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The Vital Role of Radiology in the Medical School Curriculum

¹ All authors: Department of Radiology, Indiana University School of Medicine, Rm. 1053, 702 Barnhill Dr., Indianapolis, IN 46202-5200.

Received August 20, 2002; accepted after revision October 3, 2002.

 
Address correspondence to R. B. Gunderman (rbgunder{at}iupui.edu).

Introduction

Top Introduction Why Is Radiology Needed? The Payoff Conclusion References

 
One could hardly imagine a less auspicious time to argue that radiology should play a greater role in the medical school curriculum. The curricula of the 125 United States medical schools are overstuffed, and their 65,000 medical students are staggering under the growing load of information they are expected to assimilate. Discussions of curricular innovation and reform frequently take on the character of turf wars, departments vying with one another to defend their piece of an ever more hotly contested pie. With clinical payments for radiologic services falling, academic radiologists are under increasing pressure to augment their clinical productivity, making time for teaching an ever scarcer commodity. When every hour an academic radiologist devotes to medical student teaching represents an hour of lost clinical productivity, some departments are seeking ways to reduce their teaching commitments, reallocating faculty members' time to noneducational activities that generate revenue. Hospital administrators and medical school deans are disinclined to object, because radiology is one of the key clinical revenue centers on which they have come to rely to preserve their operating margins.

Despite these inauspicious signs, however, the need for radiology in the medical school curriculum has never been greater. A substantial role in medical education is vital to radiology's own self-interest, and the need for radiology to contribute to the education of the next generation of physicians has never been greater. In a time of rapid change in biomedical science and health care, some of the traditional assumptions about medical education no longer hold true. For example, the traditional expectation that medical students will learn the structure of the human body from faculty members in anatomy is falling by the wayside, because revenue once afforded anatomists is shifting to such fields as molecular biology. Many medical schools now go begging for someone to teach gross anatomy.

Similarly, as medicine has become more and more specialized, the educational experience of students has become increasingly fragmented. The traditional mainstays of medical education, such as pathology, find it increasingly difficult to provide students with a truly integrated and comprehensive overview of how the various pieces of the puzzle of contemporary medical practice fit together. It is time to develop new centers of educational excellence in our medical schools, and this is a role that radiology is remarkably well equipped to play.

The time is ripe for radiology to play a greater role in our country's medical education [1]. We should no longer willingly cede the use of imaging in medical education to other disciplines; for example, emergency medicine physicians and pulmonologists should not be the principal faculty members who teach medical students how to interpret chest radiographs [2]. On the contrary, radiology leaders should be fighting to ensure that students learn radiology from radiologists, and the rationale for such an objective should be that radiologists teach diagnostic imaging better than anyone else. Instead of allowing administrators to consign radiology to the role of a service department with no educational commitment except to its own residents, radiologists should play a leading role in charting the future course of medical education. Medical student education need not be regarded as a money loser, and department chairs should convince medical school deans that the deans should help pay for the vital educational contributions that a committed department of radiology is capable of providing. In short, it is time for a new paradigm for radiology in medical education.

Why Is Radiology Needed?

Top Introduction Why Is Radiology Needed? The Payoff Conclusion References

 
To strike a target, it is necessary to see it. To promote an expanded and more integral role for radiology in the education of medical students, it is necessary to have clearly in mind what such a role would look like. Merely saying that radiology can make a greater contribution is not sufficient. Before entering curricular discussions, each radiology educator needs a clear approach to three questions: What is the current state of medical student education in my institution? Where can radiology make the greatest contributions? And what resources would be necessary for radiology to play such an expanded role? The precise shape of radiology's educational niche will vary from institution to institution, but a number of broad principles apply across the board. What follows is a discussion of the crucial second question concerning the nature of the substantial contributions radiology departments can make at virtually any institution.

In what context does the contemporary physician most frequently encounter the internal anatomy of the human body? The answer is not the dissection table, the pathology laboratory, or even the operating room. For most physicians, including even most surgical subspecialists (who often decide when and how to operate on the basis of imaging studies), the answer is radiology. From humble radiographs of the chest and bone to state-of-the-art multidetector CT, functional MR imaging, and positron emission tomography, radiologic images constitute the principal venue through which practicing physicians encounter their patient's internal anatomy. Moreover, the anatomy they encounter is not the static, distorted anatomy of the cadaver or the pathologic specimen, but the living anatomy of patients whose history and physical examination findings can be directly correlated. Not only anatomy but physiology and pathology are brought to life by radiology's ability to peer beneath the surface of the human body without cutting it open. Radiology's true-to-life view of such basic medical sciences holds immense educational promise.

Radiology also provides students with some of the most striking vistas in all of medicine: indelible images of human health and disease that help to illustrate for the imagination and anchor in the memory otherwise vague and intangible concepts [3]. In the past, occasional students might, through the autopsy, see how physical examination findings are grounded in pathologic anatomy. Today, by contrast, radiologic images render such anatomic correlation universally accessible, and without the patient's dying. Students sometimes study cardiac physiology without really understanding how the heart works until through nuclear medicine, CT, or sonography, they can see a patient's beating heart, directly visualizing the difference between end-diastolic and end-systolic volume, and the opening and closing of valves. Radiology provides pictures to go with concepts, enabling students to see the biologic signatures of microscopic disease processes in their patients' organs and tissues. Said one student, "I never really understood what diseases like cancer were until I looked at them on a CT scan. Once I saw inside, then I knew. Once I saw inside my own patients, then I knew even better."

Radiology enjoys an unparalleled opportunity to play an integrative role in contemporary medical education [4]. No other medical specialty regularly interacts with such a wide range of medical disciplines. The contemporary practice of neurology, neurosurgery, otolaryngology, cardiology, pulmonology, gastroenterology, orthopedic surgery, urology, obstetrics and gynecology, and a host of pediatric and surgical specialties would be rendered nearly unrecognizable without the regular input of diagnostic imaging.

Radiology enjoys a more comprehensive view of these different domains of expertise than any other department in the hospital. It lies in the vital interests of medical education that radiology capitalize on this opportunity. With an image as basic as a chest radiograph showing cardiomegaly and pulmonary edema, a radiologic educator can show beautifully what happens to a patient in congestive heart failure, integrating such diverse concepts as myocardial contractility, the Starling forces, and shortness of breath into a single coherent narrative. What medical students need is not more facts or a greater number of trees with which to populate their forest. They need an opportunity to step back and see how all the trees fit together and what that larger forest looks like. This panoramic, integrative view is one that radiology is ideally situated to provide.

Why do so many medical specialties converge on radiology? The answer is because more than ever before, radiology is the department that provides the answers. A patient with a cough and fever needs a chest radiograph to assess for pneumonia. A patient with acute abdominal pain and vomiting needs an abdominal radiograph to assess for bowel obstruction. A patient with a severe headache needs a CT of the head to assess intracranial hemorrhage. Virtually every practicing physician who sees patients regularly relies on radiology for help in determining which patients are really sick, what diseases they have, and how extensive their diseases are. Moreover, radiology plays an important role in defining treatment options, and, in the interventional setting, provides definitive therapy. Thanks to cross-sectional imaging, exploratory laparotomies have become largely a relic of the past. Instead of admitting emergency department patients to the hospital to see how their conditions evolve, imaging enables patients to be scheduled immediately for surgery, or, more commonly, to be sent home, markedly reducing costs and enhancing peace of mind. Radiology now represents an essential link in the health care chain, so much so that radiologic studies are sometimes ordered even before the referring physician sees the patient.

No matter what specialty they go into, medical students need to acquire a basic understanding of radiology and its use in contemporary medical practice. First, they need to know what tests to order [5]. Should the patient with head trauma receive radiographs of the skull? What imaging test is most appropriate in a patient with an acute abdomen? What if the patient is pregnant? When should IV contrast material be ordered for a CT scan of the head?

Students also need to acquire basic skills in image interpretation so that they are adequately prepared for postgraduate training. It is embarrassing to be an intern in the emergency department who has no clue how to read a chest radiograph. Particularly in situations in which radiologic interpretation is not immediately available, students should learn to recognize urgent radiologic findings such as a malpositioned endotracheal tube, pneumothorax, pneumoperitoneum, and a large intracranial hemorrhage [6]. In view of the integral role of radiology in contemporary medicine, how can medical schools presume to be doing a good job educating the next generation of physicians when their students receive little or no formal instruction in radiology?

Radiology provides an excellent forum in which to teach some of the most basic principles of medical reasoning. Many medical schools suppose they are providing adequate instruction in this area through courses in such subjects as biostatistics, but often nothing could be further from the truth. Divorced from the context of patient care and overly reliant on mathematic techniques, many biostatisticians leave medical students bewildered or simply cold, with little in the way of practically usable knowledge or skills. By contrast, radiology provides a context in which students can stop trying to juggle abstract probabilistic techniques and instead focus on integrating clinical features and imaging findings in the context of real cases [7]. In the setting of lung cancer detection, what is the sensitivity, specificity, and accuracy of chest radiography and how does it compare with CT? What are the effects of pretest probability of disease, such as whether the patient has a long smoking history, and how does such information apply to the different contexts of screening and diagnosis? What roles in this equation are played by benefits such as prolonged survival and costs such as lost productivity? How can we assess the larger effectiveness and efficiency of diagnostic testing? Most importantly, how do these concepts pertain to this particular patient for whom we are thinking of ordering a chest radiograph?

Equally important, radiology provides an excellent forum in which to address the widely neglected topics of health promotion, disease prevention, and community health. The clinical curricula of many medical schools are focused almost exclusively on the diagnosis and treatment of disease in individual patients, a situation in which medicine's performance is mixed, at best. For example, the 5-year mortality rate of approximately 90% for bronchogenic carcinoma, the number one cancer killer in the United States, has changed relatively little over the past few decades. Approximately 90% of such cancers are attributable to cigarette smoking, and one of the most important predictors that a patient will attempt to quit smoking cigarettes is being advised to do so by a physician. Even when so advised, however, 90% of such attempts end in failure. The chest radiographs, CT scans, and nuclear medicine studies commonly used to diagnose, stage, and monitor progression of lung cancers provide medical students with vivid pictures of the insidious and relentless modus operandi of this disease, conferring on public health statistics an immediacy they might otherwise lack. Moreover, these images deserve wider use in such contexts as patient counseling and public health education, in which current smokers can be more effectively persuaded to kick the habit and school children can be more strongly dissuaded from ever adopting it. When people see firsthand what smoking can do to the human body, they are more inclined to take its risks seriously. A related discussion in which medical students need to be involved is the proposed use of chest CT to screen smokers for early-stage lung cancer, including such issues as the design of clinical trials, the potential biases of screening programs, and various methods for measuring their costs and benefits. Medical students should learn to think of health not only in terms of individual patients but populations as well. Radiology provides an excellent forum in which to discuss such principles.

Through exposure to radiology, students can be taught the importance of communication, a vital but frequently neglected art in contemporary medical education. When a physician orders an imaging study, what sort of information should be provided? Is it enough to tell the radiologist that the study is being performed to rule out pneumonia, or does the radiologist need to know about fever, cough, chronicity of the complaints, and any underlying medical conditions? What sort of output should the referring physician expect to receive from the radiologist, and what is the effect of the quality of this output on the referring physician's ability to formulate a specific question or questions? What information is truly relevant in helping the radiologist to determine which examination to perform, how to perform it, or even whether an imaging examination is really indicated in the first place? What diagnostic information from the radiologist is truly relevant to the care of the patient, and how can that information be conveyed in a way that optimizes the contribution radiology makes to that larger objective? By showing students what can go wrong when communication is poor and the advantages offered by high-quality communication, we can show students important lessons that extend far beyond the confines of radiology.

The Payoff

Top Introduction Why Is Radiology Needed? The Payoff Conclusion References

 
Given all the reasons why many radiology departments have tended not to embrace the teaching of medical students, why should radiology leaders seek out opportunities for their faculties to make greater contributions to medical education? Perhaps the most important reason is the fact that teaching, and in particular, teaching well, is one of the most fulfilling aspects of a career in medicine. When challenged and engrossed, medical students are a delight to work with, and educators find it immensely rewarding to see students making good use of what they have learned to take better care of patients. Most of us have learned vastly more from others than we will ever discover on our own, and one of the best ways of repaying the immense debt we owe to those who went before us is to help pass on what we know to those who come after us. The very word "doctor" comes from a Latin root meaning teacher, and teaching is the essence of what it means to be a physician. Those who teach well enjoy a remarkable opportunity to add an additional vital dimension of personal fulfillment to their careers. In a time when more and more radiologists are feeling burned out and the ranks of academic radiology are sadly thin, this dimension of professional life is one to which all radiologists must attend.

Another crucial reason actively to seek out opportunities to contribute to medical education is the need to attract the very best students into careers in radiology [8]. For the foreseeable future, the number of radiologists in the United States will be insufficient to meet the demand for radiologic services. If we are to increase the size of residency training programs, a sufficient number of high-quality applicants must be motivated to fill those slots. Moreover, the fate of radiology itself hinges on the quality of people who choose to enter its ranks, and whether the employment prospects for radiologists be one of feast or famine, the field must be composed of the best and brightest. By establishing radiology as one of the most important contributors to the medical school curriculum and a center of excellence in the quality of its teaching programs, radiology departments can ensure that students will think highly of the field and give strong consideration to entering it [9]. If radiology is taught poorly or not at all, many of the best students will never think of entering the field, and radiology and the patients it serves will suffer.

It is also vital that the many students who do not choose careers in radiology emerge from their training with high regard for the field, well trained to make good use of radiologic resources in the care of their patients. If radiologists teach as little as possible, students may come away with the feeling that radiologists are not committed to medical education or patient care, and that attitude may be reflected in their interactions with those in radiology for years to come. On the other hand, if students regard radiology as one of the most important contributors to their medical education and think of radiologists as among their very best teachers, that attitude of respect and appreciation will manifest itself in a readiness to collaborate in the use of diagnostic imaging for optimal patient care. Image may not be everything, but as radiologists above all should recognize, image is a matter of considerable importance. How radiologists are perceived within the medical school sets the tone for how radiology will be viewed within the larger context of medicine.

At Indiana University, the department of radiology has made substantial investments in medical student teaching. Members of our faculty teach first-year anatomy, second-year Introduction to Clinical Medicine, and a month-long required senior clerkship in radiology. We estimate that over the 4-year curriculum, the average student receives 165 hr of dedicated instruction in radiology, in addition to extensive interaction with radiologists during other clinical rotations.

Moreover, our radiology clerkship plays an anchor role in the assessment of students' communication skills in the medical school's competency-based curriculum. Students receive extensive instruction in how to prepare and present 10-min lectures on clinical imaging topics of their own choosing. Each student receives a constructive evaluation of the quality of his or her presentation, and questions on the clerkship final examination are drawn in part from what students have taught their colleagues during the month. Approximately one quarter of classroom instruction is provided by radiology residents, giving them valuable teaching experience and an opportunity to test the waters of academic radiology.

Such investments in medical student teaching are costly, but we believe the rewards far outweigh the costs. For example, the winner of the medical school's Golden Apple Award for the professor who makes the greatest contribution to student education is usually a member of the radiology department. Our required radiology clerkship is annually chosen the best clerkship in the medical school, over such programs as internal medicine, surgery, and pediatrics. Each year, we attract the very best and brightest medical students to our radiology residency program, and over the past 5 years, we have drawn more students into radiology careers than any other United States medical school. It takes a great deal of effort to become a center of educational excellence, but the sense of satisfaction that our faculty derive from their teaching and the huge ancillary benefits in enhanced patient referrals, good working relationships, and national reputation dwarf the costs.

Conclusion

Top Introduction Why Is Radiology Needed? The Payoff Conclusion References

 
Suppose an academic radiologist believes strongly that radiology should be playing a greater role in the local medical school curriculum. What steps can that radiologist take to enhance both the quantity and the quality of radiology's contribution? An old maxim states that those who fail to plan, plan to fail. Only with a well-conceived vision of where radiology education ought to be in 3 years and a strategy for achieving that vision can radiologists realistically expect to achieve their educational goals. To begin with, one should identify other radiology faculty members who feel similarly and engage them in discussions of educational strategy. These sessions should address the three strategic questions noted earlier concerning the current state of the medical school curriculum, radiology's potential contributions, and the resources that would be needed to bring them about. In addition, it is important to develop a curricular plan, including specific new teaching opportunities, which might take the form of new courses or new radiology components in existing courses.

Wherever possible, radiology's contributions should dovetail with the teaching of other medical disciplines; for example, neuroradiology should be taught when students are studying neuroanatomy and neurology. Radiology instruction should also be tailored to the students' knowledge level so that more senior students are expected to show higher level reasoning drawing on their greater clinical experience. Faculty members should be identified to play particular curricular roles, including not only specific teaching assignments but also service on the medical school's curriculum council and other faculty committees. Needs for clinical release time should be specified, and a plan for financial accountability should be formulated. Medical student education is one of the core missions of the academic radiology department, and to reap the substantial rewards that educational excellence affords, radiologists should be prepared to make the same investments necessary to achieve excellence in clinical service and research.

References

Top Introduction Why Is Radiology Needed? The Payoff Conclusion References

 

1. Holt NF. Medical students need more radiology education. (letter) Acad Med 2001;76:1[Medline]
2. Robinson AE, Voci S. On teaching radiology to medical students: a commentary. Acad Radiol 2002;9:224 –225[Medline]
3. Gunderman R, Williamson K, Fraley R, Steele J. Expertise: implications for radiological education. Acad Radiol 2001;8:1252 –1256[Medline]
4. Ekelund L, Elzubeir M. Diagnostic radiology in an integrated curriculum: evaluation of student appraisal. Acad Radiol 2000;7:965 –970[Medline]
5. Scheiner JD, Novelline RA. Radiology clerkships are necessary for teaching medical students appropriate imaging work-ups. Acad Radiol 2000;7:40 –45[Medline]
6. Scheiner JD, Noto RB, McCarten KM. Importance of radiology clerkships in teaching medical students life-threatening abnormalities on conventional chest radiographs. Acad Radiol 2002;9:217 –220[Medline]
7. Bui-Mansfield LT, Chew FS. Radiologists as clinical tutors in a problem-based medical school curriculum. Acad Radiol 2001;8:657 –663[Medline]
8. Gunderman RB, Alexander S, Jackson VP, Lane KA, Siddiqui AR, Tarver RD. The value of good medical student teaching: increasing the number of radiology residency applicants. Acad Radiol 2000;7:960 –964[Medline]
9. Pretorius ES, Hrung J. Factors that affect National Resident Matching Program rankings of medical students applying for radiology residency. Acad Radiol 2002;9:75 –81[Medline]

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