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Interpretation of radiological images: towards a framework of knowledge and skills

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Abstract

The knowledge and skills that are required for radiological image interpretation are not well documented, even though medical imaging is gaining importance. This study aims to develop a comprehensive framework of knowledge and skills, required for two-dimensional and multiplanar image interpretation in radiology. A mixed-method study approach was applied. First, a literature search was performed to identify knowledge and skills that are important for image interpretation. Three databases, PubMed, PsycINFO and Embase, were searched for studies using synonyms of image interpretation skills or visual expertise combined with synonyms of radiology. Empirical or review studies concerning knowledge and skills for medical image interpretation were included and relevant knowledge and skill items were extracted. Second, a preliminary framework was built and discussed with nine selective experts in individual semi-structured interviews. The expert team consisted of four radiologists, one radiology resident, two education scientists, one cognitive psychologist and one neuropsychologist. The framework was optimised based on the experts comments. Finally, the framework was applied to empirical data, derived from verbal protocols of ten clerks interpreting two-dimensional and multiplanar radiological images. In consensus meetings adjustments were made to resolve discrepancies of the framework with the verbal protocol data. We designed a framework with three main components of image interpretation: perception, analysis and synthesis. The literature study provided four knowledge and twelve skill items. As a result of the expert interviews, one skill item was added and formulations of existing items were adjusted. The think-aloud experiment showed that all knowledge items and three of the skill items were applied within all three main components of the image interpretation process. The remaining framework items were apparent only within one of the main components. After combining two knowledge items, we finally identified three knowledge items and thirteen skills, essential for image interpretation by trainees. The framework can serve as a guideline for education and assessment of two- and three-dimensional image interpretation. Further validation of the framework in larger study groups with different levels of expertise is needed.

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Acknowledgments

We thank the following persons for their contribution: Dr. E. J. Custers and Dr. K. L.Vincken.

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Authors and Affiliations

  1. Radiology Department, E01.132, University Medical Center (UMC) Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands

    A. van der Gijp, I. C. van der Schaaf, J. C. B. M. Huige, C. J. Ravesloot & J. P. J. van Schaik

  2. Department of Education, Utrecht University, Utrecht, The Netherlands

    M. F. van der Schaaf

  3. Center for Research and Development of Education, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands

    Th. J. ten Cate

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  1. A. van der Gijp
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  2. M. F. van der Schaaf
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  3. I. C. van der Schaaf
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Correspondence to A. van der Gijp.

Appendices

Appendix 1: The search syntax of the literature study

Search terms entered into databases

Databases

Interpretation skills OR interpretation activities OR cognitive skills OR cognitive activities OR interpretation abilities OR reading skills OR reading abilities OR perceptual activities OR perceptual abilities OR perceptual skills OR expertise

AND

Radiology OR radiologist OR radiologic OR radiologists

Pubmed

PsychINFO

Embase

Appendix 2: Final definitions of the knowledge and skills in the framework

Requisite knowledge and skills

Knowledge and skills which are used in all components

Knowledge of anatomy

Knowledge of anatomy, in particular radiological anatomical structures, as visualised with radiological imaging methods

Knowledge of pathology

Knowledge of pathology (diseases) and in particular features of pathology as visualised with radiological imaging methods, but also including knowledge of the clinical features, treatment and prevalence of the disease

Knowledge of radiological imaging techniques

Knowledge of the acquisition of the images and the effect of radiological techniques on the image representation (Lesgold et al. 1988)

Spatial abilities

The ability to imagine a 2D representation as a 3D structure, to mentally rotate this structure and to analyse the relationship between different spatial representations (Linn and Petersen 1985)

Image manipulation skills (navigating through, changing views or contrast)

To have knowledge of the effects of image manipulation on image representation and the ability to choose the optimal representation for a task, e.g. by navigating through the image, changing contrast or changing views (meta-representational competence)(Hegarty 2010)

Acquaintance of clinical information and context

Using clinical information (from the request form, the patient status and from patient interaction) or clinical context (type of hospital, requesting clinician etc.) for interpretation of the radiological examination

Perception

Identification of radiological findings

Using efficient search strategies

Apply efficient search strategies, such as global search, systematic search and hypothesis-guided search. Search strategies might be successively applied during interpretation of a radiological image (Wolfe et al. 2010)

Discriminating normal from abnormal findings

Discriminate normal (and normal variance) from abnormal findings (Boutis et al. 2010)

Pattern recognition

Recognizing the diagnosis directly and unconsciously, based on similar patterns in visual memory

Analysis

Examination of the features of radiological findings

Comparing with previous images

Comparing radiological findings with findings on previous examinations of the patient

Characterizing findings

Evaluating features (e.g. density, shape, contour) of the findings, if necessary by using post processing

Discriminating relevant from irrelevant findings

Discriminate clinically relevant findings from findings which are not clinical relevant

Synthesis

The synthesis of radiological and clinical findings into a conclusion about the differential diagnosis and patient management

Information retrieval

Skills for a purposeful search for information in a system, in which information is stored and represented (e.g. information in books, the internet) (Bates et al. 2005). For the purpose of the verbal protocols: to realise that more information (clinical information, information out of books) is necessary to interpret the image properly

Integrating radiological findings

Connecting radiological findings with each other (e.g. a lung nodule and mediastinal lymph nodes)

Generating a (differential) diagnosis

Generating a list of possible diagnoses in order of probability. This incorporates generating as well as rejecting diagnoses and the classification of diseases, such as type or stage

Deciding about advice or action

Decide if it is necessary to give an advice (e.g. further examinations, follow up exams) or take action (e.g. calling the requesting clinician immediately)

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van der Gijp, A., van der Schaaf, M.F., van der Schaaf, I.C. et al. Interpretation of radiological images: towards a framework of knowledge and skills. Adv in Health Sci Educ 19, 565–580 (2014). https://doi.org/10.1007/s10459-013-9488-y

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