It can be difficult to design curricula for medical students who pick radiology reading rooms as an elective. The passive nature and poor structure of many reading-room programs have earned some the nickname "radi-holidays," but that doesn't have to be the case, according to a new article in the Journal of the American College of Radiology.
Students' reading-room curricula should contain attendance and feedback systems, written goals and expectations, evaluations at the middle and end of the course, and a final debriefing session, wrote Dr. David Naeger and colleagues from the University of California, San Francisco (UCSF). They looked at the full range of resources, including radiology residents, that can be used to provide a better learning experience (JACR, June 2013, Vol. 10:6, pp. 442-448).
"Reading room electives are among the most challenging curricula to develop for medical student educators," they wrote. "Students tend to have few responsibilities and poorly defined learning objectives. ... Radiology electives must break free of the 'radi-holiday' stereotype and adopt increased responsibilities and expectations, similar to rigorous clinical subinternships"
The authors have instituted their recommendations in a medical school with 600 students and an affiliation with an academic hospital. Has it been successful?
"Every section operates differently at academic centers, so in some sections -- for example, chest radiology -- almost all of these recommendations have been working well, and students like it," said Naeger, a clinical professor of radiology and associate program director of nuclear medicine residency at UCSF. "In some sections, new changes are coming out slower, so there's a lot of variability in how well it works, depending on what section you're in."
Tough environment
Designing reading-room electives has always been challenging for educators. To begin, the main activity in such electives is "passive shadowing," a process that inherently lacks accountability and is very different from the well-defined patient care and clinical responsibilities of most residents, the authors wrote. And, unfortunately, the reading room isn't necessarily a welcoming place for the new trainee.
Among the challenges, it's difficult to identify entry-level tasks suitable for medical students, the study team wrote. In addition, the sporadic nature of student enrollment in some reading rooms prevents the consistent assignment of these tasks to students.
Second, radiology training is generally not considered "essential" for graduation from medical school. As a result, many schools lack radiology learning objectives to guide reading-room and other electives.
"Finally, the shiftlike rotation of attending radiologists, fellows, and residents, even from day to day, can limit the ownership supervising instructors have of students' learning," the authors wrote. "To overcome such challenges, electives need to have a structure as detailed as those of other clinically oriented electives."
At the same time, the courses should continue to be flexible and enjoyable; the authors insist that it is possible to have a learning environment that is both fun and well-structured. To this end, they listed a number of recommendations:
- First-day orientation with the attending radiologist. This should be preceded by a welcome email to explain the basics, and it will help ensure that courses do not begin with confusion and a lack of structure. Required activities should be explained in detail, and an orientation guide should contain detailed expectations and learning objectives.
- Complete and well-designed learning objectives. There is complex science behind the crafting of learning objectives, according to the authors, and if experts aren't available, sources such as the Alliance for Medical Student Educators in Radiology can help. For example, general radiology objectives might include the learner being able to describe the process for ordering an imaging exam, to explain typical workflow and educational practices in the reading room, and to design an imaging-based case presentation using necessary technology.
- Demands for accountability and reliability. Professional conduct requires daily attendance, on-time arrival, and staying until the end of the day or until a specific end point is achieved.
- Student feedback. An anonymous system for student feedback is essential for course improvement. Because of the small number of students involved, systems such as E*Value, which hide feedback until a sufficient number of responses are available for aggregation, may be helpful, the authors wrote. Alternatively, a staff member not involved with education could be tapped to read the responses, or they can simply be held back manually until enough suggestions are received to anonymize the responses.
Evaluations should be conducted at the middle and at the end of the course. They should evaluate specific domains of competency, and ideally they should mirror those developed by the Accreditation Council for Graduate Medical Education (ACGME) for resident assessment. This would include medical knowledge, patient care, professionalism, communication and interpersonal skills, practice-based learning and improvement, and systems-based practice. A last-day debriefing session should be scheduled with the attending radiologist.
Other opportunities
Students should be given opportunities not just to shadow radiologists but also to share in their work, though specialized software and other logistical challenges make a true "apprenticeship" difficult, Naeger and colleagues wrote. Varied supplemental learning activities, such as gathering case histories and looking up relevant literature, should be used, adding structure to the somewhat random learning environment found in shadowing radiologists who are performing daily case work. Time should be made for one-on-one teaching with the general radiologist.
Learning can be enhanced by reviewing interactive case modules with questions appropriate to the student's level and abilities, supplemented by selected literature examples, the group wrote. Students should be given opportunities to prepare research abstracts, present cases, and attend interdisciplinary conferences, when possible.
Good resources are available to help create the end-of-elective test, such as the free Radiology ExamWeb.
"Rigorous electives are possible in the reading-room setting," Naeger and colleagues wrote. "Such electives are educational, and they better represent the modern practice of radiology. The essential components of a successful elective include well-defined expectations and learning objectives, active participation in varied educational activities, and objective methods of evaluation."
Get involved
Finally, designing better reading-room curricula offers an opportunity for residents who have an interest in teaching.
"Residents who are interested in having a much greater role in teaching should talk to the attendings and see what can be done," Naeger said. "At the University of California, San Francisco, we actually have a dedicated position for one resident who helps us with educational administrative tasks and has a much greater role than the average resident. This is great practice for mentoring into an academic career, so I think absolutely there are roles where they can do more of the one-on-one teaching, or help with the learning objectives."
Even so, an attending radiologist should be responsible for each individual student, according to the authors. This individual might be the course director or, in large departments, a section representative. The responsible individual should be backed by the rest of the department, and everyone should have a common understanding of the activities and expectations of the elective.
"I think the biggest way residents can help is to engage students more in the reading-room setting when they're assigned there," Naeger told AuntMinnie.com. "Everyone in the reading room allows students to sort of passively observe. But it turns out they can look up histories, research things on the Internet, or look up articles to help us determine the best interpretation of studies. The residents can help with that by having the students participate in looking up this information, and also participate in teaching while the reading is happening."
