Although the correct ordering and interpretation of imaging tests are essential skills for physicians, only 25% of U.S. medical schools require rotations or clerkships in radiology. Without an adequate education in radiology, students leave medical school not at all confident in their abilities to select and interpret these studies. Left unchecked, these gaps in knowledge may follow the trainee into practice, compromising the physician's ability to deliver high quality care. You have the power to change that, and your radiology rotation will allow you to build a stronger foundation in this very important area.
The radiology rotation takes on added importance for students seeking to pursue radiology as a career. NRMP surveys of residency program directors have shown that radiology rotation performance is an important factor used to make interview decisions. In the 2016 survey, "grades in clerkship in desired specialty" was given a mean importance rating of 4.3 on a scale of 1 (not at all important) to 5 (very important). Letters of recommendation in the specialty were also highly rated in the selection process, and these letters are often based on student performance during the rotation.
I am often asked for advice on how to do well in the radiology rotation or clerkship. Below I offer some very specific recommendations to make the most of your learning opportunities in this important rotation, and leave your attending and resident with a favorable impression.
Learn How To Interpret Chest And Abdominal Radiographs
The ability to accurately interpret chest and abdominal films is of obvious importance for residents and practicing physicians. However, the evidence indicates that many physicians lack confidence in image interpretation. Studies have shown that inaccurate interpretation is common among primary care physicians, emergency medicine physicians, and anesthesiologists. In one study of medical students, residents, and fellows, a correct diagnosis of pneumothorax, misplaced central line, and pneumoperitoneum was made only 9%, 26%, and 46% of the time, respectively. "Only 14% of the participants felt capable of interpreting CXR independently," wrote the authors. Given these findings, medical students rotating through radiology should make the interpretation of chest and abdominal radiographs a priority.
Become Familiar With Appropriate Imaging Tests For Different Problems
MRI, CT, or ultrasound? This is a question that comes up countless times every day in hospitals and clinics across the country. Not uncommonly, the imaging test that is chosen is not the most appropriate for the patient's particular condition or problem. The end result is the performance of unnecessary tests at considerable expense.
Although you may enter your radiology rotation focused on gaining comfort and confidence in your ability to read studies, I also recommend that you take a step back, and ask yourself if the study ordered is the most appropriate test for the question at hand.
In the 1990s, the American College of Radiology first developed evidence-based appropriateness criteria for imaging tests. These guidelines are updated annually by diagnostic imaging experts, and made available at the organization's website. Although radiologists are familiar with these guidelines, specialists in other fields are generally unaware that this resource exists. This is an excellent resource for medical students as well, and you are encouraged to refer to it regularly during your radiology rotation and beyond.
Observe Effective Communication Between Radiologists And Referring Physicians
Although in-person communication was a staple of the radiologist's workday in decades past, changes in technology placed more and more distance between radiologists and referring physicians. Now the pendulum is ready to shift back, as there is a growing body of evidence showing the benefits of face-to-face communication in the delivery of high quality patient care.
While a large part of your time will be spent reading studies with your team, you'll also be able to observe interactions between radiologists and referring physicians, either over the phone or in person. Your attending may pick up the phone to notify a provider about critical findings. A resident may consult with your attending, inquiring about the most appropriate imaging study to answer a difficult clinical question.
Carefully observe these interactions from the perspective of both the radiologist and referring physician. What are the elements of an effective collaboration? What behaviors or attitudes will you incorporate into your own practice, either as a referring physician or radiologist, to facilitate an accurate exchange of information that leads to the selection of the best test?
Maintain The Radiologist's Efficiency
The workload for today’s radiologist has increased tremendously. According to a study published in Academic Radiology, the number of images requiring interpretation per minute per staff radiologist has risen from 2.9 in 1999 to 16.1 in 2010.
“The modern radiologist must now interpret many times more examination images when compared to similar examinations performed 10–20 years ago,” wrote the authors. “Although these advances in sensitivity and specificity are thought to translate to improved patient care, these increasing imaging volumes are placing an ever-increasing burden on the practicing radiologist."
What does this mean for you as a medical student? It means that you must take care not to decrease your attending radiologist’s efficiency.
Ask Questions At Appropriate Times
How often are radiologists interrupted? In a detailed time study of neuroradiology fellows, researchers at the University of Wisconsin found that fellows had to switch from interpretive to non-interpretive tasks more than 11 times per hour.
"Image interpretation is a very cognitively demanding task -- exactly the kind of thing that is highly susceptible to errors in the setting of frequent disruption," says Dr. Akash Kansagra, Assistant Professor in the Department of Radiology at the Washington University Mallinckrodt Institute of Radiology.
Medical students should realize that they too can be a source of interruptions, especially by asking questions at inappropriate times. Your education is important but you must look for appropriate times to ask questions. A useful approach is to ask your attending or resident for their preferences when you join them in the reading room to start your day.
Maintain Your Interest And Enthusiasm
"We are a friendly bunch, who enjoys what we do, and we are eager to share our knowledge and experiences with you," writes the Department of Radiology at the University of Wisconsin. You'll find that many radiologists are eager to teach, and enjoy educating enthusiastic medical students.
Between periods of teaching, there may be long stretches of time in which there is little or no interaction. During these times, your interest and energy level can easily wane. One medical student from Stanford University described what typically happens:
However, as a medical student, shadowing in the reading rooms can be quite tedious. The radiology residents themselves, and even some of the attendings, point-blank told me that this would be the case. As a medical student, there is almost nothing you can contribute to the process, and you can only ask a few questions here and there, because they do have work to do, and don’t have time to explain to you about everything that they are seeing or thinking...
Do Your Part To Reduce Environmental Noise In The Reading Room
Although you may think of the reading room as a quiet place where the radiologist is able to intensely focus, environmental noise is a problem for many radiologists, as described below in an article published in Radiologia:
There are many elements that contribute to environmental noise in a radiology department: the examination rooms with their beep shots, film processors, personnel giving instructions to patients, issuing of reports or conversations, clinical consultations and among users either over the phone or in person. This volume of noise can be found in conventional radiology rooms as well as in digital environment ones, where the latter also have the equipment of the workstations, air conditioning systems and printers that make noise. Background noise is a ‘‘silent’’ enemy that we can get used to, but it can increase fatigue and decrease user’s productivity when interfering with report dictation.
The use of voice recognition software to dictate reports is becoming much more common. During the dictation process, students must remain quiet. Errors in the dictation can easily occur because of background noise.
Prepare For The Next Day's Assignment
In most radiology rotations, medical students spend several days in one section of the department before rotating through another section. In this manner, a student may be exposed to chest imaging, musculoskeletal imaging, body CT/MR, ultrasound, neuroradiology, nuclear medicine, breast imaging, and interventional radiology. To prepare for each section, advance reading is recommended. Below are some online tutorials which students have found useful.
Make The Most Of Your Learning Opportunities
Most radiologists will stop from time to time to point out findings. If you’re asked to read a film or study, go through your approach and thought process out loud. That’s far better than remaining silent for several minutes. If you can offer a diagnosis, great. If not, you have at least succeeded in describing what you see, and doing so in an orderly manner.
Clerkships may allow students to take a more active role in the reading room. For example, the student may be assigned several cases to assess at their own workstation. Following this, cases are reviewed in depth with the faculty member. If this is not part of the structure of your radiology rotation, some degree of assertiveness may be necessary for you to assume a similar role. If you notice that a workstation is free, ask your attending if you can read some studies on your own. Then when the attending is free, review your findings. Although this can be an excellent way to learn, the feasibility of this approach is obviously limited by the availability of an open workstation.
Be Professional In Your Interactions
In an interesting opinion piece published in Diagnostic Imaging, Dr. Junzi Shi describes the perceptions of the radiology elective or rotation among medical students. "The radiology rotation in US medical schools is known for being an easy rotation for third- and fourth-year medical students. The term on the street is 'radiation vacation.'"
The way in which students view or approach the rotation can have an effect on their attitudes and behaviors. As with other rotations, your professionalism matters. Heed the words of the Department of Radiology at the Geisel School of Medicine:
The workstations are our offices and consulting rooms. Talking loudly, discussing personal matters, answering a cell phone and similar behaviors are unprofessional and distracting while we are reading studies. Any behavior that would be inappropriate during a clinical interaction is inappropriate in our reading rooms.
In your desire to make a favorable impression, take care not to make others look bad. If the attending directs a question to a resident, it would be considered poor form for the medical student to blurt out the answer. Yet this happens more often than you would expect. Don’t be one of those students.
Develop A Strong Relationship With An Attending Physician
During most radiology rotations, students move from one service to another every few days. This can make it difficult for students to form close relationships with any one attending. "Every half day you spend with a different person," wrote one student. "So you establish no relationship with anyone. No one ever gives you meaningful feedback...no one gets an idea of where you are at because no one sees you for more than 3 hours..."
For students seeking to secure a strong letter of recommendation, this presents a major problem. Look for ways to work with an attending beyond the normal workday. Consider participating in a research project or collaborating on a case report or review article. If that fails, remember that you can always do a subspecialty radiology rotation which will allow for much more interaction on a single service.
Finally, I would like to leave with you with some excellent advice offered in the video below featuring Dr. Petra Lewis, Professor of Radiology at the Geisel School of Medicine. Medical students interested in radiology as a career will find this information particularly useful.
Dr. Samir Desai is the author of The Successful Match 2017 and the co-host of the Success in Medicine podcast.