Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform.

INTRODUCTION: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures. METHODS: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type. RESULTS: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels. CONCLUSIONS: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

An assessment of radiology resident competency in identifying suppurative retropharyngeal lymphadenitis: an examination using the WIDI SIM platform.

BACKGROUND AND PURPOSE: Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8 years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.

Radiology resident competency in detecting basilar artery occlusion: a simulation-based assessment.

PURPOSE: Basilar artery strokes are rare but can have characteristic imaging findings that can often be overlooked. This retrospective study aims to assess radiology residents' ability to identify CT imaging findings of basilar artery occlusion in a simulated call environment. METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM)-a tested and reliable computer-aided emergency imaging simulation-was employed to assess resident readiness for independent radiology call. The simulations include 65 cases of varying complexity, including normal studies, with one case specifically assessing basilar artery stroke. Residents were presented with a single, unique case of basilar artery occlusion in two separate years of testing and were only provided with non-contrast CT images. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 454 radiology residents were tested in two separate years on the imaging findings of basilar artery occlusion using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Basilar artery occlusion was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 14% of radiology residents were able to correctly identify basilar artery occlusion on non-contrast CT. CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the detection of basilar artery occlusion, highlighting the potential need for increased educational efforts in this area.

Enhancing Radiology Education With a Case-Based Intro to Radiology on the UF WIDI e-Learning Platform.

RATIONALE AND OBJECTIVES: This study explores the implementation and efficacy of an online, interactive, case-based radiology education tool, Wisdom in Diagnostic Imaging (WIDI) Case-Based Intro to Radiology (CBIR). We hypothesize that the WIDI CBIR platform would enhance radiology teaching, foster critical thinking, and provide a comprehensive curriculum in imaging interpretation and utilization. MATERIALS AND METHODS: A focus group consisting of 1 undergraduate, 7 medical students, 9 physician assistant students, and 3 PhD students participated in this study. We tested 3 different teaching methods: a didactic approach without WIDI, a proctored didactic approach using WIDI, and a flipped classroom approach using WIDI. An online survey was conducted to assess student preference and feedback on these methods and the use of WIDI in their curriculum. RESULTS: Most students preferred the proctored didactic approach with WIDI. They reported that the platform complemented their curriculum and encouraged critical thinking. The modules covered adequate clinical and imaging details and enhanced their skills in imaging interpretation. Despite the limitations of a small sample size and reliance on self-reported outcomes, this study indicates that the WIDI platform could be integrated into PA and medical school curricula throughout the US, offering a standardized radiology curriculum. CONCLUSION: The UF WIDI appears to be a promising tool for modernizing radiology education, improving imaging interpretation skills, and enhancing appropriate imaging selection among nonradiologist medical learners. WIDI offers case-based education in imaging use, workflow, search-pattern selection, and interpretation of common radiological findings, potentially bridging the gap in radiology education. Further research and larger studies are required to assess the long-term impact on performance and clinical practice.

Bubbles in the belly: How well do radiology trainees recognize pneumatosis in pediatric patients on plain film?

OBJECTIVES: Pneumatosis intestinalis is a radiographic finding that refers to the presence of gas within the walls of the small or large bowel. This sign is diagnostic in the setting of premature infants with suspected necrotizing enterocolitis. Earlier detection of NEC on X-ray is vital to improve the overall management in these infants. The identification of pneumatosis intestinalis concerning for necrotizing enterocolitis by the "on-call" trainee is critical in the care of the preterm infant. Our objective was to study trainees' ability to identify pneumatosis on an emergent overnight film. METHODS: The Emergent/Critical Care Imaging SIMulation (WIDI SIM) is a strategically designed computer-aided simulation of an emergency imaging experience that has been rigorously tested and proven to be a reliable means for assessing radiology trainee preparedness to competently and independently cover radiology call. One test case each year included requires the trainee to accurately identify pneumatosis on a plain radiograph of the abdomen in a neonate. RESULTS: A total of 463 radiology trainees from 32 distinct training programs across the country were given a case of pneumatosis using the WIDI simulation web-based testing platform. On average only 28% of radiology trainees were able to correctly identify pneumatosis intestinalis on plain film. Although the sample sizes in the upper-level trainees were smaller, those with greater number years of training performed better. CONCLUSIONS: Further training must be given to radiology trainees to accurately recognize pneumatosis and report concerns for necrotizing enterocolitis. ADVANCES IN KNOWLEDGE: This paper is the first to describe and assess the ability of the "on-call" radiology trainee to accurately recognize pneumatosis and report concerns for necrotizing enterocolitis. Our paper includes the largest cohort of radiology trainees evaluated to this date.

Rate of resident recognition of nonaccidental trauma: how well do residents perform?

BACKGROUND: A resident working under the entrustable professional activity of a graduated independent coverage model must identify nonaccidental trauma and notify clinicians of this concern to facilitate potential removal of the child from harm. The resident's role in identifying child abuse has not previously been studied. OBJECTIVE: The purpose of this study was to assess radiology residents' ability to identify radiographic imaging findings of nonaccidental trauma in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a strategically designed computer-aided simulation of an emergency imaging experience that has been rigorously tested and proven to be a reliable means for assessing resident preparedness to competently and independently cover radiology call. The residents are provided with 65 cases of varying difficulty, including normal studies. Those cases include ones that require the resident to accurately identify skeletal findings of nonaccidental trauma. The residents respond using free text that is then scored manually by faculty members utilizing a robust grading rubric. Missed cases are then categorized by observation error and/or interpretative errors. RESULTS: A total of 675 radiology residents were given a case of nonaccidental trauma using the WIDI simulation web-based test platform between 2014 and 2017. Child abuse was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. Correct diagnostic score averages per year ranged from 10% to 79%. In year 1, 71% of residents correctly diagnosed nonaccidental trauma with a total of 101 participants. In year 2, 130 residents participated with only 20% answering correctly. In year 3, there were 201 participants with 79% correctly diagnosing nonaccidental trauma. In year 4, only 10% of 243 residents accurately diagnosed nonaccidental trauma. Residents from various stages of training were tested. Cases used with leading histories provided, accounted for a higher correct call rate. CONCLUSION: Radiology residency programs may be deficient in teaching residents to accurately recognize and report child abuse. This deficiency has potential implications for programs where a radiology attending is not present after hours as it raises the concern that child abuse may be missed by residents taking independent call. These data further question whether graduating radiologists are competent to recognize nonaccidental trauma and demonstrates the need for additional mandatory training during radiology residency.

Full Resolution Simulation for Evaluation of Critical Care Imaging Interpretation; Part 2: Random Effects Reveal the Interplay Between Case Difficulty, Resident Competence, and the Training Environment.

RATIONALE AND OBJECTIVES: To further characterize empirical data from a full-resolution simulation of critical care imaging coupled with post hoc grading of resident's interpretations by senior radiologists. To present results from estimating the random effects terms in a comprehensive mixed (hierarchical) regression model. MATERIALS AND METHODS: After accounting for 9 fixed effects detailed in Part 1 of this paper, we estimated normally distributed random effects, expressed in terms of score offsets for each case, resident, program, and grader. RESULTS: The fixed effects alone explained 8.8% of score variation and adding the random effects increased explanatory power of the model to account for 36% of score variation. As quantified by intraclass correlation coefficient (ICC = 28.5%; CI: 25.1-31.6) the majority of score variation is directly attributable to the case at hand. This "case difficulty" measure has reliability of 95%. Individual residents accounted for much of the remaining score variation (ICC = 5.3%; CI: 4.6-5.9) after adjusting for all other effects including level of training. The reliability of this "resident competence" measure is 82%. Residency training program influence on scores was small (ICC = 1.1%; CI: 0.42-1.7). Although a few significantly high and low ones can be identified, reliability of 73% militates for caution. At the same time, low intraprogram variation is very encouraging. Variation attributable to differences between graders was minimal (ICC = 0.58%; CI: 0.0-1.2) which reassures us that the method of scoring is reliable, consistent, and likely extensible. CONCLUSION: Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. A comprehensive mixed model of the resulting scores reliably quantifies case difficulty and resident competence.

Full Resolution Simulation for Evaluation of Critical Care Imaging Interpretation; Part 1: Fixed Effects Identify Influences of Exam, Specialty, Fatigue, and Training on Resident Performance.

RATIONALE AND OBJECTIVES: To describe our full-resolution simulation of critical care imaging coupled with posthoc grading of resident's interpretations and present results from the fixed effects terms in a comprehensive mixed regression model of the resulting scores. MATERIALS AND METHODS: The system delivered full resolution DICOM studies via clinical-grade viewing software integrated with a custom built web-based workflow and reporting system. The interpretations submitted by participating residents from 47 different programs were graded (scores of 0-10) on a case by case basis by a cadre of faculty members from our department. The data from 5 yearly (2014-2018) cycles consisting of 992 separate 65 case, 8 hour simulation sessions were collated from the transaction records. We used a mixed (hierarchical) statistical model with nine fixed and four random independent variables. In this paper, we present the results from the nine fixed effects. RESULTS: There were 19,916/63,839 (27.0%, CI 26.7%-27.4%) scores in the 0-2 range (i.e., clinically significant miss). Neurological cases were more difficult with adjusted scores 2.3 (CI 1.9-3.2) lower than body/musculoskeletal cases. There was a small (0.3, CI 0.20-0.38 points) but highly significant (p<0.0001) decrease in score for the final 13/65 cases (fifth quintile) as evidence of fatigue during the last hour of an 8 hour shift. By comparing adjusted scores from mid-R1 (quarter 3) to late-R3 (quarter 12) we estimate the training effect as an increase of 2.2 (CI 1.90-2.50) points. CONCLUSION: Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. Analysis of the resulting scores yields multiple insights into the interpretative process.

Bad for Breathing: A Pictorial of Drug-Induced Pulmonary Disease.

Drug-induced lung disease has been described with over 300 different agents, some of which are asymptomatic and may first present on imaging. These pulmonary diseases may present with variable imaging manifestations, and often overlap with other etiologies such as rejection, lymphoproliferative disorders, and infection that may be suspected in this patient population. However, there are several drugs that have classic imaging appearances, and in the proper clinical context, the radiologist should include their toxicity in the differential diagnosis, potentially expediting withdrawal of the drug and avoiding irreversible lung injury such as fibrosis.