Whom would you contact, or what resources you would use to get more radiology exposure? (B) There are a variety of ways to learn more about radiology or get clinical exposure, can you share for me what this would entail for you? Possible prompts: websites, podcasts, research opportunities, mentorship opportunities. 6. Finally, I would like to get your opinion about how you would change your radiology experience to get the best medical education. Alternative wording: (A) Moving forward, what would be your suggestion for how to change your learning about radiology in medical school? (B) Ultimately our goal is to make your radiology experience in medical school the best it can be, and that is dependent on your feedback. Saying that, what would be your input on how to change the way radiology is dealt with in medical school? 7. Closing question: Does anyone in the group have any questions they would like to ask?
Education and Training / Formation et perfectionnement professionnel
The Exposure Dilemma: Qualitative Study of Medical Student Opinions and Perceptions of Radiology Kari L. Visscher, MD, MScBMCa,*, Georges Nassrallah, BSc, MDb, Lisa Faden, PhDc, Daniele Wiseman, MD, FRCPCa a
Department of Medical Imaging, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada b Department of Medicine, Schulich School of Medicine & Dentistry, London, Ontario, Canada c Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
Abstract Purpose: According to a national survey of over 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists. The purpose of this study is to use qualitative methods to explore the ways exposure to radiology in medical school impacts students’ opinions and perceptions of radiology and radiologists. Methods: After receiving ethics approval, 4 focus groups were conducted, 1 per year of undergraduate medical training at Western University. The transcribed audio recordings and accompanying field notes, together with the open-ended questions obtained from the national survey, were analyzed using thematic analysis. Results: Five hundred sixty students in medical school years 1 and 2 (preclerkship) participated in the national survey and 18 in the focus groups; 336 students in years 3 and 4 [clerkship] participated in the national survey and 10 in the focus groups. Three major findings emerged from the analysis of the data. First, stereotypes are perpetuated mainly through informal interactions. Second, there is limited exposure to radiology and radiologists in medical school, especially in preclerkship. Third, students want to know what to expect if they choose a career in radiology. Conclusions: Medical students, especially those in preclerkship, are seeking accurate information to modify or reinforce radiology stereotypes. Limited exposure makes interactions with students impactful and mentorship essential. Students want meaningful interactions with radiologists and radiology residents. Resume Objectif : Un sondage national mene aupres de plus de 900 etudiants en medecine canadiens revele que le stereotype du radiologiste travaillant seul dans une chambre noire persiste. Cette etude a pour objectif d’utiliser des methodes qualitatives pour explorer la fac¸on dont l’exposition a la radiologie pendant les etudes en medecine influe sur l’opinion et les perceptions des etudiants a l’egard de la radiologie et des radiologistes. Methodes : Une fois le projet approuve par le comite d’ethique, quatre groupes de discussion ont ete reunis, soit un a l’intention des etudiants de chaque annee d’etudes de premier cycle en medecine a la Western University. La transcription des enregistrements sonores et les notes prises sur le vif, ainsi que les reponses aux questions ouvertes recueillies dans le cadre du sondage national ont fait l’objet d’une analyse thematique. Resultats : Cinq cent soixante etudiants de premiere et de deuxieme annees de medecine (avant le debut du stage clinique) ont participe au sondage national et 18, aux groupes de discussion, alors que 336 etudiants de troisieme et de quatrieme annees (stage clinique) ont participe au sondage national et 10, aux groupes de discussion. L’analyse des donnees a permis trois grandes observations. D’abord, les stereotypes sont principalement perpetues dans le cadre d’echanges informels. Ensuite, les etudiants en medecine sont peu exposes a la radiologie et aux radiologistes, surtout s’ils n’ont pas encore fait de stage clinique. Enfin, les etudiants veulent savoir ce qui les attend s’ils choisissent de poursuivre une carriere en radiologie. Conclusions : Les etudiants en medecine, en particulier ceux qui n’ont pas encore effectue de stage clinique, veulent obtenir des renseignements exacts qui permettront de briser ou de confirmer les stereotypes associes a la radiologie. Cette exposition limitee a la * Address for correspondence: Kari L. Visscher, MD, MScBMC, Department of Medical Imaging, C/O London Health Sciences Centre, Victoria
Hospital, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada. E-mail address: [email protected] (K. L. Visscher).
0846-5371/$ - see front matter Ó 2015 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2014.12.008
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radiologie donne un caractere percutant aux interactions avec les etudiants et un caractere essentiel au mentorat. Les etudiants veulent avoir des interactions concretes avec les radiologistes et les residents en radiologie. Ó 2015 Canadian Association of Radiologists. All rights reserved. Key Words: Education; Medical students; Radiology and radiologists; Qualitative research; Undergraduate medical education
According to a national survey (NS) of more than 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists [1]. This study also found that one of the most cited factors deterring medical students from pursuing a career in radiology is lack of previous exposure or mentorship in the field. Furthermore, lack of exposure to research and observerships was offered as a possible factor contributing to the persistently low number of females pursuing a career in radiology. These findings reflect a problem for the future of radiology. With a trend towards decreasing applications for radiology resident programs, it is of interest to explore new possibilities for promoting the profession. Although more studies are needed to better assess this association, the question remainsdhow does exposure to radiology in medical school shape students’ opinions and perceptions of radiology and radiologists? Previous studies have found that exposure to radiology in preclinical years has a positive and long-lasting impact on medical students’ attitudes towards radiology. Also, early exposure reduced the prevalence of negative stereotypes about radiologists among graduating medical students [2,3]. Furthermore, a study that involved the development of a radiology medical student society with active staff involvement demonstrated a 5-fold increase in the number of students applying to radiology as a career [4]. The methodology of the aforementioned studies used quantitative methods, primarily surveys with closed-ended questions. Although valuable, there has been a growing recognition in medical education literature that some of the relevant and pressing questions in the field cannot be satisfactory explored with this approach [5]. As such, a valuable complementary approach is the application of qualitative methods to gain new insights into the experiences and perspectives of medical students [6]. In radiology education literature, there is a salient deficit of qualitative studies that endeavor to better understand how medical students develop their perceptions of radiology and radiologists, as well as how these perceptions may impact the profession. The purpose of this study was 2-fold and will be presented in 2 papers. For this paper, we used qualitative methods to explore how exposure to radiology during medical school impacts medical students’ opinions and perceptions of radiology and radiologists. To do this, we used student comments collected by the NS combined with data from focus groups (FG) of medical students at 1 medical school to further explore 2 main questions:
1. What are the perceptions that medical students have of radiology and of radiologists? 2. How does formal and informal exposure to radiology in medical school shape these perceptions? After presenting our findings, we discuss the potential implications of these perceptions on the future of the profession. Methods Rationale Qualitative methodology was chosen for its potential to interpret human experience in order to identify problems and form theories [7]. Of the various qualitative methods, FGs were deemed most appropriate for several reasons. FGs allow for a discussion of complex topics and emphasize the interactions among participants to generate data and explore multiple perspectives on a topic. In theory, the group setting provides a safe environment that enables participants to share experiences and perceptions and to discuss difficulties or suboptimal practices. Also, interactions among participants can provide valuable information regarding group norms and less easily articulated attitudes [6,8]. Design Following institutional ethics approval, between September 2012 and April 2013, students in each of the 4 years of undergraduate medical education from Western University, London, Ontario, Canada were invited to participate in FGs. Participation was voluntary and written informed consent was attained. To protect anonymity and confidentiality no personally identifiable data was collected. For this reason, we are unable to attribute comments to specific participants. Data were collected by way of semi-structured FGs utilizing a moderator guide (Appendix 1) developed from the literature [9] and through discussion among the authors about the purpose of the study and the findings of the previous (NS) study. Each session was 1.5-2 hours in length and moderated by the primary investigator (K.L.V.). Sessions were recorded using a voice recorder and transcribed verbatim. Field notes were taken by the coauthor (G.N.) to document interactions, expression and events that would not have been captured on the voice recordings.
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As in most groups, there were people who naturally spoke more often. Full effort was made to include all participants in the discussion. This was achieved with directed questions. For example, the moderator was intentional about asking the less vocal participants how they felt about a discussion topic or if they had any comments. Field notes captured the nonverbal participation of quieter participants, such as head nods or softly spoken words of agreement or disagreement. This was taken into consideration during the analysis. Data Analysis Data sources for the thematic analysis included: 1) transcribed audio recordings of the 4 FGs, 2) field notes from the FGs, and 3) responses from open-ended questions on the NS. These sources were analyzed using modified thematic analysis (Table 1). Modifications involved independent initial analysis by the authors K.L.V. and G.N. The authors then met to compare and contrast coding, and to clarify and resolve variations in understanding and coding. The final analysis was then independently reviewed by the coauthor L.F. to ensure that the analysis provided a reasonable account of the data without gaps or leaps of logic. Any differences identified were discussed until agreement by all 3 authors was reached. This strategy is referred to as investigator triangulation [10,11], and is accepted as a means of increasing the strength (or validity) of qualitative data analysis [12].
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Finding 1: The Stereotype of the Isolated and Sedentary Radiologist is Perpetuated Mainly Through Informal Interactions For this study, informal interactions included what family, friends, colleagues, and other services said or did to convey an opinion about radiology. Despite having a limited understanding of what a radiologist is or does, most students expressed skepticism that the stereotypes could be false. However, students were interested in obtaining accurate information from radiologists or radiology residents in order to refute or support these perceptions. ‘‘[Interest groups] are our first exposure to what it’s actually like, because you hear all these rumors about what happens in radiology and we get these ideas that you’re stuck in a dark room, looking at a computer screen all day. Then you have these interest groups and you [radiologists] come and say ‘No, it’s not like that. This is what I do day-to-day. This is how I set up my practice.’’’ [FG Y1] The motivation to seek out information and openness to modify beliefs was strongest in first year students and tapered noticeably by fourth year. Finding 2: There is Limited Formal (Curricular) and Informal (Extracurricular) Exposure to Radiology and Radiologists, Especially in Preclerkship
Results Participants in the NS portion of the study included 917 medical students from 14 English-speaking accredited medical schools across Canada. Of the 917 respondents, 21 were excluded because they were not medical students. Participants in the FG portion of the study included 28 medical students from the University of Western Ontario. Of those, 560 students in the NS and 18 in the FG were in preclerkship, and 336 students in the NS and 10 in the FG were in clerkship. Within the FGs, 9 were female and 19 male, of which 2 females and 6 males were considering a career in radiology. Specific to the focus of this paper, that data revealed 3 major findings.
Students noted that they rarely heard from radiologists throughout their formal curriculum. When diagnostic imaging was presented or taught, it was often given only cursory attention, and was most often presented by nonradiologists. Students in the second-year FG commented: ‘‘We don’t get many radiology lectures so I don’t really know who the radiologists are,’’ and, ‘‘Given the way out curriculum is structured I am not sure it is conducive to exploring radiology because it is not given its own dedicated time and is more interspersed into whatever we are looking at.’’ The majority of the students stated that they did not have enough information about radiology to consider it as a career option. One student said, ‘‘Had I been told it were more accessible in my early years, or had I obtained more
Table 1 Phases of thematic analysis [8] Phases
Description of process
Data familiarization Generating codes Searching for themes Reviewing themes
Reading and rereading the data, noting down initial ideas Coding interesting features of data in systematic fashion across entire data set. Then collating relevant data under each code. Collating codes into potential themes. Then gathering data relevant to each potential theme Checking if themes work in relation to the codes and to the entire data set. Then generating a thematic ‘‘map’’ of the analysis Ongoing analysis to refine the specifics of each theme, and the overall story the analysis tells, generating clear definitions and names for each theme. Selection of compelling extract examples, final analysis of the selected extracts, relation back of the analysis to the research question and literature, producing a scholarly report of the analysis
Defining and naming themes Produce the report
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exposure to it in my pre-clinical years, things may currently be different as I could have started to build a portfolio towards applying for a radiology residency’’ [NS Y3]. In all of the FGs, students expressed disappointment that they rarely encountered radiologists who promoted radiology as a profession. When interaction did occur, students had mixed experiences. For example, a fourth year student from the FG shared a positive interaction: ‘‘I had a really good experience in first year. You had a department introduction day. It was . very focused on what it is that you do, and why it is exciting.’’ However, a fourth-year student from the NS shared a negative impression: ‘‘Many of the staff, residents, and fellows were the worst people to work with. Consistently dismissing me, terrible teaching, negative attitudes and comments about their own careers, patients, colleagues and life in general.’’ Overall, students wanted to know that the radiologists valued them as learners. In particular, they were looking to see if the radiologists wanted them around and were interested in their education and well-being. They were looking to make some degree of a personal connection. This goes for both staff and residents. One fourth year medical student commented that it is ‘‘not just the staff, but the residents in the program that can be good mentors.’’ Although some students had positive experiences interacting with radiology departments, the majority expressed frustration and disappointment because they felt ignored. These students commented, ‘‘The organization of [the radiology selective] I think reinforces the radiology stereotype that nobody actually wants to talk to you’’ [FG Y3], and, ‘‘You establish no relationship with anyone. No one ever gives you meaningful feedback.’’ [FG Y4]. Many participants viewed their interactions with radiologists as unrealized learning opportunities. Finding 3: Students, Especially Those in Preclerkship, Want to Have the Information That They Need to Make a Decision About a Career in Radiology Students recognized that radiology is an integral part of the health care team. In particular, they wanted to know more about the specific rewards of a career in radiology and whether radiologists enjoy their jobs and want to come to work each day: ‘‘When a staff physician is exciting and enthusiastic and loves their job and makes you interested in something, for me that is top priority for making my career choice’’ [FG Y4]. Students wanted to know more about the clinical value and impact of the profession. One fourth year student commented, ‘‘[Radiologists get] exposure to most, if not all, of the interesting cases that come into the hospital.’’ [FG Y4]. Furthermore, students expressed that before they could consider a career in radiology, they needed more information. In particular, they wanted to learn more about lifestyle, research and observership opportunities, Canadian Residency Matching Service (CaRMS) applications and competitiveness, residency difficulty, the need for
fellowships, job availability, and the impact that outsourcing and teleradiology will have on the job market. Also, to a lesser extent, they wanted to know about radiation exposure and earning potential. Discussion Medical Students, Especially Those in Preclerkship, Want Accurate Information to Modify or Reinforce Radiology Stereotypes The stereotype of the isolated, sedentary radiologist persists, limiting the pool of medical students who consider a career in radiology. Although this finding is similar to other studies [1,3,13,14] our results suggest stereotypes persist mainly through informal interactions and the dearth of accurate information presented by radiologists or radiology residents. This concept of informal interactions or the ‘‘hidden curriculum’’ is important, having been recognized by the Association of Faculties of Medicine of Canada in its report ‘‘The Future of Medical Education in Canada [FMEC].’’ The FMEC defines the hidden curriculum as ‘‘a set of influences that function at the level of organizational structure and culture, affecting the nature of learning, professional interactions, and clinical practice.’’ One of its goals is to ‘‘ensure that the hidden curriculum is regularly identified and addressed by students, educators, and faculty throughout all stages of learning’’ [13]. Similarly several authors agree that student observations of behaviors are a much greater influence than the professionalism taught in the classroom [13,15,16]. As such, those involved with undergraduate medical training need to pay particular attention to educator professionalism, not only with direct medical student interaction but also with colleague interactions being observed by medical students. As Dixie Anderson, a radiologist at Washington University recognized more than 20 years ago, ‘‘Our teachings reflect our attitudes, prejudices, honesty, and humility. It is our example that will be remembered long after the differential diagnoses are forgotten. Our example, our hidden curriculum, must be considered, guarded, and used wisely’’ [17]. Furthermore, our results demonstrate that preclerkship students, especially those in first year, are the most open minded to using the information presented to modify or reinforce these beliefs. This finding is not uncommon, as Inui [18] noted, As they move through their undergraduate medical education experience, our students also move from being open-minded to being fact-surfeited, from being intellectually curious to being increasingly focused on just that set of knowledge and skills that must be acquired to pass examinations, from being open-hearted and empathetic to being emotionally well-defended, from idealistic to cynical about medicine, medical practice, and the life of medicine.
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In radiology literature, this finding has been seen indirectly through previous work demonstrating that radiology education early in medical school improves the impression of radiology as a specialty and increases interest in radiology as a career [2,3]. For example, in a survey of 64 second-year medical students at a single U.S. institution after an 1-hour, case-based introductory interventional radiology lecture, 29% said their impressions of and interest in the practice of Interventional Radiology had significantly improved and 46% had a better impression [19]. Accordingly, recruitment efforts are likely to be most effective if concentrated in year one of medical school. The method by which accurate information is conveyed may vary depending on the institution, but it is important that there be an intentional and thoughtful effort to provide enough information so that a reasonable medical student could make an informed career choice. Also, for those not interested in radiology as a career, the information provided may serve as the groundwork necessary for positive working relationships across specialties [14]. Limited Exposure to Radiology and Radiologist Makes Interactions With Students Impactful and Mentorship Essential Medical students felt that they were lacking formal (curricular) and informal (extracurricular) opportunities to learn radiology. As a result, interactions with radiology and radiologists seem to have a sizeable impact on the students’ opinions and perceptions. In other words, there appears to be a high impact to interaction ratio. This is partially extrapolated from the fact that there were polar opinions about radiology stemming from a single or small number of interactions. Although there are likely many confounding variables contributing to the strong opinions expressed by some of the students, it is sensible to consider that by providing more neutral or positive experiences, the negative experiences may be less impactful. As with statistics, by increasing the sample size of experiences the students’ perceptions will more accurately reflect the realty of what a radiologist is and does. Another possible outcome associated with limited exposure is that without extracurricular mentorship from radiologists or radiology residents, students may be overlooking radiology as a career option. For example, one third-year student from the NS commented, ‘‘Unless you know early on that [radiology is] a strong consideration you [will] not search for early exposure [which] is difficult to obtain unless you have a mentor.’’ Furthermore, students recognize radiology as a competitive specialty and those considering it as a career option expressed a need to have more extracurricular opportunities such as mentorship, observerships, and research. Also, there was confusion and lack of awareness about where one might go to find information about obtaining such opportunities. Although mentorship, research and observerships were cited as being important for developing a competitive resume
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for CaRMS application, only mentorship was mentioned as being paramount in making career decisions: ‘‘It [good mentorship] weights much more highly then you would think it would in the decision making process. Having someone you look up to, even though it is just one sample out of one hundred thousand others, it is really influential’’ [FG Y4]. This finding is supported by a systematic review of the literature that found mentorship is influential on personal development, career guidance, and career choice [20]. Students Want Meaningful Interactions With Radiologists and Radiology Residents Although what defines a meaningful interaction may vary depending on the population in consideration, some generalities exist [21,22]. As a starting point and memory aid consider these 4 words when interacting with medical students: engage, explain, converse, and offer. Engage Take a moment to engage and include the medical student in what you are doing. Ask what he or she is interested in learning, and try to demonstrate how radiology is used in their area of interest, or discuss what they will need to know about radiology to be a better resident or clerk in that specialty. Explain Make explicit your mental process when examining a study. Explain what you find interesting or how your finding(s) may impact patient care. Converse Be open to discussing the practical side of radiology including what your day-to-day work is like. Share your perspectives and insights about lifestyle, research and observership opportunities, CaRMS applications and competitiveness, residency difficulty and need for fellowships, job availability including the impact that outsourcing and teleradiology has on the job market, and to a lesser extent radiation exposure and earning potential. Offer Offer opportunities to ‘‘stand out’’ for those expressing interest, such as by giving them a role in research, case reports, lunchtime or grand round presentations. Limitations While the survey component of this study included a large sample of responses from medical schools across Canada, the FG component of this study involved a convenience sample of 28 medical students from a single institution. Although this would be a limitation in quantitative research methodology, in qualitative research it is less of a concern as the goal of this work is to produce ‘‘better ways of thinking about problems that we face,’’ as well as support creative
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problem solving [23]. The strength of qualitative research is measured in the transferability of its discoveries, not in their generalizability [24]. In summary, the data from this study suggests that medical students experience a deficit of quality exposure to radiology. To varying amounts, this deficit impacts their interest in radiology as a career, perpetuates the negative radiology stereotypes, and contributes to a lack of positive relations with physicians in other fields. Being cognizant of how medical students perceive radiology is an important first step in capitalizing on the rich opportunities for change that exist in undergraduate medical education. Especially in a time when radiologists are redefining their ‘‘value added’’ roles in academic medicine, involvement in undergraduate medical education is a prime target [25]. Going forward, the second part of this study will involve examining how the medical students at Western University assess quality when evaluating radiology exposure during medical school. Moreover, important insights will be revealed on how to increase interest in radiology as a career; develop those who are interested into competitive CaRMS applicants; and educate those not interested on how to be more effective radiology collaborators. References [1] Zener R, Visscher KL, Lee S, Richetts M, Spear S, Wiseman D. Why are fewer women selecting a career in radiology? Paper presented at: European Congress of Radiology. March 7-11, 2013; Vienna, Austria. [2] Branstetter 4th BF, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: The effect of early exposure. AJR Am J Roentgenol 2007;188:W9e14. [3] Branstetter 4th BF, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinions about radiology. Acad Radiol 2008;15:1331e9. [4] Murphy KD, Yu JN, Heitzman ER, Groskin SA, Wasenko JJ, Wilfred C. The impact of a radiology medical student society on student interest and career choice in radiology. Acad Radiol 1997;4:855. [5] Watling CJ, Lingard L. Grounded theory in medical education research: AMEE guide no. 70. Med Teach 2012;34:850e61. [6] Khan ME, Anker M, Patel BC, Barge S, Sadhwani H, Kohle R. The use of focus groups in social and behavioural research: Some methodological issues. World Health Stat Quart 1991;44:145e9.
[7] Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description - the poor cousin of health research? BMC 2009;9:52. [8] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psych 2006;3:77e101. [9] Greenbaum TL. The Practical Handbook and Guide to Focus Group Research. Lexington, MA: D.C. Heath; 1988. [10] Mitchell ES. Multiple triangulation: A methodlogy for nursing science. Adv Nurs Sci 1986;8:18e26. [11] Thurmond VA. The point of triangulation. J Nurs Scholarsh 2001;33: 253e8. [12] Burnard P, Gill P, Stewart K, Treasure E, Chadwick B. Analysing and presenting qualitative data. Br Dent J 2008;204:429e32. [13] Van Deven T, Hibbert K, Faden L, Chhem RK. The hidden curriculum in radiology residency programs: A path to isolation or integration? Eur J Radiol 2013;82:883e7. [14] Gunderman RB, Hill DV. Student concerns and misconceptions about a career in radiology. Acad Radiol 2012;19:366e8. [15] Glicken AD, Merenstein GB. Addressing the hidden curriculum: Understanding educator professionalism. Med Teach 2007;29:54e7. [16] Gunderman RB. Why teaching should be recognized as an essential component of radiology residency training. Acad Radiol 2000;7: 1123e5. [17] Anderson DJ. The hidden curriculum. AJR Am J Roentgenol 1992;159: 21e2. [18] Inui TA. Flag in the Wind: Educating From Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. [19] Ghatan CE, Kuo WT, Hofman LV, Kothary N. Making the case for early medical student education in interventional radiology: a survey of 2nd-year students in a single U.S. institution. J Vasc Interv Radiol 2010;21:549e53. [20] Melnyk BM. Mentoring in academic medicine. A systematic review. Worldviews Evidence-Based Nurs 2007;4:170e1. [21] Department for Communities and Local Government. The Benefits of Meaningful Interaction. Rapid Evidence Assessment of Existing Literature. London, England: Queen’s Printer and Controller of Her Majesty’s Stationery Office; 2011. [22] Department for Communities and Local Government. Guidance on Meaningful Interaction. How Encouraging Positive Relationships Between People Can Help Build Community Cohesion. Wetherby, England: Communities and Local Government; 2008. [23] Regehr G. It’s NOT rocket science: Rethinking our metaphors for research in health professions education. Med Educ 2010;44: 31e9. [24] Merriam SB, editor. Qualitative Research: A Guide to Design and Implementation. 1st edition. San Francisco, CA: Jossey-Bass; 2009. [25] Gunderman RB. Medical students are our future. J Am Coll Radiol 2005;2:795e7.
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Appendix 1. Moderator Guide This moderator guide was created at the London Health Sciences Centre, Victoria Hospital Radiology Department in conjunction with the Center for Education Research and Innovation at Western University. The guide is meant to be a loose framework that the moderator can use to organize the focus group discussions around certain topics of interest. The aim is to stimulate discussion that can be used to better understanding how exposures to radiology in medical school impacts students’ perceptions and opinions of radiology. Agenda 1. Introduction of the research team. 2. Review of the study purpose and goals. 3. Discussion about confidentiality and risks of participation. 4. Answering questions and obtaining voluntary consent. 5. General rules of conduct for the session. 6. Begin discussion using the question guide below as framework. 7. Conclusion. Questions 1. First of all, I am interested in knowing what opportunities you have had to learn about radiology while in medical school. Alternative wording: (A) tell me about any of your experiences that have contributed to your understanding of what a radiologist does? (B) What opportunities have you had in medical school to learn about what radiologists do? 2. If you were trying to balance the pros and cons of a career in radiology, what would you put on your list? Alterative wording: (A) What do you consider the most attractive and least attractive aspects of a career in radiology? (B) What is it about radiology that is attractive or unattractive to you? Possible probes: (A) Radiology is perceived by some medical students as a very competitive field to get into. Does that influence your decision-making? (B) How does salary fit into your thinking about radiology? (C) Some see radiology as a male-dominated field. Does that affect your thinking? (D) Some people view radiology work as isolated or lacking in patient contact. What do you think about that? (E) Some people see the rapid changes in technology as making the future of radiology work uncertain. Is this part of your thinking? (F) Some medical students have reported that they hear negative comments about radiology from doctors in other specialties. Do those comments impact your thinking about radiology? 3. Can you share with me your opinions about what you need to learn about radiology in medical school to be a good doctor in any specialty?
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Alternative wording: (A) Regardless of what field of medicine you choose as a career, can you tell me what you think you need to know about radiology to be a good doctor? (B) In essence medical school is about learning the essentials of general medicine, what do you think is essential to know about radiology? 4a. When I was in medical school, I was unaware of all the subspecialties within radiology. Let’s work together to list each subspecialty and briefly discuss what each role entails. Alternative wording: (A) Radiology consists of several subspecialties, can you help me make a list and describe briefly what each of the specialties do? (B) Can you share with me your understanding of the different subspecialties in radiology? Let’s start by making a list and discuss what each subspecialty does. 4b. With this information about the different subspecialties, would you reconsider any of the factors on the pro and con lists? Alternative wording: (A) Now that you have a more comprehensive list of what a radiologist does, do you still think the factors you listed as attractors or dissuaders are accurate? (B) Considering the information of all the different subspecialties, are there any changes you would make to the list of attractors or dissuaders? 5. What resources would you use to improve your understanding of or exposure to radiology? Alternative wording: (A) Whom would you contact, or what resources you would use to get more radiology exposure? (B) There are a variety of ways to learn more about radiology or get clinical exposure, can you share for me what this would entail for you? Possible prompts: websites, podcasts, research opportunities, mentorship opportunities. 6. Finally, I would like to get your opinion about how you would change your radiology experience to get the best medical education. Alternative wording: (A) Moving forward, what would be your suggestion for how to change your learning about radiology in medical school? (B) Ultimately our goal is to make your radiology experience in medical school the best it can be, and that is dependent on your feedback. Saying that, what would be your input on how to change the way radiology is dealt with in medical school? 7. Closing question: Does anyone in the group have any questions they would like to ask?