Arvin E. Robinson

On Teaching Radiology to Medical Students: A Commentary

The article by Scheiner and colleagues of Brown Medical School (Providence, RI) (1) and the correspondence from Afaq of the Imperial College School of Medicine (London, England) (2) in this issue of Academic Radiology reiterate an old problem. In fact, Afaq cites 30 years of references on the difficulty of gaining access to medical students to teach them radiology. The senior author’s experience at four medical schools confirms this impression. Although we found radiology course electives to be popular, they were never required until we reached the University of Rochester. However, development of our “double helix” curriculum with emphasis on problem-based learning and small-group discussions led to the demise of this short radiology lecture series for preclinical medical students. Scheiner et al (1) most ably present the problem that currently exists. Medical students now receive most of their initial exposure to radiographic images through daily patient rounds on their clinical services. Although the clinicians who lead these rounds are most knowledgeable about basic radiographic findings within their specialty, there is a tendency for the clinicians to overread the images when influenced by physical findings and clinical history. In addition, these rounds are held in large groups, and the medical student rarely obtains an optimal position for viewing the images and hearing the discussion. This is now further compromised by workstation reviews in the filmless environment. When viewed from an off-center location, many monitor screens lack full fidelity and in fact obscure detail for everyone except those few within direct vision. Let us reemphasize that our clinical colleagues are not always uncomfortable reviewing radiologic images of disorders in their specialty or subspecialty. When our ultrasound (US) section converted to a filmless system, we did not anticipate the objection and inconvenience expressed by some of our colleagues, most notably pediatric urologists and pediatric orthopedists. Although US images in many cases are static representations of dynamic evaluations (similar to fluoroscopy), these clinicians used the film images (and now paper copies that we presently supply) to discuss patient care issues with the children’s families. However, even though clinicians may be knowledgeable and comfortable viewing images, they usually teach imaging as a correlative adjunct to physical diagnosis and clinical history rather than as a scientific depiction of the pathophysiology of disease. The emphasis of the new curriculum on problem-based learning and small-group discussions is an opportunity for radiologists to be more effective as consultants. However, participation in this new curriculum is extremely labor intensive. Since only a few medical students can be taught at a time, multiple groups of students must be taught; thus it is difficult to find enough radiologists to teach all of these groups because it impinges on their limited clinical and academic time. Medical student teaching is too often considered a distraction from the perceived primary goal of resident education. Radiology clinical clerkships are still a ready opportunity for teaching and medical student contact. They are also more effective when available in the 3rd or 4th year of medical school. If special attention is to be paid to medical student education, it may become difficult to find enough space to accommodate all students that are interested. However, observation of image interpretation sesAcad Radiol 2002; 9:224–225

Integration, acceptance testing, and clinical operation of the Medical Information, Communication and Archive System, phase II

The Medical Information, Communication and Archive System (MICAS) is a multivendor incremental approach to picture archiving and communications system (PACS). It is a multimodality integrated image management system that is seamlessly integrated with the radiology information system (RIS). Phase II enhancements of MICAS include a permanent archive, automated workflow, study caches, Microsoft (Redmond, WA) Windows NT diagnostic workstations with all components adhering to Digital Information Communications in Medicine (DICOM) standards. MICAS is designed as an enterprise-wide PACS to provide images and reports throughout the Strong Health healthcare network. Phase II includes the addition of a Cemax-Icon (Fremont, CA) archive, PACS broker (Mitra, Waterloo, Canada), an interface (IDX PACSlink, Burlington, VT) to the RIS (IDXrad) plus the conversion of the UNIX-based redundant array of inexpensive disks (RAID) 5 temporary archives in phase I to NT-based RAID 0 DICOM modality-specific study caches (ImageLabs, Bedford, MA). The phase I acquisition engines and workflow management software was uninstalled and the Cemax archive manager (AM) assumed these functions. The existing ImageLabs UNIX-based viewing software was enhanced and converted to an NT-based DICOM viewer. Installation of phase II hardware and software and integration with existing components began in July 1998. Phase II of MICAS demonstrates that a multivendor open-system incremental approach to PACS is feasible, cost-effective, and has significant advantages over a single-vendor implementation.

Archive selection for the MICAS, a multi-vendor incremental approach to PACS

From the time a decision was made to purchase an archive until a purchase order was issued took approximately 10 months. During this period an RFI was developed, issued and the results analyzed. Technical discussions were held and site visits were made. To ensure that current information was available, a complete review of available multi-modality DICOM compliant archives were made at the 1997 RSNA. With this information in-hand and the future development path for MICAS specified, a detailed RFQ was developed, responses were received and evaluated. A purchase order was to be issued by the end of the first quarter 1998. The archive vendor will have been selected by the time this paper appears in print. The oral presentation of this work will review the responses of the archive vendors and present the basis for selection. It is planned to publish our findings. The archive is the heart and brains of PACS. It controls information acquisition, distribution and storage plus work flow. It is critical that DICOM compliance and interoperability between all components of the PACS be an absolute requirement, especially for the archive.

Melanoma metastatic to the bronchus: radiologic features in two patients.

Two patients with cutaneous melanoma metastatic to the bronchus are described. Chest radiographs revealed only indirect signs of bronchial obstruction. Computed tomography (CT) clearly demonstrated the intraluminal lesion. Magnetic resonance (MR) imaging signal characteristics were not specific for melanoma.

The strategic and operational characteristics of a distributed phased archive for a multivendor incremental implementation of picture archiving and communications systems

The long-term (10 years) multimodality distributed phased archive for the Medical Information, Communication and Archive System (MICAS) is being implemented in three phases. The selection process took approximately 10 months. Based on the mandatory archive attributes and desirable features, Cemax-Icon (Fremont, CA) was selected as the vendor. The archive provides for an open-solution allowing incorporation of leading edge, “best of breed” hardware and software and provides maximum flexibility and automation of workflow both within and outside of radiology. The solution selected is media-independent, provides expandable storage capacity, and will provide redundancy and fault tolerance in phase II at minimum cost. Other attributes of the archive include scalable archive strategy, virtual image database with global query, and an object-oriented database. The archive is seamlessly integrated with the radiology information system (RIS) and provides automated fetching and routing, automated study reconciliation using modality worklist manager, clinical reports available at any Digital Imaging and Communications in Medicine (DICOM) workstation, and studies available for interpretation whether validated or not. Within 24 hours after a new study is acquired, four copies will reside within different components of the archive including a copy that can be stored off-site. Phase II of the archive will be installed during 1999 and will include a second Cemax-Icon archive and database using archive manager (AM) Version 4.0 in a second computer room.

Maintaining consultation skills in today's practice environment.

Many excellent points are brought forward in Dr Gunderman’s presentation in this issue of Academic Radiology (1). Interpersonal and communication skills are surely important and need to be taught and perfected in the residency environment. The academic radiologists are responsible for the manner in which their graduates practice their specialty. Curiosity is important if the information gained is effective in synthesizing the radiologic findings with the clinical parameters. However, it is also important that questions asked or information received relate to the radiologic interpretation. Otherwise, time may be wasted with ineffective communication that is not focused and productive. While we have the responsibility to advocate for radiology, other physicians also feel obliged to do so for their specialty. We need to be sure to not be too critical of their diagnostic skills in gleaning the important points that need to be pursued by radiologic imaging or other procedures. The radiologist who plays “20 questions” before rendering an opinion might become more confused than helpful. Honesty is also essential, particularly when there is a tendency to be less direct for fear of adverse medical legal or practice profile consequences. Helpfulness is important but needs to be carefully tempered with timeliness and efficiency. Larger groups or sections might develop a frontline or an “officer of the day” assignment that allows others to pursue consultation and teaching in a less interrupted environment. Timeliness requires a delicate balance between helpfulness and efficiency. Radiology is a victim of its own circumstances. Continued development of new technologies has broadened opportunities for less-invasive diagnostic and interventional procedures than have previously been encountered. The resultant “mountains of clinical work” are compounded by the current radiology staffing shortage. This is particularly critical in the academic environment, where we need to practice good radiology in order to teach it effectively. Reimbursement schemes and incentive plans are not the cause of ineffective or improper consultation. However, the magnitude of the clinical workday compounds the difficulties in achieving all of Dr Gunderman’s goals. As we approach this new era in radiology of a filmless