July 2017 - Donna Magid, M.D., M.Ed.
GOAL: To introduce the principles of intelligent and effective use of Diagnostic Imaging to future clinicians in every specialty, to allow exploration of Radiology as a career choice, and to arm the future clinician with the tools to consult with Imaging and to function safely and productively in emergent or routine clinical scenarios. Introduction of the comprehensive and systemic search approach, checklists and sequential analysis (‘Describe first diagnose second’), common pitfalls and pearls, to provide a platform for handling increasingly complex clinical scenarios and unknowns.
Emphasis on communication between clinicians and Imaging, American College of Radiology Appropriateness Criteria (ACR AC) as a high-value-care (HVC) resource, cost/benefit ratios, Six Competencies, precise and concise medical English usage, accessing the Vertical Advisory, awareness of medical-legal consequences, sensitivity to patient perceptions, and clinical and conference survival skills.
I. ‘Hot Seat’ Objectives for classroom performance assessment as integrated with and addressing the 6 Competencies:
- Patient Care
- Medical Knowledge
- Practice-Based Learning
- Interpersonal, Communications
- Systems-Based Practice
This course involves a great deal of active ‘Hot Seat’. The Hot Seat interactive learning style requires that each student in turn come to the front of the class, visually assess and then precisely and professionally describe a presented unknown image; and generate a series of appropriate hypothetical actions and queries to drive clinical and imaging analysis, rapid accurate cost-effective diagnosis and treatment (eg, Is there a second view; Are there old films; Was there trauma, Are the VS stable, Is this in the Normal Variants text, Where does it hurt with one finger, How old is this patient, Are there ECG changes, etc). A hierarchal age, gender, and situationally appropriate DDx from most to least likely is required, as well as appropriate urgent recognition of and proposed course of action for potentially life-threatening or emergent hypothetical situations.
Appropriate Body Language (*4,5)
- Consistantly excellent, controlled, polished; projects with confidence and clarity; no extraneous or non-professional theatrics or gestures, hands composed and controlled
- Usually excellent, sound grasp of non-verbal demands of course, moving up personal slope of improvement, usually controls excessive gesturing or nervous gestures
- At expected level for year (2nd, 3rd,4th), improving as behavior shaped, making good effort
- Even with feedback and encouragement persists in more unnecessary/distracting gestures, motions than expected; slower to move up improvement slope
- Persistent inappropriate body language, fiddling, demeanor; resistant to re-shaping
Medical and English Language Usage (*4,5)
- Superb communicator, describes precisely and concisely, understands and uses cardinal medical directions (cephalad, caudal, sagittal, volar, plantar, etc) instead of ‘near’, ‘over’, etc. Understands descriptive conventions (eg how to describe Orthopaedic findings, fracture deformities, modality-appropriate terms for ‘black, white, gray’). Approaches 2nd year resident level of description.
- Excellent, language used with care and precision, minimal colloquialisms, ‘telephone model’ status not always achieved but referring clinician would grasp most salient points; similar to new 1st year resident
- At expected level for year and making efforts to improve precision and control colloquialisms. Descriptions clear. Once prompted can continue, fine-tune, or correct description.
- Retains more colloquial or casual speech patterns than others at grade level, Still falls back on pointing and ‘There’ to avoid verbal description, does not always switch gears from personal to professional mode, grasp of cardinal directions not yet firm.
- Significantly less precise than others at grade, needs more control over slang and casual descriptors, does not use cardinal directions accurately. Needs marked improvement in usage.
Hierarchy of Findings and “What Next” Options (*1,2,3,5)
- Recognizes life-threatening and urgencies promptly, knows which findings/situations require prompt direct physician-to-physician communication, can single out and triage most important findings in image with multiple findings, consistently excellent ‘what next’ choices.
- Strong grasp of clinical priorities and emergencies, has progressed in triaging findings, needs occasional leading to connect with significance of finding or to choose ‘next step’
- Comprehension of significance of findings at expected level for grade, intelligent ‘what next’ choices although needs some prompting or Devil’s Advocating, making effort and improving ability to prioritize imaging findings by clinical significance and relevance. (2nd yrs—if need ‘jump start’ or clue to focus on a finding, can produce grade-appropriate hypothetical discussion of significance by 2nd or 3rd week of course)
- Can usually be led to an answer if prompted step-by-step, often cannot connect separate findings/facts to get ‘big picture’(3rd,4th yrs). 2nd years— by 3rd week, even if led step-by-step do not have overview abilities to come up with DDx or ‘next step’ options.
- Consistantly unable to focus on which finding is most relevant or threatening; cannot organize separate facts or findings into reasonable hierarchy of significance, does not suggest appropriate ’what next’ to propel hypothetical Dx/treatment. Significantly weaker than others at grade.
Medical Knowledge and DDx (*1,2,3)
- Consistently excellent analysis of extractible data, leads to intelligent and constructive DDx, incorporates and mentions data/findings supporting or discrepant with suggested DDx items, demonstrates depth and certainty of knowledge. Understands current thinking or controversies in pathogenesis.
- Sound grasp of clinical data, implications, textbook concepts; usually can recruit and organize abstract knowledge relevant to case at hand to support choices; rarely if even makes suggestion or call which would be counterproductive or harmful
- Sound grasp of basics appropriate to grade and experience. Consistent. Willing to acknowledge when guessing or very uncertain how to proceed. Will be safe under supervision and improving.
- Uneven, often inaccurate or complete; occasionally makes decisions which would be deleterious, or does not always grasp ‘big picture’ unless/until led.
- Consistantly deficient or uneven in retrieving appropriate clinical facts or knowledge; apparent fund of knowledge well below others at grade; appears to need constant attentive clinical supervision exceeding that appropriate for peers.
Systems-Based Imaging Practice (*6)
- Knows why and how to provide relevant and necessary information (correct name, hx #, allergies, DOB, LMP, floor and contact #s, problem lists and meds, clinical query to be addressed) for each study ordered; consistently suggests and sequences clinically and economically appropriate ’next action’ (2nd view, physical exam, old films and records, another imaging study). Learns and applies ACR Appropriateness Criteria often.
- Usually strong-to-excellent ‘what next’ sequencing and how to protect pt. from unnecessary dose/risk/expense (ie, when old films/labs/physical findings impact clinical impressions and choices); refers to ACR-AC
- Appropriate grasp of sequences and indications; remembers to reference old studies/history; choices usually would move Dx and care forward and rarely would harm or impede care.
- Episodic uneven command (for year) of fundamentals of selecting procedures and ‘what next’; suggestions or choices occasionally ‘leap-frog’ normal sequences and may create unnecessary cost or risk for pt.
- Significantly below-grade grasp of ‘what-to-order-when’, ‘what-next’; fails to use ACR Appropriateness Criteria even after suggested several times; choices have put hypothetical patients at risk multiple times during course and without sufficient evidence of remediation/improvement.
Student has ‘eye’ (*1,3): Innate visual/perceptive ability; while an excellent ‘eye’, much like an excellent singing voice, cannot be achieved by all, the vast majority of students can demonstrate improvement from whatever baseline they have, through conscientious use of check-lists and search techniques and concerted efforts to see as many cases as possible, conference, texts, web sites, etc.
- Inherent visual skills (`2nd yr resident) which are volitionally and intentionally advanced during course by meticulous absorption of proposed search-pattern methods, case files, check-lists, “Do Not Miss” lists; aware of and uses ways to manipulate presented visual data to maximize analysis.
- Usually sees findings and has maximized innate initial visual sensitivity by working on image volume and check-lists; approaches new resident’s level of detection.
- Usually can find/appreciate finding, or ‘go with it’ if led to finding; usually at conference or using web sites to enhance volume of cases seen; improves over course from baseline by own efforts.
- Uneven, does not always ‘see’ finding or pickup on cues directing student to findings; does not take advantage of common data-modification (2nd view, modify black/white scale or window, zoom or magnify) to enhance perception. Some conference/web site usage to enhance volume.
- Has unusual difficulty appreciating visual findings/changes/characteristics usually seen by 80-90% of students; inadequate effort to improve from own baseline.
Absorbs and applies very basic “10 Commandment” sine qua nones (*1,3,4,5,6)
- Rapidly and correctly absorbs tenets and rationales, learns to ask for 2nd or 3rd view and to examine pt. and old records before moving on to risky/costly 2nd test, understands pragmatic and safety-minded underpinning of patient care and decision making.
- Solid grasp of same, great improvement over month, usually above average in exercising pragmatism and protectionism
- At expected level for year, with evidence of solid improvement and grasp of significance of seemingly simple ‘Commandments’; can be led to correct answers with slight leading/prompting.
- Less definite or less consistent grasp of application of Commandments from case to case; can not always use prompting or clues to arrive at correct conclusions/observations.
- Significantly or consistently below grade in absorbing pragmatic and protective tenets and applying them to case at hand, even if led.
Calls for or offers ‘Consultation’ appropriately (*1,4,5,6): hot-seat student may, if stumped, elect to call for a ‘consult’ from rest of class, whom in turn are to refrain from answering until asked; helps students to measure themselves against peers, lets slightly slower students work to arrive at correct answer; teaches more advanced or quicker students to respect colleagues and take turns.
- Excellent sense of when to call Consult (ie recognizes limits of knowledge), refrains from consulting/calling out appropriately. Often is Consultant with correct answer (for year).
- Usually good sense of when to call Consult; often has answer (for level) if Consulted.
- At expected level of judgment as to when to ‘fold’ and call Consult, participates at expected level for year when called for Consult, usually good enough judgment to protect hypothetical pt.
- Occasionally reluctant to admit inability to deduct answer; rarely has correct Consult answer.
- Significantly below level both in admitting when no answer is forthcoming, and in supplying correct Consult/answer once asked; lack of judgment/insight into own limits of knowledge=red flag
CORE SYLLABUS (varies slightly month-to-month) 7-2012
KIDDY PHYSICS FOR BIOLOGISTS (2-3 hrs Day 1, DM): Facts over Fear
Introduction to Radiology history and development in the world and at Hopkins. Principles of analogue and digital image generation, maximizing image quality, ordering the correct test for a given clinical question. Explanations of various ways to measure dose, spectrum of consequences to the individual and the population, doses of common tests, national and institutional regulations and forbidden behaviors. Rudiments of radiation safety and protection for the student/caregiver, operating room fluoroscopic radiation protection, how to handle and store protective garments, how rooms or work areas are shielded and monitored, occupational exposure as a career choice. Cost/benefit assessment in selecting a test or being exposed at different levels, hypothetical situations with potentially pregnant or otherwise concerned patients, examples of comparable ‘relative risks’ and how to answer patient questions about imaging exams or dose.
TALK THE TALK (2 hrs, DM)
Introduction to specific vocabulary of Radiologists and Imaging (grey scale, radiodensity, ‘x-ray’ vs ‘image, radiograph, film, study’, contrast and noise, resolution, CT windows, collimation and centering, proper descriptors for US, CT, MRI, Nuclear Medicine, PET. Re-emphasis of importance of medical linguistic precision, both for excellence in patient care and to avoid medical-legal mishaps. Shaping of generated verbal behavior as new students describe a series of simple cases with obvious findings. Implications of ‘normal’ vs ‘unremarkable’ vs ‘unchanged’. Variety of plain film cases (from sinuses to chest to joints to medical or incidental foreign matter to mummies with odd artifacts) also geared to give me some idea of how well this class knows anatomy, can ‘see’ potential findings, can generate descriptors, how fast their behavior can be modified, how fast they absorb concepts, spectrum of experience (eg, mostly 2nd years April and May,requiring vastly adjusted speed and depth of explanation than 3rd and 4th years other months) etc; while reviewing same anatomy and verbal descriptive conventions (anatomic position, medial/lateral, varus/valgus, cephalo/caudal, dorsal/ventral, proximal/distal, Orthopaedic conventions, possible sources of ambiguity -eg ‘3rd finger’ as long finger vs ring finger). Series of cases apparently normal on first view, grossly abnormal on second view, as cautionary examples of dangers of limited or inadequate exams.
MAGID’S TEN COMMANDMENTS (clinical pointers and survival skills) ongoing referrals throughout course, emphasizing pragmatism, clarity, pitfalls, and common errors.
BASICS OF ELECTRONIC PRESENTATIONS (.5 hr, DM)
How to choose topic given time frame (Comprehensive Bone Tumors or all radiographic of Rheumatoid Arthritis impossible, one specific tumor or or one aspect of RA, yes), how to time talks, how to project confidence, avoid rushing or stumbling. Imaging presentations demand more attention to visual attributes, in the process teaching the students some of the elements of preparation, organization, and presentation. Factors maximizing image reproduction, slide clarity and legibility; limits for lines of word text (8) or charts (too many cells + tiny type= instant snooze) ; professional implications of fonts, colors (radiologists prefer light-on-dark text and darker backgrounds to make an image the primary light source), background selection, animations (professionalism undermined by cutesy or inappropriate distractions); importance of intellectual property integrity, clear source attribution by slide, common pitfalls.
FRACTURES 101 and PEDIATRIC FRACTURES (3-5 hrs, DM)
Introduction to the specific descriptive language of fractures and the Orthopaedic descriptive conventions. Biomechanics of bone and mechanisms of injury. Importance of accurate and specific physical exam and conveyed clinical information; implications of common ‘buzz words’ (e.g. ‘Snuff box tenderness’, ‘Pain only at night relieved by aspirin’, ‘T-boned’, ‘Found down’, ‘Refuses to walk’.). Common injury mechanisms and outcome by age (e.g., consequences of fall on outstretched hand by age, ‘twisted ankle’, ‘jumped’). Review of histologic and radiographic changes during bone repair, remodeling, physical rehabilitation. Pathologic fractures. Common ‘leave me alone’ or ‘don’t worry’ findings and ‘incidentalomas’ in trauma patients. Potential clinical pitfalls in the initial assessment (rotation, joint above/below, common associated injuries, nerves or vessels at higher-than-usual risk).
‘Ages and Stages’ of skeletal development, growth, and remodeling. Physeal structure, normal bone growth, and pediatric injuries, including Salter classification, prognostic factors, consequences of physeal disruption, leg length discrepancy and introductory gait/posture concepts, leg lengthening and limb salvage procedures and underlying physiology. Lower extremity axes of alignment from birth to adulthood and secondary consequences. Bone age vs. chronological age, male vs. female growth rates, normal variants, which may simulate findings and how to assess same using Normal Variants text. April’s Curse: lawnmower injuries. Non-accident al pediatric trauma (abuse).
NUTSHELL PELVIS (~2 hr, DM)
Introduction to the pelvic ring, normal structures and terminology, bulky 3D structures when imaged 2D. Embryology of hip development, weight-bearing transmission and upright posture, Wolffe’s Law, other bony ‘rings’ in the body. Positioning, consequences of moving patient with severe pelvic trauma. CT vs. plain film: dose, cost, clinical efficacy. Checklists and critical lines for assessing the pelvic ring and acetabulum. Consideration of consequences of retrograde or vulnerable blood supply in the femoral head (and scaphoid, talus) and osteonecrosis; nontraumatic etiologies of same. Developmental considerations in femoral head sphericity, cortical and trabecular development, and DDH, again emphasizing biomechanics, Wolffe’s Law, forces acting on bone, genes vs. environment. Pelvic ring trauma, reduction of fractures as a clinical emergency, polytrauma considerations, short and long-term consequences of pelvic trauma from arthritis to infertility. Lower velocity trauma (falls), pathologic fractures, hardware and implants. Foreign matter, confusing radiodensities/lucencies, common findings on pelvic films. IVDA, infection, osteomyelitis.
NUTSHELL C SPINE: How Not to Kill or Paralyze Anyone (~1 hr, DM)
Systematic approach to analyzing normal and then abnormal cervical spine plain films, why study limited to 3 views, other possible views, alternative views for patients unable to cooperate (e.g., swimmer’s, when a second or third attempt at odontoid may be useful, when to never (and why not to) help the patient comply with positioning). How to assess a cervical trauma film series, ‘clearing’ the C spine’ vs. ‘clearing’ the lateral radiograph’, collars, normal alignment and lordosis, normal range of motion. Focus on C1-C2 injury and instability: acute and chronic trauma, flexion/extension measurements and rules, rheumatoid arthritis, os odontoidum or hypoplasia, syndromes. Graphic examples of why a tendency towards conservatism when clearing C spines saves lives/function. When to get a CT, an MR, or both; orthopaedic/structural skeletal injury vs. potential neurologic injury. Pre-vertebral soft tissue in trauma, infection, allergy, hemorrhage and tumor. How one might handle it if others pressure one to clear a patient’s films when one is either uncertain or too inexperienced. Common cervical surgical procedures (Southwick Robinson anterior approach, posterior laminectomy, pedicle fusion, tumor reconstruction).
WHEN GOOD LINES GO BAD: Intro to Medical Implants (~2-3 hr, DM)
Introduction to radiographic appearance and appropriate radiographic position of lines, catheters, PICCs, pulmonary artery catheters, NG and ET tubes, cardiac implants and pacemakers, drains and peri-operative findings, surgical stents, etc, chest and abdomen. Multiple examples of normals followed by multiple misplaced material or misinterpreted positions; pitfalls or hazards of only having one view when films done portable; importance of assessing the side hole as well as the tip in NG or pleural tube placement; understanding nuanced phrasing of radiology descriptors and degrees of doubt. Some pragmatic tips for learning how to place lines; considerations of patient size/height, distance from skin entry to desired final tip position. Appropriate handling of packaged lines, catheters to avoid material failure (fractured lines), checking removed material to confirm integrity before discarding. Pneumothorax: a series of cases emphasizing how to pick up the tinier findings, before there is clinical consequences, how to search for the pleural edge, pitfalls complicating such detection (rib edges paralleling dropping pleura, overexposure, failure to use magnification, complacency or failure to obtain official final report if reviewing film on floor). Tension pneumothorax, typical and atypical.
DON’T LEAVE HOME WITHOUT IT: COMMON CHEST AND ABDOMEN MUST-SEES (with LINES , ~6-8 hrs. total, DM)
Given last, so as to not be redundant with those already teaching the students chest/abdomen; provides a safety net to insure chest/abdomen basics have been covered monthly. A series of ‘Aunt Minnies’ (ie, usually need only see once to understand and remember; common sources of student embarrassment or misstatements during rounds if not seen at least once such as azygos lobe, interposed colon, unremarkable feces resembling masses or bone destruction, etc); normals and abnormals I believe any student should be able to recognize in the middle of the night regardless of future career goals (such as SBO, pneumoperitoneum, biliary air or pneumotosis intestinalis, pancreatitis, gallstones, ascites, lobar distribution of pulmonary disease, differential of various types of cavities in lungs, old granulomatous disease, normal calcifications such as phleboliths, seminal vesicles, skin injection granulomata); and radiographic aspects of relatively rare diseases or ‘zebras’ disproportionately encountered or discussed at Hopkins vs. community hospitals , ( such as pulmonary disease presenting to Orthopaedics as joint pain in HPOA with bronchial tumor). Students over the years have commented when they have encountered these basics on Step One or Step Two, which is passed along to current students.
OTHER FACULTY CONSISTENTLY IN CORE COURSE:
- Dr. D. Feigin CORE CHEST lectures (1-2 hrs, plus several conferences, Core HO): How to search chest radiographs, vocabulary of chest analysis, systematic analysis of frontal and lateral, 30 key anatomic structures, characteristics of interstitial vs alveolar processes, differential diagnoses of same, mechanisms of same, pulmonary vasculature, cardiac contours, other patterns (nodular, bronchial, destructive, etc) and DDx of same, cavitary patterns, vascular patterns, and CT correlates of all above.
- Dr. W. Scott (~4 hr total/mo)—case correlates of Chest and Abdomen, ‘hot seat’ approach
- Dr S.Siegelman (1-2 hr.mo plus variable hr/mo conferences with students and residents) - case correlates and lectures on Chest, Abdomen, CT, CT/PET
- Dr. Atif Zaheer (1 hr) Body CT basics
- Dr. P. Wheeler (2-3 hr/mo) case correlates (‘hot seat) of Chest and Abdomen
- Dr. K. Macura (1 hr/mo) - Patient with Possible Pulmonary Embolism (reinforced by ACR Appropriateness Criteria review with Magid)
- Drs. S. Sheth, U. Hamper, and Chief Technologist Mr R. DeJong (3 hr.mo) - Introductory Ultrasound including a hands-ob scanning lab, lectures on Emergency Situations, Ob/Gyn US, Common Situtations; usually plus 1-2 hr/mo conference, plus Tutorial morning.
- Dr. R. Wahl (1 hr/mo) – Introductory PET
- Neuroradiology (2 hr/week)
- Residents and Fellows - several hrs/ wk, plus Tutorials
An attempt is made monthly to cover the spectrum of imaging from traditional (plain film) through CT, MRI, US, PET, Neuro Imaging, Interventional Radiology, mammo, etc., as well as common emergencies or clinical scenarios. Actual content varies slightly month-to-month depending on faculty availability, national meetings, etc.
AREAS COVERED BY OTHER faculty, residents, and Fellows (varies slightly from month to month depending on individuals’ schedules, commitments):
BASIC CHEST ~ 6 hr/mo plain film and basic concepts, with handouts
- 2-4 hrs Chest CT, ICU, related vascular, trauma, etc.
- 2 EMed and 1 CT Tutorials, usually including relevant cases.
- Resident Interesting Case Conference 1 hr/wk usually focused on Chest/Abdomen.
BASIC ABDOMEN AND GI ~ 4 hrs/mo plain film, barium, CT, MR, US;
- 1x tutorial in Fluoroscopy, 2x tutorials EMed, 1x US, 1x CT usually including relevant cases.
- Resident Interesting Case Conference 1hr/wk usually focused on Chest/Abdomen.
NEURORADIOLOGY ~ 6-8 hrs/mo basic anatomy and imaging techniques, CT vs MR, Trauma, Stroke, other emergencies, Interventional Neuroradiology, PET
SPINE IMAGING ~ 1.5-2 hrs/mo.
NUCLEAR MEDICINE/PET ~ 1-2 hr/mo
U/S ~3 hr/mo classroom, 1 hr/mo. Hands-on introduction to scanning equipment, plus 1 Tutorial
PEDIATRIC IMAGING ~ 2-3 hr/mo (in addition to my Pediatric Fractures session)
Body CT ~ 2-3 hr/mo lectures, 1 Tutorial, heavy exposure at daily Resident AM Conference and weekly SSS Interesting Case Conference
Body MR ~ 2-3 hr/mo plus heavy conference exposure as above
INTERVENTIONAL RADIOLOGY ~ 1 hr/mo plus Tutorial plus variable case conference time
MSK (DM’s Core sessions plus ~ 1-2 hrs Benson, Carrino, Fayad, MSK Fellow, plus ~ 2 conferences/mo)
PHYSICS (1 hr/mo .Dr. Mahesh, plus DM’s 2 hr ‘Kiddy Physics” first day)