Beverly P. Wood

General competencies in radiology residency training: definitions, skills, education and assessment.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project is a long-term initiative by which the ACGME is increasing emphasis on educational outcomes in the accreditation of residency education programs (http://www.acgme.org). The impetus for this project is a system of medical education that relies heavily on public funding and is therefore accountable to the public to meet public needs and prepare well-qualified new physicians as cost effectively as possible. The current model of accreditation focuses on the potential of a residency program to educate residents (ie, whether the program complies with the requirements, has established objectives and an organized curriculum, and evaluates the residents and itself). Examining structure and process, however, is not a direct way to measure the quality of a program’s educational outcomes. In future, accreditation will focus on a program’s actual accomplishments, through assessment of program outcomes (ie, whether residents achieve the stated learning objectives, whether the program provides evidence of this achievement, and whether it demonstrates continuous improvement in its educational process). The ACGME Outcome Project Advisory Committee identified six general competencies that were subsequently endorsed by the ACGME in February 1999: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. By July 2002 all Residency Review Committees (RRCs) must include minimum language regarding the general competencies and evaluation processes in their respective program requirements. A major activity of the Outcome Project was the identification and development of measurement tools for programs to use as part of an overall evaluation system. The ACGME and the American Board of Medical Specialties (ABMS) collaborated on developing a “Toolbox of Assessment Methods” (version 1.1, September 2000; ACGME/ABMS; http://www.acgme.org/outcome/assess /toolbox.asp). The Toolbox includes descriptions of instruments recommended for use by programs assessing the outcomes of their educational efforts, as well as information pertaining to the use, the psychometric qualities, and the feasibility and practicality of different assessment methods. A radiology “quadrad,” made up of representatives from the radiology RRC (including a resident member of the RRC), the American Board of Radiology (ABR), and the Association of Program Directors in Radiology (APDR), was formed in the spring of 2000 to interpret the six competencies as they relate to radiology. The Acad Radiol 2002; 9:721–726

Tutoring Diagnostic Problem Solving

This paper presents an approach to intelligent tutoring for diagnostic problem solving that uses knowledge about causal relationships between symptoms and disease states to conduct a pedagogically useful dialogue with the student. An animated pedagogical agent, Adele, uses the causal knowledge, represented as a Bayesian network, to dynamically generate a diagnostic process that is consistent with the best practice approach to medical diagnosis. Using a combination of hints and other interactions based on multiple choice questions, Adele guides the student through a reasoning process that exposes her to the underlying knowledge, i.e., the patho-physiological processes, while being sensitive to the problem solving state and the students current level of knowledge. Although the main focus of this paper is on tutoring medical diagnosis, the methods described here are applicable to tutoring diagnostic skills in any domain with uncertain knowledge.

Image Gently: Why We Should Talk to Parents About CT in Children

AJR:192, May 2009 The utilization of CT continues to increase in the United States and the world [3, 12]. Since its introduction in the early 1970s, CT use has risen from 2 million studies per year to more than 65 million annually. Each new CT unit purchased from 1995 to 2004 averaged more than 2,200 new studies per year [9]. There are now more than 10,000 CT units estimated to be in operation. Approximately 7 million CT scans were obtained in children in 2007. Although CT examinations make up 11% of the number of radiologic procedures, radiation from CT delivers as much as 70% of the diagnostic imaging–related radiation dose [12]. Broder et al. [13] have indicated dramatic changes in CT use in children. In their pediatric emergency department, visit volume from 2000 to 2006 remained stable, but chest CT increased 435% and cervical spine CT, 366%.

Image Gently: improving health literacy for parents about CT scans for children.

In a pivotal report issued in 2004 (Health Literacy: A Prescription to End Confusion), the Institute of Medicine discussed the critical need for improved health literacy for the 90 million American adults who have difficulty understanding basic health information. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health” [1]. The report indicates that “over 300 studies have shown that health information cannot be understood by most people for whom it was intended.” This report stressed the need for a concerted effort by all stakeholders to improve educational opportunities for patients and their families. Patients often have a poor concept of the radiation dose and risk associated with CT [2]. In a study by Larson et al. [3], only 13% of parents understood that there is a theoretical risk that the radiation associated with CT might increase the risk of cancer. Some experts believe that parents may contribute to the increasing demand for CT as they seek rapid diagnosis and decision making without understanding the potential risks [4]. The purpose of this commentary is to discuss the importance of informing caretakers of children undergoing CT examinations about the potential radiation risk and describe some educational tools, developed by the Alliance for Radiation Safety in Pediatric Imaging, that are now available for hospitals, practices, and parents on the Image Gently and American Academy of Pediatrics (AAP) websites. CT is an invaluable diagnostic and management planning tool for health-care providers treating children and adults [5]. Since its introduction in the 1970s, CT use has risen from 2 million studies per year to over 65 million with 7 million CT scans obtained in children in 2007 [6]. The potential radiation risk from CT scans is receiving considerable attention in both the medical literature and lay press [7–11]. The effect of low-level radiation remains controversial with data supporting several differing perspectives [12–15]. Some leading experts propose that low-level radiation has no effect (that there is a threshold below which no harm occurs). Many scientific organizations and experts, however, advocate that radiation even at low levels has a harmful effect and support the concept of a linear, nothreshold model for ionizing radiation risk of cancer induction [16–20]. Because of decreased body fat, increased radiosensitivity and longer life expectancy, children are at increased risk [21–23]. As the true risk from lowPediatr Radiol (2009) 39:112–116 DOI 10.1007/s00247-008-1101-9

Chest radiographic data acquisition and quality assurance in multicenter studies

Background. Multicenter studies rely on data derived from different institutions. Forms can be designed to standardize the reporting process allowing reliable comparison of data. Objective. The purpose of the report is to provide a standardized method, developed as a part of a multicenter study of vertically transmitted HIV, for assessing chest radiographic results. Materials and methods. Eight hundred and five infants and children were studied at five centers; 3057 chest radiographs were scored. Data were entered using a forced-choice, graded response for 12 findings. Quality assurance measures and inter-rater agreement statistics are reported. Results. The form used for reporting chest radiographic results is presented. Inter-rater agreement was moderate to high for most findings, with the best correlation reported for the presence of bronchovascular markings and/or reticular densities addressed as a composite question (kappa = 0.71). The presence of nodular densities (kappa = 0.56) and parenchymal consolidation (kappa = 0.57) had moderate agreement. Agreement for lung volume was low. Conclusion. The current tool, developed for use in the pediatric population, is applicable to any study involving the assessment of pediatric chest radiographs for a large population, whether at one or many centers.

Pseudohyperphalangism in fetal Dilantin syndrome.

Apparent distal hyperphalangism was observed in three siblings with fetal Dilantin syndrome. Other stigmata of this syndrome were also present. The anomaly in these patients was cuased by division of an otherwise normal phalanx, as opposed to the case in true hyperphalangism.

Renal cystic disease in infants and children.

Renal cystic disease is a common abnormality of the kidney in the pediatric age group. Cystic disease may occur as a sporadic dysplasia or, somewhat more commonly, represent a genetic disorder. Establishment of an accurate diagnosis, prognosis, and treatment requires a broad approach to the problem, including radiologic imaging, renal function testing, and occasionally surgical biopsy. Interpretation of the imaging studies requires understanding of the patterns of renal cystic disease in the pediatric age group.

Competency-based training: accreditation as a pathway to wisdom.

Competence builds on fundamental knowledge, skills, and personal moral and ethical characteristics; that these characteristics can be measured in some way is fostered by accrediting groups, and that they can be gained and further developed requires curiosity, critical awareness, and self-assessment

Commentary on “A Critical Review of the Classic Metaphyseal Lesion: Traumatic or Metabolic?”

197 Ayoub et al. [1] that classic metaphyseal lesions are not traumatic lesions contradicts published investigations and is made in contrast to the classic discussions of child abuse in publications such as that of John Caffey [5].” Caffey noted these lesions as early as the 3rd (1956) edition of his text, Pediatric X-Ray Diagnosis [5], in which metaphyseal “chip” fractures occurred in the entity he termed “traumatic infantile hyperostosis.” In a 1957 article [6] and the 4th (1961) edition of his text, Pediatric X-Ray Diagnosis [7], Caffey presented a diagram depicting “corner” and “bucket-handle” patterns of metaphyseal injury. In the 6th and subsequent editions of his book, Caffey stated that these injuries were the consequence of the battered child syndrome. Kleinman (Kleinman PK, oral communication, 2013) noted that Frederick Silverman [8] wrote about Caffey’s assertion that these lesions represented inflicted injuries. In 1953, Silverman [9] used the term “metaphyseal lesions,” and stated that these injuries were due to child maltreatment. He continued to do so in the textbook, The Battered Child [10], which led to multiple texts and scientific articles that mentioned similar characteristic inflicted injuries. In 2011, to provide further evidence of the association of classic metaphyseal lesions and abuse, Kleinman et al. [11] identified the absence of metaphyseal abnormalities in 42 low-risk infants versus nine classic metaphyseal lesions in 18 infants who were at high risk for physical abuse, and they found a statistically significant difference (p < 0.0001) between the two groups. According to Dr. Kleinman (Kleinman PK, oral communication, 2013), Ayoub and his coauthors [1] do not justify their stated conclusion that, “Classic metaphyseal lesions are not true fractures but rather a combination of tissue-processing artifacts and misinterpreted findings of healing rickets.” Kleinman and his coinvesCommentary on “A Critical Review of the Classic Metaphyseal Lesion: Traumatic or Metabolic?”

Blended learning in medicine: trouble in paradise?

529 thoughts, and are eager to form communities that can discuss common problems and issues. Principles and advantages of blended learning include the following: 1. Collaboration 2. Knowledge sharing, learning from others 3. Reapplication of knowledge and learning of others based on experience and shared context 4. Differentiation based on region, culture, population 5. Effective technology environments and application With online communities becoming ubiquitous, this form of learning and sharing experiences has replaced the need to attend the same course or meeting or to communicate synchronously. We all await the day when “blended” is eliminated from the vocabulary, and the term refers only to “learning” in whatever form or delivery it takes [3]. Beverly P. Wood Section Editor Pediatric Imaging bwood@usc.edu