Imbalanced specialty representation of USMLE and NBME test writers.

PURPOSE: The United States Medical Licensing Examination (USMLE) is an examination series required for allopathic physician licensure in the United States (US). USMLE content is created and maintained by the National Board of Medical Examinations (NBME). The specialty composition of the USMLE and NBME taskforce members involved in the creation of examination content is currently unknown. METHODS: Using the 2021 USMLE and 2021 NBME Committees and Task Forces documents, we determined each member's board-certified primary specialty and involvement in test material development committees who we dubbed "test writers". Total active physicians by primary specialty were recorded from the 2020 Physician Specialty Data Report published by the Association of American Medical Colleges (AAMC). Descriptive statistics and chi-square analysis were used to analyze the cohorts. RESULTS: The USMLE and NBME test writer primary specialty composition was found to be significantly different compared to the US active physician population (USMLE χ2[32] = 172, p < .001 and NBME χ2[32] = 200, p < .001). Only nineteen specialties were represented within USMLE test writers, with three specialties being proportionally represented. Two specialties were represented within NBME test writers. Obstetrics and Gynecology physicians were proportionally represented in USMLE but not within NBME test writers. Internal Medicine (IM) accounts for the largest percentage of all USMLE test writers (60/197, 30%) with an excess representation of 31 individuals. CONCLUSIONS: There is an imbalance in the specialty representation of USMLE and NBME test writers compared to the US active physician population. These findings may have implications for the unbiased and accurate portrayal of topics in such national examinations; thus, future investigation is warranted.

A Novel USMLE® Step 1 Based Approach to Introducing Radiation Oncology to Second-Year Preclinical Medical Students.

There is a paucity of formalized exposure to Radiation Oncology (RO) for preclinical medical students across the United States as well as barriers to implementation within undergraduate medical education curriculum at many institutions. We present a novel approach to implementing an introductory RO didactic lecture to second-year medical students by interweaving associated oncological and ionizing radiation content represented on the United States Medical Licensing Exam® (USMLE®) Step 1 examination. Students had synchronous and asynchronous opportunities to engage with the 1.0-h didactic lecture administered by an attending Radiation Oncologist faculty member. Students were electronically invited to anonymously rank the effectiveness of the lecture materials on a 5-point Likert scale. Performance on standardized board-style questions regarding radiation biology and radiation side effects was recorded before and after the lecture and compared to the historic performance of previous institutional second-year medical student cohorts. The lecture material effectiveness received a mean score of 4.50 on a 5-point Likert scale. There was a statistically significant improvement in student performance on a board-style radiation side effect question from 39% on a pretest to 76% on a posttest. A USMLE® topic-based approach may be an effective way to implement a formalized introduction to RO to preclinical medical students while simultaneously improving performance on relevant standardized board-style questions. Providing evidence that RO topics appear on the USMLE® Step 1 examination curriculum was a powerful incentive for implementation when negotiating with curriculum offices.

Analysis of Oncology and Radiation Therapy Representation on the National Board of Medical Examiners Official Practice Material for the United States National Standardized Medical Board Examinations.

Radiation therapy (RT) is a critical component of multidisciplinary cancer care, but has inconsistent curricular exposure. We characterize the radiation oncology (RO) content on the standardized undergraduate medical examinations by comparing its context and prevalence with other domains in oncology. National Board of Medical Examiners (NBME) self-assessments and sample questions for the United States Medical Licensing Exam (USMLE) Steps 1-3 and NBME clinical science shelf examinations were accessed (n = 3878). Questions were inductively analyzed for content pertaining to oncology and treatment modalities of RT, systemic therapy (ST), and surgical intervention (SI). Questions were coded using USMLE Physician Tasks/Competencies and thematic analysis. Descriptive statistics and analyses using the Kruskal-Wallis test are reported. A total of 337 questions (8.6%) within the USMLE and shelf exams included oncology content, with 101 questions (2.6%) referencing at least one cancer treatment modality (n = 35 RT, 45 ST, 57 SI). Treatment questions were more common on USMLE Step 2 CK (n = 35/101, 32%) compared to Step 1 (n = 23/101, 23%) and Step 3 (n = 8/101, 8%) (p < 0.001). RT was significantly less likely to be the correct answer (2/35, 6%) compared to ST (4/45, 9%) and SI (18/57, 32%) (p = 0.003). Therapeutic oncology questions are uncommon on the examination material, with an under-representation of radiation-related content, and contextual bias favoring surgical approaches. We advocate for greater RO involvement in the content creation of such examinations to help trainees better understand multidisciplinary cancer care.

Patient-centered radiology: a roadmap for outpatient imaging.

Creating a patient-centered experience is becoming increasingly important for radiology departments around the world. The goal of patient-centered radiology is to ensure that radiology services are sensitive to patients' needs and desires. This article provides a framework for addressing the patient's experience by dividing their imaging journey into three distinct time periods: pre-exam, day of exam, and post-exam. Each time period has aspects that can contribute to patient anxiety. Although there are components of the patient journey that are common in all regions of the world, there are also unique features that vary by location. This paper highlights innovative solutions from different parts of the world that have been introduced in each of these time periods to create a more patient-centered experience. CLINICAL RELEVANCE STATEMENT: Adopting innovative solutions that help patients understand their imaging journey and decrease their anxiety about undergoing an imaging examination are important steps in creating a patient centered imaging experience. KEY POINTS: • Patients often experience anxiety during their imaging journey and decreasing this anxiety is an important component of patient centered imaging. • The patient imaging journey can be divided into three distinct time periods: pre-exam, day of exam, and post-exam. • Although components of the imaging journey are common, there are local differences in different regions of the world that need to be considered when constructing a patient centered experience.

Use of a Convex Pouching System in the Postoperative Period: A National Consensus.

Convex pouching systems have been available for ostomy patients for decades; however, controversy remains over the use of convexity in the postoperative period. A group of 10 nurses and physicians with expertise caring for patients with an ostomy completed a scoping review identifying research-based evidence and gaps in our knowledge of the safety and effectiveness related to the use of a convex pouching system following ostomy surgery. Results of this scoping review demonstrated the need for a structured consensus to define best practices when selecting a pouching system that provides a secure and reliable seal around the stoma, avoids undermining and leakage of effluent from the pouching system, and contributes to optimal health-related quality of life for patients following ostomy surgery. The expert panel reached consensus on 8 statements for the use of convex products immediately after surgery and throughout the first 6 months after stoma creation, as well as describing goals in choosing the best pouching system for the patient with an ostomy.

Survey Results on Use of a Convex Pouching System in the Postoperative Period.

PURPOSE: The purpose of this study was to validate time frames for postoperative care following stoma surgery and to determine participants' current practice with convex pouching systems during the postoperative period. DESIGN: A Cross-sectional survey. SUBJECTS AND SETTING: The sample comprised 332 ostomy care specialists practicing in the United States. Most (n = 220; 66%) had more than 10 years' experience caring for patients with ostomies, 82% (n = 272) were certified WOC or ostomy care nurses (CWOCN and COCN), and 7% (n = 23) were board-certified colorectal surgeons. METHODS: A 23-item online questionnaire was created for purposes of the study. Items in the questionnaire queried professional background and experience caring for patients with an ostomy. A single item was used to identify postoperative care periods following ostomy surgery. Additional items queried current practice patterns related to use of convex pouching systems and the timing of their use. Data were collected from January 18 to February 8, 2021. RESULTS: Most respondents (n = 270; 90%) agreed with the following postoperative periods after ostomy surgery: immediate postoperative period (days 0-8); postoperative period (days 9-30); and transition phase (days 31-180). Most respondents (n = 274; 95%) indicated they would use a convex pouching system when clinically appropriate during the first 30 days following ostomy surgery and 79% (n = 228) indicated using a convex pouching system regardless of when the surgery was performed. Less than 1% (n = 2) indicated never using convexity within the first 30 days following stoma surgery, and only 3% (n = 8) indicated avoidance of convexity pouching systems in the immediate postoperative period. CONCLUSIONS: Findings indicate that use of convexity during the postoperative period is prevalent to provide a secure seal and predictable wear time.

Special Report of the RSNA COVID-19 Task Force: Crisis Leadership of Major Health System Radiology Departments during COVID-19.

Severe acute respiratory syndrome coronavirus 2 has spread across the world since December 2019, infecting 100 million and killing millions. The impact on health care institutions during the coronavirus disease 2019 pandemic has been considerable, with exhaustion of institutional and personal protective equipment resources during local outbreaks and crushing financial consequences for many institutions. Establishing adaptive principles of leadership is necessary during crises, fostering quick decision-making and workflow modifications, while a rapid review of data must determine necessary course corrections. This report describes concepts of crisis leadership teams that can help maximize their effectiveness during the current and future pandemics.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient.

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Analysis of 612 Benign Papillomas Diagnosed at Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated With Upgrade, and a Proposal for Selective Surgical Excision.

BACKGROUND. Despite numerous published studies, management of benign papillomas without atypia remains controversial. OBJECTIVE. The purpose of this study was to determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. METHODS. This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between December 1, 2000, and December 31, 2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. RESULTS. The study included 612 benign papillomas in 543 women (mean age, 54.5 ± 12.1 [SD] years); 466 papillomas were excised, and 146 underwent imaging or clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p < .05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for 60 years and older vs 0.7% for younger than 60 years), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥ 10 mm vs 0.6% if < 10 mm). Three of 14 upgraded papillomas were associated with four or more metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age 60 years old and older, size 10 mm or larger, and presence of four or more metachronous or concurrent peripheral papillomas achieved an AUC of 0.91, sensitivity of 79%, and spec-ificity of 89% for upgrade. Selective surgery based on presence of any of these five factors, although excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would have spared 294 of 612 lesions from routine excision and identified all 14 upgraded lesions. CONCLUSION. Benign nonatypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the five criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. CLINICAL IMPACT. The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.

Upright Tomosynthesis-guided Breast Biopsy: Tips, Tricks, and Troubleshooting.

The advent and implementation of digital breast tomosynthesis (DBT) have had a significant effect on breast cancer detection and image-guided breast procedures. DBT has been shown to improve the visualization of architectural distortions and noncalcified masses. With the incorporation of DBT imaging, biopsy of those findings seen only with DBT is feasible, and the need for localization and surgical excision to determine the pathologic diagnosis is avoided. The additional benefits of reduced procedural time, better localization, and increased technical success support the use of DBT for breast biopsy. DBT-guided biopsy can be performed with the patient prone or upright, depending on the table or unit used. Upright positioning enables improved patient comfort, particularly in patients who have restricted mobility, weight-related limitations, and/or difficulty lying prone for an extended period. Upright DBT-guided breast procedures require a cohesive team approach with overlapping radiologist and technologist responsibilities. Since this is a common breast procedure, the radiologist should be familiar with preprocedural considerations, patient preparations, and use of the biopsy equipment. The basic principles of upright DBT-guided breast biopsy are described in this comprehensive review. The various procedural components, including alternative approaches and techniques, are discussed. Tips and tricks for navigating the biopsy procedure to minimize complications, imaging examples of crucial steps, and supporting diagrams are provided. In addition, the challenges of performing upright DBT-guided biopsy, with troubleshooting techniques to ensure a successful procedure, are reviewed. ©RSNA, 2021.

Improved Appropriateness of Advanced Diagnostic Imaging After Implementation of Clinical Decision Support Mechanism.

The Protecting Access to Medicare Act (PAMA) mandates clinical decision support mechanism (CDSM) consultation for all advanced imaging. There are a growing number of studies examining the association of CDSM use with imaging appropriateness, but a paucity of multicenter data. This observational study evaluates the association between changes in advanced imaging appropriateness scores with increasing provider exposure to CDSM. Each provider's first 200 consecutive anonymized requisitions for advanced imaging (CT, MRI, ultrasound, nuclear medicine) using a single CDSM (CareSelect, Change Healthcare) between January 1, 2017 and December 31, 2019 were collected from 288 US institutions. Changes in imaging requisition proportions among four appropriateness categories ("usually appropriate" [green], "may be appropriate" [yellow], "usually not appropriate" [red], and unmapped [gray]) were evaluated in relation to the chronological order of the requisition for each provider and total provider exposure to CDSM using logistic regression fits and Wald tests. The number of providers and requisitions included was 244,158 and 7,345,437, respectively. For 10,123 providers with ≥ 200 requisitions (2,024,600 total requisitions), the fraction of green, yellow, and red requisitions among the last 10 requisitions changed by +3.0% (95% confidence interval +2.6% to +3.4%), -0.8% (95% CI -0.5% to -1.1%), and -3.0% (95% CI 3.3% to -2.7%) in comparison with the first 10, respectively. Providers with > 190 requisitions had 8.5% (95% CI 6.3% to 10.7%) more green requisitions, 2.3% (0.7% to 3.9%) fewer yellow requisitions, and 0.5% (95% CI -1.0% to 2.0%) fewer red (not statistically significant) requisitions relative to providers with ≤ 10 requisitions. Increasing provider exposure to CDSM is associated with improved appropriateness scores for advanced imaging requisitions.

Telehealth, Telemedicine, and Related Technologic Platforms: Current Practice and Response to the COVID-19 Pandemic.

BACKGROUND: Providing health care at a distance has evolved over the past decades, resulting in a myriad of terms and styles of care delivery. Telehealth is defined as any health care service delivered at a distance. Nursing services have been delivered by a wide range of specialty nurses for many years using various technological formats. Clinical experience suggests that few WOC nurses had extensively adopted these technologies and principles into their practice as recently as 2019. However, the COVID-19 pandemic of 2020 has forced both administrators and clinicians to rapidly adapt or introduce telemedicine technologies to deliver specialty care including WOC nurse services. CASES: Three WOC nurses were chosen to describe the use of telehealth technologies to illustrate opportunities for WOC nurses to integrate telehealth nursing into a health care setting. Two adapted telehealth technology into their practice before the pandemic, and one started telehealth practice as a means to provide care after the onset of the pandemic. Disadvantages and advantages are discussed to provide further information regarding WOC patient care using these technologies. CONCLUSION: The pandemic crisis has accelerated the need for health care to reimagine the delivery of care to patients. Telehealth technologies and principles have emerged as essential for WOC nurses to deliver safe and effective care.

Asymmetric Ductal Ectasia: An Often Overlooked Sign of Malignancy.

OBJECTIVE. The objective of this article is to define the clinical significance of asymmetric ductal ectasia by a review of literature and to describe the imaging findings. CONCLUSION. Asymmetric ductal ectasia has a significant risk for malignancy and high-risk lesions. The findings on conventional imaging may be subtle and easily overlooked. Asymmetric ductal ectasia should be included in the search pattern during image interpretation. Tissue sampling is usually warranted. Ultrasound is critical in identifying ductal abnormalities to guide biopsy.

Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage.

BACKGROUND: The purpose of this article is to examine the evidence related to a unique phenomenon of purple-maroon discoloration of the buttocks found in homecare patients and to recommend a label for this phenomenon. CASES: Initially, we searched the literature to identify and retrieve any evidence related to this unique form of purple-maroon discoloration of the buttocks. No evidence was found. To illustrate the condition, we compared 4 cases of what we have labeled chronic tissue injury to 6 patients with purple-maroon discoloration of the buttocks from different causes. CONCLUSION: Chronic tissue injury is characterized by a persistent purple-maroon discoloration located on the fleshy portion of the buttocks that does not improve or deteriorate. Unlike other causes of purple discoloration such as deep tissue pressure injury, there is minimal change in the discoloration over time. Additional research is needed to further our understanding of the histopathology of this phenomenon.

Postoperative enhancement on breast MRI: Time course and pattern of changes.

Expected postoperative enhancement on breast MRI can appear similar to enhancement seen in recurrent or residual malignancy. Our aim was to assess the time course and patterns of enhancement at the surgical site, thereby helping to distinguish between benign and malignant postoperative enhancement. In 200 MRI scans performed in 153 patients after breast conservation treatment, 43 after surgical excision of atypia, and 4 patients after benign excisional biopsy were categorized by postoperative time interval. We defined 4 patterns of morphologic enhancement on MRI: cavity wall/seroma (Pattern I); thin linear (Pattern II); mass (Pattern III); and fat necrosis (Pattern IV). Of 200 MRI scans, 66 (33%) demonstrated enhancement at the surgical site. Enhancement typically decreased through the postoperative follow-up period. Enhancement was observed in 41% (28/68) of cases beyond the 18-month interval but was uncommon after 5 years. Pattern III enhancement was the morphologic pattern seen most commonly with malignancy (5/19 cases, 26%). When associated with delayed washout kinetics, it was even more strongly predictive of malignancy (4/5 cases, 80%). In patients with a history of excisional biopsy and no prior radiation treatment, the percentage of MRI scans showing enhancement was significantly lower than (21% vs 49% with P-value .0027) in patients who had undergone radiation. Enhancement at the surgical site occurred in one-third of cases up to 5 years after surgery, particularly in patients who underwent both radiation and surgery. Mass enhancement, particularly in conjunction with delayed washout kinetics, is most predictive of malignancy and should prompt biopsy or re-excision.

Patient-centered Radiology: Where Are We, Where Do We Want to Be, and How Do We Get There?

Purpose The objectives of the Radiological Society of North America (RSNA) Patient-Centered Radiology Steering Committee survey were to (a) assess RSNA members' general attitudes and experiences concerning patient-centered radiology, with specific attention paid to radiologist-to-patient communication; (b) examine the members' barriers to communicating more directly with patients; and (c) explore their perceptions of how such barriers can be overcome. Materials and Methods A total of 5999 radiologists were invited by e-mail to complete an anonymous electronic survey developed by the Steering Committee and the RSNA Department of Research. Participants were asked to identify aspects of patient-centered care important to their practice, report on their interactions with patients, and share their opinions on radiologist-patient communication. Statistical analyses were performed by using the χ2 test and analysis of variance. Results The response rate was 12% (n = 694, 109 invitations were undeliverable). Most respondents (89%, 611 of 684) agreed that promoting awareness of the role of radiology in patients' overall health care is important to how they practice. The majority (73%, 421 of 575) reported that time or workload frequently prevented them from communicating directly with patients. The majority (74%, 423 of 572) reported that a personal sense of satisfaction was likely to motivate them to communicate more directly with patients, but many commented that changes to reimbursement and compensation would help them communicate with patients more directly. Conclusion Many radiologists support the concept of communicating more directly with patients but report they are constrained by time or workload. Changes to reimbursement schemes may help mitigate these barriers to one crucial aspect of patient-centered care. © RSNA, 2017 Online supplemental material is available for this article.

Selective serotonin reuptake inhibitor antidepressant use in first trimester pregnancy and risk of specific congenital anomalies: a European register-based study.

Evidence of an association between early pregnancy exposure to selective serotonin reuptake inhibitors (SSRI) and congenital heart defects (CHD) has contributed to recommendations to weigh benefits and risks carefully. The objective of this study was to determine the specificity of association between first trimester exposure to SSRIs and specific CHD and other congenital anomalies (CA) associated with SSRI exposure in the literature (signals). A population-based case-malformed control study was conducted in 12 EUROCAT CA registries covering 2.1 million births 1995-2009 including livebirths, fetal deaths from 20 weeks gestation and terminations of pregnancy for fetal anomaly. Babies/fetuses with specific CHD (n = 12,876) and non-CHD signal CA (n = 13,024), were compared with malformed controls whose diagnosed CA have not been associated with SSRI in the literature (n = 17,083). SSRI exposure in first trimester pregnancy was associated with CHD overall (OR adjusted for registry 1.41, 95% CI 1.07-1.86, fluoxetine adjOR 1.43 95% CI 0.85-2.40, paroxetine adjOR 1.53, 95% CI 0.91-2.58) and with severe CHD (adjOR 1.56, 95% CI 1.02-2.39), particularly Tetralogy of Fallot (adjOR 3.16, 95% CI 1.52-6.58) and Ebstein's anomaly (adjOR 8.23, 95% CI 2.92-23.16). Significant associations with SSRI exposure were also found for ano-rectal atresia/stenosis (adjOR 2.46, 95% CI 1.06-5.68), gastroschisis (adjOR 2.42, 95% CI 1.10-5.29), renal dysplasia (adjOR 3.01, 95% CI 1.61-5.61), and clubfoot (adjOR 2.41, 95% CI 1.59-3.65). These data support a teratogenic effect of SSRIs specific to certain anomalies, but cannot exclude confounding by indication or associated factors.