Analyzing the Administrative Burden of Competency Based Medical Education.

PURPOSE: Postgraduate residency programs in Canada are transitioning to a competency-based medical education (CBME) system. Within this system, resident performance is documented through frequent assessments that provide continual feedback and guidance for resident progression. An area of concern is the perception by faculty of added administrative burden imposed by the frequent evaluations. This study investigated the time spent in the documentation and submission of required assessment forms through analysis of quantitative data from the Queen's University Diagnostic Radiology program. METHODS AND MATERIALS: Data regarding time taken to complete Entrustable Professional Activities (EPA) assessments was collected from 24 full-time and part-time radiologists over a period of 18 months. This data was analyzed using SPSS to determine mean time of completion by individuals, departments, and by experience with the assessment process. RESULTS: The average time taken to complete an EPA assessment form was 3 minutes and 6 seconds. Assuming 3 completed EPA assessment forms per week for each resident (n = 12) and equal distribution among all staff, this averaged out to an additional 18 minutes of administrative burden per staff member over a 4 week block. CONCLUSIONS: This study investigated the perception by faculty of additional administrative burden for assessment in the CBME framework. The data provided quantitative evidence of administrative burden for the documentation and submission of assessments. The data indicated that the added administrative burden may be reasonable given mandate for CBME implementation and the advantages of adoption for postgraduate medical education.

Competency-Based Medical Education in Radiology: A Survey of Medical Student Perceptions.

PURPOSE: Implementing competency-based medical education in diagnostic radiology residencies will change the paradigm of learning and assessment for residents. The objective of this study is to evaluate medical student perceptions of competency-based medical education in diagnostic radiology programs and how this may affect their decision to pursue a career in diagnostic radiology. METHODS: First-, second-, and third-year medical students at a Canadian university were invited to complete a 14-question survey containing a mix of multiple choice, yes/no, Likert scale, and open-ended questions. This aimed to collect information on students' understanding and perceptions of competency-based medical education and how the transition to competency-based medical education would factor into their decision to enter a career in diagnostic radiology. RESULTS: The survey was distributed to 300 medical students and received 63 responses (21%). Thirty-seven percent of students had an interest in pursuing diagnostic radiology that ranged from interested to committed and 46% reported an understanding of competency-based medical education and its learning approach. The implementation of competency-based medical education in diagnostic radiology programs was reported to be a positive factor by 70% of students and almost all reported that breaking down residency into measurable milestones and required case exposure was beneficial. CONCLUSIONS: This study demonstrates that medical students perceive competency-based medical education to be a beneficial change to diagnostic radiology residency programs. The changes accompanying the transition to competency-based medical education were favored by students and factored into their residency decision-making.

Creating a Competency-Based Medical Education Curriculum for Canadian Diagnostic Radiology Residency (Queen's Fundamental Innovations in Residency Education)-Part 1: Transition to Discipline and Foundation of Discipline Stages.

PURPOSE: The Royal College of Physicians and Surgeons of Canada (RCPSC) has mandated the transition of postgraduate medical training in Canada to a competency-based medical education (CBME) model divided into 4 stages of training. As part of the Queen's University Fundamental Innovations in Residency Education proposal, Queen's University in Canada is the first institution to transition all of its residency programs simultaneously to this model, including Diagnostic Radiology. The objective of this report is to describe the Queen's Diagnostic Radiology Residency Program's implementation of a CBME curriculum. METHODS: At Queen's University, the novel curriculum was developed using the RCPSC's competency continuum and the CanMEDS framework to create radiology-specific entrustable professional activities (EPAs) and milestones. In addition, new committees and assessment strategies were established. As of July 2015, 3 cohorts of residents (n = 9) have been enrolled in this new curriculum. RESULTS: EPAs, milestones, and methods of evaluation for the Transition to Discipline and Foundations of Discipline stages, as well as the opportunities and challenges associated with the implementation of a competency-based curriculum in a Diagnostic Radiology Residency Program, are described. Challenges include the increased frequency of resident assessments, establishing stage-specific learner expectations, and the creation of volumetric guidelines for case reporting and procedures. CONCLUSIONS: Development of a novel CBME curriculum requires significant resources and dedicated administrative time within an academic Radiology department. This article highlights challenges and provides guidance for this process.

Development and Validation of a Risk Model for Breast Cancer-Related Lymphedema.

Importance: Approximately 1 in 5 patients with breast cancer who undergo axillary lymph node dissection will develop lymphedema. To appropriately triage and monitor these patients for timely diagnosis and treatment, robust risk models are required. Objective: To evaluate the prognostic value of mammographic breast density in estimating lymphedema severity. Design, Setting, and Participants: This prognostic study collected data from July 16, 2018, to March 3, 2020, from the electronic health records of patients of the Cancer Rehabilitation and Survivorship Program at the Princess Margaret Cancer Centre in Toronto, Ontario, Canada. Participants included women who had completed curative treatment for a first diagnosis of breast cancer and who were referred to the program. Also included were a sample of patients in the general breast oncology population who were receiving follow-up care at the center during the same period but who were not referred to the program. All patients attended follow-up appointments at the Princess Margaret Cancer Centre from January 1, 2016, to May 1, 2018. The cohort was randomly split 2:1 to group patients into a training cohort and a validation cohort. Exposures: Participant demographic and clinical characteristics included age, sex, body mass index (BMI), medical history, cancer characteristics, and cancer treatment. Main Outcomes and Measures: Spearman correlation coefficient between measured and predicted volume of lymphedema was calculated. Area under the curve (AUC) values were generated for predicting the occurrence of at least mild lymphedema (volume, >200 mL) and severe lymphedema (volume, >500 mL) at the time of initial lymphedema diagnosis. Results: A total of 373 female patients (median [interquartile range] age, 52.3 [45.9-60.1] years) were eligible for this analysis. Multivariate linear regression identified 3 patient factors (age, BMI, and mammographic breast density), 1 cancer factor (number of pathological lymph nodes), and 1 treatment factor (axillary lymph node dissection) as independent prognostic variables. In validation testing, Spearman correlation revealed a statistically significant moderate correlation (coefficient, 0.42; 95% CI, 0.26-0.56; P < .001) between measured volume and predicted volume of lymphedema. The AUC values were 0.72 (95% CI, 0.60-0.83) for predicting the occurrence of mild lymphedema and 0.83 (95% CI, 0.74-0.93) for severe lymphedema. Conclusions and Relevance: This prognostic study found that patients with low breast density appeared to be at a higher risk of developing severe lymphedema. The finding suggests that by combining breast density with established risk factors a multivariate linear regression model could be used to predict the development of lymphedema and provide volumetric estimates of lymphedema severity in patients with breast cancer.

Using simultaneous PET/MRI to compare the accuracy of diagnosing frontotemporal dementia by arterial spin labelling MRI and FDG-PET.

PURPOSE: The clinical utility of FDG-PET in diagnosing frontotemporal dementia (FTD) has been well demonstrated over the past decades. On the contrary, the diagnostic value of arterial spin labelling (ASL) MRI - a relatively new technique - in clinical diagnosis of FTD has yet to be confirmed. Using simultaneous PET/MRI, we evaluated the diagnostic performance of ASL in identifying pathological abnormalities in FTD (FTD) to determine whether ASL can provide similar diagnostic value as FDG-PET. METHODS: ASL and FDG-PET images were compared in 10 patients with FTD and 10 healthy older adults. Qualitative and quantitative measures of diagnostic equivalency were used to determine the diagnostic utility of ASL compared to FDG-PET. Sensitivity, specificity, and inter-rater reliability were calculated for each modality from scores of subjective visual ratings and from analysis of regional mean values in thirteen a priori regions of interest (ROI). To determine the extent of concordance between modalities in each patient, individual statistical maps generated from comparison of each patient to controls were compared between modalities using the Jaccard similarity index (JI). RESULTS: Visual assessments revealed lower sensitivity, specificity and inter-rater reliability for ASL (66.67%/62.12%/0.2) compared to FDG-PET (88.43%/90.91%/0.61). Across all regions, ASL performed lower than FDG-PET in discriminating patients from controls (areas under the receiver operating curve: ASL = 0.75 and FDG-PET = 0.87). In all patients, ASL identified patterns of reduced perfusion consistent with FTD, but areas of hypometabolism exceeded hypoperfused areas (group-mean JI = 0.30 ± 0.22). CONCLUSION: This pilot study demonstrated that ASL can detect similar spatial patterns of abnormalities in individual FTD patients compared to FDG-PET, but its sensitivity and specificity for discriminant diagnosis of a patient from healthy individuals remained unmatched to FDG-PET. Further studies at the individual level are required to confirm the clinical role of ASL in FTD management.

A novel mechanism of toxic injury to the Papez circuit from chemotherapy.

Toxic effects of chemotherapy delivered via Ommaya reservoir include pericatheter necrosis and toxic leukoencephalopathy. Imaging evidence of toxicity is often asymptomatic, but can be clinically consequential. A young patient, treated for cerebrospinal fluid relapse of acute lymphoblastic leukemia with methotrexate and cytarabine via Ommaya reservoir, presented with acute deterioration of short-term memory. MRI demonstrated extra-ventricular Ommaya catheter position and typical methotrexate-induced changes in the deep white matter, but also signal alteration in the forniceal columns and mammillary bodies, components of the Papez circuit. This case presents a novel mechanism of chemotherapy-induced neurotoxicity associated with extra-ventricular Ommaya catheter position. Specifically, the clinical and imaging findings suggest that extra-ventricular Ommaya catheter position may lead to a direct methotrexate-induced toxicity to the Papez circuit. This provides further clinical evidence of the function of the circuit. The possibility that this patient received a supratherapeutic dose of methotrexate may explain why this presentation with profound memory impairment is not more common. However, this case also provides a potential explanation for patients who receive standard dose chemotherapy via extra-ventricular Ommaya catheter and develop milder memory loss.

Isolated traumatic rupture of the gallbladder.

Gallbladder injury resulting from blunt abdominal trauma is rare, being found in only about 2% of patients who undergo laparotomy for abdominal trauma. Its small size and anatomic location-partially embedded in the liver tissue, surrounded by the omentum and intestines, and overlaid by the rib cage-provides good protection. Diagnosis can be difficult, and delay may result in the development of weight loss, nausea, vomiting, abdominal distension, jaundice, ascites, and abdominal pains. Delayed imaging with computed tomography can aid in diagnosis, especially in differentiating benign processes from true gallbladder injuries. Treatment for gallbladder injury is most commonly cholecystectomy. Mortality rates in patients with gallbladder injuries are related to associated injuries, including cardiac, thoracic or intra-abdominal hemorrhage, or multi-organ failure and/or brain damage. In isolated gallbladder injury, the prognosis is good.