Bridging the Radiology-Pediatrics Interaction Gap by Incorporating a PGY4 Radiology Resident into the General Pediatrics Team

Abstract

To bridge the gap between clinicians and radiologists, radiology residents rounded with inpatient pediatric medicine teams to present and interpret daily imaging studies, as well as assist with decisions and indications for radiologic exams. Surveys were sent to team members who rotated with radiology residents, and the consensus strongly favored having radiology residents on future rotations. Team members responded that they benefitted from a better understanding of radiology exams, their indications and limitations.

Introduction

According to the Association of American Medical Colleges, only 21.4% of medical schools require radiology clerkships¹. Also, a recent report assessing radiology education in medical school found that only 34.9% of 444 senior medical students from a variety of institutions had experienced dedicated radiology training with only 10.8% required to take a dedicated radiology rotation². The same study found that the large majority of students underestimated risks of imaging procedures. Further, the majority of students (77%) had never heard of the American College of Radiology (ACR) appropriateness criteria, which have been established by multispecialty panels to determine which imaging study is most indicated in various clinical situations². Similarly, authors of another study found that 96% (213 of 223) of third and fourth year medical students had never heard of the ACR appropriateness criteria³.

A study of PGY1 interns found that 63.7% were expected to independently preview imaging exams, but only 60.2% claimed high confidence in recognizing common emergent pulmonary findings, such as pneumonia, pneumothorax, or position of lines/tubes, on chest radiographs⁴. The same study noted that 80.2% of PGY1s had never heard of the ACR appropriateness criteria⁴. The findings of these studies suggest a radiology education gap in the medical school curriculum and residency orientation programs that may lead to poorly prepared interns.

The Accreditation Council for Graduate Medical Education (ACGME) implemented the Next Accreditation System (NAS) in July 2013, and is based on residents achieving specialty specific milestones in each of the six core competencies, including communication skills, patient care, professionalism, medical knowledge, systems based practice, and practice based learning improvement⁵. In the past, various clinical services, including pediatrics, rounded daily in radiology allowing trainees in both departments the opportunity to observe, learn and practice interdisciplinary core communication skills that can lead to improved patient care and a better understanding of systems based practice. However, this valuable core experience has gradually disappeared with the introduction of PACS (picture archiving and communication system).

Our institution sought to address this loss of educational interaction by developing an innovative pediatric rotation. We incorporated a PGY4 radiology resident (PGY4RR) into the pediatrics inpatient team to increase radiology exposure and education for pediatric residents and medical students rotating on pediatrics. During a 24-month period, 24 PGY4RRs spent one month each with the pediatrics team. On daily rounds, the PGY4RR provided educational value by previewing and presenting imaging studies, reviewing and discussing indications for future studies, and advising the team on the imaging approach best suited to answer patient specific clinical questions. The PGY4RR was also available to lead brief daily didactic sessions with members of the team as requested.

The purpose of this study is to survey pediatrics team members to determine if they supported the rotation and if it was of educational benefit to them.

Methods

Over two years, 24 PGY4RRs each spent four weeks on pediatrics. Resident responsibilities included:

1. presentation of imaging studies on daily rounds,

2. teaching medical students and residents imaging indications, limitations, appropriateness and basic interpretation concepts,

3. review of various other imaging (including outside studies) as needed, and

4. assistance with decisions regarding future exams.

If the PGY4RR encountered unfamiliar subject matter, then he/she consulted an attending pediatric radiologist and reported back to the team. The Institutional Review Board (IRB) granted approval, and primary care team members were surveyed (n=143), including pediatric attendings, residents, and medical students (Appendix A). Survey completion was not incentivized, but was incorporated into the routine, electronic end-of-rotation survey. Survey completion was an inclusion criteria; each question had to have a response to advance to the next screen. Participants were informed their responses would be confidential and anonymous. One hundred and four responses were received (72.7%). Repeated reminders were sent to nonresponders to increase response rate.

We designed a survey to assess the subjective impact on pediatric team members. A literature search revealed no similar validated pediatric surveys. After developing approximately 40 items that were relevant to the construct of interest, we reviewed and consolidated items into nine questions. Items were grouped into questions on resident knowledge and educational impact on the primary team, questions on future inclusion of a PGY4RR on rounds, and a question on likelihood of providing further clinical history when ordering radiologic exams. Prior to pilot survey distribution, we performed informal cognitive interviews with several trainees who were not part of the study cohort to verify that respondents interpreted questions as intended^6–8. A pilot survey was performed and adjustments were made in data collection techniques to maximize the response rate, including incorporation into routine end-of-rotation survey. Previously published survey development principles were followed⁸. Specifically, survey items were written in the form of a question using construct specific responses with an odd number using a 5 point Likert scale or a 10 point rating⁶. Data were compiled electronically using Microsoft Excel. This rotation evaluation survey was deemed exempt by the ethics review board.

Results

One hundred and four of 143 surveys (72.7%) were completed- all questions had a response selected- by pediatrics team members. Of the 104 respondents, 51 (49%) were medical students, 39 (37.5%) were residents, and 14 (13.5%) were attendings.

Questions on Resident Knowledge and Educational Impact on the Primary Team

Survey participants were asked how many weeks they rotated with the PGY4RR. Responses included 4 weeks (n=43 [41.3%]), 3 weeks (n=31 [29.8%]), 2 weeks (n=24 [23.1%]), and 1 week (n=6 [6%]).

Survey participants were asked to rate how knowledgeable the PGY4RR consultant was in his/her respective field. On a scale of 1–10, 1 was defined as not knowledgeable and 10 as very knowledgeable. The largest group (n=44 [42.3%]) rated the PGY4RR at 10, or very knowledgeable. Ratings ranged from 9 (n=11 [10.6%]), to 8 (n=34 [32.7%]), to 7 (n=9 [8.6%]), and finally, 5 (n=6 [5.7%]). There were no ratings below 5.

Respondents were asked to rate their post-rotation understanding of indications for various radiology exams on a scale of 1–10 (1=no better understanding and 10=much better understanding). 88% of respondents gave a score of 6 or above, indicating improved understanding of exam indications. Ratings were 10 (n=24 [23.1%]), 9 (n=10 [9.6%]), 8 (n=21 [20.2%]), 7 (n=14 [13.5%]), 6 (n=22 [21.2%]), 5 (n=11 [10.6%]) and 4 (n=2 [2%]).

Next we asked team members to rate their understanding of limitations and appropriateness of various radiological exams on a scale of 1–10 after having the PGY4RR rotate with them (1=no better and 10=much better understanding). 80% of respondents gave a score of 6 or above, indicating improved understanding of limitations and appropriateness of radiologic exams. The responses were 10 (n=19 [18.3%]), 9 (n=10 [9.6%]), 8 (n=12 [11.5%]), 7 (n=23 [22.1%]), 6 (n=19 [18.3%]), 5 (n=17 (16.3%)], 4 (n=2 [2%]), and finally 1 (n=2 [2%]).

The next question asked team members whether the incorporation of a PGY4RR into pediatric rounds was beneficial to learning basic radiology concepts. 99% felt that having a PGY4RR was either very (n=67 [64.4%]) or somewhat (n=36 [34.6%]) beneficial. One responded no harm or benefit (n=1 [1%]) and no one responded harmful.

Questions on Future Inclusion of a PGY4RR on Rounds

Respondents were asked if they would like to have a PGY4RR consultant on future pediatric rotations. 91% responded yes, definitely (n=80 [77%]), or probably yes (n=14 [13.5%]). 10% were neutral (n=10), and none responded probably or definitely not.

When respondents were asked whether they would like to have a PGY4RR round with them on other rotations, most 90.3% answered yes definitely (n=75 [72.1%]) or probably yes (n=19 [18.2%]), and a minority (n=10 [10%]) were neutral. None responded no. When asked “Which other rotation(s) would you like to have a PGY4RR (Select all that apply)?” Respondents selected: internal medicine (n=40), surgery (n=38), pediatrics (n=31), emergency medicine (n=29) and intensive care unit ICU (n=24).

Questions on Providing History

Finally, we asked, “Did having a PGY4RR on rounds change the likelihood that you will provide more history when ordering imaging exams?” The majority responded they were definitely (n=15 [30%]) or probably more likely (n=19 [38%]) to provide more history. The remaining responded no change (n=16 [32%]) and none responded less likely.

Discussion

Due to the ever increasing use of diagnostic imaging in medicine, knowledge of basic radiology concepts is necessary for today’s practitioners⁹. Being able to diagnose basic, critical conditions (such as pneumothorax) is a necessary and expected skill for clinicians and interns to treat time sensitive, life threatening conditions effectively¹⁰. Although the addition of PACS in patient care has helped make imaging results rapidly available, the disadvantage is that the tradition of beginning rounds in radiology to view and discuss radiological studies has mostly been abandoned. To bridge this educational gap, we implemented an innovative rotation that allowed trainees to gain cross-specialty clinical exposure with case-specific discussions of imaging studies. Radiology residents were able to practice core communication consultation skills and members of the pediatrics team were able to gain knowledge of radiology procedures, including their indications and findings.

To our knowledge, no study of this size has evaluated the educational benefit or support for incorporating a radiology resident into rounds and none has specifically studied the impact on a core pediatrics rotation team members, including medical students and residents. One recent manuscript published under “The voice of experience” column in the Journal of the American College of Radiology, piloted a similar experience with a single senior radiology resident rounding daily for two weeks on internal medicine¹¹. Although this pilot included only one resident for two weeks, the study showed positive feedback from the 20 clinicians surveyed after the rotation. Similar to our larger study, respondents agreed that the rotation improved radiology knowledge and strongly agreed that they would like to have a radiology resident on future rounds. However, much like our study, the authors did not specify if the responding clinicians were attendings, trainees or students, nor did they state if they continued the rotation¹¹. Naeger et al’s study, based on pre- and post-lecture surveys, showed that radiology residents gained a statically significant increase in perceived knowledge of what clinicians want in radiology reports pertaining to the topics discussed in a clinician driven multidisciplinary conference series¹². They also reported a significant increase in resident desire to continue incorporation of clinicians into core radiology resident conferences¹². Our study showed a similar positive response to interdisciplinary teamwork between pediatrics and PGY4RR: 99% and 98% felt it was beneficial to learning, and enhanced their understanding of radiology procedures. Further, our study demonstrates pediatrics team members understanding of radiology study limitations and appropriateness were rated as improved by 96% of respondents. This improved understanding of appropriateness is sorely needed if Saha et al.’s report showing that 80.2% of PGY1 residents were not aware of ACR appropriateness criteria is an indication^3,4. Expanding clinician knowledge of limitations and appropriateness of radiologic exams may lead to more judicious use of imaging, thus potentially reduce radiation exposure and cost.

The importance of radiology involvement in morning report was demonstrated in a 1997 study by D’Alessandro et al.¹³ Authors assessed the content of pediatrics morning report without a radiologist present and found that despite showing 559 imaging studies during 338 case presentations, unanswered questions concerning radiological study indications, techniques and findings were common. Authors concluded that pediatricians must learn basic radiology interpretation methods, imaging indications and ways to use the radiologist as a consultant¹³. There is a known patient care benefit that comes from working in teams, and valuable opportunities for radiology trainees to hear clinicians explain their imaging needs and potentially improve their communication skills. Pediatric trainees have the opportunity to gain knowledge of radiology study indications, limitations, appropriateness and findings- each of which will be commonly utilized skills later as practitioners. After rotating with a PGY4RR, 68% of respondents said they were more likely to provide additional history when ordering radiology exams. Although we cannot say why the majority said they would provide more history, it is possible that pediatrics team members became more aware of the importance of history in image interpretation, as well as a better understanding of how to use the radiologist as a consultant¹⁴, ¹⁵.

This study has several limitations. It was performed over two years at a single institution. The survey was completed by a larger number of medical students and residents (n=44) than attendings (n=6). This was likely due to the makeup of the team members, i.e. one attending with several residents and students. Because few attendings were surveyed, the results are unlikely to represent their opinions. While survey responses are rarely 100%, it is possible that our 72.7% response rate may have led to some degree of response bias due to a larger percentage of those who enjoyed the experience responding. To limit bias introduced in questions where one side of an issue was mentioned in the stem, responses were provided on both sides of the issue. Because the survey was educational and cross-sectional, it could not be randomized or controlled.

Future research could include validation of results and stratification of results into resident, medical student and attending categories. Although verbal feedback from residents indicates a very positive experience, a survey on the impact and opinions of the PGY4RR completing the rotation is planned after a sufficient number of residents have completed the experience. It may also be useful to study a similar rotation for radiology residents in a different specialty than pediatrics, especially since 90% of respondents stated they would like to have a radiology resident on other rotations.

This rotation was part of our radiology residency program and did not incur additional cost or manpower needs. The rotation is generalizable to other institutions with radiology residencies and the experience could be created on any core clinical rotations desired. Potential barriers starting such a rotation may include manpower needs and scheduling flexibility.

Conclusions

Incorporating a PGY4RR into the pediatrics team was strongly supported and beneficial to the learning environment. Pediatric team members responded that they increased their radiology knowledge, gained a better understanding of exam appropriateness, and indicated they would like to incorporate PGY4RRs into future pediatrics and non-pediatrics rotations.

Biography

Munir Patel, MD, (top left), is at Mount Sinai St. Luke’s-Roosevelt Hospital Center, Department of Surgery New York, NY – Resident in General Surgery. Randall Heller, MD, (top center), is at Saint Luke’s Hospital Department of Radiology & University of Missouri-Kansas City School of Medicine – Resident in Radiology. Danielle A. Cunningham, MSIV, (top right), MSMA member since 2012, is at the University of Missouri-Kansas City School of Medicine – Medical Student. Brett Donegan, MD, (bottom left), is Saint Luke’s Hospital Department of Radiology & University of Missouri-Kansas City School of Medicine – Resident in Radiology. Lisa H. Hutchison, MD, FAAP, FACR, (bottom right), is in the Department of Radiology at the University of Missouri-Kansas City School of Medicine, former Professor of Radiology and Pediatrics.

Contact: dacg2d@mail.umkc.edu