Med School Reboot
Many medical schools take an antiquated approach to radiology education, but as imaging awareness increases, some schools are overhauling their programs.
Some things are meant to go together: peanut butter and jelly, peas and carrots, milk and cookies, and radiology and the continuum of patient care. While that last couplet may not be a household phrase, radiology is undoubtedly an integral part of medicine.
Whether a patient needs an X-ray of a simple bone fracture, a mammogram to screen for breast cancer, or an MRI to investigate a life-threatening brain tumor, imaging is intertwined with nearly all aspects of health care.
As medical students learn to care for their patients, appropriate use of imaging is key. For the more than 90 percent of medical students who are not planning on a career in radiology specialties, it is vital to understand imaging's impact on patients, says David M. Naegar, MD, assistant professor of clinical radiology and co-director of the Henry L. Goldberg Center for Advanced Imaging Education at the University of California, San Francisco. "Radiology is such a massive part of health care that if providers do not understand imaging, they cannot be good doctors."
Yet most medical schools do not emphasize radiology education. A 2012 study of U.S. medical schools reveals that just 25 percent require radiology as a clinical rotation.1 Instead, most medical students receive dedicated imaging training only as elective clinical rotations, according to another 2012 survey of medical school deans and radiology department chairs.2 Otherwise, the survey shows, imaging is integrated into preclinical courses, most notably anatomy, and later into core clinical rotations such as internal medicine, surgery, and obstetrics and gynecology.
The use of diagnostic imaging has increased rapidly in recent years. Between 1996 and 2010, the number of CTs performed tripled and MRIs quadrupled among six large integrated health systems alone.3 Naeger says radiology has become increasingly important in health care. But as imaging has advanced, he says, medical school "curricula have changed at a much more deliberate pace, so it's a lot easier for old habits in medical schools' approach to radiology education to persist."
Many medical schools follow an antiquated approach to radiology education, where students can elect to take a radiology rotation only during the fourth year. Waiting until the fourth year may make students less likely to become radiologists because they have already been exposed to and declared their interest in other medical specialties by that time. Caroline W.T. Carrico, MD, associate professor of radiology and director of medical student education in the department of radiology at Duke University, also notes, "By waiting until the final year of medical school to introduce students to diagnostic and interventional radiology, it significantly limits the time that students have to integrate good imaging utilization practices as they learn about and begin to practice patient care." She hopes that moving radiology education into the preclinical and core clerkship year will help students learn basic imaging principles that will help them better use imaging in care of their patients. "In order to be granted valuable time in the medical school curriculum calendar, academic radiology departments will need to create and sustain high-quality instructional courses and learning opportunities for medical students," she says.
Vasantha D. Aaron, MD, assistant professor of clinical radiology and imaging sciences at Indiana University School of Medicine, says schools need a new curricula that gets students involved in radiology rather than just having them observe radiologists at work. "It's hard to be engaged if you're just watching other people work without any participation yourself," she says. One reason that approach has endured is because the Liaison Committee on Medical Education simply says that schools must offer "educational opportunities" in radiology, without specifying what those opportunities should entail.
Emily M. Webb, MD, associate professor of clinical radiology and co-director of the Henry I. Goldberg Center for Advanced Imaging Education at the University of California, San Francisco, says radiologists should petition the Association of American Medical Colleges and the Liaison Committee on Medical Education for explicit radiology training guidelines. "We need more radiologists to advocate on a national level to get established standards and competencies on the books," she says.
Radiologists agree that new curricula should focus less on image interpretation and more on other aspects of imaging. "Historically, people were taught in medical school that everybody needed to know how to interpret images, but as imaging has become more complex and medicine more specialized, it's important that images be interpreted by the people who received dedicated training in it," Naeger says. Instead, medical school training should focus on aspects of imaging as appropriateness, radiologists' roles as consultants in patient care, how to use and understand radiology reports, and the importance of radiologists' interpretations of images. "We don't really care about medical students learning to interpret a CT scan, for instance," Webb says. "We want them to know when to order a CT scan and for what type of indication and when they should ordering an ultrasound instead."
"Radiology is such a massive part of health care that if providers do not understand imaging, they cannot be good doctors." —David M. Naeger, MD
Radiology education is gaining increasing attention in medical schools today, with some schools overhauling their programs. For instance, Duke University recently expanded its radiology elective into a required clerkship. As part of that transition the course went from a predominantly observational approach to a more interactive format. Under the new format, students participate in activities that are geared to help them better understand the complexity of imaging exams. They observe and help with patients during imaging exams and image-guided procedures to develop patient empathy, hear lectures by radiologists and radiology residents, and, when time permits, help interpret imaging studies. Carrico says that curriculum is tailored so that students learn the value of radiology. "I want them to appreciate how useful a radiology consult can be, as opposed to ordering numerous different exams that may or may not be suited to answer the clinical question," she says. "They need to know that they can help guide imaging utilization."
One key to establishing a successful radiology program is having radiologists as teachers. The 2012 survey of medical school deans and radiology department chairs indicates that nonradiologists frequently teach imaging in both preclinical and clinical settings. "As radiologists, we created that problem by not making ourselves available and instead staying in the reading rooms and expecting students to come to us," Webb says. "As the curricula started changing and we hadn't shown up in the classroom yet, other providers took the reins, which is obviously a suboptimal situation because they don't know exactly what these students should be learning." Now that radiologists are showing interest in teaching, Webb says, they are being welcomed into the educational environment. "The other providers are happy to have us take it over," she says.
Teach Them Well
Teaching medical students how to use imaging appropriately will help them improve patient care throughout their careers. Steven M. Westphal, MD, assistant professor of clinical radiology and imaging sciences and program director of nuclear sciences and program director of nuclear medicine at the Indiana School of Medicine, notes that providers often request imaging exams that are not ideal for the problems they want to solve, leading to challenges down the line. "If an inappropriate exam is done, a patient's insurance may not want to pay for it, which could saddle them with a pretty big bill," Westphal explains. "And from a radiologist's perspective, it's frustrating because we have to take time away from looking at scans to call the referring physicians and ask them whether they would prefer another exam." If providers learn about appropriate imaging during medical school, those challenges should diminish.
Comprehensive radiology education may also have a positive impact on the industry as a whole because providers will learn to see radiologists as consultants in health care — a goal of ACR’s Imaging 3.0™ initiative. Aaron says medical schools must stress that radiologists are available to collaborate with providers to ensure high-quality care. "They need to know that they can always call the radiologist or go by the reading room to consult with them just like they would a surgeon or anyone else," she explains. If these concepts are taught early, they will become second-nature to providers. "The goal is to introduce these concepts at the medical-student level so that from the first day, the students see radiologists as partners in patient care," Carrico says. "Hopefully, for the next generation, this will be a routine mindset."
By Jenny Jones
1. Poot JD, et al. “Understanding the US Medical School Requirements and Medical Students’ Attitudes About Radiology Rotations.” Acad Radiol 2012;19(3):369–73.
2. Straus C, et al. “Medical Student Radiology Education: Summary and Recommendations From a National Survey of Medical School and Radiology Department Leadership.” JACR 2014;11(6):606–10.
3. Smith-Bindman R, et al. “Use of Diagnostic Imaging Studies and Associated Radiation Exposure for Patients Enrolled in Large Integrated Health Care Systems, 1996-2010.” JAMA 2012;307(22):2400–09.