Michael A. Brooks

MEDICAL EDUCATION AND THE TYRANNY OF COMPETENCY

Those who educate medical students and physicians work in a world suffused with the concept of competency. This article examines the intellectual origins and hidden assumptions of this concept and argues that it is an inadequate, and even harmful, concept to use as a guiding motif for professional education. The competency model—which tends to be top-down and prescriptive—does not provide the framework for objective educational assessment that it claims to provide. The alternative apprenticeship model is more appropriate for professional education and is more consistent with what psychological research has shown about the acquisition of expertise.

Reproducibility and validity of lung density measures from cardiac CT Scans--The Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study.

RATIONALE AND OBJECTIVES Cardiac computed tomographic (CT) scans for the assessment of coronary calcium scores include approximately 70% of the lung volume and may be useful for the quantitative assessment of emphysema. The reproducibility of lung density measures from cardiac computed tomography and their validity compared to lung density measures from full-lung scans is unknown. MATERIALS AND METHODS The Multi-Ethnic Study of Atherosclerosis (MESA) performed paired cardiac CT scans for 6814 participants at baseline and at follow-up. The MESA-Lung Study assessed lung density measures in the lung fields of these cardiac scans, counting voxels below -910 HU as moderate-to-severe emphysema-like lung regions. We evaluated: 1) the reproducibility of lung density measures among 120 randomly selected participants; 2) the comparability of measures acquired on electron beam CT (EBCT) and multidetector CT (MDCT) scanners among 10 participants; and 3) the validity of these measures compared to full-lung scans among 42 participants. Limits of agreement were determined using Bland-Altman approaches. RESULTS Percent emphysema measures from paired cardiac scans were highly correlated (r = 0.92-0.95) with mean difference of -0.05% (95% limits of agreement: -8.3, 8.4%). Measures from EBCT and MDCT scanners were comparable (mean difference -0.9%; 95% limits of agreement: -5.1, 3.3%). Percent emphysema measures from MDCT cardiac and MDCT full-lung scans were highly correlated (r = 0.93) and demonstrated reasonable agreement (mean difference 2.2%; 95% limits of agreement: -9.2, 13.8%). CONCLUSIONS Although full-lung imaging is preferred for the quantification of emphysema, the lung imaging from paired cardiac computed tomography provided a reproducible and valid quantitative assessment of emphysema in a population-based sample.

Identification of Coronary Artery Calcification and Diagnosis of Coronary Artery Disease by Abdominal CT : A Resident Education Continuous Quality Improvement Project

RATIONALE AND OBJECTIVES Coronary artery calcium (CAC) scoring is an excellent imaging tool for subclinical atherosclerosis detection and risk stratification. We hypothesize that although CAC has been underreported in the past on computed tomography (CT) scans of the abdomen, specialized resident educational intervention can improve on this underreporting. MATERIALS AND METHODS Beginning July 2009, a dedicated radiology resident cardiac imaging rotation and curriculum was initiated. A retrospective review of the first 500 abdominal CT reports from January 2009, 2011, and 2013 was performed including studies originally interpreted by a resident and primary attending physician interpretations. Each scan was reevaluated for presence or absence of CAC and coronary artery disease (CAD) by a cardiovascular CT expert reader. These data were then correlated to determine if the presence of CAC had been properly reported initially. The results of the three time periods were compared to assess for improved rates of CAC and CAD reporting after initiation of a resident cardiac imaging curriculum. RESULTS Statistically significant improvements in the reporting of CAC and CAD on CT scans of the abdomen occurred after the initiation of formal resident cardiac imaging training which included two rotations (4 weeks each) of dedicated cardiac CT and cardiac magnetic resonance imaging interpretation during the residents second, third, or fourth radiology training years. The improvement was persistent and increased over time, improving from 1% to 72% after 2 years and to 90% after 4 years. CONCLUSIONS This single-center retrospective analysis shows association between implementation of formal cardiac imaging training into radiology resident education and improved CAC detection and CAD reporting on abdominal CT scans.

Synthetic ECG-Gated Cardiac Computed Tomography for In Vivo Imaging of the Temporary Total Artificial Heart

To date, there have been >1000 implantations of temporary total artificial hearts (TAH-t). As expected, complications related to the use of the TAH-t can occur.1 A noninvasive imaging modality that would be capable of diagnosing mechanical failure, surgical complications, and thromboembolic phenomena related to the TAH-t is desirable. Echocardiography is not suitable to evaluate a TAH-t because ultrasound cannot penetrate air and the polyurethane components in the TAH-t assembly. Cardiac magnetic resonance imaging is likewise unsuitable because of the susceptibility to artifacts that the titanium valve components in the TAH-t would create. Conventional computed tomography (CT) is limited by motion artifact.2 Cardiac CT (CCT) can produce motion-artifact–free images of the heart. If performed with retrospective gating, CCT can also be used to acquire time-resolved images. However, CCT requires simultaneous recording of the patient’s ECG, and patients who have a TAH-t do not generate an ECG. Consequently, a variation in technique is necessary to image patients with TAH-t with this modality. Detailed below …

A potential role of ECG-gated CT for the diagnosis of pulmonary vein thrombus: an illustrative case report

The presence of tumor thrombus in patients with lung cancer confers a risk of stroke and other end-organ ischemic events. This case highlights a potential role for electrocardiogram (ECG)-gated computed tomography (CT) in the diagnosis of this pathologic process. In this case, pulmonary vein thrombus was definitively identified by an ECG-CT following discordant results between CT and transthoracic echocardiogram. In addition, this case demonstrates how management decisions are affected by physician accessibility to and familiarity with specific imaging tests.