ACR Appropriateness Criteria® Acute Onset Flank Pain-Suspicion of Stone Disease (Urolithiasis)

Noncontrast CT (NCCT) is the imaging study of choice for initial evaluation of patients with acute onset of flank pain and suspicion of stone disease without known prior stone disease. NCCT can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain. Although less sensitive in the detection of stones, ultrasound may have a role in evaluating for signs of obstruction. Radiography potentially has a role, although has been shown to be less sensitive than NCCT. For patients with known disease and recurrent symptoms of urolithiasis, NCCT remains the test of choice for evaluation. In pregnancy, given radiation concerns, ultrasound is recommended as the initial modality of choice with potential role for noncontrast MRI. In scenarios where stone disease suspected and initial NCCT is inconclusive, contrast-enhanced imaging, either with MRI or CT/CT urogram may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Defining the Roles and Responsibilities for the Vice Chair for Academic Affairs/Faculty Development in Radiology

RATIONALE AND OBJECTIVES

To inform the development of a job description for Vice-Chairs for academic affairs (VCAA), members of the Alliance of Leaders in Academic Affairs in Radiology (ALAAR) were surveyed to better understand their current job responsibilities and how they would ideally allocate their professional time.

MATERIALS AND METHODS

Based on a survey of 33 university-affiliated radiology departments and discussion among ALAAR members, the authors developed a detailed job description for the VCAA. The 21-question survey was composed and validated by experts in the field. It was distributed to all members of ALAAR via email with an electronic link and was open for 5 months. Results of the survey were tabulated, and a job description was crafted to represent the foundational roles of academic affairs leaders in radiology.

RESULTS

The response rate for institutions represented in ALAAR was 73% (33/45). All participants reported that they practiced in a university-affiliated institution. Faculty size varied from ≤49 (30.3%, 10/33), 50-99 faculty (24.2%, 8/33), and ≥100 faculty members (45.5%, 15/33). Only 24% of survey respondents had a detailed job description at the time of hire. More than 40% attested to significant oversight over faculty development programs (45%), mentorship programs (42%, and promotions (45%). Respondents ideally want increased oversight (defined as >10%) over exit interviews, faculty awards, promotions, onboarding, recruitment and hiring, and wellness programming.

CONCLUSION

The aspirational mission of the VCAA is to oversee components of sequential stages in the professional lifecycle of faculty members but a common job description for this role is lacking.

Structured Reports and Radiology Residents: Friends or Foes?

Structured reports offer overall improvement in quality and safety, largely centered upon more effective communication. Structured reporting is helpful to trainees as a method to develop organized search patterns and include pertinent positive and negative findings. However, limitations of structured report use include lack of development of individualized search patterns and failure to recognize key elements of the report to be formulated in the impression. Instruction on the value of a structured reporting approach, its impact on patient care and clinical service, and compliance with billing requirements must be balanced with early and consistent feedback on appropriate use and reporting errors. It is incumbent upon radiology educators to integrate and optimize structured reporting in the learning environment. This manuscript addresses the impact of structured reporting on radiology education, reviewing quality and safety considerations, detailing benefits and drawbacks for trainees, and offering strategies for optimizing the use of structured reporting/templates in the training environment.

Affecting Change: Enhancing Feedback Interactions with Radiology Trainees

Feedback is a critical part of the learning process and is a valuable tool to empower adult learners. Modern feedback theory places the learner at the center of the feedback encounter. Individual and institutional barriers to effective giving and receiving of feedback can be overcome through education and attention to the form and content of feedback. We review the elements of effective feedback and address issues of framing, environmental, and social factors which aid in providing psychological safety and trust, as necessary elements to create a culture of feedback in radiology training programs. We provide practical strategies to empower learners with the necessary skills to solicit, receive, and reflect on feedback.

ACGME Diagnostic Radiology Milestones 2.0: the Time is Now

The Accreditation Council for Graduate Medical Education oversees graduate medical education in the United States. Designed to provide broad based training in all aspects of imaging, the diagnostic radiology residency program must provide educational experiences that not only provide technical, professional, and patient centered training, but also meet accreditation standards. With the breadth of material to cover during training, carefully orchestrated educational experiences must be planned. This manuscript offers residency program leaders resources to meet the challenges of the new Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones 2.0 and highlights potential opportunities for future educational endeavors.

Strengthening the Clinical Learning Environment by Mandate-Implementing the ACGME Common Program Requirements

RATIONALE

Three years ago, the Accreditation Council for Graduate Medical Education (ACGME) introduced updated Common Program Requirements in recognition of the need to further promote resident and faculty member well-being and patient safety. The ACGME acknowledged residencies would need time to comply with new requirements. This grace period, however, concluded as of July 1, 2019, and programs now risk citations for failure to implement new requirements.

METHODS AND RESULTS

The authors, members of the Association of Program Directors in Radiology Common Program Requirements Ad Hoc committee, developed downloadable resources provided in the Appendix delineating the 2019 Common Program Requirements and offering sample resources as compliant solutions.

CONCLUSION

The resources offer a national standardized approach to educating trainees in these essential skills and should be especially helpful to programs with access to fewer resources. In addition to achieving compliance, incorporation of these resources into residency training will ensure the next generation of radiologists are equipped to add value while remaining physically and emotionally healthy.

Auditing RadExam: Employing Psychometrics to Improve Exam Quality

INTRODUCTION

RadExam is a question item and exam database jointly developed by the Association of Program Directors in Radiology and the American College of Radiology to provide formative resident assessment, offering performance metrics benchmarked against institutional and national resident performance. Beyond resident performance, data is available on question and exam performance. Despite considerable investment in the education and training of its question writers and editors and meticulous attention to current psychometrically validated methods, it was anticipated a minority of exam questions would still perform poorly. Audits were performed to identify these questions, identify reasons for poor performance, and modify or replace so-affected questions. Exam performance was also assessed.

METHODS

Two audits were performed, the first after the February-May 2018 RadExam pilot phase, and the second nearly 1 year after the full implementation of RadExam. In each audit, RadExam subspecialty editors evaluated all exam questions and exams using statistical data: question and test number of administrations, question p value, question Discrimination Index (DI), question Bloom's taxonomy learning level, exam P-value, and the number of image-based questions in each exam. Identified questions were modified or removed and replaced.

RESULTS

Audit 1 was performed after the administration of 3114 exams comprised of 2520 questions administered across 100 residency programs. Audit 1 identified 617 questions with DI <0.1 and 565 questions with unacceptable P-values, all of which were modified or replaced. Audit 2 was performed after the administration of 16,416 exams, comprised of 2,507 questions. Audit 2 identified 229 questions with DI <0.1 and 290 questions with unacceptable P-values, representing a 49.1% decrease in total flagged questions compared to Audit 1. Statistically significant decreases were seen in questions with both DI and P-values outside of the desired range across nearly all subspecialties.

CONCLUSION

The positive impact of our audit system on question and exam performance was reflected in a significant decrease in the number of questions flagged and improved overall exam performance in Audit 2. This illustrates the positive impact of Audit 1.

Vice Chair for Education: Twelve Roles to Provide a Framework for Success

RATIONALE AND OBJECTIVES

An increase in the administrative work in our healthcare system has led to an increase in the number of administrative positions in radiology departments. Many of these are Vice Chair roles, including Vice Chair for Education (VCEd). The responsibility of this position has expanded, often far beyond the original definition. This article defines the role and expectations of the Vice Chair for Education and provides suggestions for success.

MATERIALS AND METHODS

This article will review 12 vital roles that a Vice Chair for Education must play to be an effective advocate for radiology education within a department.

RESULTS

Key attributes of an educational leader are delineated, divided into 12 areas or roles.

CONCLUSION

This article summarizes key leadership skills needed by Vice Chairs for Education in order for them to be effective in their role.

Nontraumatic abdominal pain in pregnancy: imaging considerations for a multiorgan system problem

Nontraumatic abdominal pain in the pregnant patient can present a clinician with a variety of diagnostic possibilities. The overlap between signs and symptoms expected in normal pregnancy and these many pathologic possibilities does little to help focus the clinician's diagnostic efforts. Fear of ionizing radiation's effects on the fetus has driven efforts to refine medical imaging algorithms in such a way as to attempt to eliminate its use at all cost. In today's world, we are nearly there. In this review the differential diagnosis of nontraumatic abdominal pain in the pregnant patient will be explored. Of note is the recurring theme that much of what can be done today with regard to diagnostic imaging, both in general and with regard to this specific subset of patients, centers on the use of the non-ionizing modalities of ultrasound and magnetic resonance imaging.

Interpretation of head CT scans in the emergency department by fellows versus general staff non-neuroradiologists: a closer look at the effectiveness of a quality control program

Prior studies have evaluated discordance rates among radiology residents in interpretation of head computed tomograms (CTs). To our knowledge, there has been no study to compare performance among first-year fellows and more experienced general staff radiologists. This study will compare performances of these groups and evaluate the effect of a redundant system as part of a quality control program. Retrospective review of 3,886 consecutive head CTs in the Emergency Department from 7/01/04 to 6/30/2005 was performed. Fellows interpreted 2,150 and general staff radiologists 1,736 cases. Staff radiologist mean experience was 4 years (2-10 years). All primary interpretations were over-read by staff neuroradiologists (>10 years experience) as quality control. Discrepancies were divided into "major discordance" and "minor discordance." Major discordance is defined as a misread occurred that potentially delayed clinical management and thus may have incurred in mortality or disability. Minor discordance is defined as if there was no change in clinical management or impact on the patient's outcome. The patient electronic medical records were obtained and retrospectively reviewed to identify if there was an acute change in clinical management. Overall discordance rate of both groups was 2.7% (103/3,886), 0.3% major false negative (10/3,886), 1.7% minor false negative (65/3,886), 0.4% false positive (15/3,886). Fellows overall discordance rate was 2.6% (55/2,150) with major false negatives 4/2,150 (0.2%) and 2.8% (48/1,736) for general staff radiologists with 6/1736 (0.3%) major false negatives, p values 0.69 and 0.14, respectively. Three out of ten major false negatives were confirmed with the quality assurance interpretation on follow-up studies; four cases were in agreement with initial interpretation. Performance among first-year fellows and general staff radiologists in interpretation of head CTs was highly accurate (97.3%) without statistically significant difference between the groups. The overall relatively low discrepant rate between fellowship trainees and generalist staffs, as well as the negligible change in clinical management, suggests little utility in over-reads of head CT scans by the neuroradiology service as part of a year-round quality control program. However, because of a relative high discrepant rate in the early months of fellowship training (>5%) in our study, it may be wise to implement a quality assurance program in the first few months to improve patient care. Increasing over-reading rate may reduce false negative rate, as the overall false positive rate is relatively low (<0.5%).