Structured reporting in radiology: a systematic review to explore its potential.

OBJECTIVES: Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is necessary to verify that radiology reporting can benefit from SR. Therefore, the purpose of this systematic review is to explore the level of evidence of structured reporting in radiology. Additionally, this review provides an overview on the current status of SR in radiology. METHODS: A narrative systematic review was conducted, searching PubMed, Embase, and the Cochrane Library using the syntax 'radiol*' AND 'structur*' AND 'report*'. Structured reporting was divided in SR level 1, structured layout (use of templates and checklists), and SR level 2, structured content (a drop-down menu, point-and-click or clickable decision trees). Two reviewers screened the search results and included all quantitative experimental studies that discussed SR in radiology. A thematic analysis was performed to appraise the evidence level. RESULTS: The search resulted in 63 relevant full text articles out of a total of 8561 articles. Thematic analysis resulted in 44 SR level 1 and 19 level 2 reports. Only one paper was scored as highest level of evidence, which concerned a double cohort study with randomized trial design. CONCLUSION: The level of evidence for implementing SR in radiology is still low and outcomes should be interpreted with caution. KEY POINTS: • Structured reporting is increasingly being used in radiology, especially in abdominal and neuroradiological CT and MRI reports. • SR can be subdivided into structured layout (SR level 1) and structured content (SR level 2), in which the first is defined as being a template in which the reporter has to report; the latter is an IT-based manner in which the content of the radiology report can be inserted and displayed into the report. • Despite the extensive amount of research on the subject of structured reporting, the level of evidence is low.

Holistic processing only? The role of the right fusiform face area in radiological expertise.

Radiologists can visually detect abnormalities on radiographs within 2s, a process that resembles holistic visual processing of faces. Interestingly, there is empirical evidence using functional magnetic resonance imaging (fMRI) for the involvement of the right fusiform face area (FFA) in visual-expertise tasks such as radiological image interpretation. The speed by which stimuli (e.g., faces, abnormalities) are recognized is an important characteristic of holistic processing. However, evidence for the involvement of the right FFA in holistic processing in radiology comes mostly from short or artificial tasks in which the quick, 'holistic' mode of diagnostic processing is not contrasted with the slower 'search-to-find' mode. In our fMRI study, we hypothesized that the right FFA responds selectively to the 'holistic' mode of diagnostic processing and less so to the 'search-to-find' mode. Eleven laypeople and 17 radiologists in training diagnosed 66 radiographs in 2s each (holistic mode) and subsequently checked their diagnosis in an extended (10-s) period (search-to-find mode). During data analysis, we first identified individual regions of interest (ROIs) for the right FFA using a localizer task. Then we employed ROI-based ANOVAs and obtained tentative support for the hypothesis that the right FFA shows more activation for radiologists in training versus laypeople, in particular in the holistic mode (i.e., during 2s trials), and less so in the search-to-find mode (i.e., during 10-s trials). No significant correlation was found between diagnostic performance (diagnostic accuracy) and brain-activation level within the right FFA for both, short-presentation and long-presentation diagnostic trials. Our results provide tentative evidence from a diagnostic-reasoning task that the FFA supports the holistic processing of visual stimuli in participants' expertise domain.

Reversal of the hanging protocol of Contrast Enhanced Mammography leads to similar diagnostic performance yet decreased reading times.

OBJECTIVES: Contrast-enhanced mammography (CEM) was found superior to Full-Field Digital Mammography (FFDM) for breast cancer detection. Current hanging protocols show low-energy (LE, similar to FFDM) images first, followed by recombined (RC) images. However, evidence regarding which hanging protocol leads to the most efficient reading process and highest diagnostic performance is lacking. This study investigates the effects of hanging-protocol ordering on the reading process and diagnostic performance of breast radiologists using eye-tracking methodology. Furthermore, it investigates differences in reading processes and diagnostic performance between LE, RC and FFDM images. MATERIALS AND METHODS: Twenty-seven breast radiologists were randomized into three reading groups: LE-RC (commonly used hangings), RC-LE (reversed hangings) and FFDM. Thirty cases (nine malignant) were used. Fixation count, net dwell time and time-to-first fixation on malignancies as visual search measures were registered by the eye-tracker. Reading time per image was measured. Participants clicked on suspicious lesions to determine sensitivity and specificity. Area-under-the-ROC-curve (AUC) values were calculated. RESULTS: RC-LE scored identical on visual search measures, t(16)= -1.45, p = .17 or higher-p values, decreased reading time with 31%, t(16)= -2.20, p = .04, while scoring similar diagnostic performance compared to LE-RC, t(13.2) = -1.39, p - .20 or higher p-values. The reading process was more efficient on RC compared to LE. Diagnostic performance of CEM was superior to FFDM; F (2,26) = 16.1, p < .001. Average reading time did not differ between the three groups, F (2,25) = 3.15, p = .06. CONCLUSION: The reversed CEM hanging protocol (RC-LE) scored similar on diagnostic performance compared to LE-RC, while reading time was a third faster. Abnormalities were interpreted quicker on RC images. A RC-LE hanging protocol is therefore recommended for clinical practice and training. Diagnostic performance of CEM was (again) superior to FFDM.

The Neural Implementation of Surgical Expertise Within the Mirror-Neuron System: An fMRI Study.

Motor expertise is an important aspect of high-level performance in professional tasks such as surgery. While recently it has been shown that brain activation as measured by functional magnetic resonance imaging (fMRI) within the mirror-neuron system (MNS) is modulated by expertise in sports and music, little is known about the neural underpinnings of professional, e.g., surgical expertise. Here, we investigated whether and (if so) how surgical expertise is implemented in the MNS in medical professionals across three levels of surgical qualification. In order to answer the more specific research question, namely, if the neural implementation of motor expertise develops in a linear or non-linear fashion, the study compares not only brain activation within the MNS related to action observation of novices and experts, but also intermediates. Ten novices (medical students), ten intermediates (residents in orthopedic surgery) and ten experts (orthopedic surgeons) watched 60 video clips (5 s each) of daily-life activities and surgical procedures each while their brain activation was measured using a 3-T fMRI scanner. An established localization procedure was followed to functionally define the MNS for each participant individually. A 2 (video type: daily-life activities, surgical procedures) × 3 (expertise level: novice, intermediate, expert) ANOVA yielded a non-significant interaction. Furthermore, separate analyses of the precentral and parietal part of the MNS also yielded non-significant interactions. However, post hoc comparisons showed that intermediates displayed marginally significantly lower brain activation in response to surgery-related videos within the MNS than novices. No other significant differences were found. We did not find evidence for the hypothesis that the brain-activation level in the MNS evoked by observing surgical videos reflects the level of surgical expertise in the professional task of (orthopedic) surgery. However, the results suggest a potential non-linear relationship between expertise level and MNS-activation level.

What We Do and Do Not Know about Teaching Medical Image Interpretation.

Educators in medical image interpretation have difficulty finding scientific evidence as to how they should design their instruction. We review and comment on 81 papers that investigated instructional design in medical image interpretation. We distinguish between studies that evaluated complete offline courses and curricula, studies that evaluated e-learning modules, and studies that evaluated specific educational interventions. Twenty-three percent of all studies evaluated the implementation of complete courses or curricula, and 44% of the studies evaluated the implementation of e-learning modules. We argue that these studies have encouraging results but provide little information for educators: too many differences exist between conditions to unambiguously attribute the learning effects to specific instructional techniques. Moreover, concepts are not uniformly defined and methodological weaknesses further limit the usefulness of evidence provided by these studies. Thirty-two percent of the studies evaluated a specific interventional technique. We discuss three theoretical frameworks that informed these studies: diagnostic reasoning, cognitive schemas and study strategies. Research on diagnostic reasoning suggests teaching students to start with non-analytic reasoning and subsequently applying analytic reasoning, but little is known on how to train non-analytic reasoning. Research on cognitive schemas investigated activities that help the development of appropriate cognitive schemas. Finally, research on study strategies supports the effectiveness of practice testing, but more study strategies could be applicable to learning medical image interpretation. Our commentary highlights the value of evaluating specific instructional techniques, but further evidence is required to optimally inform educators in medical image interpretation.

Teaching Systematic Viewing to Final-Year Medical Students Improves Systematicity but Not Coverage or Detection of Radiologic Abnormalities.

PURPOSE: Systematic viewing of images is widely advocated in radiology; it is expected to lead to complete coverage of images and consequently more detection of abnormalities. Evidence on the efficacy of teaching systematic viewing to students is conflicting. The aim of this study was to investigate the effects of teaching systematic viewing to final-year medical students on systematicity of viewing behavior, coverage of the image, and detection. METHODS: Final-year medical students (n = 60) viewed 10 chest radiographs in a first series before training and another 10 radiographs in a second series after training. Between series, students were taught basic chest radiographic viewing, in either a systematic or a nonsystematic manner. With eye tracking, systematicity (Levenshtein distances), coverage (percentage of image viewed), and detection (sensitivity and specificity) were measured. RESULTS: In a mixed two-by-two design, significantly higher sensitivity was found after training compared with before training (F1,55 = 6.68, P = .012, ηp2 = .11) but no significant effect for type of training (F1,55 = 1.24, P = .30) and no significant interaction effect (F1,55 = 0.12, P = .73). Thus, training in systematic viewing was not superior to training in nonsystematic viewing. A significant interaction of training type and time of viewing was found on systematicity (F1,49 = 20.0, P < .01, ηp2 = .29) in favor of the systematic viewing group. No significant interaction was found for coverage (F1,49 = 0.43, P = .51) or specificity (F1,55 = .124, P = .73). CONCLUSIONS: Both training types showed similar increases in sensitivity. Therefore, it might be advisable to pay less attention to systematic viewing and more attention to content, such as the radiologic appearances of diseases.

The challenges of studying visual expertise in medical image diagnosis.

CONTEXT: Visual expertise is the superior visual skill shown when executing domain-specific visual tasks. Understanding visual expertise is important in order to understand how the interpretation of medical images may be best learned and taught. In the context of this article, we focus on the visual skill of medical image diagnosis and, more specifically, on the methodological set-ups routinely used in visual expertise research. METHODS: We offer a critique of commonly used methods and propose three challenges for future research to open up new avenues for studying characteristics of visual expertise in medical image diagnosis. The first challenge addresses theory development. Novel prospects in modelling visual expertise can emerge when we reflect on cognitive and socio-cultural epistemologies in visual expertise research, when we engage in statistical validations of existing theoretical assumptions and when we include social and socio-cultural processes in expertise development. The second challenge addresses the recording and analysis of longitudinal data. If we assume that the development of expertise is a long-term phenomenon, then it follows that future research can engage in advanced statistical modelling of longitudinal expertise data that extends the routine use of cross-sectional material through, for example, animations and dynamic visualisations of developmental data. The third challenge addresses the combination of methods. Alternatives to current practices can integrate qualitative and quantitative approaches in mixed-method designs, embrace relevant yet underused data sources and understand the need for multidisciplinary research teams. CONCLUSION: Embracing alternative epistemological and methodological approaches for studying visual expertise can lead to a more balanced and robust future for understanding superior visual skills in medical image diagnosis as well as other medical fields.

Fluid state and blood pressure control: no differences between APD and CAPD.

The aim of this study was to compare fluid state, ambulatory blood pressure, and sodium removal in automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). This observational, cross-sectional study comprised 20 APD and 24 CAPD patients with a mean duration on peritoneal dialysis of 30 ± 26 and 21 ± 23 months, respectively. Sixty-four percent of the patients were treated with icodextrin. The methods used were 24 hr dialysate and urine collections, standardized 3.86% glucose peritoneal equilibration test (PET), bioimpedance analysis, and 24 hr ambulatory blood pressure monitoring. Extracellular water (ECW) corrected for body weight was 0.23 6 0.03 L/kg both in APD and CAPD patients. The slope normovolemia value according to Chamney was 0.0 6 0.2 L/kg in APD patients and 0.0 6 0.05 L/kg in CAPD patients (not significant [NS]). Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were respectively, 132 ± 25 and 79 ± 8 mm Hg in APD and 129 ± 16 and 76 ± 11 mm Hg in CAPD patients (NS). Sodium concentration in dialysate was respectively, 129.5 ± 3.5 mmol/L in APD and 132.4 ± 4.1 mmol/L in CAPD (p= 0.017). Dialysate sodium removal was 80.6 ± 78.4 mmol/24 hr in APD and 108.7 ± 96.8 mmol/24 hr in CAPD patients (NS). Natriuresis was respectively, in APD 76.6 ± 65.5 mmol/24 hr and in CAPD 93.5 ± 61.7 mmol/24 hr (NS). Total sodium removal was 149.5 ± 76.6 mmol/24 hr in APD and 198.4 ± 75.0 mmol/24 hr in CAPD (p= .039). Despite a higher daily sodium removal in CAPD patients, fluid state and blood pressure were not different between APD and CAPD. In general, volume status and blood pressure appeared to be reasonably controlled in this unselected population.

Learning physical examination skills outside timetabled training sessions: what happens and why?

Lack of published studies on students' practice behaviour of physical examination skills outside timetabled training sessions inspired this study into what activities medical students undertake to improve their skills and factors influencing this. Six focus groups of a total of 52 students from Years 1-3 using a pre-established interview guide. Interviews were recorded, transcribed and analyzed using qualitative methods. The interview guide was based on questionnaire results; overall response rate for Years 1-3 was 90% (n = 875). Students report a variety of activities to improve their physical examination skills. On average, students devote 20% of self-study time to skill training with Year 1 students practising significantly more than Year 3 students. Practice patterns shift from just-in-time learning to a longitudinal selfdirected approach. Factors influencing this change are assessment methods and simulated/real patients. Learning resources used include textbooks, examination guidelines, scientific articles, the Internet, videos/DVDs and scoring forms from previous OSCEs. Practising skills on fellow students happens at university rooms or at home. Also family and friends were mentioned to help. Simulated/real patients stimulated students to practise of physical examination skills, initially causing confusion and anxiety about skill performance but leading to increased feelings of competence. Difficult or enjoyable skills stimulate students to practise. The strategies students adopt to master physical examination skills outside timetabled training sessions are self-directed. OSCE assessment does have influence, but learning takes place also when there is no upcoming assessment. Simulated and real patients provide strong incentives to work on skills. Early patient contacts make students feel more prepared for clinical practice.