Curriculum Matters! Designing Curriculum for Radiology Resident Rotations

To understand the overall challenges and interest in curriculum development, it is important to first understand the changes in medical training over the past two decades. In the past, medical students would select a year of internship that usually involved circulating through multiple clinical rotations prior to entering a 4-year radiology residency program. There was no CaRMS match, and the number of applicants for the few residency positions in radiology was low. Residents were referred to by their training year; R1ȓ4 to reflect their 4-year training program. From the 1970s up to early 1980s, most radiology programs did not have separate rotations during the first year and residents were based at a single hospital rotation for 6ȓ12 months performing general radiology. With the advances in cross-sectional imaging and the introduction of ultrasound and computed tomography in the 1980s, radiology programs introduced core rotations based on monthly changes with some rotations taking up to 2ȓ4 months. The introduction of magnetic resonance imaging and more invasive technology with angiography/interventional radiology contributed to the expansion of the rotations. As a result, many of the early rotations were so-called modality-based, concentrating on training of a single technology for the month.

Appendices

Appendix Abdominal/Body Imaging Rotations

Adapted from: Victoria Hospital LHSC Abdominal/Body Imaging Rotation Documents

The rotation will be an integrated abdominal/body imaging rotation for radiology residents which will focus on cross-sectional abdominal/body imaging modalities CT, US, and MRI with some radiography/fluoroscopy. Some chest CT will be included where possible.

1.1 Rotation Objectives by Resident Year

By the end of the PGY2 Rotation the resident will:

• Experience 3ȓ4 months in the department with a focus on CT, US, and fluoroscopy

• Identify and communicate imaging indications and diagnosis of trauma and acute/urgent abdominal diseases

• Demonstrate an introductory knowledge of differential diagnosis

1.1.1 Assessment

• Residents will be assessed daily through a review of their knowledge of abdominal anatomy in each modality and their ability to perceive and analyze imaging findings.

By the end of the PGY3/4 Rotation the resident will:

• Gain a further 2 months experience in the department with a focus on CT, US, and MRI

• Demonstrate an abdominal MRI integrating multimodality imaging

• Consolidate previous knowledge from PGY2 and begin formulating complete differential diagnosis in their daily reviews of cases

• Demonstrate supervisory skills in interactions with technologists, medical students, and other off-service residents

• Demonstrate leadership and collaboration skills in interactions with junior residents (where applicable)

• Triage, protocol, and prioritize cases

(Residents who would like further experience in biopsies can obtain additional experience if requested.)

1.1.2 Assessment

• Residents will be assessed daily through a review of their knowledge of abdominal anatomy in each modality and their ability to perceive and analyze imaging findings

By the end of the PGY 5 Rotation the resident will:

• Experience an additional 1 month elective CT,US, and MRI

• Demonstrate ability to identify abdominal imaging diseases with further development of differential diagnosis combining real-practice aspects with Royal College examination requirements appropriate for a PGY5 candidate

• Function as a junior consultant, taking on supervisory responsibilities and requesting staff assistance when necessary in alignment with graded responsibilities as part of developing the CanMEDS competencies

CanMEDS Rotation Objectives Pgy2ȓ5

In accordance with RCPSC CanMEDS roles, the rotation-specific objectives are as follows:

2.1 Medical Expert

2.1.1 Technology

• An understanding of various technologies, recent advances, advantages vs. limitations

• An understanding of the role of technologists and expertise

• An understanding of scanning protocols, postprocessing techniques

• Knowledge of appropriate contrast utilization and techniques (IV, oral, etc.)

• Develop an understanding about the physics involved with each technique including artifacts

• Be knowledgeable about quality assurance of each modality

2.1.2 Anatomy

• Cross-sectional anatomy of the abdomen (GI, GU, Vascular, Lymphatics, etc.) in all modalities

• Normal variants

• Pathways of pathology spread

2.1.3 Skills

• Able to insert angiocatheter for venous access

• Able to apply the appropriate protocol(s) for each patient

• Able to modify scanning protocols based on variations of clinical and technical factors

• Able to supervise examinations including checking acute cases from ER, trauma

• Able to diagnose and treat complications related to intravenous injections (limitations, extravasation, reactions, etc.)

• Senior residents should be able to perform simple biopsies including the organization of the procedure (pre, during, and post)

• Understand the various oral and rectal preparations for fluoroscopic examinations and performance of those examinations

2.1.4 Interpretation

• Knowledge of abdominal pathologies and the capability of the exam to evaluate the pathology

• Knowledge of the diagnostic ability of each examination including recognizing artifacts, limitations, potential contraindications, and complications

• Learn the importance of comparisons with previous examinations and correlative imaging including clinical information on the case and clinical expectation of the results

• Knowledge of additional examinations required for further diagnostic or therapeutic intervention

• Ability to recognize critical acute diagnosis

• Ability to develop appropriate differential diagnosis and suggest appropriate further imaging, therapy, or clinical action required

2.1.5 Communicator

• Develop communication skills with attending radiologists and radiology residents with a positive and enthusiastic attitude toward learning

• Develop communications skills with referring physicians, residents including results of examinations (preliminary and final report), notification of complications and follow-up

• Develop communications skills with patients (families) when asked about results in an ethical and appropriate manner or when dealing with a complication of an examination

• Ability to discuss and obtain informed consent from patient, parent, or legal guardian

• Communicate with support staff within the specialty, technologists, nurses, clerical booking personnel, as well as with referring support staff such as ward clerks, nurses, etc.

• Listen effectively to concerns of others and enjoy continuous learning

• Once an acute diagnosis is made, the ability to communicate urgent results by immediate communication with referring/attending physicians and documentation of the discussion

• Ability to dictate in a concise, clear manner to facilitate typing of reports by stenographers and developing an appropriate usage of the radiology lexicon

• Complete communication process by signing reports in timely manner

2.1.6 Collaborator

• Ability to communicate and develop an expertise related to consultation on abdominal imaging cases and an appreciation of other specialists imaging requirements

• Develop a cooperative attitude and facilitate imaging requests, working as a team with clinicians

• Assist clinicians in understanding appropriateness criteria for examinations (best test)

2.1.7 Manager

• Ability to triage cases based on urgency

• Ability to manage workload on a daily basis by reviewing cases at appropriate intervals and an appropriate work ethic

• Work effectively within the context of the subspecialty area

2.1.8 Health Advocate

• A global understanding of the determinants of health

• An understanding of cross-sectional imaging determinants which include awareness of radiation safety, contraindications to examinations (pregnancy, metals in MRI, body habitus, etc.), and alternate methods of imaging such as no radiation vs. radiation based on the understanding of the clinical requirements and the appropriateness of each examination

• Contribute to the improved health of the patients and communities by advocating the best examination and promoting appropriate access

2.2 Scholar

2.2.1 Learning

• Daily case review and differential diagnosis discussions with radiologists

• Develop a lifelong learning strategy

• Read core reference textbook and utilize journals/on-line resources (see references below)

• Utilize information technology (electronic patient record) or patient chart to obtain clinical information relevant to the examination

• Develop an ability to critically appraise resources of radiological information

• Participate in abdominal imaging resident and clinical rounds and be a role model for residents/students

• Contribute toward learning of other residents by submitting two teaching file cases/month of rotation in electronic format

• PGY 2: Fundamental interpretation skills of emergency imaging and trauma which include bowel diseases (perforation, obstruction, ischemia, appendicitis, other “itis,” inflammatory and infection, neoplasms), renal/retroperitoneal acute diseases (renalcolic, infection, neoplasm, hemorrhage, etc.), thoracic dissection, PE, pneumonia, pulmonary edema, etc.

• PGY 3/4: To consolidate differential diagnosis of diseases, patterns of spread of disease, building on previous rotation

• PGY 5: To develop into junior clinical consultant, supervising area, and developing some independence in reporting whilst reviewing key diseases and differentials in preparation for exams

2.2.2 Teaching

• Participate in weekly abdominal imaging rounds with abdominal radiologists which will include one presentation by resident once a month to peer group to develop teaching expertise

• Teaching off-service residents/students (formally/informally) as required by Radiology program

• Learn to teach by presenting one rounds/month to other radiology residents of interesting cases during rotation and by mentoring off-service residents or medical students

• Teach clinical staff at regular clinical service rounds (general surgery, urology, other) and be an advocate of abdominal imaging and radiology

2.2.3 Professional

• Deliver high-quality imaging, optimized for disease entity, clinical requirements

• Encouraged to support the imaging profession and to develop a sense of professionalism by becoming a member of professional organizations (CAR, RSNA, AJR, etc.)

• Ensure that an examination provides and contributes toward optimized patient care and appreciating that there is a person behind the images

• Practice imaging ethically consistent with the obligations of a physician which includes respect for patient privacy and confidentiality in compliance with hospital policies

Rotation Evauluation

• Evaluation will be based on all above objectives and the completed submission of two electronic teaching file cases/month

• Evaluation may include an Objective Stuctured Clinical Examination (OSCE)

• In-Training Resident Evaluation (ITRE) will consist of a composite evaluation by all supervisors at the end of rotation

• The level of expertise should increase over the course of the rotation(s) and will be evaluated based on appropriate resident year

• Expectation for residents to achieve an average or above average evaluation on ITRE for the rotation