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Integrating Evidence-Based ImagingInto the Radiology Core Clerkship:

A Proposed Teaching Tool ofImaging Strategies

Rohini Nadgir, MDa, Priscilla J. Slanetz, MD, MPHb

Purpose: Despite an increasing emphasis on incorporating evidence-based practice into medical studenteducation curricula, no previous work has specifically addressed the incorporation of evidence-based imagingstrategies into a radiology clerkship. The authors therefore introduced an evidence-based imaging curriculumduring the required radiology core clerkship at their institution and then formally evaluated the sessions.

Methods: From March 2007 to March 2008, 150 students in the radiology core clerkship underwent adidactic session on the principles of evidence-based imaging and then participated in a small-group case-basedsession. At the end of the clinical rotation, students evaluated the exercise for its effectiveness in teachingimaging strategies and its impact on their future careers.

Results: Of the 134 students (89%) who responded, 119 (89%) felt challenged to think differently aboutradiology as a result of these sessions, 129 (96%) believed that they had a better understanding of the indicationsfor certain imaging tests than before the experience, and 119 (89%) were certain that they would use thisinformation later in their careers. The majority, 86 of 134 (64%), preferred the interactive small-group sessionover a didactic session. Students praised the opportunity to work in teams, work on common clinical scenarios,and gain some awareness of the costs of different imaging tests. A minority of students cited concern for the highvolume of information presented per session and a preference to cover more scenarios per session.

Conclusion: An evidence-based imaging curriculum was comfortably integrated into a required radiologyclerkship and was well received by students.

Key Words: Evidence based, education, student

J Am Coll Radiol 2010;7:517-521. Copyright © 2010 American College of Radiology

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NTRODUCTION

he need for improved utilization of resources for opti-izing patient care is becoming increasingly apparent. In

he United States, physicians and patients are faced withver escalating health care costs and relatively limitedesources. Technologic advancements, particularly inmaging, contribute substantially to these rising healthare costs [1]. Lack of understanding regarding the mostppropriate indications for and clinical effectiveness of

Department of Radiology, Boston Medical Center and Boston Universitychool of Medicine, Boston, Massachusetts.

Department of Radiology, Beth Israel Deaconess Medical Center and Har-ard Medical School, Boston, Massachusetts.

Corresponding author and reprints: Rohini Nadgir, MD, Boston Medicalenter, Department of Radiology, 88 E Newton Street, 2nd Floor, Boston,

iA 02118; e-mail: rohininadgir@yahoo.com.

2010 American College of Radiology091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.01.021

arious imaging modalities available by many orderinghysicians further contributes to this large-scale healthare problem. Ultimately, lack of informed understand-ng of appropriateness criteria for various imagingtudies can result in more expensive and suboptimalatient care [1,2].In the past decade, there has been a growing body of

iterature emphasizing the importance of incorporatingvidence-based practice into medical student and resi-ent education curricula [3-6]. Evidence-based practice

s defined as the integration of the best available scientificvidence with clinical expertise and patient expectationsor specific clinical problems [2,7,8]. The anticipatedffect of making clinical decisions on the basis of evi-ence may result in more cost effective and higher qualityatient care [2]. Presenting this type of thought process

n patient management at the medical student level can

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518 Journal of the American College of Radiology/Vol. 7 No. 7 July 2010

aximize the impact of cost-effective and improved pa-ient care as students embark on their professional ca-eers.

Despite the increasing emphasis on evidence-basedractice in medical student education, to our knowledge,o previous work has specifically assessed medical stu-ents’ perspectives on the incorporation of evidence-ased imaging strategies into the radiology clerkship. Forhis reason, an evidence-based imaging strategies curric-lum was incorporated into the medical student educa-ional experience during the required radiology clerkshipt our institution. The goal of this curricular change waso educate future physicians specifically about the evi-ence-based approach itself, to increase students’ aware-ess of the variety of imaging modalities available andheir clinical indications, and to promote cost-effectivetilization of imaging technology.

ETHODS

ourse Overview

formal evidence-based imaging curriculum was intro-uced into the required 4-week radiology clerkship at our

nstitution in July 2006. The curriculum consisted of twoeaching sessions; the first was a large group didactic sessionuring the first week of the rotation, and the second was amall-group, interactive case-based discussion session dur-ng the second or third week of the clerkship.

During the first didactic session, the principles of evi-ence-based imaging were reviewed. Specifically, the 5ajor steps in the algorithm were introduced, including

dentification of the clinical problem, performance ofiterature search, critical appraisal of the literature, appli-ation of these findings to the clinical question, and eval-ation of this performance on patient outcomes.Students were presented with two different clinical

cenarios: a 42-year-old woman with a palpable lump inhe axilla and a 54-year-old man with acute onset ofyspnea. Students were encouraged to consider the dif-erential diagnosis, the imaging tests available, and theelative risks and benefits of these tests. Risks discussedncluded potential radiation exposure, possibility of con-rast reaction, and relative monetary “costs” of the testseing considered. Benefits discussed included the likeli-ood that the proposed diagnosis could be “ruled in” orruled out.” Students were reminded that benefits of theroposed test should outweigh the risks. A review of thestablished science for the various imaging modalitiesnder consideration was then discussed.For the second session, students were divided into

mall groups of 2 to 4 students. Each group selected fromprovided list 1 of 12 relatively common clinically en-

ountered scenarios and was asked to prepare an interac-

ive discussion using evidence-based imaging strategies. 1

linical scenarios proposed are outlined in Table 1. Typ-cally, given class size and time constraints, only 6 to 8 ofhese scenarios were actually presented during the secondession.

Students were encouraged to reference two specificextbooks with focused discussions of case-based imagingtrategies: Evidence-Based Imaging: Optimizing Imagingn Patient Care by Medina and Blackmore [2], and Cost-ffective Diagnostic Imaging: The Clinician’s Guide, byrossman et al [9]. Students were also directed to addi-

ional online resources, including UpToDate.com, asell as PubMed and MEDLINE searches.The majority of students prepared electronic presen-

ations, while a minority presented more informal groupiscussions. All groups created a one-page handout sum-arizing the data and outlining the imaging algorithm

or the specific clinical scenario selected.

eedback Survey

he evidence-based imaging algorithm sessions were for-ally evaluated between March 2007 and March 2008.pon completion of the rotation, students were asked to

omplete an anonymized postclerkship questionnaireistributed and collected by the clerkship coordinator,valuating the logistics and content of both sessions. Stu-ents were asked to respond to specific statements to ratehe educational content and value of the experience on a-point scale: 1 � strongly agree, 2 � agree, 3 � neithergree nor disagree, 4 � disagree, and 5 � strongly dis-gree. Selections of 1 to 3 were considered positive re-ponses, and selections of 4 or 5 were considered negativeesponses. Students were also asked open-ended ques-ions on the strengths and weaknesses of the exercise.esponses were then tabulated and recorded.

ESULTS

etween March of 2007 and March 2008, 150 fourth-ear medical students completed the required core clerk-hip in radiology. Of these, 16 did not participate inither session 1 or session 2, because of scheduling con-icts. There were 134 respondents, resulting in an 89%esponse rate. Specifically, 89% (n � 119) felt challengedo think in a different way about radiology, 96% (n �29) left the sessions with a good sense of the indicationsor certain imaging studies, and 89% (n � 119) felt thathey would use what they learned in these sessions later inheir careers. Some students (36% [n � 48]) would havereferred a didactic format for the second session, but theajority (64% [n � 86]) enjoyed the group discussion

ormat. Responses to the structured questions are tabu-ated below (Figures 1-4).

With respect to the open-ended questions, there were

08 respondents for strengths of the exercise and 56

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Nadgir, Slanetz/Evidence-Based Imaging and The Radiology Core Clerkship 519

espondents for weaknesses of the exercise. Most com-only cited major strengths of the experience included

he opportunity to work in teams, increased awareness ofost of imaging tests, and greater understanding of whatvailable imaging tests are most important in various

Table 1. Clinical scenarios for session 2Clinical Scenario Clinical P

1. Acute abdominal pain 56-year-old mangrade fever, nauabdominal pain

2. Acute stroke 77-year-old hypewith acute left-s

3. Back pain 53-year-old conswith 2-month pright leg

4. Biliary obstruction 77-year-old womquadrant pain a

5. Chest and abdominal trauma 22-year-old manafter high-speed

6. Colon cancer screening 50-year-old manof colon cancer

7. Gastrointestinal bleeding 88-year-old man8. Headache 43-year-old HIV-p

with acute-onse9. Head trauma 16-year-old boy a

baseball bat, no10. Postmenopausal bleeding 64-year-old wom

spotting for 3 m11. Renal colic 33-year-old man

right flank pain12. Solitary pulmonary nodule 52-year-old smok

5-mm nodule ox-ray

�Readings were assigned from Evidence-Based Imaging: OptimCost-Effective Diagnostic Imaging: The Clinician’s Guide by Gros

411

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1 2 3 4 5

1(Strongly disagree)-5(strongly agree)

Number ofRespondents

ig 1. On a 5-point scale, respondents rated theducational experience in response to survey state-ent 1: “The imaging algorithm sessions challenged

e to think in a different way about radiology.” s

linical scenarios (Table 2). The most commonly citedajor weaknesses of the exercise included the large vol-

me of information presented per session, a preference toover more scenarios per session, a preference to select

entation Reading Assignment�

h 3-day low-a, vomiting, and

Medina, chapter 25; Grossman,chapters 9-10

nsive womaned weakness

Medina, chapter 9; Grossman,chapter 38

ction workerradiating to

Medina, chapter 16; Grossman,chapter 40

with right upperjaundice

Medina, chapter 27; Grossman,chapters 2, 5

cted from carhase

Medina, chapter 24

h family history Medina, chapter 5; Grossman,chapter 62

h melena Grossman, chapter 7itive womaneadache

Medina, chapter 10

aulted withconfused

Medina, chapter 13

with vaginalths

Medina, chapter 30

h acute-onset Medina, chapter 29; Grossman,chapter 11

with incidentalcreening chest

Medina, chapter 23; Grossman,chapter 21

g Imaging in Patient Care by Medina and Blackmore [2] andan et al [9].

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ig 2. On a 5-point scale, respondents rated theducational experience in response to survey state-ent 2: “I left the imaging algorithm sessions with a

ood sense of the indications for certain imaging

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520 Journal of the American College of Radiology/Vol. 7 No. 7 July 2010

ase scenarios from personal clinical observational expe-iences rather than a provided list, and complaints thathe assigned readings were not entirely comprehensivend slightly outdated (Table 3).

ISCUSSION

he use of evidence-based practice to make informedecisions about patient care is becoming increasingly im-ortant in terms of managing the ever increasing cost ofealth care in this country [1,2]. Imaging accounts for a

arge proportion of these health care costs, and not infre-uently, studies are performed either for inappropriatelinical indications or incorrect imaging tests are orderedor specific clinical questions [1]. It is therefore clear thatrdering physicians need to be educated about when tomage and what the most appropriate imaging test torder may be on the basis of specific clinical scenarios.lthough it is impossible for all physicians to always

30

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ig 3. On a 5-point scale, respondents rated theducational experience in response to survey state-ent 3: “I will likely use what I learned in these

maging algorithm session later in my career.”

adiologist.”

now what test is most appropriate and when, in circum-tances in which a radiologist may not always be availableor consultation, it would be certainly beneficial for therdering physician to be aware of the imaging modalitiesvailable and the resources available to make the bestecision, using the evidence-based algorithm.Teaching the evidence-based methodology at theedical school level may ultimately result in more cost

ffective and higher quality patient care as these traineesmbark on their medical careers [3-5]. We therefore im-lemented an evidence-based imaging curriculum intohe required radiology clerkship at our institution andssessed how well the curriculum was received by partic-pating medical students. To our knowledge, a formalssessment of an evidence-based imaging curriculum hasot yet been reported.On the basis of feedback from our students, we found

hat an evidence-based imaging curriculum can be incor-orated comfortably into our radiology clerkship. Theajority of students preferred the group discussion for-at and felt that it enhanced the learning experience.he strategies introduced were highly valued by medical

tudents in terms of teaching appropriate clinical indica-ions for imaging tests and their relative costs. The ma-ority of students who participated in this curriculum felthat this greater understanding would affect their futurelinical practice in a positive way.

Table 2. Positive evaluations excerpted fromstudent survey

CommentNumber ofStudents

“Learned about cost effectivenessof different studies . . . andindication of different studies”

21

“Active participation makes it easierto remember algorithm”

43

“Made students think about whydifferent modalities actually used”

21

Table 3. Negative evaluations excerpted fromstudent survey

CommentNumber ofStudents

“Didn’t go over all cases” 3“Might be nice to choose our own

case rather than selecting froma list”

4

“A lot of information to absorb inone sitting”

16

“Many sources not up-to-date” 7

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Nadgir, Slanetz/Evidence-Based Imaging and The Radiology Core Clerkship 521

Given the overwhelming positive response from ourtudents, we are continuing this curriculum during theadiology clerkship experience, incorporating changes toddress students’ concerns about the course. Since theonclusion of this investigation, we have begun to intro-uce our medical students to the use of the ACR Appro-riateness Criteria® as an additional tool in the decision-aking process. The intention is to promote student

wareness of the criteria, to teach how to access andnterpret this information, and to provide students with a

ore up-to-date source because imaging technology islways changing. We plan to ultimately expand the clin-cal scenarios to include 25 cases rather than 12 and willncorporate a self-directed learning exercise for cases notovered in the second session. Finally, the imaging strat-gies introduced in this curriculum will be incorporatedn the final examination, with cases drawn directly fromhe 25 topics, to provide a more quantitative assessmentf the educational content of this curriculum.

ONCLUSION

ur evidence-based imaging curriculum was well re-eived by our students and shows promise in terms of its

mpact on our students in considering cost-effective and

mproved patient care as they continue forward withheir careers. Although the feedback response we receivedhus far is certainly encouraging, the long-term benefit ofhis curriculum remains to be seen.

EFERENCES

. Dunnick NR, Applegate KE, Arenson RL. The inappropriate use of imag-ing studies: a report of the 2004 intersociety conference. J Am Coll Radiol2005;2:401-6.

. Medina LS, Blackmore CC. Evidence-based imaging: optimizing imagingin patient care. New York: Springer Science�Business Media; 2006.

. van Beek EJR, Malone DE. Evidence-based practice in radiology educa-tion: why and how should we teach it? Radiology 2007;243:633-40.

. Del Mar C, Glasziou P, Mayer D. Teaching evidence based medicine. BMJ2004;329:989-90.

. Coomarasamy A, Khan KS. What is the evidence that postgraduate teach-ing in evidence based medicine changes anything? A systematic review.BMJ 2004;329:1017.

. Medina LS, Blackmore CC. Evidence-based radiology: review and dissem-ination. Radiology 2007;244:331-6.

. Collins J. Evidence-based medicine. J Am Coll Radiol 2007;4:551-4.

. Ertuck SM, Odategui-Parra S, Otero H, Ros P. Evidence-based radiology.J Am Coll Radiol 2006;3:513-9.

. Grossman Z, Katz D, Alberico R, et al. Cost-effective diagnostic imaging:

the clinician’s guide. 4th ed. St Louis, Mo: Mosby Elsevier; 2006.