Educators in Boston have made their radiology clerkship more practical and effective for medical students by starting them early in the third year and focusing on small-group learning rather than large plenary sessions, according to a report in the Journal of the American College of Radiology.
Since redesigning the radiology clerkship over the past four years, the study team from Brigham and Women's Hospital and Dana-Farber Cancer Institute has logged steady growth in scores on the objective structured clinical examination (OSCE) given to their charges -- from a mean score of 53.78 (out of 100) in 2008 to 92.18 in 2012 (JACR, August 29, 2013).
Perhaps even more important, the program has become more accessible to students thanks to better scheduling that accommodates their busy third-year schedules, and it has become more effective due to an improved learning structure that focuses on interactive learning of modules in small groups.
"We came up with an introductory course for the entire third year using small-group teaching as opposed to giving big lectures; big courses don't really work because you need to interact," lead author Dr. Donald Di Salvo told AuntMinnie.com.
Starting early
Putting key radiology content at the start of the third year in the introductory course has also been helpful because it exposes students to the imaging component of disease processes just as they're learning about the clinical aspects, according to Di Salvo.
"Imaging for surgery, imaging for ob/gyn -- we've showed cases relevant to that, and you get more involvement in small groups," he said.
Harvard Medical School, which comprises four sites including Brigham and Women's Hospital, "is a little unusual in that it has a required clerkship in radiology, and that's certainly not the practice across most of the medical schools in the U.S.," Di Salvo said.
A recent survey showed that fewer than one-third of medical schools offer a radiology clerkship, and almost all are offered as electives, the authors wrote. At Harvard, scheduling problems have arisen in recent years as clerkships have begun offering medical students scholarly research opportunities in the fourth year. And students also have multiple clerkships to juggle during the third year, leaving less time for formal radiology programs.
Designing the program
The project began with a needs assessment to see what the students were being presented in their other clerkships, with the aim of tailoring the introductory radiology course to their needs. Clerkship directors in medicine, surgery, ob/gyn, pediatrics, neurology, and psychiatry were asked what types of imaging studies and clinical diagnoses students in clerkships should be exposed to.
Students helped by rating their experiences in previous years' lectures and offering suggestions anonymously, and the course was designed to bring important clinical content and radiology content together into the introductory course, and even into the nonradiology clerkships where that approach was more appropriate, the authors wrote.
The main components included the fundamentals of imaging course, clinical conferences, and the OSCE.
Fundamentals of imaging
The fundamentals of imaging course consisted of four three-hour modules, the authors explained. Each began with a brief large-group lecture to introduce general concepts. The class was then broken up into small-group learning sessions, and then pulled together again for a brief overview of concepts learned and question-and-answer sessions.
"At each tutorial station, a radiology faculty member presents several cases pertinent to a particular theme (e.g., right upper quadrant pain in the Imaging for Surgery module)," the authors explained. Offered as PowerPoint presentations, the cases are presented as clinical problems, and students are asked to think through possible diagnoses. They are then guided through appropriate imaging exams, and after 20 minutes they are sent on to the next station.
Clinical conferences
Clinical conference material came from cases in other clerkships where significant imaging was performed. Radiology clerkship students reviewed the images under the supervision of faculty members, and the cases were presented at lunchtime conferences, followed by discussion centered on the clinical topic.
Using the more interactive format, students are remembering the context of the actual cases, and they get the added bonus of seeing the interactions between clerkship directors from different disciplines, the authors wrote.
"Legitimate differences in the approach to patient workup, seen from the clinical perspective and the radiology perspective, provide a healthy arena for disagreement in the less clear-cut, gray areas of medicine," they wrote.
OSCE
Finally, the OSCE, a nine-station exam administered in the fourth year, has always contained a radiology station staffed by radiologist volunteers who present the materials and read from scripted content.
"We thus arrived at three components of our integrated radiology education program: a fundamentals-of-imaging (FOI) course as an introduction, the combined clinical-radiology conference throughout the year, and the radiology station at the end-of-year OSCE," the authors wrote.
Anonymous surveys of the program were sent to students and faculty members. In their responses, the students "overwhelmingly felt that they had gained insight into better clinical utilization of imaging studies," the authors wrote. The revised teaching format also enabled close inspection of imaging findings for details that could not be visualized in a large lecture setting, according to the responses.
"These are the kinds of things you're going to see in the coming years: a format that encourages small-group learning," Di Salvo said.
As the changes have been implemented, they have been associated with steadily rising OSCE scores, from a mean 53.78 in 2008 to 71.11 in 2010 and 92.18 in 2012. Because these exams occur in the fourth year, they may be a good representation of what students actually retain, so the improved results are encouraging, the authors wrote.
Of course, the changes as conceptualized have all evolved considerably in their implementation, based on feedback from other clerkship directors and the students, according to the authors.
"We assume that the forms these concepts can take at other institutions will likewise be different, but we hope that the underlying ideas presented here may be useful to other radiology educators," they added.
For effective learning, radiology education should include both concentrated learning modules early in the third year and continued exposure throughout the year through combined radiology-clinical conferences, the authors concluded. Aligning radiology teaching to the content of clinical clerkships fosters an environment of cooperation and inclusiveness.
Finally, they wrote, putting students at the center of radiology-clinical clerkships fosters learning, and year-end exams encourage mastery of the subject.
"If you have to show a case and talk about it, you really have to know it," Di Salvo said. "We're definitely going to keep it up; it's been pretty successful."
