SPECIAL EDITION
Learning

By MERLINA TREVINO

Building a better radiologist in the technological age involves new teaching media and methodologies. These are not only providing more resources for the resident, but they may also be changing the entire culture of radiological training.

"Teaching has been a core part of radiology since its inception," said Dr. Steven Horii, a professor of radiology at the University of Pennsylvania Medical Center.

Horii spoke at a presentation on resident training in filmless departments at the 2002 Symposium for Computer Applications in Radiology in Cleveland. Besides training radiology residents, education has always included introducing patients to the nature of radiology, including its benefits and possible dangers, he said.

In the past, radiologists used film copies of past cases saved specifically for training. These teaching films filled entire storerooms, and going back to retrieve that one case perfect for teaching often proved difficult and time-consuming. The adoption of PACS makes electronic storage and retrieval of files seem a no-brainer. Because many radiology departments have still not fully made the transition to PACS, however, the move to digital teaching files is not without its drawbacks.

"It was very easy in analog days to simply copy a film and write a bit of pertinent information on the film sleeve," said Dr. Greg Katzman, director of radiology informatics at the University of Utah Health Sciences Center. "It was quick, and everyone did it the same way. Digital images and teaching files bring a lot of baggage: How do you move images from a PACS to your computer; how do you convert a warehouse of analog cases; should images be compressed? How do you annotate cases; where do you put them; how do you find them? Most problematic is how do you display them?"

CULTURAL SHIFT

Aside from the technical difficulties involved in the creation of digital teaching files, some radiologists are finding changes in the way residents actually learn.

PACS and new technologies increase the number of exams a radiologist can perform by a staggering amount. The number of MR scans being read at the Cleveland Clinic skyrocketed from about 12,000 in 1994 to a projected 72,000 in 2002, according to radiology chair Dr. Michael T. Modic in his keynote presentation at SCAR. Radiologists saw CT exams quadruple from 24,000 in 1994 to 120,000 in 2002.

The percentage of studies in radiology at the University of Pennsylvania that were interpreted in a group (the attending radiologist plus at least one radiology resident) increased from around 42% with film to 76% with PACS, according to Horii. With too much work and not enough radiologists on staff, attending radiologists may be shifting from traditional teaching methods.

In the days of analog films, radiology residents would perform the initial reads as they hung films on the alternator. Today's attending radiologist may find it more efficient to first review and then explain cases to residents at a PACS workstation. This passive method of learning may prove to be less challenging to the resident, he said.

Because reading rooms equipped with PACS feature newer display technologies, residents may find themselves limited as well by the number of workstations in a reading room. They used to have plenty of room to gather around traditional alternators in analog reading rooms.

"Newer display technologies may place more stringent requirements on the design of reading spaces since viewing angles are more restricted," Horii said.

Horii suggested that teaching requirements, including the number of workstations needed and the amount of archive space and bandwidth necessary for electronic teaching files, should be taken into account when planning PACS installations.

DIGITAL TEACHING FILES

Despite these concerns, radiologists embrace electronic teaching as PACS continues its march into their departments. There are many advantages to a digital mode of teaching.

"The greatest advantage of an electronic format is the ubiquity with which electronic appliances surround us," Katzman said. "Everywhere you go there are computers, laptops, and PDAs, which means digital teaching is truly portable. No phone lines? No problem! Get a satellite dish. Folks in the rural U.S. can access such digital information, which was not possible before. It eases the ability to learn remotely, which now can even include CME."

With electronic teaching files, it becomes simple to incorporate Internet access. Residents will be able to mine outside resources, including Medline and popular radiology Web sites far from their immediate hospital teaching institution. Because residents, for the most part, are trained in large academic centers, most will already have experience working with PACS and will be familiar with using and gathering information from digital files.

For radiologists in smaller hospitals, Katzman outlined several methods to begin making the move to electronic teaching files on an individual basis. Radiologists have several options, from simply scanning in images and displaying them on ubiquitous image viewing software, to outsourcing the task to entities who will transfer images to Web-based repositories. Costs and levels of difficulty vary.

Should radiologists want to move beyond simple image viewers, word processing programs, presentation software, Web-based files, and Acrobat-based files provide additional options for displaying images. Although some of these options require increased skill sets such as knowledge of the HTML programming language, a are readily accessible and can be used by almost anyone using a PC.

Outsourcing the development of electronic teaching files is always an option, but Katzman cautioned radiologists to make sure to copyright contributed content, if possible. Some outsourcing programs relieve radiologists of the mechanical and technical aspects of constructing digital teaching files, but they may also have copyright over the subsequent content produced.

RADIOLOGY 101 IN YEAR 2020

One of the most important obstacles to the implementation of digital teaching files is the lack of standardization. In the good old days of analog films, attending radiologists really had only one way to attach notes to films, and films were the same no matter who taught from them.

The variety of display and image formats available with PACS has made standardization essential. This will go a long way toward making the creation and display of digital teaching files as simple and efficient for the radiologist as possible.

"We need standards for image format, compression, annotation, storage, exchange, and presentation," Katzman said. "The Medical Imaging Resource Center (MIRC) committee of the RSNA may be the ones who have the power and authority to set such standards."