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Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice
Clinical Radiology xxx (2015) e1ee8
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Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice J. Jacob a, L. Paul*, a, W. Hedges, P. Hutchison, E. Cameron, D. Matthews, S. Whiten, P. Driscoll School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, Fife KY16 9TF, UK
art icl e i nformat ion Article history: Received 5 August 2015 Received in revised form 18 November 2015 Accepted 24 November 2015
AIM: To use the Royal College of Radiologists’ Undergraduate Radiology Curriculum (RCR URC) as an innovative tool to review undergraduate radiology teaching and ensure it is comprehensive and balanced. MATERIALS AND METHODS: Quantitative and qualitative methods were used to audit and review radiology teaching for students in years 1e3. All radiological teaching on the course was mapped against the RCR URC learning outcomes. An online survey of students in year 3 (n¼138) was conducted using Likert (1e5), multiple choice, and freetext questions. RESULTS: There were 954 instances of radiology teaching, with 70% occurring during lectures. Radiology teaching was mapped to 81 of the 96 RCR URC learning outcomes (84.4%). Forty-seven of 138 students responded to the survey. They expressed confidence in understanding what basic imaging entails (x¼4.23) and the risks associated with various imaging techniques (x¼4.34). They were also confident in chest radiograph interpretation (x¼3.62), but were less confident understanding abdominal radiographs (x¼2.87). In free-text comments, students requested more tutorial-type teaching and ultrasound instruction. CONCLUSION: The RCR URC is an effective tool for auditing undergraduate radiology teaching, and other medical schools may, therefore, benefit from using this method. This evaluation process incorporating audit and feedback has identified areas for curriculum development. These include incorporating ultrasound into teaching sessions, delivering more small-group teaching, and introducing clinical placements in radiology departments. Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction * Guarantor and correspondent: L. Paul, School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, Fife KY16 9TF, UK. Tel.: þ44 0131 242 3743; fax: þ44 0131 242 3776. E-mail address: [email protected] (L. Paul). a These authors contributed equally to the study.
Radiology is a rapidly growing medical specialty. Over the past 10 years, there has been a dramatic rise in the number and complexity of imaging requests at all stages of patient care. As such, all clinicians must liaise with radiologists to ensure a successful patient journey.1 Junior
http://dx.doi.org/10.1016/j.crad.2015.11.021 0009-9260/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
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doctors also need to be competent in the interpretation of basic imaging, such as chest radiographs (CXRs),2 which may not be formally reported for what varies between several hours to several days3; however, evidence suggests that junior doctors lack confidence and are less likely than their senior colleagues to be accurate in CXR interpretation.4 Furthermore, junior doctors feel their undergraduate radiology teaching has been unstructured and inadequate, leaving them unprepared for work on the wards.5,6 In response to these expectations, the Royal College of Radiologists has published an Undergraduate Radiology Curriculum (RCR URC),7 which details the learning outcomes that medical students should have achieved by the completion of their undergraduate training. The Medical School at the University of St Andrews teaches a 3-year BSc Honors. (Medicine) degree, with graduates subsequently transferring to partner schools to complete their clinical training. The aims of this study were to establish whether the RCR URC7 could be used by nonradiology staff as an audit tool to evaluate teaching content and assess the current opinions of final-year students regarding the effectiveness of radiology teaching. To the authors’ knowledge, there are no other studies in the literature using the RCR URC to evaluate undergraduate radiology teaching in medical schools.
Materials and methods A combination of methods were used to audit and review current practice. The breadth and depth of the current radiology teaching was audited quantitatively. This was followed by a qualitative review to evaluate student perception of current teaching practices. The details for each of these are described below.
Curriculum audit During the academic year 2013e2014, all learning resources that referred to radiology were identified using the students’ online learning portal. This is a central repository for all learning materials delivered across the entire 3-year curriculum. It includes the following formats: lectures, dissection guides, laboratory practicals, guided studies (supplementary reading material), clinical skills sessions, and tutorials. Learning resources that could be accessed via an external hyperlink were not included, as this content is not under the control of the Medical School. Once identified, all learning materials were checked for references to radiology, which are described in Table 1. The RCR URC7 is divided into three sections: (1) fundamental principles; (2) common emergency conditions; and (3) common clinical presentations. These sections are further subdivided into learning outcomes. Each outcome was given a unique alphanumerical label. Each reference to radiology was mapped against these learning outcomes, assigning all alphanumerical codes that were applicable.
Table 1 List of potential references to radiology within the BSc (Medicine) learning portal. Radiological images
Textual references
Diagrams Interactive media
CT MRI NM Plain film radiographs US Functional imaging Dual-energy X-ray absorptiometry Indications for imaging Interpretation of imaging Explanation of imaging processes Anatomical descriptions of radiological findings Ethical implications of imaging Radiation protection and patient safety Radiological equipment and procedures Applied physics, e.g., how does MRI work? In-house e-learning resources
CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound.
Teaching review A purpose-designed survey was used to assess the opinions of final-year students and to gather feedback about the current delivery of radiological teaching over the 3-year degree programme. This was based on the questionnaire developed by Branstetter et al.8 but heavily adapted to fully explore the learning outcomes specified in the RCR URC.7 A combination of five multiple choice questions, 15 Likert scale9 questions, and three free-text answer boxes were utilised to explore students’ confidence in their knowledge of radiology, feedback on teaching, and awareness of radiology as a career. The survey was formatted using Qualtrics Survey Software and distributed to all final-year medical students (n¼138) following completion of their teaching. Participation was voluntary, obligation-free, anonymised, and students were free to exit at any point until submission. Informed consent was obtained online prior to commencing the survey. Every survey question required a response but these could be altered if desired. Initially, students were invited to complete the survey via an announcement on their online learning portal, with two further email reminders sent to encourage completion. In total it was available for 2 months.
Data analysis The responses from the questions based on Likert scales were coded,9 with “strongly agree” coded as 5 and “strongly disagree” coded as 1. The results were then combined to calculate the mean response for each Likert scale question, with a corresponding confidence interval. For all other questions, only the percentage values were calculated.
Ethics Ethical approval for this study was sought but deemed unnecessary as per the University Ethics Committee.
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
J. Jacob et al. / Clinical Radiology xxx (2015) e1ee8
Results
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Table 3 Number of teaching sessions that made one or more references to radiology by format and frequency of references to radiology per teaching format.
Curriculum audit There were 954 references to radiology in the learning materials supplied for the 3-year BSc (Medicine) course: 333 references were given to students in the first year, 402 in the second year, and 219 in the final year. Of note, students received 3, 5, and 2 hours of focused radiology teaching in these years, respectively. Of the references to radiology, 758/954 (79.5%) were in the format of diagnostic images. The remaining references (n¼196, 20.5%) consisted of text and diagrams. The number of references per imaging method, as well as their frequency of occurrence for each of the three year groups, is found in Table 2. The 954 references to radiology were delivered in 180 teaching sessions. The breakdown of these sessions by teaching format and the frequency of references to radiology per teaching format are shown in Table 3. Nine hundred and nineteen of the 954 (96.3%) references were mapped to one or more of the learning outcomes in the three sections of the RCR URC.7 Of those remaining, 21 were images and 14 consisted of text. References were mapped to the learning outcomes in “Fundamental principles” a total of 1256 times; to “Common emergency conditions” 197 times; and to “Common clinical presentations” 455 times (Fig 1). Of the 96 RCR URC learning outcomes, 81 (84.4%) were assigned at least one reference to radiology.
Teaching review In total, 47 out of 138 students (34%) completed the survey. Fifteen survey questions required an answer in Likert scale format, and the results are detailed in Table 4. Two questions required one or more options as a response. Firstly, students were asked to select the type(s) of radiology-related teaching they found most interesting. Overall, students scored CXR interpretation highest (n¼37), followed by computed tomography (CT; n¼27) and magnetic resonance imaging (MRI; n¼26) demonstrating anatomy and pathology. In addition, students felt medical demonstrators were the most appropriate to deliver radiology teaching (n¼35), followed by radiologists (n¼32), anatomists (n¼25), and non-radiologist clinicians (n¼9). The medical demonstrators are junior doctors who are extensively involved in the teaching of anatomy and clinical
Teaching format
Teaching session frequency (total number of teaching sessions n¼180)
Reference frequency (total number of references n¼954)
Lecture Dissection Tutorial Clinical skills Practicals Guided study Clinical placement
122 24 13 3 1 16 1
669 51 91 8 9 119 7
(67.8%) (13.3%) (7.2%) (1.7%) (0.6%) (7.2%) (0.6%)
(70.1%) (5.3%) (9.5%) (0.8%) (0.9%) (12.5%) (0.7%)
skills. Essential criteria for recruitment include completion of a medical degree and foundation programme in the UK with a background of learning anatomy by dissection. They typically occupy a 1-year teaching post at the University following selection by a panel of senior staff members, and the majority of demonstrators (4/7 in the academic year 2014/2015) have started the post straight after Foundation Year 2. Students were asked in multiple choice format if they were considering a career in radiology; five (11%) respondents said “yes”, 10 (21%) said “maybe”, and 32 (68%) said “no”. The respondents who answered “yes” were then asked if the teaching at St Andrews University influenced their decision, to which three answered “yes”, none answered “no”, and two answered “other”. The latter students were then invited to expand on this. When students were asked whether there was any radiology-related teaching that they wanted to incorporate into the curriculum, 22 (47%) said “yes”, six (13%) said “no”, and 19 (40%) said “maybe”. Students who answered “yes” were asked to elaborate using free text, and their answers fell into three broad themes: (1) explanation and applications of ultrasound; (2) increased volume of teaching on image interpretation; and (3) more opportunity to learn about clinically applied radiology and case studies. Students were also asked to respond using free text if they had any additional comments relating to the radiology teaching they had received. Answers were varied, but largely echoed the themes of the previous free-text responses.
Discussion Curriculum audit
Table 2 Number of references to radiology by imaging method, overall and per year group. Teaching year
Technique Plain film
MRI
CT
US
All years 1st year 2nd year 3rd year
485 (50.8%) 188 249 48
129 (13.5%) 61 10 58
281 (29.5%) 61 122 98
34 (3.6%) 14 15 5
CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound.
The RCR URC7 is an appropriate curriculum audit tool, which can be applied by non-radiologists. All references to radiology in the learning materials were identified and the majority were assigned learning outcomes to assess RCR URC coverage. This method should be applicable regardless of teaching format and institution. Radiology is a rapidly evolving specialty, and debate as to how to teach it at undergraduate level in the UK is relatively ongoing. A recent study by Mirsadraee et al.,10 grouped together a panel of experts to discuss this topic. They
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
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Figure 1 Frequency of references to radiology per learning outcome for each RCR URC section.
produced broad recommendations as to what should be taught, by whom, and at what stage. The RCR URC encompasses many of these recommendations, and has the benefit of being linked to Foundation Competencies from the General Medical Council (GMC) in “Tomorrow’s doctors 2009”,2 but although it is an easily accessible tool, it is not known how widely utilised the RCR URC is and whether it is currently used to inform undergraduate medical education on a UK-wide basis. In addition, recommendations from Mirsadraee et al.,10 suggest that students should have learning outcomes pertaining to interventional radiology (IR), such as indications for various procedures, and
technical and practical aspects of performing procedures. These are not currently included in the RCR URC. This has made it difficult to quantify exactly how many references to IR were made in total; however, overall, the authors found the RCR URC to be an easy to use, modern, and efficient way of auditing the curriculum. The evaluation shows that the current teaching at St Andrews is broadly consistent with the RCR recommendations,7 with relatively few discrepancies. Of all sections, “Fundamental principles” was covered most extensively, with particular emphasis on anatomy and basic interpretation. This is consistent with the aims of the curriculum at
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
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Table 4 Frequency of responses to Likert scale questions from the online student survey. Question
Strongly disagree (1)
Disagree (2)
Neither agree nor disagree (3)
Agree (4)
Strongly agree (5)
Mean (95% confidence interval) (1e5)
The curriculum at St Andrews has introduced me to the following: Requesting basic imaging in a timely fashion Providing relevant information when requesting investigations An understanding of what a basic imaging investigation (e.g., CXR) entails In St Andrews I have been introduced to the concept of risk associated with different imaging investigations (e.g. plain radiographs, CT, MRI, US) Going into clinical training, I am confident in my approach to interpreting:
2 3 0
4 6 1
13 12 3
21 21 27
7 5 16
3.57 (3.29e3.85) 3.40 (3.1e3.7) 4.23 (4.04e4.42)
0
1
2
24
20
4.34 (4.15e4.43)
chest radiographs abdominal radiographs musculoskeletal radiographs I feel confident in differentiating between soft tissue, bone, fluid and air on:
0 1 3
7 20 14
9 10 11
26 16 16
5 0 3
3.62 (3.37e3.87) 2.87 (2.61e3.13) 3.04 (2.73e3.35)
plain radiographs CT MRI US Radiological imaging is a valuable tool in understanding 3D anatomy in conjunction with lectures and dissection Please choose the most appropriate option for the statement below: I am fully aware of the role of a radiologist Choose the most appropriate option for the statements below:
0 1 1 13 0
3 7 12 17 1
2 10 13 10 3
31 22 17 5 17
11 7 4 2 26
1
6
9
25
6
3.62 (3.35e3.89)
I understand the role of consent in a radiology department I am aware of the members of the multidisciplinary team in a radiology department
2 4
14 18
12 11
15 11
4 3
3.11 (2.8e3.42) 2.81 (2.5e3.12)
4.06 3.57 3.23 2.28 4.45
(3.85e4.27) (3.29e3.85) (2.94e3.52) (1.96e2.6) (4.24e4.66)
CXR, chest radiograph; CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound; 3D, three-dimensional.
St Andrews to provide students with a strong foundation in anatomy and other basic sciences, which is still considered highly relevant in modern medical education.11 The only area of deficiency was consent for radiological procedures, which may be more appropriately covered in the clinical years. Students already cover this topic more generally in their clinical skills teaching. Of the few emergency conditions that were not adequately covered as compared to the RCR URC, imaging relating to wrist pathology was the most significant due to its relatively common presentation.12 In addition to the above discrepancies, references to radiology and total hours of focused radiology teaching were lowest in the final year. In contrast to the lecturebased teaching final year students receive in the first semester, the second semester is mainly spent researching and writing a dissertation topic, where the focus is on selfdirected learning. Their learning was supplemented by fortnightly case-based teaching sessions, which aim to enhance skills such as clinical reasoning, teamwork, and history taking. Therefore, the low volume of references to radiology in the final year is primarily due to a reduced number of teaching sessions. Moving forward, additional focused radiology teaching sessions should be dedicated to final-year students as they prepare for clinical training on hospital wards.
Although the learning outcomes of most RCR URC sections were covered well, the section with the greatest number of omissions was, “Common clinical presentations”. Not unexpectedly, gynaecological and paediatric imaging is not covered at any point; these are specialist areas that will be introduced in later clinical years. In addition, the principal technique used to investigate these areas is ultrasound,13 which is also considered to be a postgraduate skill. Nevertheless, in “Tomorrow’s doctors”2 the GMC suggest that it is vital that doctors in training have an introduction to the indications and limitations of ultrasound, to the same extent as other imaging methods. Furthermore, ultrasound is increasingly being utilised by surgical and emergency medicine clinicians in the setting of the acutely unwell patient. Therefore, there is an argument to support early practical introduction to ultrasound at an undergraduate level, which will benefit students in the future when revisiting this method in clinical practice.14
Teaching review To gain an understanding of how well radiology teaching was delivered, final-year medical students were surveyed as they have an overview of the whole curriculum. They
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
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overwhelmingly felt that their teaching augmented their understanding of three-dimensional anatomy (x¼4.45, 95% confidence interval [CI]: 4.24e4.66). This echoes the findings of Turmezei et al.15 Students generally felt confident understanding basic imaging (x¼4.23, 95% CI: 4.04e4.42) and the risks associated with various techniques including: plain film radiographs, CT, MRI and ultrasound (x¼4.34, 95% CI: 4.15e4.43); however, they were slightly less confident about requesting basic imaging (x¼3.57, 95% CI: 3.29e3.85) and what relevant information to include when writing request forms (x¼3.40, 95% CI: 3.1e3.7). In summary, students have been taught indications and limitations of basic techniques; however, the practical application of this knowledge in a clinical setting is restricted at this early stage. Although respondents generally felt confident with interpretation of plain films, this was most evident with CXRs (x¼3.62, 95% CI: 3.37e3.87), followed by musculoskeletal (MSK) films (x-3.04, 95% CI: 2.73e3.35), but less so with abdominal radiographs (AXRs; x ¼ 2.87, 95% CI: 2.61e3.13). Students rated CXRs as the most interesting of the imaging techniques covered, which may have contributed to this increased confidence in their interpretation skills. Another possible factor is that the AXR teaching was delivered by a non-radiologist clinician, and the CXR teaching was mostly delivered by medical demonstrators. The latter are doctors who have completed foundation training and are extensively involved in teaching both clinical skills and anatomy by dissection. This preference may be due to demonstrators providing clinically relevant near-peer learning, which has previously been demonstrated to be beneficial.16 The present finding, that student confidence is higher when interpreting MSK films compared to AXR, is relatively unexpected as students receive focused teaching on the interpretation of CXR and AXRs, but none on MSK films. The CXR teaching consists of two small-group tutorials. The first focusses on normal appearance and a system for interpreting CXRs, whilst the second reinforces this system when approaching common disease entities. This was supplemented with an online guided study. In contrast, teaching on AXRs consisted of a single session, with a much larger group of students (30e40) and no supplemental guided studies. Plain film interpretation has previously been identified as a source of concern for medical students.17 The present student cohort felt relatively more confident with CXRs, possibly because they are mostly taught in small groups. If this is correct, confidence in interpreting AXRs could be improved by delivering teaching in smaller groups,18 a concept supported by freetext comments from students. A challenge of delivering undergraduate medical education is establishing to what level skills must be taught, and what skills must be prioritised. A recent study by Smith et al.,19 questioned the clinical usefulness of AXRs in the emergency department, a site of frequent rotation for junior doctors. The results of this extensive literature review suggested AXRs had only limited use, and in fact, were often superseded by ultrasound or CT.
No focused teaching on MSK radiology is provided at St Andrews, but references to this area were frequent in lectures and dissection sessions. One of the fundamentals skills in understanding radiological images is being able to differentiate between different tissue types.20 Students were confident differentiating between bone, soft tissue, fluid, and air on plain films (x¼4.06, 95% CI: 3.85e4.27), which correlates with their high level of exposure to this modality and perceived confidence in interpreting CXRs. This student cohort has no hands-on experience with ultrasound imaging, and it is evident from the curriculum audit that ultrasound as a technique is not widely referenced. Therefore, as could be expected, students did not feel confident differentiating between bone/soft tissues/fluid/air on ultrasound (x¼2.28, 95% CI: 1.96e2.6). Students are aware of this deficiency, which is reflected in their requests for further teaching on ultrasound in their free-text comments. Students reported they were moderately confident in understanding the role of radiologists (x¼3.62, 95% CI: 3.35e3.89); however, it is likely that this is not a fully informed opinion due to their limited experience of radiology departments. This conclusion is supported by the findings that the students did not understand the role of consent in radiology departments (x¼3.11, 95% CI: 2.8e3.42) and were not aware of the composition of a multidisciplinary team (MDT; x ¼ 2.81, 95% CI: 2.5e3.12).
Lessons learnt The learning outcomes listed in the RCR URC7 can be used to identify gaps and imbalances in radiology teaching. This was made possible by the fact the learning materials at St Andrews are concentrated in a single online learning portal. Other medical schools could utilise this method as a means of reviewing and standardising their radiology teaching so that all medical school graduates are prepared for the radiology-related challenges they may face as junior doctors. References to radiology were largely covered in the context of lectures, which accounted for 70% of the total. In comparison, tutorials only accounted for 9.5%. Current evidence suggests that radiology teaching should be delivered in small groups18, and be delivered by radiologists21 or medical demonstrators, to provide the most effective learning environment. By adjusting the teaching at St Andrews’ to include more small group tutorials, it will be in accordance with current evidence and feedback from the student survey. Ultrasound is a key technique that is under-utilised in the present teaching at St Andrews; however, ultrasound is one of the most frequently used imaging techniques in clinical practice, and students are likely to encounter ultrasound during their medical training.22 Finding opportunities to integrate ultrasound into the curriculum is therefore important, but may prove challenging given that it is a technical skill that requires specialist training of both staff and students. Despite this, several studies have demonstrated feasibility and success in teaching ultrasound skills
Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021
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to medical students.14,22e24 Applications of ultrasound may include teaching of surface anatomy in clinical skills or the dissection room,22,23 as well as learning procedures from simple cannulation to central-line insertion on cadavers.14 Furthermore, ultrasound could facilitate the understanding of physiological and pathological processes, e.g., using echocardiograms to visualise the movements of the myocardium,23 or assessing an abdominal aortic aneurysm. The latter is important in light of development of portable ultrasound equipment and the resulting implementation of the focussed assessment with sonography in trauma (FAST) scan. FAST scan is an increasingly utilised bedside test to evaluate the critically unwell patient by determining the presence of free fluid in the abdomen, pelvis, and pericardium.25 Through the use of portable ultrasound equipment, normal living anatomy can be demonstrated to the students, which may improve future confidence when encountering FAST scans. Other institutions have shown encouraging outcomes when training undergraduates in focused emergency ultrasound skills.14,24 Only 11% of respondents were actively considering radiology as a career, which is less than previously reported papers.26 The UK has some of the lowest numbers of consultant radiologists per capita in the Western world.1 In order to cope with increasing demand for imaging services and accommodate potential 7-day service provision in the National Health Service (NHS), the RCR has laid out plans to increase the number of radiology trainees1 and advised a standardised undergraduate radiology teaching programme,7 which is engaging, upto-date, and clinically relevant. To nurture an interest in radiology at an early stage, medical students may benefit from undertaking clinical placements in radiology departments, which have been shown to heavily influence choice of career.26,27 In addition, this will help improve student understanding of the radiology MDT, consent for imaging, and the practicalities of performing imaging, which were identified as gaps in the current teaching at St Andrews.
in different opinions. A repeat study would therefore be useful. The authors acknowledge that the conclusions drawn from the survey were based on a relatively low response rate of 34%. As the survey was voluntary, there is the possibility of a selection bias, which may mean that the results are not entirely representative of the cohort as a whole. Although students’ confidence in interpreting imaging studies was ascertained, we did not test their accuracy in reporting images. As such it is unknown whether this confidence equates to competence. In future research, an objective assessment encompassing the learning outcomes of the RCR URC would help to ascertain whether student confidence was correlated with ability. It would also demonstrate the degree to which coverage of the RCR URC is related to eventual knowledge of learning outcomes. This audit of the curriculum is based on references to radiology rather than time spent teaching. Many of the references were delivered in the context of other teaching sessions as part of the integrated curriculum; therefore, the number of hours of radiology teaching students received overall cannot be estimated. Although the hours spent delivering specific radiology teaching could be calculated (e.g., tutorials on CXR interpretation), this figure represents the minimum value, and the overall time spent on teaching radiology would be much higher. In conclusion, the RCR URC7 can be used in a novel way by non-radiologists to audit undergraduate radiology teaching. This approach may therefore be of use in other medical schools to ensure consistency in the way students are taught. The teaching at St Andrews is in accordance with the majority of RCR URC7 learning outcomes, but there are some deficient areas. Increasing the number of universitybased tutorials and integrating ultrasound into the curriculum may bridge some of these gaps and also satisfy student demand. Radiology is a fundamental part of modern medicine and future research must ensure that medical students are graduating with the skills and knowledge to effectively integrate this specialty into their clinical practice.
Limitations
Acknowledgements
Despite a thorough approach, all possible references to radiology in the curriculum could not be identified. This was as a result of external references on websites, which may have changed since their original recommendation to students in 2013e2014, as well as hard copies of images that are only available in the dissection room and are used to variable degrees. These potential references are likely to have contributed a very small proportion of overall references, and thus would not have had a significant impact on the results of the present study. Third-year medical students were surveyed in one academic year (2013e2014) regarding their overall experience of radiology at St Andrews as they have experienced the whole curriculum. There have been no major changes to the curriculum since this cohort of students started medical school; however, it is possible that subsequent final-year cohorts may have slightly different experiences, resulting
The authors thank Naomi Kelly and Simon Glover.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.crad.2015.11.021.
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27.
final year medical students sitting the final objective structured clinical examination (OSCE). BMC Med Educ 2011;11:11. Jeffrey D, Goddard P, Callaway M, et al. Chest radiograph interpretation by medical students. Clin Radiol 2003;58(6):478e81. Zou L, King A, Soman S, et al. Medical students’ preferences in radiology education: a comparison between the socratic and didactic methods utilizing PowerPoint features in radiology education. Acad Radiol 2011;18(2):253e6. Smith JE, Hall EJ. The use of plain abdominal X rays in the emergency department. Emerg Med J 2009;26(3):160e3. The Royal College of Radiologists. Specialty training curriculum for clinical radiology. London: The Royal College of Radiologists; 2014. Murphy KP, Crush L, O’Malley E, et al. Medical student knowledge regarding radiology before and after a radiological anatomy module: implications for vertical integration and self-directed learning. Insights Imaging 2014;5(5):629e34. Swamy M, Searle RF. Anatomy teaching with portable ultrasound to medical students. BMC Med Educ 2012;12:99. Griksaitis MJ, Sawdon MA, Finn GM. Ultrasound and cadaveric prosections as methods for teaching cardiac anatomy: a comparative study. Anat Sci Educ 2012;5(1):20e6. Wong I, Jayatilleke T, Kendall R, et al. Feasibility of a focused ultrasound training programme for medical undergraduate students. Clin Teach 2011;8(1):3e7. Brenchley J, Walker A, Sloan JP, et al. Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emerg Med J 2006;23(6):446e8. Branstetter BF, Humphrey AL, Schumann JB. The long-term impact of preclinical education on medical students’ opinions about radiology. Acad Radiol 2008;15(10):1331e9. Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med 1997;12(1):53e6.
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Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice J. Jacob a, L. Paul*, a, W. Hedges, P. Hutchison, E. Cameron, D. Matthews, S. Whiten, P. Driscoll School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, Fife KY16 9TF, UK
art icl e i nformat ion Article history: Received 5 August 2015 Received in revised form 18 November 2015 Accepted 24 November 2015
AIM: To use the Royal College of Radiologists’ Undergraduate Radiology Curriculum (RCR URC) as an innovative tool to review undergraduate radiology teaching and ensure it is comprehensive and balanced. MATERIALS AND METHODS: Quantitative and qualitative methods were used to audit and review radiology teaching for students in years 1e3. All radiological teaching on the course was mapped against the RCR URC learning outcomes. An online survey of students in year 3 (n¼138) was conducted using Likert (1e5), multiple choice, and freetext questions. RESULTS: There were 954 instances of radiology teaching, with 70% occurring during lectures. Radiology teaching was mapped to 81 of the 96 RCR URC learning outcomes (84.4%). Forty-seven of 138 students responded to the survey. They expressed confidence in understanding what basic imaging entails (x¼4.23) and the risks associated with various imaging techniques (x¼4.34). They were also confident in chest radiograph interpretation (x¼3.62), but were less confident understanding abdominal radiographs (x¼2.87). In free-text comments, students requested more tutorial-type teaching and ultrasound instruction. CONCLUSION: The RCR URC is an effective tool for auditing undergraduate radiology teaching, and other medical schools may, therefore, benefit from using this method. This evaluation process incorporating audit and feedback has identified areas for curriculum development. These include incorporating ultrasound into teaching sessions, delivering more small-group teaching, and introducing clinical placements in radiology departments. Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction * Guarantor and correspondent: L. Paul, School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, Fife KY16 9TF, UK. Tel.: þ44 0131 242 3743; fax: þ44 0131 242 3776. E-mail address: [email protected] (L. Paul). a These authors contributed equally to the study.
Radiology is a rapidly growing medical specialty. Over the past 10 years, there has been a dramatic rise in the number and complexity of imaging requests at all stages of patient care. As such, all clinicians must liaise with radiologists to ensure a successful patient journey.1 Junior
http://dx.doi.org/10.1016/j.crad.2015.11.021 0009-9260/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
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doctors also need to be competent in the interpretation of basic imaging, such as chest radiographs (CXRs),2 which may not be formally reported for what varies between several hours to several days3; however, evidence suggests that junior doctors lack confidence and are less likely than their senior colleagues to be accurate in CXR interpretation.4 Furthermore, junior doctors feel their undergraduate radiology teaching has been unstructured and inadequate, leaving them unprepared for work on the wards.5,6 In response to these expectations, the Royal College of Radiologists has published an Undergraduate Radiology Curriculum (RCR URC),7 which details the learning outcomes that medical students should have achieved by the completion of their undergraduate training. The Medical School at the University of St Andrews teaches a 3-year BSc Honors. (Medicine) degree, with graduates subsequently transferring to partner schools to complete their clinical training. The aims of this study were to establish whether the RCR URC7 could be used by nonradiology staff as an audit tool to evaluate teaching content and assess the current opinions of final-year students regarding the effectiveness of radiology teaching. To the authors’ knowledge, there are no other studies in the literature using the RCR URC to evaluate undergraduate radiology teaching in medical schools.
Materials and methods A combination of methods were used to audit and review current practice. The breadth and depth of the current radiology teaching was audited quantitatively. This was followed by a qualitative review to evaluate student perception of current teaching practices. The details for each of these are described below.
Curriculum audit During the academic year 2013e2014, all learning resources that referred to radiology were identified using the students’ online learning portal. This is a central repository for all learning materials delivered across the entire 3-year curriculum. It includes the following formats: lectures, dissection guides, laboratory practicals, guided studies (supplementary reading material), clinical skills sessions, and tutorials. Learning resources that could be accessed via an external hyperlink were not included, as this content is not under the control of the Medical School. Once identified, all learning materials were checked for references to radiology, which are described in Table 1. The RCR URC7 is divided into three sections: (1) fundamental principles; (2) common emergency conditions; and (3) common clinical presentations. These sections are further subdivided into learning outcomes. Each outcome was given a unique alphanumerical label. Each reference to radiology was mapped against these learning outcomes, assigning all alphanumerical codes that were applicable.
Table 1 List of potential references to radiology within the BSc (Medicine) learning portal. Radiological images
Textual references
Diagrams Interactive media
CT MRI NM Plain film radiographs US Functional imaging Dual-energy X-ray absorptiometry Indications for imaging Interpretation of imaging Explanation of imaging processes Anatomical descriptions of radiological findings Ethical implications of imaging Radiation protection and patient safety Radiological equipment and procedures Applied physics, e.g., how does MRI work? In-house e-learning resources
CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound.
Teaching review A purpose-designed survey was used to assess the opinions of final-year students and to gather feedback about the current delivery of radiological teaching over the 3-year degree programme. This was based on the questionnaire developed by Branstetter et al.8 but heavily adapted to fully explore the learning outcomes specified in the RCR URC.7 A combination of five multiple choice questions, 15 Likert scale9 questions, and three free-text answer boxes were utilised to explore students’ confidence in their knowledge of radiology, feedback on teaching, and awareness of radiology as a career. The survey was formatted using Qualtrics Survey Software and distributed to all final-year medical students (n¼138) following completion of their teaching. Participation was voluntary, obligation-free, anonymised, and students were free to exit at any point until submission. Informed consent was obtained online prior to commencing the survey. Every survey question required a response but these could be altered if desired. Initially, students were invited to complete the survey via an announcement on their online learning portal, with two further email reminders sent to encourage completion. In total it was available for 2 months.
Data analysis The responses from the questions based on Likert scales were coded,9 with “strongly agree” coded as 5 and “strongly disagree” coded as 1. The results were then combined to calculate the mean response for each Likert scale question, with a corresponding confidence interval. For all other questions, only the percentage values were calculated.
Ethics Ethical approval for this study was sought but deemed unnecessary as per the University Ethics Committee.
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Results
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Table 3 Number of teaching sessions that made one or more references to radiology by format and frequency of references to radiology per teaching format.
Curriculum audit There were 954 references to radiology in the learning materials supplied for the 3-year BSc (Medicine) course: 333 references were given to students in the first year, 402 in the second year, and 219 in the final year. Of note, students received 3, 5, and 2 hours of focused radiology teaching in these years, respectively. Of the references to radiology, 758/954 (79.5%) were in the format of diagnostic images. The remaining references (n¼196, 20.5%) consisted of text and diagrams. The number of references per imaging method, as well as their frequency of occurrence for each of the three year groups, is found in Table 2. The 954 references to radiology were delivered in 180 teaching sessions. The breakdown of these sessions by teaching format and the frequency of references to radiology per teaching format are shown in Table 3. Nine hundred and nineteen of the 954 (96.3%) references were mapped to one or more of the learning outcomes in the three sections of the RCR URC.7 Of those remaining, 21 were images and 14 consisted of text. References were mapped to the learning outcomes in “Fundamental principles” a total of 1256 times; to “Common emergency conditions” 197 times; and to “Common clinical presentations” 455 times (Fig 1). Of the 96 RCR URC learning outcomes, 81 (84.4%) were assigned at least one reference to radiology.
Teaching review In total, 47 out of 138 students (34%) completed the survey. Fifteen survey questions required an answer in Likert scale format, and the results are detailed in Table 4. Two questions required one or more options as a response. Firstly, students were asked to select the type(s) of radiology-related teaching they found most interesting. Overall, students scored CXR interpretation highest (n¼37), followed by computed tomography (CT; n¼27) and magnetic resonance imaging (MRI; n¼26) demonstrating anatomy and pathology. In addition, students felt medical demonstrators were the most appropriate to deliver radiology teaching (n¼35), followed by radiologists (n¼32), anatomists (n¼25), and non-radiologist clinicians (n¼9). The medical demonstrators are junior doctors who are extensively involved in the teaching of anatomy and clinical
Teaching format
Teaching session frequency (total number of teaching sessions n¼180)
Reference frequency (total number of references n¼954)
Lecture Dissection Tutorial Clinical skills Practicals Guided study Clinical placement
122 24 13 3 1 16 1
669 51 91 8 9 119 7
(67.8%) (13.3%) (7.2%) (1.7%) (0.6%) (7.2%) (0.6%)
(70.1%) (5.3%) (9.5%) (0.8%) (0.9%) (12.5%) (0.7%)
skills. Essential criteria for recruitment include completion of a medical degree and foundation programme in the UK with a background of learning anatomy by dissection. They typically occupy a 1-year teaching post at the University following selection by a panel of senior staff members, and the majority of demonstrators (4/7 in the academic year 2014/2015) have started the post straight after Foundation Year 2. Students were asked in multiple choice format if they were considering a career in radiology; five (11%) respondents said “yes”, 10 (21%) said “maybe”, and 32 (68%) said “no”. The respondents who answered “yes” were then asked if the teaching at St Andrews University influenced their decision, to which three answered “yes”, none answered “no”, and two answered “other”. The latter students were then invited to expand on this. When students were asked whether there was any radiology-related teaching that they wanted to incorporate into the curriculum, 22 (47%) said “yes”, six (13%) said “no”, and 19 (40%) said “maybe”. Students who answered “yes” were asked to elaborate using free text, and their answers fell into three broad themes: (1) explanation and applications of ultrasound; (2) increased volume of teaching on image interpretation; and (3) more opportunity to learn about clinically applied radiology and case studies. Students were also asked to respond using free text if they had any additional comments relating to the radiology teaching they had received. Answers were varied, but largely echoed the themes of the previous free-text responses.
Discussion Curriculum audit
Table 2 Number of references to radiology by imaging method, overall and per year group. Teaching year
Technique Plain film
MRI
CT
US
All years 1st year 2nd year 3rd year
485 (50.8%) 188 249 48
129 (13.5%) 61 10 58
281 (29.5%) 61 122 98
34 (3.6%) 14 15 5
CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound.
The RCR URC7 is an appropriate curriculum audit tool, which can be applied by non-radiologists. All references to radiology in the learning materials were identified and the majority were assigned learning outcomes to assess RCR URC coverage. This method should be applicable regardless of teaching format and institution. Radiology is a rapidly evolving specialty, and debate as to how to teach it at undergraduate level in the UK is relatively ongoing. A recent study by Mirsadraee et al.,10 grouped together a panel of experts to discuss this topic. They
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Figure 1 Frequency of references to radiology per learning outcome for each RCR URC section.
produced broad recommendations as to what should be taught, by whom, and at what stage. The RCR URC encompasses many of these recommendations, and has the benefit of being linked to Foundation Competencies from the General Medical Council (GMC) in “Tomorrow’s doctors 2009”,2 but although it is an easily accessible tool, it is not known how widely utilised the RCR URC is and whether it is currently used to inform undergraduate medical education on a UK-wide basis. In addition, recommendations from Mirsadraee et al.,10 suggest that students should have learning outcomes pertaining to interventional radiology (IR), such as indications for various procedures, and
technical and practical aspects of performing procedures. These are not currently included in the RCR URC. This has made it difficult to quantify exactly how many references to IR were made in total; however, overall, the authors found the RCR URC to be an easy to use, modern, and efficient way of auditing the curriculum. The evaluation shows that the current teaching at St Andrews is broadly consistent with the RCR recommendations,7 with relatively few discrepancies. Of all sections, “Fundamental principles” was covered most extensively, with particular emphasis on anatomy and basic interpretation. This is consistent with the aims of the curriculum at
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Table 4 Frequency of responses to Likert scale questions from the online student survey. Question
Strongly disagree (1)
Disagree (2)
Neither agree nor disagree (3)
Agree (4)
Strongly agree (5)
Mean (95% confidence interval) (1e5)
The curriculum at St Andrews has introduced me to the following: Requesting basic imaging in a timely fashion Providing relevant information when requesting investigations An understanding of what a basic imaging investigation (e.g., CXR) entails In St Andrews I have been introduced to the concept of risk associated with different imaging investigations (e.g. plain radiographs, CT, MRI, US) Going into clinical training, I am confident in my approach to interpreting:
2 3 0
4 6 1
13 12 3
21 21 27
7 5 16
3.57 (3.29e3.85) 3.40 (3.1e3.7) 4.23 (4.04e4.42)
0
1
2
24
20
4.34 (4.15e4.43)
chest radiographs abdominal radiographs musculoskeletal radiographs I feel confident in differentiating between soft tissue, bone, fluid and air on:
0 1 3
7 20 14
9 10 11
26 16 16
5 0 3
3.62 (3.37e3.87) 2.87 (2.61e3.13) 3.04 (2.73e3.35)
plain radiographs CT MRI US Radiological imaging is a valuable tool in understanding 3D anatomy in conjunction with lectures and dissection Please choose the most appropriate option for the statement below: I am fully aware of the role of a radiologist Choose the most appropriate option for the statements below:
0 1 1 13 0
3 7 12 17 1
2 10 13 10 3
31 22 17 5 17
11 7 4 2 26
1
6
9
25
6
3.62 (3.35e3.89)
I understand the role of consent in a radiology department I am aware of the members of the multidisciplinary team in a radiology department
2 4
14 18
12 11
15 11
4 3
3.11 (2.8e3.42) 2.81 (2.5e3.12)
4.06 3.57 3.23 2.28 4.45
(3.85e4.27) (3.29e3.85) (2.94e3.52) (1.96e2.6) (4.24e4.66)
CXR, chest radiograph; CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; US, ultrasound; 3D, three-dimensional.
St Andrews to provide students with a strong foundation in anatomy and other basic sciences, which is still considered highly relevant in modern medical education.11 The only area of deficiency was consent for radiological procedures, which may be more appropriately covered in the clinical years. Students already cover this topic more generally in their clinical skills teaching. Of the few emergency conditions that were not adequately covered as compared to the RCR URC, imaging relating to wrist pathology was the most significant due to its relatively common presentation.12 In addition to the above discrepancies, references to radiology and total hours of focused radiology teaching were lowest in the final year. In contrast to the lecturebased teaching final year students receive in the first semester, the second semester is mainly spent researching and writing a dissertation topic, where the focus is on selfdirected learning. Their learning was supplemented by fortnightly case-based teaching sessions, which aim to enhance skills such as clinical reasoning, teamwork, and history taking. Therefore, the low volume of references to radiology in the final year is primarily due to a reduced number of teaching sessions. Moving forward, additional focused radiology teaching sessions should be dedicated to final-year students as they prepare for clinical training on hospital wards.
Although the learning outcomes of most RCR URC sections were covered well, the section with the greatest number of omissions was, “Common clinical presentations”. Not unexpectedly, gynaecological and paediatric imaging is not covered at any point; these are specialist areas that will be introduced in later clinical years. In addition, the principal technique used to investigate these areas is ultrasound,13 which is also considered to be a postgraduate skill. Nevertheless, in “Tomorrow’s doctors”2 the GMC suggest that it is vital that doctors in training have an introduction to the indications and limitations of ultrasound, to the same extent as other imaging methods. Furthermore, ultrasound is increasingly being utilised by surgical and emergency medicine clinicians in the setting of the acutely unwell patient. Therefore, there is an argument to support early practical introduction to ultrasound at an undergraduate level, which will benefit students in the future when revisiting this method in clinical practice.14
Teaching review To gain an understanding of how well radiology teaching was delivered, final-year medical students were surveyed as they have an overview of the whole curriculum. They
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overwhelmingly felt that their teaching augmented their understanding of three-dimensional anatomy (x¼4.45, 95% confidence interval [CI]: 4.24e4.66). This echoes the findings of Turmezei et al.15 Students generally felt confident understanding basic imaging (x¼4.23, 95% CI: 4.04e4.42) and the risks associated with various techniques including: plain film radiographs, CT, MRI and ultrasound (x¼4.34, 95% CI: 4.15e4.43); however, they were slightly less confident about requesting basic imaging (x¼3.57, 95% CI: 3.29e3.85) and what relevant information to include when writing request forms (x¼3.40, 95% CI: 3.1e3.7). In summary, students have been taught indications and limitations of basic techniques; however, the practical application of this knowledge in a clinical setting is restricted at this early stage. Although respondents generally felt confident with interpretation of plain films, this was most evident with CXRs (x¼3.62, 95% CI: 3.37e3.87), followed by musculoskeletal (MSK) films (x-3.04, 95% CI: 2.73e3.35), but less so with abdominal radiographs (AXRs; x ¼ 2.87, 95% CI: 2.61e3.13). Students rated CXRs as the most interesting of the imaging techniques covered, which may have contributed to this increased confidence in their interpretation skills. Another possible factor is that the AXR teaching was delivered by a non-radiologist clinician, and the CXR teaching was mostly delivered by medical demonstrators. The latter are doctors who have completed foundation training and are extensively involved in teaching both clinical skills and anatomy by dissection. This preference may be due to demonstrators providing clinically relevant near-peer learning, which has previously been demonstrated to be beneficial.16 The present finding, that student confidence is higher when interpreting MSK films compared to AXR, is relatively unexpected as students receive focused teaching on the interpretation of CXR and AXRs, but none on MSK films. The CXR teaching consists of two small-group tutorials. The first focusses on normal appearance and a system for interpreting CXRs, whilst the second reinforces this system when approaching common disease entities. This was supplemented with an online guided study. In contrast, teaching on AXRs consisted of a single session, with a much larger group of students (30e40) and no supplemental guided studies. Plain film interpretation has previously been identified as a source of concern for medical students.17 The present student cohort felt relatively more confident with CXRs, possibly because they are mostly taught in small groups. If this is correct, confidence in interpreting AXRs could be improved by delivering teaching in smaller groups,18 a concept supported by freetext comments from students. A challenge of delivering undergraduate medical education is establishing to what level skills must be taught, and what skills must be prioritised. A recent study by Smith et al.,19 questioned the clinical usefulness of AXRs in the emergency department, a site of frequent rotation for junior doctors. The results of this extensive literature review suggested AXRs had only limited use, and in fact, were often superseded by ultrasound or CT.
No focused teaching on MSK radiology is provided at St Andrews, but references to this area were frequent in lectures and dissection sessions. One of the fundamentals skills in understanding radiological images is being able to differentiate between different tissue types.20 Students were confident differentiating between bone, soft tissue, fluid, and air on plain films (x¼4.06, 95% CI: 3.85e4.27), which correlates with their high level of exposure to this modality and perceived confidence in interpreting CXRs. This student cohort has no hands-on experience with ultrasound imaging, and it is evident from the curriculum audit that ultrasound as a technique is not widely referenced. Therefore, as could be expected, students did not feel confident differentiating between bone/soft tissues/fluid/air on ultrasound (x¼2.28, 95% CI: 1.96e2.6). Students are aware of this deficiency, which is reflected in their requests for further teaching on ultrasound in their free-text comments. Students reported they were moderately confident in understanding the role of radiologists (x¼3.62, 95% CI: 3.35e3.89); however, it is likely that this is not a fully informed opinion due to their limited experience of radiology departments. This conclusion is supported by the findings that the students did not understand the role of consent in radiology departments (x¼3.11, 95% CI: 2.8e3.42) and were not aware of the composition of a multidisciplinary team (MDT; x ¼ 2.81, 95% CI: 2.5e3.12).
Lessons learnt The learning outcomes listed in the RCR URC7 can be used to identify gaps and imbalances in radiology teaching. This was made possible by the fact the learning materials at St Andrews are concentrated in a single online learning portal. Other medical schools could utilise this method as a means of reviewing and standardising their radiology teaching so that all medical school graduates are prepared for the radiology-related challenges they may face as junior doctors. References to radiology were largely covered in the context of lectures, which accounted for 70% of the total. In comparison, tutorials only accounted for 9.5%. Current evidence suggests that radiology teaching should be delivered in small groups18, and be delivered by radiologists21 or medical demonstrators, to provide the most effective learning environment. By adjusting the teaching at St Andrews’ to include more small group tutorials, it will be in accordance with current evidence and feedback from the student survey. Ultrasound is a key technique that is under-utilised in the present teaching at St Andrews; however, ultrasound is one of the most frequently used imaging techniques in clinical practice, and students are likely to encounter ultrasound during their medical training.22 Finding opportunities to integrate ultrasound into the curriculum is therefore important, but may prove challenging given that it is a technical skill that requires specialist training of both staff and students. Despite this, several studies have demonstrated feasibility and success in teaching ultrasound skills
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to medical students.14,22e24 Applications of ultrasound may include teaching of surface anatomy in clinical skills or the dissection room,22,23 as well as learning procedures from simple cannulation to central-line insertion on cadavers.14 Furthermore, ultrasound could facilitate the understanding of physiological and pathological processes, e.g., using echocardiograms to visualise the movements of the myocardium,23 or assessing an abdominal aortic aneurysm. The latter is important in light of development of portable ultrasound equipment and the resulting implementation of the focussed assessment with sonography in trauma (FAST) scan. FAST scan is an increasingly utilised bedside test to evaluate the critically unwell patient by determining the presence of free fluid in the abdomen, pelvis, and pericardium.25 Through the use of portable ultrasound equipment, normal living anatomy can be demonstrated to the students, which may improve future confidence when encountering FAST scans. Other institutions have shown encouraging outcomes when training undergraduates in focused emergency ultrasound skills.14,24 Only 11% of respondents were actively considering radiology as a career, which is less than previously reported papers.26 The UK has some of the lowest numbers of consultant radiologists per capita in the Western world.1 In order to cope with increasing demand for imaging services and accommodate potential 7-day service provision in the National Health Service (NHS), the RCR has laid out plans to increase the number of radiology trainees1 and advised a standardised undergraduate radiology teaching programme,7 which is engaging, upto-date, and clinically relevant. To nurture an interest in radiology at an early stage, medical students may benefit from undertaking clinical placements in radiology departments, which have been shown to heavily influence choice of career.26,27 In addition, this will help improve student understanding of the radiology MDT, consent for imaging, and the practicalities of performing imaging, which were identified as gaps in the current teaching at St Andrews.
in different opinions. A repeat study would therefore be useful. The authors acknowledge that the conclusions drawn from the survey were based on a relatively low response rate of 34%. As the survey was voluntary, there is the possibility of a selection bias, which may mean that the results are not entirely representative of the cohort as a whole. Although students’ confidence in interpreting imaging studies was ascertained, we did not test their accuracy in reporting images. As such it is unknown whether this confidence equates to competence. In future research, an objective assessment encompassing the learning outcomes of the RCR URC would help to ascertain whether student confidence was correlated with ability. It would also demonstrate the degree to which coverage of the RCR URC is related to eventual knowledge of learning outcomes. This audit of the curriculum is based on references to radiology rather than time spent teaching. Many of the references were delivered in the context of other teaching sessions as part of the integrated curriculum; therefore, the number of hours of radiology teaching students received overall cannot be estimated. Although the hours spent delivering specific radiology teaching could be calculated (e.g., tutorials on CXR interpretation), this figure represents the minimum value, and the overall time spent on teaching radiology would be much higher. In conclusion, the RCR URC7 can be used in a novel way by non-radiologists to audit undergraduate radiology teaching. This approach may therefore be of use in other medical schools to ensure consistency in the way students are taught. The teaching at St Andrews is in accordance with the majority of RCR URC7 learning outcomes, but there are some deficient areas. Increasing the number of universitybased tutorials and integrating ultrasound into the curriculum may bridge some of these gaps and also satisfy student demand. Radiology is a fundamental part of modern medicine and future research must ensure that medical students are graduating with the skills and knowledge to effectively integrate this specialty into their clinical practice.
Limitations
Acknowledgements
Despite a thorough approach, all possible references to radiology in the curriculum could not be identified. This was as a result of external references on websites, which may have changed since their original recommendation to students in 2013e2014, as well as hard copies of images that are only available in the dissection room and are used to variable degrees. These potential references are likely to have contributed a very small proportion of overall references, and thus would not have had a significant impact on the results of the present study. Third-year medical students were surveyed in one academic year (2013e2014) regarding their overall experience of radiology at St Andrews as they have experienced the whole curriculum. There have been no major changes to the curriculum since this cohort of students started medical school; however, it is possible that subsequent final-year cohorts may have slightly different experiences, resulting
The authors thank Naomi Kelly and Simon Glover.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.crad.2015.11.021.
References 1. The Royal College of Radiologists. Clinical Radiology workload: guidance on radiologists’ workload figures. London: The Royal College of Radiologists; 2012. 2. General Medical Council. Tomorrow’s doctors: outcomes and standards for undergraduate medical education. London: GMC; 2009. 3. The Royal College of Radiologists. Unreported X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans: results of a snapshot survey of English National Health Service (NHS) trusts. London: The Royal College of Radiologists; 2015.
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Please cite this article in press as: Jacob J, et al., Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.11.021