Tag: education

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Let’s Go Back To The Fundamentals Of Radiology

fundamentals

Yes. I lived in a different world from residents today. We didn’t have all the electronic resources such as virtual flashcards, digital ebooks for almost everything, Radexams, Case stacks, Radprimer, question banks, and other online electronic resources. In addition, there were fewer texts for every topic than what we see today. And, we had only one general review text for the boards (Dahnert). But, as I remember, almost all radiology residents back in my day would read these topic-based physical textbooks to understand the fundamentals of radiology. We needed to read this material to grasp the essence of what we needed to know. Many of today’s residents no longer ascribe to this philosophy and jump right into other ancillary electronic material. 

Moreover, without reading the textbooks that I did when I started, I would never have had the fundamentals I have today to synthesize findings and differentials quickly. By skipping out on reading the fundamental texts, residents build knowledge layered upon a flimsy thin base. They can’t answer the why and how of what we do. And they are much less likely to pass the written board examination. This result is precisely what we ultimately find. So, let’s talk about why returning to reading primary physical textbooks is critical before jumping into all the electronic resources.

Active Learning With A Physical Textbook Is Better For The Fundamentals

Reading with a physical textbook rather than electronic reading material is more efficient. If you are not convinced, take a look at my former article, eBooks vs. Printed Radiology Books- A Death Match Part II. In this article, you will find evidence that using physical texts is better than electronic material for learning material. Holding a book in your hand, highlighting, and taking active notes on flashcards, is more efficient for remembering the material. So, although more portable, electronic resources may not give you the same bang for your buck.

Putting Your Money Where Your Mouth Is!

I know. Many of you have tons of debt from medical school. However, when you pay for something, you establish an unwritten commitment to it. So, when you buy your textbook, you are much more likely to feel like you have to use it, read it, and mark it up. Sharing ebooks with your colleagues is just not the same. Therefore, you should consider going back to the old-fashioned concept of owning your textbooks to increase your retention and maximize the possibility of passing the written boards.

Much Better To Have Conceptual Learning Than Learning Lists!

To this day, I can still remember where and when I learned certain concepts, such as features of extra-axial vs. intra-axial brain tumors (check out Osborn!) or patterns of arthritis (Arthritis In Black And White). When you go directly to the electronic references without reading these source textbooks, you are much more likely to see random lists without knowing the why behind the finding. And, you are much less likely to remember the key concepts that will help you make diagnoses later on. You know what they say – give a man a fish, and he will eat for a day. Teach a man to fish, and they will be able to eat for a lifetime! It’s true! So, make sure to learn the concepts from the text first!

More Difficulties With Complexities And Artifacts

It is much easier to figure out complex problems that don’t follow the rules if you know the basics. And, in radiology, very few cases are precisely what the literature describes. When you know the concepts behind the images, you can adjust your ideas to suit the case and allow you to make the appropriate differential diagnosis because you understand why it can fit what you are seeing. When you are reading electronic material distilled down to the bare bones, you lose out on this ability to make the diagnosis when it doesn’t necessarily follow the rules!

Getting Back To Fundamentals!

I am a purveyor of electronics. It is fun to play around with cell phones, computers, and gadgets. But, based on real-world experience with resident success, I implore residents from the first through third years to opt into reading primary textbooks to establish foundations in their knowledge base. Electronic media does play a role in learning. But, residents should consider delegating that role to the reinforcement of knowledge and not as a place to start. In the end, it is your choice. But, residents that read the introductory texts do better on the boards and make themselves better radiologists!

 

 

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Service Exceeding Education At Your Program? Do Something About It!

service exceeding education

All radiology residencies have an Achilles heel. In the pursuit of creating an excellent education for all radiology residents, programs need to balance the “service obligations” with the “educational” environment. Now, there is a lot of debate about service exceeding education. But, we all know of rotations where the service obligations seem to outweigh what you may learn on rotation. You may have a mammography rotation where your attendings need you to complete all the needle localizations at the expense of learning diagnostic and screening mammograms. Or, perhaps, you have an interventional rotation where you can’t get into cases because the technologists need the residents to consent all the patients. Regardless, what do you do when you find yourself not receiving the education you think you should receive?

How To Improve A Rotation With Service Exceeding Education? A Playbook!

Step 1- Be Specific About The Problem Of Service Exceeding Education

The first thing you need to do is to be specific and write down the particular problems in the rotation. In other words, what are the educational circumstances that your program is not meeting? If you believe that the residents don’t have enough paracenteses, write that down. If you find that the nuclear medicine attending is never in the reading in the room or is not giving enough lectures, make sure to add that onto the list. Make sure you enumerate each of those problems. Eventually, you will want to address the issues with the educational committee.

Step 2- Cross-Reference with The ACGME Program Requirements

Next, check the ACGME program requirements. See if the problem is one that directly contradicts the philosophy and regulations of the program requirements. If so, write down how the issue interferes with the program’s goals. This step is critical because programs must fulfill their educational objectives to their residents. If they do not, programs can meet repercussions from the ACGME. At worst, the ACGME may not reaccredit your program until they comply. Some corrections can be costly. You can expedite change if you document how the issues may prevent the program from meeting the ACGME bylaws.

Step 3- Document The Issues And Provide Data

Now that you have the specific issues and why they may interfere with the program’s goals, create a data trail. For example, if you are not receiving the right number of conferences every week, document all the faculty’s conferences. Or, figure out what number per week you have been receiving or the rate of cancellation of lectures every week. You will need to have some hard data when the time comes to present the issues. Objective data helps because you can eventually factually show that the fix can improve the problem.

Step 4 – Create A Plan To Fix The Problem

Come up with a financial or educational plan to solve the problem. Say your program lacks a statistician and you need one to satisfy the research requirement, come up with the potential costs of hiring one for the hospital or the program. Of course, it is a good idea to meet with your faculty to figure out satisfactory solutions. As a resident, you may lack the experience to know some of the costs and problems that the institution may encounter when they attempt to fix the problem. So, gather a team of folks that do know more about the area you wish to improve.

Step 5- Formally Meet With The Program Director, GME Committee, Etc.

Since you have already enumerated the problems, figured out how they interfere with the program education/requirements, provided accurate, objective data, and created a plan to fix the problem, now is the time to meet with the appropriate committee. You should submit the initial run through to the education committee or the program directors at the program level. Here the committee can discuss the issues and enact a plan. If the solution is not amenable to being fixed at this level, the education committee can submit the plan to the GME level, hospital level, etc. Nevertheless, you need to formally present a plan so that the program or hospital can make a solution.

Step 6- Implement The Plan

Now that the institution or residency is backing the solution, you should be part of the team that seeks to implement the solution. Make sure that the plan is working as stated and followup to check for a positive outcome. Most of the time, you will find a reasonable solution for the previous issues. (But not always!)

Step 7- Document Outcomes

Now that your institution has “repaired” the problem, you still have more work to do. Make sure that the fix is not worse than the problem itself. It is therefore vital to objectively document how the changes to the program have affected the outcomes. If the hospital institutes a policy that faculty members that miss lectures will receive a pay cut and the lecturers continue to miss giving noon conferences, the fix was not an adequate solution. So, this step is crucial to show that you have a viable solution to your original problems.

Why Bother With All This Extra Work To Remedy Service Exceeding Education?

Well, the answer to this question relatively simple. Your radiology residency program is the foundation for your future career. And, if your education is not adequate, it will reflect in your future employment.

Furthermore, this learning experience is not only good for learning how to fix your residency. It is also a great way to learn the principles to enact change in any career stage. You can adapt the same steps to almost any situation where you want to enact helpful change. So, figure out those areas in your program where service requirements overburden learning and think about ways to enhance your residency rotations using this seven-step guide. It is an exercise worth the effort!

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Can Clinical Decision Support Systems Help To Improve Radiology Resident Education?

During my residency only a little bit more than 14 years ago, I can still remember grabbing a ream of sheets from the bin to check the day’s CT protocols. We would quickly read through each one to make sure that the appropriate test was indicated as was ordered by the referring physician. Somehow, I think this process is currently an anachronism at many radiology residency programs. The pressure to complete studies in rapid fashion have changed the way things are done. It seems almost all the cases come directly from either the emergency room or from the referring physician directly to the scanner. No longer is the resident an intermediary in the process (a potential delay in the system). Instead, there is a corresponding increase in tests with incorrect indications and/or wrong technique, only to increase radiation dosages and the cost to the system. The ordering physicians, not the imaging experts, have hijacked what should be the domain of the radiologist: to decide if imaging examinations are appropriate.

Why do I bring this topic to our attention? First and foremost, of course, patient care suffers. But also, as today’s topic implies, it also affects the education of the radiology resident. So how do we get control back over the reins of imaging from a standpoint of improving resident education? Initially, we have to understand the role of protocols in the education of the radiology resident. And then, I will briefly discuss what imaging clinical decision support systems are and how clinical decision support systems can potentially enhance the education of residents as well as the appropriate use of imaging.

Protocols And Educational Implications For The Radiology Resident

One of the most important roles of radiologist is to be a consultant for the appropriate use of imaging. As I described above, the process of checking protocols significantly enhanced my knowledge on this topic.  What may have seemed at the time as a questionable activity bordering on scut, I now see as invaluable. Related to my prior experience with protocoling CT scan studies, I now understand when contrast should be administered, how certain studies are typically performed, and most importantly, what are good indications for a study to be completed. At many programs, this educational opportunity is no longer available due to financial and political pressures upon radiology departments to get through the system. Any study ordered must get done in a timely fashion, no matter whether the study is indicated or not! It only matters that it was ordered. Correspondingly, resident involvement in this process has significantly decreased over time.

So, how does removing this educational opportunity for radiology residents change the knowledge base of the radiology resident?  First of all, you are taking away important practical knowledge that can reduce the value of new radiologists as a consultant for determining appropriateness of individual imaging studies. Second, new radiologists will be less likely to understand how to tailor individual studies to the indications of the ordering physician. And finally, the potential implications of issues like when to use intravenous contrast can be underestimated, both from a contrast complication and an appropriate indication point of view. So herein lies the potential savior to return the educational opportunities of protocoling back to the radiology resident- The Clinical Decision Support System!

The Clinical Decision Support System

Here is the definition of clinical decision support systems according to the government– “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”

In terms of imaging, the potential implications of a clinical decision support system from a cost and educational standpoint are myriad. No longer are all imaging studies going to be ordered without the approval a computerized system. When can this potentially occur? How would the radiology resident role going to be affected by the implementation of such systems? Let’s talk about both of these questions…

Institution of Clinical Decision Support Systems And The Potential Effect Upon The Radiology Resident

At first, institution of electronic clinical decision support systems were going to be mandatory as January 1, 2017. The date was subsequently changed to January 1, 2018. We will see if this date is going to be the finalized implementation deadline.

But let’s say that a good quality clinical decision support system became mandatory at all institutions for ordering imaging studies at the beginning of 2018. How would that affect the residents? First thing that would you notice, bogus indicated studies would all of a sudden significantly decrease dramatically. The system should theoretically block anything that has a questionable indication from getting through from the clinician order to actual practice. Second, there could potentially be a flood of phone calls. Since any study with a questionable indication or a complex protocol would not be able to get through the system, instead, clinicians would be forced to ask the radiologist what kind of protocol should be implemented for these cases. Not only would this be a boon for patient safety (decreased radiation dosages) and appropriateness of imaging, clinical decision support systems can actually bring the control of image ordering back to the radiologist. More specifically, a good quality clinical decision support system can theoretically allow the radiology resident to protocol examinations appropriately in concert with the ordering physician and tailor examinations to the indication that is needed. Resident protocol education can be restored!!!

Interestingly, a clinical decision support system for imaging was actually one of the few parts of the health care bill that actually had the potential to decrease costs and quality of care in addition to improving resident educational experiences. Ironically of course, it may never be implemented depending upon how the political situation in Washington affects health care.

Clinical Decision Support Systems For Imaging Can Be The Resident Radiologist’s Best Friend

In summary, clinical decision support systems have the potential to be one of the true benefits to the health care system, in terms of costs and quality of care. But, one of the most overlooked implications is actually the potential educational benefits to the radiology resident. No longer would ordering be in the hands of untrained ordering physicians. Instead, control will again lie in the hands of the radiology resident allowing him/her to protocol patients once again appropriately and giving the radiology resident the education he/she needs to become a true imaging expert.