SPECIAL EDITION
Residency

By David Hirschorn, M.D.

The positioning of radiologic informatics as a new branch of the radiologic sciences is gaining momentum. In the abstract submissions for this year's RSNA meeting, the term radiology informatics appears not only as a subcategory for scientific presentations, but also as its own session type. Indeed, "Leading medicine's digital transformation" is the theme for RSNA 2002.

This greater emphasis on informatics is also reflected in the steady growth of the Society for Computer Applications in Radiology (SCAR, www.scarnet.org). And specialized fellowship training in radiologic informatics can now be found at several institutions.1

But how well prepared are radiology residents for this new era of digital imaging? How much informatics training do they receive during residency? At most of the institutions surveyed for this article, three sources-basic informatics lectures as part of the physics curriculum, applications training, and grand rounds-constitute almost all of the informatics training for residents.

- Radiologic physics. One of the major forces that motivates residents when they choose what to study is relevance to their examinations. "Is it on the test?" is often the main criterion for deciding whether to study a particular subject. Informatics is on the test, but to a very limited extent.

Radiology residents must pass one oral and two written examinations to receive their board certification from the American Board of Radiology. One of the written exams covers radiologic physics, encompassing the basic scientific principles relevant to the practice of diagnostic radiology. Although the subject outline of these principles on the ABR's Web site does include a section on computers, it has not been updated since 1988.2 While the basic physics of ionizing radiation hasn't changed much in the past 14 years, the speed and capabilities of computers and the ways in which we use them have changed drastically.

Most institutions use some of the time allotted to physics lectures to educate their residents in the basic informatics required by the board exams. This includes topics such as image storage, data storage requirements for different modalities, and data transfer rates. But this is a far cry from what radiologists need to know as they embark on their careers. As the need to incorporate new information technologies into their practice increases, they may have to help make equipment purchasing decisions. The more senior partners of practices often assume that the more junior members are knowledgeable about information technology because they grew up using computers.

- Applications training. A second source of informatics training is applications training. During their initial job orientation, new residents are given instruction on using the PACS, the radiology information system (RIS), and the voice recognition (VR) system, assuming the residency program has access to these systems. Training is provided either by the vendor or by inhouse training staff, often on a one-to-one basis or in a small group. Online user manuals are often available, and some PACS offer an online self-guided tutorial.

Residents may not realize it, but this is part of their informatics training. It forces them to think about the flow of information throughout the system. They quickly learn, for example, that an exam cannot be performed until it is ordered (except in emergency cases), an exam is not complete until a technologist marks it as such, and the report can not be dictated until the exam is marked complete. These multiple levels of dependencies were not as apparent before the implementation of PACS and RIS.

Residents also learn how to interact with databases to find images and reports using multiple search criteria, including patient ID, modality, date, and dictating radiologist. They begin to recognize which search methods yield quicker results-usually those with narrower criteria-and this, too, is a form of informatics training.

- Grand rounds. Several traveling lecturers give grand rounds presentations on radiologic informatics. Among them are Dr. Keith Dreyer, vice chair of radiology informatics at Massachusetts General Hospital, Dr. Eliot Siegel, director of radiology for the VA Maryland Health Care System, and Dr. Paul Chang, director of radiology informatics at the University of Pittsburgh. These experts discuss topics such as voice recognition, PACS, networking, and electronic presentations. While they are not as in-depth as a formal lecture series, the lectures serve to introduce these topics to audiences of house staff and attendings, many of whom have never heard of them before.

Dreyer notes that there is no formal informatics training at Massachusetts General Hospital outside of the applications training for PACS, RIS, and VR. This was also my experience during residency at UMDNJNew Jersey Medical School.

GOING THE EXTRA MILE

Three residency programs, however, go the extra mile when it comes to informatics training.

Dr. Steven Horii, a professor of radiology at the University of Pennsylvania, takes special care to ensure that his residents are well prepared for the technological challenges of the future. Although his residents receive ample clinical conferences from his colleagues, few can teach them informatics. Horii thus devotes five or six lectures per year to issues such as PACS workflow and integrated systems, storage and archive mechanisms, medical image displays, and quality assurance. Occasionally, residents want to know more about DICOM and what it means to the practicing radiologist. But Horii guides the discussion of these nuts-and-bolts subjects to their effect on the planning of new radiology departments and practices and their physical room design. As both a physician and an engineer, Horii teaches his residents how to talk to architects. By the time residents graduate, they have heard more than 20 of these lectures.

Dr. Nicholas Hangiandreou, an assistant professor of medical physics, teaches physics to radiology residents at the Mayo Clinic in Rochester, MN. The informatics training his group provides goes beyond the usual fare to include such topics as PACS, teleradiology, networks, servers, archives, electronic displays, and digital radiography. It accounts for a full 10% of the lecture schedule, almost double the amount other programs devote to it.

Radiology residents at the University of California, San Francisco will have a new opportunity this year: flex time to participate in research in the Laboratory for Radiological Informatics, said Katherine Andriole, Ph.D., PACS clinical coordinator. Few residency programs offer such a resource for informatics research. UCSF residents receive basic applications training for PACS and RIS and physics training for computed radiography, digital radiography, and other modalities.

The department also offers a one-or two-month formal rotation for medical students called Introduction to Digital Imaging, which covers PACS, RIS, Integrating the Healthcare Enterprise (IHE), image processing, image quality assessment, and cost-effectiveness studies. Residents' flex time may be used for that course as well. UCSF offers two formal courses for graduate students in medical informatics: Introduction to Medical Imaging Informatics and Medical Image Processing and Analysis.

LOOKING TO THE FUTURE

One way for residency programs to keep up with the specialty's technological transformation is through direct communication between residency program directors and consensus groups of experts. Organizations such as the American College of Radiology and SCAR should lead the way in formulating an informatics curriculum and keeping it up to date.

The ACR and the Association of Program Directors in Radiology set an example by collaborating on a set of video teaching modules for the residents' nonclinical skills curriculum required by the Accreditation Council for Graduate Medical Education. Modules on job search and contracting issues, radiology business issues, and ACR standards are included in the series. Radiologic informatics might be an appropriate addition as a nonclinical but vital skill for radiologists.

Not surprisingly, SCAR has its own group of experts as well as an education committee that is in the process of formulating curriculum recommendations. This subject was discussed at length at the SCAR residents' roundtable discussion during the society's annual symposium in May.

At that meeting, Dr. Jean Jeudy of the American Association of Academic Chief Residents in Radiology presented results of a survey of informatics training in about 30 residency programs. The findings were abysmal; most programs indicated no training at all. The few that did have training mentioned only some applications training on the PACS and RIS and some PowerPoint instruction.

These findings, however, did generate objective evidence for the need for curriculum change. While the society offers a host of printed educational materials, including primers on security, archiving, and quality assurance, it remains to be decided what material should be considered essential for residents.

What is certain is that residents face a new type of radiology practice that is far more technologically advanced and complex than that of the previous generation of radiologists. The senior partners of those practices will tend to look to the new recruits for direction, so new hires must be prepared. While they need not become DICOM wizards, they will be expected to understand how to evaluate a vendor's claims for compatibility. While they probably won't have to compute file sizes, they will need to assess new storage and display equipment as a practice or department grows and its equipment ages.

Residents are not expected to become experts in all the clinical subspecialties of radiology, but they should attain a basic proficiency in them. And although residents do not have to become informatics experts, they need a foundation so they know where to find answers to the technological questions they will undoubtedly face in the future.

Dr. Hirschorn is head of the residents' section of the Society for Computer Applications in Radiology. He has just completed his residency at UMDNJ-New Jersey Medical School and is a fellow in radiologic informatics/MRI at Massachusetts General Hospital/Harvard Medical School.

References