A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools.

US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.

Perspective on the New IR Residency Selection Process: 4-year Experience at a Large, Collaborative Training Program.

Interventional Radiology (IR) was officially approved by the American Board of Medical Specialties in 2012 and the Accreditation Council of Graduate Medical Education as a unique, integrated residency in 2014. Its establishment and distinction from diagnostic radiology was compelled by the increasing emphasis on clinical care delivery by IRs. The shift in the IR training paradigm, as exemplified in the Integrated IR residency programs, appeals to a distinct cohort of applicants, prompting the need to re-evaluate the recruitment and selection process. This article discusses selection criteria for identifying ideal candidates for the new IR training model (focusing on Integrated IR residency training), highlights the importance of collaboration between the IR and DR selection committees, and illustrates the changes made at a single institution over the course of 4 selection cycles prior to the COVID-19 pandemic as well as significant changes in the current climate of the global pandemic.

Needs Assessment Using a Structured Prioritization Schema: An Open Letter to PACS Vendors.

PURPOSE: The aim of this work was to prioritize in a quaternary academic environment necessary elements of a replacement PACS. METHODS: This quality improvement work was conducted at one academic medical center and was "not regulated" by the institutional review board. Three workgroups (10-15 members each) with unique resident, fellow, and attending radiologists; IT specialists; and departmental leaders convened in 2018 to prioritize elements for a PACS replacement project, including integrated IT tools. Each workgroup met two or three times and represented one of three missions (clinical, research, and education). Six elements assigned the highest priority were distilled from each workgroup. The resulting 18 elements were condensed into survey format and distributed to all department residents, fellows, and faculty members for 5-point Likert-type prioritization stratified by mission. Data were collected over 2 weeks. RESULTS: The survey response rate was 37% (71 of 192; 17 of 44 residents, 3 of 27 fellows, and 51 of 121 faculty members). Self-reported work effort was 63 ± 26% clinical, 14 ± 11% education, 15 ± 21% research, and 8 ± 14% administration. Aggregate priority ratings across all domains were highest for "stable system with predictable behavior" (mean, 4.51), "minimizes repetitive non-value-added work" (mean, 4.40), "interoperability" (mean, 4.12), and "near-instantaneous load times" (mean, 4.07). Clinical-specific ratings for these elements were even higher (means, 4.85-4.90). The lowest aggregate scores were mobile device compatibility (mean, 3.03), connectivity to nonaffiliated sites (mean, 3.01), and integrated instant messaging (mean, 2.87). CONCLUSIONS: The department prioritized a stable and interoperable system that minimized non-value-added work. In other words, participants wanted a functioning PACS. PACS vendors should prioritize a reliable experience over niche add-ons.

Establishing a Surgical Preliminary Year in the IR Residency: Keys to Success.

The training paradigm of the interventional radiologist has quickly evolved with the approval of the integrated interventional radiology (IR) residency by the American Board of Medical Specialties and the Accreditation Council of Graduate Medical Education. Prior to appointment in an integrated IR program, a resident must complete a preliminary clinical year, which may be surgical, medical, or transitional. The unique procedural- and clinical-based skillset required of the IR resident is best aligned with a surgical preliminary year. The following is a review of the steps to successful creation of a surgical preliminary year based on a single institution's experience.

The Breast Radiologist as a Public Educator: Designing an Effective Presentation for a Lay Audience.

Educating the public about breast cancer screening and diagnosis is important. Medical and regulatory agencies encourage shared decision making about undergoing breast cancer screening, and there are many places women can get information and misinformation. The Internet and other media sources present information that may not be correct or understandable. Breast radiologists are uniquely qualified to provide women with the accurate information necessary to enable informed choices. As a specialty, we have an obligation to our community to provide relevant and understandable information. We can accomplish that through community outreach forums. Presentations should be understandable with plain language, focusing on our key message and using pertinent images or icons. Slides should be simple and avoid medical jargon or complex statistics. As we engage with the community, we provide a vital service to the health of our community and foster respect of our specialty.

Breast care problems on call: training residents to manage effectively.

PURPOSE: Our aim was to assess and address the challenges radiology residents face when managing breast imaging emergencies on call and to determine if targeted educational interventions improved resident confidence and knowledge. METHODS: We created surveys to determine resident comfort level with and knowledge of appropriate management of breast imaging emergencies. We also created structured educational interventions to improve resident confidence and knowledge. The effectiveness of these interventions was assessed with pre- and post-intervention surveys given to the 43 residents at our institution. RESULTS: Thirty-six of the 43 residents at our institution completed both surveys. The results showed that 33 of 36 residents (91.7%) felt an increase in their comfort level after utilizing one or both of the interventions. There was also significant improvement in resident knowledge; the average resident score on the knowledge questions improved from 40 to 68% (p < 0.0001). CONCLUSION: Managing breast imaging emergencies on call can be challenging and stressful for residents. Educational interventions such as our targeted teaching tools can significantly improve resident confidence and knowledge. Presenting dedicated teaching materials directed at a previously identified knowledge deficit and source of stress significantly improved resident knowledge base and confidence in managing breast imaging emergencies on call.

An Introductory, Computer-Based Learning Module for Interpreting Noncontrast Head Computed Tomography.

Introduction: New radiology and other residents must quickly assimilate a vast amount of anatomic and pathologic information when learning to interpret noncontrast head computed tomography (CT). No interactive, computer-based module using a search-pattern approach to provide new residents with the groundwork for interpretation of noncontrast head CT previously existed. Methods: We developed such a learning module using PowerPoint. First-year radiology residents completed the module prior to their neuroradiology rotation, and neurology residents completed it during orientation. Residents took 20-question pre- and posttests to assess knowledge and a postmodule survey. Each resident was randomized to one of two pretests and took the opposite as the posttest. Scores were collected over 5 years for radiology residents and 4 years for neurology residents. Statistical analysis of scores was performed using t tests. Results: Forty-seven first-year radiology residents and 31 neurology residents completed the module and the pre- and posttests. Scores for all residents either stayed the same or increased, regardless of the order of the versions of the pre- or posttests; the mean score increase was 4 (p < .0001) out of 20. Radiology residents had higher mean scores than neurology residents on the pre- and posttests, which were statistically significant (p < .04 and .0004, respectively). Feedback on the survey was overwhelmingly positive. Discussion: This computerized learning module is effective for teaching basic interpretation skills to new radiology and neurology residents. The module allows for asynchronous, programmed learning and the use of a step-by-step search-pattern approach.

Improving our PRODUCT: a quality and safety improvement project demonstrating the value of a preprocedural checklist for fluoroscopy.

RATIONALE AND OBJECTIVES: To implement a preprocedural checklist in gastrointestinal (GI)/genitourinary (GU) fluoroscopy suites to assist radiology residents in performing studies with optimal fluoroscopic technique with a goal to lower radiation dose delivered to patients and operators. MATERIALS AND METHODS: We introduced a preprocedural checklist in the form of a mnemonic to first-year resident fluoroscopy operators. The checklist was augmented by teaching sessions at the fluoroscopy tower. Fluoroscopy time (FT) was collected for GI/GU fluoroscopy studies performed by first-year residents who did not use the checklist (year 1) and compared with FT from first-year residents who used the checklist for one full academic year (year 2). Residents in both groups were surveyed to assess their knowledge of radiation safety at the end of their respective radiology 1 (R1) academic years. RESULTS: A total of 778 examinations were analyzed from year 1, and 941 total examinations from year 2. After implementation of the checklist, mean FT for all studies decreased by 41.1 seconds (P < .0001) in year 2 residents. Multivariate linear regression confirmed that year of examination was the strongest independent predictor of FT when other covariates such as resident age, gender, and experience and patient age and gender were included. Radiation safety knowledge was similar in both groups but self-reported confidence in safe fluoroscopy tower operation increased slightly in year 2 (P = .144). CONCLUSIONS: A visual preprocedural radiation safety checklist in GI/GU fluoroscopy was associated with a reduction in mean FT and may contribute to a culture of radiation safety awareness.

Residents' ability to interpret radiology images: development and improvement of an assessment tool.

RATIONALE AND OBJECTIVES: Despite increasing radiology coverage, nonradiology residents continue to preliminarily interpret basic radiologic studies independently, yet their ability to do so accurately is not routinely assessed. MATERIALS AND METHODS: An online test of basic radiologic image interpretation was developed through an iterative process. Educational objectives were established, then questions and images were gathered to create an assessment. The test was administered online to first-year interns (postgraduate year [PGY] 1) from 14 different specialties, as well as a sample of third- and fourth-year radiology residents (PGY3/R2 and PGY4/R3). RESULTS: Over a 2-year period, 368 residents were assessed, including PGY1 (n = 349), PGY3/R2 (n = 14), and PGY4/R3 (n = 5) residents. Overall, the test discriminated effectively between interns (average score = 66%) and advanced residents (R2 = 86%, R3 = 89%; P < .05). Item analysis indicated discrimination indices ranging from -0.72 to 48.3 (mean = 3.12, median 0.58) for individual questions, including four questions with negative discrimination indices. After removal of the negatively indexed questions, the overall predictive value of the instrument persisted and discrimination indices increased for all but one of the remaining questions (range 0.027-70.8, mean 5.76, median 0.94). CONCLUSIONS: Validation of an initial iteration of an assessment of basic image-interpretation skills led to revisions that improved the test. The results offer a specific test of radiologic reading skills with validation evidence for residents. More generally, results demonstrate a principled approach to test development.

24/7/365 in-house radiologist coverage: effect on resident education.

RATIONALE AND OBJECTIVES: To compare programs with and without 24-hour/7 days a week/365 days a year (24/7/365) in-house radiologist coverage regarding resident perceptions of their on-call experience, volume of resident dictations on call, and report turnaround time. MATERIALS AND METHODS: Residents from six academic radiology departments were invited to participate in an 11-item online survey. Survey items were related to workload, level of autonomy, faculty feedback, comfort level, faculty supervision, and overall educational experience while on call from 8 pm to 8 am. Each site provided data on imaging volume, radiologist coverage, volume of examinations dictated by residents, number of residents on call, and report turnaround time from 8 pm to 8 am. F-ratios and eta-squares were calculated to determine the relationships between dependent and independent variables. A P value < .05 was considered statistically significant. RESULTS: A total of 146 (67%) of 217 residents responded. Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage. CONCLUSION: More rapid report turnaround time related to 24/7/365 coverage may come at the expense of resident education.

Prevalence of malignancy in thyroid nodules with an initial nondiagnostic result after ultrasound guided fine needle aspiration.

The objective of this study was to determine the rate of malignancy in thyroid nodules with an initial nondiagnostic fine needle aspiration. From October 2001 to April 2007, biopsies were performed on 1344 thyroid nodules in our practice. Biopsies were performed on nodules using 25-27 gauge needles, ultrasound guidance and multiple passes using both suction and capillary action. We retrospectively reviewed the results of these biopsies as well as any further management of nodules that received nondiagnostic results (IRB HUM00006459). Following initial biopsy, 295/1344 (21.9%) of nodules received nondiagnostic pathologic results. Of this population, 39 nodules (13.1%) were lost to follow-up. Of the remaining 256 nodules that received a repeat FNA, surgical excision, or greater than 24 months of clinical and imaging follow-up, only five cancers were detected, representing only 2% of the population that received an initial nondiagnostic biopsy result. All of these cancers were papillary neoplasms. When rigorous, ultrasound-guided, fine needle aspiration of thyroid nodules is performed, a nondiagnostic histopathologic result should not be interpreted as suspicious for thyroid cancer. Given the low rate of malignancy in this population (2%), we suggest that clinical and imaging follow-up of these nodules, opposed to repeat sampling, is warranted.

Imaging radiation-induced normal tissue injury.

Technological developments in radiation therapy and other cancer therapies have led to a progressive increase in five-year survival rates over the last few decades. Although acute effects have been largely minimized by both technical advances and medical interventions, late effects remain a concern. Indeed, the need to identify those individuals who will develop radiation-induced late effects, and to develop interventions to prevent or ameliorate these late effects is a critical area of radiobiology research. In the last two decades, preclinical studies have clearly established that late radiation injury can be prevented/ameliorated by pharmacological therapies aimed at modulating the cascade of events leading to the clinical expression of radiation-induced late effects. These insights have been accompanied by significant technological advances in imaging that are moving radiation oncology and normal tissue radiobiology from disciplines driven by anatomy and macrostructure to ones in which important quantitative functional, microstructural, and metabolic data can be noninvasively and serially determined. In the current article, we review use of positron emission tomography (PET), single photon emission tomography (SPECT), magnetic resonance (MR) imaging and MR spectroscopy to generate pathophysiological and functional data in the central nervous system, lung, and heart that offer the promise of, (1) identifying individuals who are at risk of developing radiation-induced late effects, and (2) monitoring the efficacy of interventions to prevent/ameliorate them.

Apprenticeships ease the transition to independent call: an evaluation of anxiety and confidence among junior radiology residents.

RATIONALE AND OBJECTIVES: The aims of this study were to quantify resident anxiety when beginning independent call and to assess whether an apprenticeship experience (buddy call) can lessen anxiety and improve confidence. MATERIALS AND METHODS: A prospective cohort comparison of two groups of radiology residents beginning independent call, one of which was provided with a buddy call experience, was performed. Anxiety and confidence were assessed using the Endler Multidimensional Anxiety Scales-State (EMAS-S), with total score, autonomic emotional, and cognitive worry components, and a five-point, Likert-type scale, respectively. Both groups were asked about the perceived value of a buddy call experience. RESULTS: EMAS-S scores improved significantly over 5 days of call in both groups (control, n = 10, P = .0005; buddy call, n = 9, P = .0001), and image interpretation confidence correspondingly increased (control, P = .0004; buddy call, P = .003). Compared to the control group, autonomic emotional scores were significantly lower in the buddy call group on the first day of independent call (P = .040), and cognitive worry and total EMAS-S scores were significantly lower on day 5 (both P values = .03). Buddy call was independently associated with improved autonomic emotional and film interpretation confidence scores (both P values = .02). All members of the buddy call group indicated that the experience was very helpful in preparing for call. CONCLUSIONS: Beginning independent call is associated with high anxiety, and buddy call reduces that anxiety, beyond the effect of time alone. Residents who participated in buddy call found it helpful in preparing for independent call. These findings support the use of buddy call and tiered call structures as means to introduce junior residents to independent call.

Comparison of discrepancy rates in resident and faculty interpretations of on-call PE CT and V/Q scans: is one study more reliable during off hours?

PURPOSE: There has been no comparison of concordance rates for residents' and faculty members' interpretations of pulmonary embolism (PE) CT and ventilation/perfusion (V/Q) studies. If significantly different rates of agreement are demonstrable, this could influence which test is ordered during off hours. The purpose of this study was to evaluate how the performance of residents compared with that of faculty members in interpreting these two modalities. METHODS: Interobserver agreement between preliminary resident reports and final attending radiologist interpretations was calculated retrospectively for PE CT studies (n = 1,179) and V/Q scans (n = 331) interpreted by on-call residents from April 2007 to October 2008. Discordant cases were reviewed for clinical significance and outcomes at 3 months. Interobserver variability was also evaluated relative to residents' training levels and faculty members' years of experience. RESULTS: Interobserver agreement between faculty members and residents was substantial, at 95% for PE CT (κ = 0.77) and 77.9% for V/Q scans (κ = 0.67). Although changes in interpretation were significantly more common with V/Q scans (22.1% vs 5%; χ(2) < .0001), the rates of clinically significant discrepancy did not differ significantly between the modalities (2.1% for V/Q vs 1.2% for PE CT; χ(2)P = .20). The overall discrepancy rate and the rate of clinically significant discrepancy did not correlate with residents' training levels or faculty members' years of experience. CONCLUSIONS: Concordance rates for residents' interpretations of V/Q scans and PE CT studies were high, and discrepancies resulting in changes in patient management were rare for both modalities. Residents' preliminary interpretations of both modalities are reliable and safe for making initial patient management decisions.

Posterior acoustic enhancement in hepatocellular carcinoma.

OBJECTIVES: The purpose of this study was to assess sonographic appearances of hepatocellular carcinoma with particular attention to posterior acoustic effects. METHODS: We performed an Institutional Review Board-approved retrospective review of patients with hepatocellular carcinoma who had undergone sonographically guided procedures in our department between 2001 and 2010. A total of 247 masses thought to represent hepatocellular carcinoma were identified; 27 were excluded because of prior angioembolization (altering the sonographic appearance), alternate histologic diagnoses, and incomplete patient information or imaging. Ultimately, 220 masses in 185 patients (138 men and 47 women; average age, 59.1 years) constituted the study population. Preprocedure sonograms were reviewed in consensus by 3 abdominal radiologists; the liver echo texture, lesion echogenicity, and posterior acoustic effect were rated and correlated with patient data. RESULTS: The average mass size was 3.1 cm (range, 0.7-17 cm). In total, 84.1% of the masses (n = 185) arose in abnormally echogenic/attenuating livers; 54.1% of the masses (n = 119) were predominantly hypoechoic, 23.2% (n = 51) isoechoic, and 22.7% (n = 50) hyperechoic. Target-type morphologic characteristics were noted in 41 masses. Many masses (52.7% [n = 116]) had no specific posterior acoustic effect, but nearly half (46.4%) had either mild (n = 64) or marked (n = 38) posterior acoustic enhancement. The remaining masses (0.9% [n = 2]) had posterior shadowing. Posterior acoustic enhancement was most common among hyperechoic masses (62% with posterior acoustic enhancement), target-type masses (63%), and masses larger than 5 cm (81.5%). CONCLUSIONS: Posterior acoustic enhancement is present to some degree in almost half of hepatocellular carcinomas, which may relate to the tissue characteristics of the tumor or the cirrhotic liver itself. Attention to this finding, including scanning without spatial compounding, is recommended during sonographic screening for hepatocellular carcinoma in the growing population of patients with liver disease.

How long have I had my cancer, doctor? Estimating tumor age via Collins' law.

To estimate the"age" of cancers at the time of diagnosis, we reviewed data on the "time to local/regional recurrence" (LRF) following initial surgical resection for three common cancers, then applied a modified version of Collins' law. We conducted a systematic review of English medical literature to identify studies reporting LRF rates, over time, following surgery alone for breast, lung, or colorectal cancer. Patients who received radiation/hormones/chemotherapy were excluded since these therapies may alter tumor growth kinetics after surgery. For each disease, data were considered in three ways: 1) absolute cumulative LRF rate over time; 2) percentage of LRFs manifest over time (to facilitate comparisons between studies with different absolute magnitudes of LRFs); and 3) weighted average of the percentage of LRFs manifest over time. For breast cancer (based on data from 3043 patients from 5 studies), we found that the median time to LRF was 2.7 years. For lung cancer (based on data from 1190 patients from 4 studies), the median time to LRF was 1.5 years. For rectal cancer (based on data from 3334 patients from 10 studies), the median time to LRF was 1.5 years. Based on Collins' law, the distribution of time to LRF suggests that the age of most of the solid tumors studied was 3 to 6 years.

Local failure after complete resection of N0-1 non-small cell lung cancer.

PURPOSE: To estimate the risk of local-regional failure (LRF) after surgery for operable NSCLC, and the effect of clinical/pathologic factors on this risk. METHODS: Records of 335 patients undergoing complete resection (lobectomy, pneumonectomy) for pathological T1-4 N0-1 NSCLC (without post-operative radiation) from 1996 to 2006 were reviewed. Crude and actuarial estimated failure rates were computed; local-regional sites included ipsilateral lung, surgical stump, hilar, mediastinal, or supraclavicular nodes. Failure times in sub-groups were calculated with the Kaplan-Meier method and compared via log-rank test. Independent factors adversely affecting LRF were determined with Cox regression. RESULTS: The median follow-up duration for event-free surviving patients was 40 months (range: 1-150). The crude and actuarial 5-year probability of any failure (LR or distant) were 33% and 43%, respectively. Of all failures; 37% were LR only, 35% LR and distant and 28% distant only. The 5-year crude and actuarial probability of LRF were 24% and 35% (95% CI: 29-42%). Five-year crude LRF rates for T1-2N0, T1-2N1, T3-4N0 and T3-4N1 disease were 19% (41/216), 27% (16/59), 37.5% (15/40) and 40% (8/20), respectively. The corresponding actuarial estimates were T1-2N0 28%, T1-2N1 39%, T3-4N0 50% and T3-4N1 67%. In Cox multiple regression analysis, lymphovascular space invasion (p=0.03, HR: 1.7) and tumor size (p=0.01, HR: 1.67 for 5 cm increment) were associated with an increased risk of LRF. CONCLUSION: Five-year LRF rates are ≥19% in essentially all patient subsets.

Multi-modality CADx: ROC study of the effect on radiologists' accuracy in characterizing breast masses on mammograms and 3D ultrasound images.

RATIONALE AND OBJECTIVES: To investigate the effect of a computer-aided diagnosis (CADx) system on radiologists' performance in discriminating malignant and benign masses on mammograms and three-dimensional (3D) ultrasound (US) images. MATERIALS AND METHODS: Our dataset contained mammograms and 3D US volumes from 67 women (median age, 51; range: 27-86) with 67 biopsy-proven breast masses (32 benign and 35 malignant). A CADx system was designed to automatically delineate the mass boundaries on mammograms and the US volumes, extract features, and merge the extracted features into a multi-modality malignancy score. Ten experienced readers (subspecialty academic breast imaging radiologists) first viewed the mammograms alone, and provided likelihood of malignancy (LM) ratings and Breast Imaging and Reporting System assessments. Subsequently, the reader viewed the US images with the mammograms, and provided LM and action category ratings. Finally, the CADx score was shown and the reader had the opportunity to revise the ratings. The LM ratings were analyzed using receiver-operating characteristic (ROC) methodology, and the action category ratings were used to determine the sensitivity and specificity of cancer diagnosis. RESULTS: Without CADx, readers' average area under the ROC curve, A(z), was 0.93 (range, 0.86-0.96) for combined assessment of the mass on both the US volume and mammograms. With CADx, their average A(z) increased to 0.95 (range, 0.91-0.98), which was borderline significant (P = .05). The average sensitivity of the readers increased from 98% to 99% with CADx, while the average specificity increased from 27% to 29%. The change in sensitivity with CADx did not achieve statistical significance for the individual radiologists, and the change in specificity was statistically significant for one of the radiologists. CONCLUSIONS: A well-trained CADx system that combines features extracted from mammograms and US images may have the potential to improve radiologists' performance in distinguishing malignant from benign breast masses and making decisions about biopsies.