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A Novel Reconstruction Technique to Reduce Stair-Step Artifacts in Sequential Mode Coronary CT Angiography

The Small Pixel Effect in Ultra-High-Resolution Photon-Counting CT of the Lumbar Spine

AI-Based Measurement of Lumbar Spinal Stenosis on MRI: External Evaluation of a Fully Automated Model

Machine Learning–Based Perivascular Space Volumetry in Alzheimer Disease

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Clinical Safety of Gadobutrol: Review of Over 25 Years of Use Exceeding 100 Million Administrations

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Evaluation of the Contrast Enhancement Performance of Gadopiclenol for Magnetic Resonance Angiography in Healthy Rabbits and Pigs

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Addressing the Contrast Media Recognition Challenge: A Fully Automated Machine Learning Approach for Predicting Contrast Phases in CT Imaging

Investigative Radiology. 59(9):635-645, September 2024.

Morphological and Quantitative Parametric MRI Follow-up of Cartilage Changes Before and After Intra-articular Injection Therapy in Patients With Mild to Moderate Knee Osteoarthritis: A Randomized, Placebo-Controlled Trial

Investigative Radiology. 59(9):646-655, September 2024.

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Radiology Research in Quality and Safety: Current Trends and Future Needs

Affiliations.

1 Department of Radiology and Imaging Sciences, Emory University Hospital Midtown, 550 Peachtree St, Atlanta, Georgia 30308. Electronic address: [email protected].
2 Department of Radiology, University of Virginia, Charlottesville, Virginia.
3 Department of Radiology, NYU School of Medicine, New York, New York.
4 Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia.
5 Division of Abdominal Imaging and Intervention, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
6 Abdominal and Cross-Sectional Interventional Radiology, University of Michigan School of Medicine, Ann Arbor, Michigan.
7 Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
8 Department of Radiology, Division of Interventional Radiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York.
9 Sunnybrook Health Sciences Centre, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
10 Harrington Healthcare System, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
11 Lean Six Sigma, UPMC Health Plan, Pittsburgh, Pennsylvania.
12 Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
PMID: 28193376
DOI: 10.1016/j.acra.2016.07.021

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.

Keywords: Culture of Safety; Performance Metrics; Quality and Safety Research.

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v.1(1); 2010 Jan

The future role of radiology in healthcare

European society of radiology 2009.

Neutorgasse 9/2, 1010 Vienna, Austria

Rapidly evolving changes in the way that healthcare is administered, coupled with the amazing recent advances within imaging, has necessitated a review of the way in which radiology should be regarded. This review considers some aspects of these changes and offers some recommendations.

Introduction

Radiology has been a distinct medical specialty with unique technical challenges from its inception. The origins of specialisation can be traced back to the technical nature of X-ray image capture and perhaps more significantly the difficulty of exposing, transporting and developing images on fragile glass plates for subsequent interpretation. Despite pressure in the early 1900s to define radiology as a technical service, radiographic image interpretation and reporting required medically trained specialists. Therefore, radiologists have been clinical specialists, who have been obliged to also become experts in image capture technology, broad-based advances in engineering and, more recently, applications of information technology for healthcare, which continue to drive and be driven by radiology.

Radiology is now the key diagnostic tool for many diseases and has an important role in monitoring treatment and predicting outcome. It has a number of imaging modalities in its armamentarium which have differing physical principles of varying complexity. The anatomical detail and sensitivity of these techniques is now of a high order and the use of imaging for ultrastructural diagnostics, nanotechnology, functional and quantitative diagnostics and molecular medicine is steadily increasing. Technological advances in digital imaging have also enabled the images produced to be post-processed, manipulated and also transmitted rapidly all over the world to be viewed simultaneously with the transmitting centre.

Radiologists have been strongly involved in these technological developments and have been responsible for much of the evaluation of the strengths and weaknesses of different investigations. Radiologists have developed the knowledge of the appropriate integrated imaging algorithms to maximise clinical effectiveness. They have also been responsible for the implementation of these developments into the clinical setting and for ensuring the best use of assets and healthcare resources.

The improved image clarity and tissue differentiation in a number of situations has dramatically increased the range of diagnostic information and in many cases the demonstration of pathology without the requirement of invasive tissue sampling (histology). This increased information also requires careful interpretation without preconception to avoid prejudging the findings. The use of imaging for functional evaluation and cellular activity has created a new challenge for radiologists whose training has predominantly been based on the anatomical and pathological model with limited experience in physiology and cell function. It has therefore been the case that in some super specialist areas of work, clinician specialists may believe that radiologists have not contributed sufficiently to the care of patients [ 1 ]. It is therefore incumbent on radiologists to mobilise their skills to utilise these new approaches to evaluate clinical questions in the most effective way. For this reason the radiological training programme for Europe is now mainly system- and disease-focussed to ensure that radiologists can respond to the multiple interactions of patient care.

Although the training programmes are repositioning radiology in this way, these developments are now occurring and are affecting all radiologists who in general, at present, are satisfied with their overall position within the respective health care system in most European countries. Radiologists have no difficulties in finding professionally fulfilling and well-paid employment. Indeed the rapid rise in workload and complexity of examinations have resulted in a shortage of radiologists in most countries which may reduce the opportunity or desire to move and up-date sufficiently with these advances. The availability of high-speed internet transfer of images may affect the requirement and role of local radiologists by transferring images to major centres for rapid specialist interpretation. Thus the rapidly developing and expanding field of imaging becomes a challenge to our specialty, especially as it has also become so attractive to others. We should therefore be concerned to ensure the future of radiology as a medical specialty and take into consideration the forces and the dynamics surrounding our profession by meeting them with foresight and flexibility.

Although as a specialty we must embrace the opportunities that these developments create, the requirements to embrace all aspects of the speciality are now considered unattainable for any individual, especially in an environment where the clinicians themselves are focussed on specific anatomical or disease-related areas as specialists. Therefore the dilemma for radiology and radiologists is how to achieve the objectives of the specialty and still provide a comprehensive service within the confines of a radiology department where so many of the tasks previously undertaken by clinicians are now the province of radiology.

The need for change

Numerous facilities in clinical services are collectively used by different specialties: operating rooms are not owned by surgeons anymore, ICUs have become independent of departments of cardiology, internal medicine, or neurology, while emergency rooms are not part of traumatology departments. Hospital beds are no longer dedicated to individual specialists or specialties and are available for radiologists for one or two nights following interventional procedures in some hospitals. At present the radiology department remains predominantly the domain of the radiologist, but this is changing and there is no specific reason why imaging facilities should not be used by other clinical specialists trained in imaging, and images produced in these departments may also be reported remotely.

New knowledge in imaging is being developed at an increasingly rapid rate. The field of radiology has expanded dramatically. The range of radiology covers diseases from the foetus through to the multi-morbid aging population, from prostate to the pituitary gland and from pancreatic neoplasia to bone dysplasia. No single person can master all the available knowledge. However, the referring physicians need a clinical interface with the imaging specialist. In order to create added value for the referring clinician, the radiologist must fully understand the clinical problem. The radiologist is expected to be able to do this at a different level and for all medical specialties. Therefore clinical experience is required before embarking training in imaging, and appropriate training in specific clinical specialties may also be needed. If not, imaging may increasingly be regarded as a sub-entity within the clinical specialty and in that setting each specialty will take care of its own specialised imaging and training, and the influence of the radiological expertise would diminish.

Public recognition of the clinical role of radiology is essential and is very much dependent on contact with the patients [ 2 ]. However, over the past years radiologists reading more and more complex examinations have become less and less visible for patients and the public. Moreover, in some health care systems the emphasis of radiology work is placed on the in-patient referrals to major general (secondary) and university (tertiary) hospitals where the role of the radiologist as part of the team is less obvious to the patient. There has been less focus on the provision of radiology services to primary care (including general practitioners and office based specialists), where the requirements are different, with a need for a more general service but still involving a range of imaging services, and where the individual role of the radiologist is more obvious to the patient.

In some countries clinical specialists may be the primary providers and interpreters of imaging in their offices. This has potential disadvantages for the patients. The self-reporting clinician may focus on the images to confirm or refute a preconceived clinical diagnosis whereas the interface of a radiologist, reporting the images, provides an independent opinion. It is also suboptimal for funding healthcare, as self-referral has been shown to increase numbers of radiological procedures and consequently costs. Moreover, radiologists will ensure the appropriate use of equipment and quality control, and apply radiation protection principles which are particularly pertinent with the massive increase in the use of multi-detector CT [ 3 ].

Radiology has prospered by staying ahead of the wave of progress. But radiologists will have to change many of their attitudes and rethink their professional training to accommodate to the dramatic revolution and evolution of radiology [ 4 ]. Radiologists need to adapt to the changes in technology in order for the profession to deliver the service that patients expect and medical progress requires.

Specialisation in radiology

One solution has been a gradual increase in the degree of specialisation of radiologists along systems and disease-related specialties, which has been strongly advocated by the ESR in its curriculum. Some radiologists have focussed on particular imaging modalities which may have assisted the development of these modalities, but the range of imaging techniques to evaluate particular clinical scenarios is such that this approach is not appropriate when dealing with clinicians who have all specialised along systems and disease-based pathways. The current curriculum for training has been adapted to take this process into account. It now separates radiologists, following training to a core level in all aspects of radiology including all techniques, into two main categories:

Radiologists who have additional dedicated training to provide special interests in two or possibly three system-based specialties. These radiologists work in teams to provide a 24/7 comprehensive radiological service and at present represent the largest radiological community.
Radiologists who have subsequently focussed on one field of radiology which parallels a medical or surgical specialty and who work primarily in that subspecialty in secondary or tertiary referral centres.

It is however still debated how far subspecialisation should proceed and how enthusiastically it should be promoted. It is also unclear how the process should be managed in order to provide an integrated cohesive imaging service to the patients and their clinicians.

Reasons for subspecialisation

The argument for subspecialisation is strong and a number of factors should be taken into account.

Our field has become so complex that no individual can maintain the level of expertise needed to practice the entire field of radiology. At present we insist that radiologists become at least minimally competent in the entire field although it is virtually impossible today to remain a radiologist with competence in all areas of our specialty [ 5 ]. However, in interventional radiology, for example, sub-specialist training is needed to gain deeper knowledge, new techniques and practical experience to provide a high level of clinical service. The technical demands for procedural skills and familiarity with new devices mean that only a few members of a group can develop the expertise to practice interventional radiology. Mammography quality standards require that physicians practising mammography interpret a minimum number of cases and attain specific breast-related continuing medical education to continue the practice.

There are many examples of the effect of rapid developments but the increase in the temporal and spatial resolution of acquisition in CT and the complexities of new software packages in MR have been paramount. The former has involved radiologists in many non-invasive vascular imaging interpretations that were previously the domain of the sub-specialist. The latter has resulted in functional imaging, spectroscopy and diffusion imaging requiring specialist knowledge to conditions which hitherto have been the responsibility of the clinical radiologist such as the early evaluation of stroke patients. The emergence of fusion imaging presents further challenges to staying abreast of this evolving technology. As the field of radiology expands, the degree of sub-specialisation requires maintaining competence increases [ 5 ]. Thus the growing array of radiological tools will require radiologists in various practice settings to make fundamental decisions about how to focus and balance their areas of expertise [ 6 ]. It is impossible for the radiologist, who is providing a busy comprehensive service, to assimilate these advances.

Secondary and tertiary based clinicians have long since abandoned the concept of the generalist and focus on particular systems or disease-related areas. While the imaging of disease becomes ever more complex, the clinical conditions remain mainly unchanged although the ability of the clinical specialist to treat these conditions is advancing. This reduced pace of change enables the clinicians to assimilate and often develop new ways of addressing the diseases in their special area, thus posing a challenge to the radiologist who is not aware of these developments.

Now better and faster imaging machines enable more accurate diagnosis with less risk and at lower costs than ever before so that radiologists will not be the only specialty to be able to identify disease sites and morphology. The developments also apply to clinical sciences such as the rapid growth of anti-cancer drugs requiring a new insight by imaging of tumour response, or to developments in laparoscopic surgery which need detailed staging of disease by radiology.

The patient characteristics, clinical history and examination remain important to guide the investigative choices and are an integral part of the clinical examination. Clinical information is important to correlate with the imaging findings, especially to avoid false positive imaging diagnoses. However, in many circumstances a long differential diagnosis may be resolved by modern objective imaging which can provide a precise diagnosis in a few minutes. The role of surgeons has also been changed by the emergence of laproscopic surgery and by image-guided endoscopic and interventional techniques. These developments require even more precise delineation of the lesion before intervention and yet even closer collaboration between radiologists and referring clinicians.

A reduced level of expertise of the non sub-specialised radiologists may reduce the quality of patient care, and also the respect radiologists are accorded by their colleagues in other medical disciplines. For example an experienced neurologist or orthopaedic surgeon is unlikely to rely on a diagnosis made on a MR study by a radiologist who has had only 3–4 months of training in neuroradiology or musculoskeletal imaging. This lack of confidence in radiologists would force them to rely on their own interpretations. They no longer want radiologists to report back with generalised observations about the abnormalities.

Teleradiology is becoming a significant component in the delivery of radiological services due to the high quality and speed of image transmission. Communication of images between radiologists, via local or distant networks is now a widely available option to solicit a specialised opinion in selected cases. This enables subspecialty opinions to be provided easily and quickly, thus undermining the role of the radiologist who does not possess a specialised knowledge. The patients and their clinicians are now rightly expecting an expert opinion and it is possible now to obtain one through teleradiology services.

There are often short innovation cycles of radiological equipment and it is important that there are specialist radiologists who are able to assist the manufacturers with technological developments and clinical implementation. It is also important to emphasise that radiologists have special expertise in technology not possessed by other clinicians, which provide an indispensable link with other disciplines such as physicists, experts in information technology, molecular biology and engineering. It is essential that knowledge of the technology used is included in radiological core and subspecialty training.

It is imperative that radiologists are engaged in research in their own discipline. Research in radiology is part of the huge domain of clinical research requiring imaging and at present much of this research is undertaken through multidisciplinary protocols led by clinicians and scientists with radiologists seen as a relatively small contributor. Unless specialisation occurs, radiologists will be unable to reverse this situation and thus risk a further loss of influence in the future of imaging at a time when there is a major transformation to functional and molecular imaging. The breadth of research topics relevant to radiology is constantly expanding and includes development in technology and its applications, epidemiology, molecular biology, computer science and other basic research fields.

Reasons for maintaining radiology with special interest(s)

In most secondary care centres and large private radiological offices radiologists have developed additional expertise in two or three clinical disciplines which supplement the delivery of a general service and complement each other within the department or practice. This enables the practice and individual radiologists to add value to the clinicians and provide support to each other.

While a number of disorders may be confined to one organ or system, such as musculoskeletal or intra-cerebral abnormalities, others may involve a number of systems such as diabetes, some neoplastic disorders or inflammatory diseases. There may also be circumstances were the initial patient imaging examination may reveal other abnormalities, which were unsuspected and potentially life-threatening. A patient, who may have a specific lesion directly related to the individual specialty, may have co-morbidity that will affect their management, while other abnormalities and disease processes can and are demonstrated incidentally by radiology, and the radiologist is essential to avoid assumptions and also false positive conclusions. In these circumstances the radiologist needs to have a broad perspective and a wide knowledge of anatomy, pathology and imaging signs. This is difficult to maintain, even when the initial training is broad-based, if the subsequent work is highly specialised. It is important that there is good joined-up thinking to avoid the patient having unnecessary examinations and being referred to a variety of physicians.

Some imaging examinations are commonly performed in most hospitals and all radiologists should be sufficiently experienced to manage and interpret them.

The value of different modalities varies by disease and clinical question and some modalities have considerable limitations in some organ systems. Radiographs, ultrasound, computed tomography (CT), magnetic resonance (MR) and nuclear medicine techniques are all of value in different clinical situations in musculoskeletal radiology while in neuroradiology MR and CT are predominant.

If all radiologists are sub-specialists, it requires a large staff to cover all emergency work in-house. Sub-specialist staffing requirements are also increased to cover sickness and leave of absence, if continuity of service is to be achieved. Teleradiology may be of value but there is a resultant loss of contact between the radiologists and clinicians, if this is used extensively. The use of this technology is under scrutiny and is being restricted in some countries to ensure that quality issues are robust. Emergency radiology is now becoming a specialist area and the presence of radiologists on site in major accident and emergency departments is essential for the smooth running of the service and although some local emergency radiology reporting has been replaced by teleradiology.

If all radiologists are sub-specialists, there may be a loss of unity in the department and a loss of interest in discussing cases. Satellite organ- or disease-based departments may become an expectation with a potential duplication and under use of expensive capital equipment and clinicians may set up their own subspecialty radiology departments in conjunction with either the sub-specialist radiologist or a clinician who has done some imaging training as part of their specialist clinical training.

In many countries in Europe sub-specialisation and access to complex equipment is limited. Therefore no opportunities are available to train or practice in a subspecialty. This situation is changing by implementing fellowship programmes and by the use of electronic teaching files and internet-accessible case collections but it may be resource-limited and the complex sub-specialisation model may not be appropriate outside the major university hospital setting.

How should sub-specialisation be implemented in radiological practice?

Subspecialisation is established in university hospital settings and large hospital-based non-academic practice groups, who are increasingly appreciating the value of having this high level of expertise within their groups, and the process towards increasing super-specialisation is already upon us and is continuing. Neuroradiologists focus on spinal, paediatric, interventional, or head and neck radiology. Interventional radiologists may concentrate on vascular procedures, non-vascular intervention, or oncologic procedures, such as percutaneous tumour ablation or chemo-embolisation. Thoracic radiologists are often divided into those who provide cardiac imaging and those limiting their practice to the lungs and mediastinum.

However the primary care physician will need help from radiologists to decide which imaging procedure will most likely provide the diagnosis without having to go through the escalating sequence of imaging or other tests. Radiologists will also be expected to manage and report these examinations, many of which will cover a spectrum of common disorders which form the mainstay of any primary care service. To be able to render these consultative services, the radiologist will need to keep abreast with the new key developments in most subspecialties [ 1 ].

It is therefore likely that more than one model of practice will continue, depending on the physical circumstances of the service required, but in order to be valuable to the clinicians, the radiologists must have sufficient insight into the clinical problems being investigated and greater skills in interpreting more complex images than the clinicians themselves. In areas where there are significant ‘turf strains’, of which there are an increasing number, subspecialty qualifications may be a requirement. Radiologists should therefore have areas of subspecialty competence, even if they still provide a broad service most of the time.

Clinical competence

One of the main reasons why radiologists are losing many turf issues is their inadequate clinical culture. A high level of technical training is not sufficient for dealing with clinicians and their clinical queries. Medical practice is becoming increasingly interdisciplinary due to the vastness of knowledge involved. The importance of clinical training has been emphasised previously by the ESR but it is still not a requirement for entry into radiology in a number of European countries. It is essential that, if radiologists are expected to understand the clinical features and treatment of sub-specialist areas, they have a good clinical base on which to build that knowledge. Good clinical training will enable radiologists to interact at the appropriate level with clinicians. Therefore radiologists, to be able to take part in an interdisciplinary discussion as a key player, will not only have to be specialised in the imaging of a specific organ system but also to be able to discuss complex clinical cases. Clinicians require radiologists who understand the clinical questions, keep updated with the most recent advances in the disease processes and have knowledge of the relevant therapies.

A basic clinical experience and knowledge should be achieved prior to entering radiology. A 1–2 year programme of clinical work would ensure a sound basic knowledge and give the appropriate skills for caring for patients and interacting with clinicians. Attempting to develop a sound clinical base during radiological training may be difficult to organise and will distract and potentially dilute the radiological training programme. Further subspecialty clinical knowledge and experience may then be achieved in a number of different ways, which are not mutually exclusive, including combined clinical and radiological rounds, interdisciplinary meetings, scientific literature and research and where possible clinical secondments.

As part of this clinical knowledge and experience, radiologists in specialised situations must have a good understanding of the physiology, pathology, and up-to-date therapies applicable to their respective organ system. They must also be experts in the multiple imaging modalities applicable to the clinical problem addressed [ 1 ]. Whatever methodology is adopted to develop the necessary clinical experience, it should be focussed in the area in which a radiologist will practice, and would be more appropriately embedded in the subspecialty training.

Interventional radiology

The field of interventional radiology has moved at great speed over the last few years, and there is no evidence of a reduction in the pace. Indeed quite the opposite is true as more and more surgical procedures are performed with minimal invasion. Radiology has led the field but is being overwhelmed by the volume of work and the desire of surgeons and physicians to take over this work. In order to preserve radiology’s place, it is essential that a radiologist’s training in interventional radiology is structured in such a way to ensure that they not only have the core diagnostic imaging skills, knowledge and technical interventional competence, but also have sufficient clinical skills and training to care for their patients. Interventional radiologists must also be given the necessary resources of clinic time, hospital facilities and support to take and treat direct referrals. An innovative approach to training in conjunction with our surgical, cardiological and oncological colleagues is required to ensure that radiologists remain key operators in this subspecialty. Interventional radiology should also be funded and recognised for the clinical work they provide. In health economies that use Diagnostic Related Groups (DRG) for payment purposes, it is of utmost importance that patients admitted for an interventional procedure create income for the radiology department in due proportion to the gain provided to the hospital by the intervention and the hospital stay.

Training implications

The European Training Charter for Clinical Radiology [ 7 ] identifies the first 3 years devoted to developing the core skills and knowledge in all aspects of diagnostic radiology. The following 2 years may be spent either undertaking subspecialty training or gaining further experience while developing areas of special interest by focussing more time in two or three organ- or disease-related specialties.

In a report of the 2005 Intersociety Conference, Reed Dunnick et al. also advocate that the first 3 years of training in radiology could constitute a core curriculum. However, they suggest that this would be followed by a three-year focused programme. In America, this would replace their traditional fellowship and could include clinical training. During this period of training each resident would be required to focus on one or perhaps two subspecialty areas. A variety of choices would be available depending on an individual’s interest.

There may be organisational challenges to obtaining subsequent clinical experience during subspecialty training although this could be on the basis of supernumerary status which would provide clinical exposure without taking clinicians resident positions, but gaining a sound clinical base prior to starting radiology is entirely possible given the acquiescence of national policies. Additional clinical experience should follow a structured curriculum individualised for each subspecialty.

There is a fundamental requirement to increase the exposure of medical students to imaging taught by radiologists. Presently, the number of radiologists involved in undergraduate training is low. As a result the potentials and excitement of radiology as a career are not transmitted and the realisation that radiologists are key players in the patient care pathway is not embedded in the medical student’s psyche at an early stage. There are a number of initiatives that have been developed in Europe for increasing the teaching of radiology at undergraduate level and these should be further promoted.

Teleradiology: an opportunity

Teleradiology is now an established method of providing radiological services. It is well developed in the provision of on-call emergency reporting being used by over 70% of radiological practices in the US both by groups in the US and by Night hawk services around the world. Teleradiology is also established for the provision of radiological services to remote rural communities and for sub-specialist opinions and for specialist case transfers. In the UK it is now used to provide primary reporting services from centres both in Europe and by international providers.

With the costs of data transmission decreasing as fast as the costs of computing power, practical opportunities for global teleradiology are rapidly increasing as the cost effectiveness of PACS and digital radiology increases. In our financially constrained world, the clinical losses associated with generalised use of teleradiology may be accepted by governments and health care insurers as a means of cost containment [ 1 ].

However, exchanges of information with referring physicians in conferences or reading rooms are an integral part of delivering a clinical radiological service. It would be a great loss to the profession if radiologists were to be identified by other physicians and patients only as image readers sitting exclusively in front of workstation screens and ceasing to be clinicians [ 1 ].

The obligation or responsibility or opportunity of a radiologist to go beyond the dictated report and to offer consultant services to his or her clinical colleagues is what allows the specialty to be more than a technical service. This will be even more significant as computer-assisted diagnostic programmes extend to more body parts. If a radiologist provides nothing more than an observation of abnormal densities, radiology will be minimised or eliminated [ 8 ]. Similarly the role of laboratory medicine was minimised when chemical autoanalyzers provided results cheaply and accurately and the printed values were significant to the referring physician without any interpretation or consultation with a laboratory physician.

With so many technological advances it is not surprising that radiology utilisation of high-cost studies such as CT and MR is expanding rapidly worldwide. This has resulted in a larger and more complex workload. However the number of radiologists worldwide has not increased at the same rate as the number of examinations. Radiologists have only been able to manage this increase by improved workflow and productivity due in part to digital technology. Digital imaging, workstations, speech recognition technology, PACS and ease of communication via the internet have all facilitated workflow. Teleradiology may increase productivity in some circumstances such as night cover in smaller practices and provision of radiology reporting services to rural communities. It has also been used in some countries to compensate for manpower shortages and when used in a proactive and controlled fashion may help to avoid loosing turf to clinical colleagues. It is not however the ultimate solution to manpower problems which are better resolved by training sufficient radiologists to provide the service within the locality of the clinicians and patients. Teleradiology must not be allowed to commoditise imaging services and should only be used to support the comprehensive diagnostic service provided by radiologists within groups or local area networks.

Patient relations

Radiological societies maintain (and radiologists do not publicly disagree) that to improve the public perception of the role radiologists play in patient care, closer contact with patients is essential [ 9 ]

Radiological services are essential to the care of patients. To the patients, however, radiological services may seem somewhat inconvenient, mysterious or frightening, or may even be a painful intrusion of their privacy. The perception is further altered by the fact that patients typically do not choose their radiologist; the referring physician, the health plan or another intermediary usually makes that choice. Often patients and their diagnostic radiologist never meet. This situation substantially alters the service bond between them, actually making the relationship more demanding in a number of ways [ 10 ]. Moreover, nurses, technologists and others are increasingly participating in the performance of imaging examinations. For many patients, radiologists are identified only with the equipment used and not as physicians who play a vital role in the decisions that affect them. The use of technologists, nurses, and physician assistants for intravenous injection of contrast material makes radiologist-patient contact even less common [ 2 ]

Patients believe that the clinician who requested the examination and has received the report is actually the physician who has interpreted the study [ 2 ]. On the other hand, there is widespread agreement that patients prefer to hear the results of imaging examinations from the radiologist at the time of the procedure rather than to hear them later from the referring physician, regardless of the findings [ 11 ]. And in another study it has been shown that radiologists and referring physicians alike tend to support the proposition that, if asked, radiologists should disclose the results of imaging studies to patients [ 12 ].

It seems to be important for the future of the specialty for radiologists to have more contact with patients in the setting of high-cost, high-impact imaging procedures. The very position of radiology in a variety of hierarchies ranging from political to economic may depend on increased recognition by the public of radiologists as physicians. However, results of a survey by Margulis and Sostman [ 2 ] show that more than a half of the injections of contrast medium in radiological practices are performed by non-physicians. Radiologists are often but by no means always present in the facility during performance of the study and radiologists rarely introduce themselves to the patient. Radiologists should always introduce themselves to patients before any interventional procedure. This is not only good manners but it also establishes the radiologist’s clinical role in the whole spectrum of planning the treatment and assessing the prognosis and the response during follow-up.

Involvement in primary care (general practice (GP) and office based practice)

Primary care is the point of first patient contact and offers continuous comprehensive and coordinated care to populations undifferentiated by gender, disease or organ system. In order for comprehensive care to take place in the primary care setting, the GP often requires access to a wide range of imaging services. This enables the GP to diagnose and treat the more common diseases without recourse to hospital services. It also empowers the GP to investigate the patient more fully so that, if a transfer to a hospital specialist is required, such referral can, in many cases be for therapeutic care rather than for further investigation.

A GP may wish to work up a patient more fully in conjunction with the clinical radiologist, who may be a sub-specialist or a radiologist with special interests, so that the requirement for outpatient referral to specialty services may be avoided or may be a more focussed and constructive consultation. For such a means of referral to be effective, the radiologist will need to establish preferred investigation pathways with the clinicians to whom ultimately the patients may be referred. Finally, the GP may be able to treat a patient directly with the assistance of the radiologists and some image-guided therapeutic procedures can be undertaken by radiologists directly for GPs on an outpatient, day-case or short-stay basis.

In the past the workload of departments of radiology was concentrated primarily on supporting the care of hospital patients and on providing imaging services for outpatients attending consultant clinics. GPs’ rights to request radiological examinations should be however similar to those enjoyed by hospital specialists. The concept that expensive investigation should be limited to clinical specialists is not sustainable. Specialists and GPs should have similar rights to request examinations. This is particularly highlighted with MRI or CT, where a single examination may avoid the need for an outpatient visit or an invasive procedure, which would cost considerably more. If GPs are undertaking primary diagnosis and management of patients, then clinical radiologists are acting as first-line clinicians and it is entirely reasonable for the radiologist to undertake the most appropriate examination. The radiologist also possesses the knowledge and competence to ensure compliance with all aspects of radiation protection and justification of investigations which is particularly relevant regarding CT. They should therefore recommend additional examinations where appropriate and manage the imaging diagnostic process in conjunction with the primary care clinician. The value of investigation which does not show an abnormality but reduces uncertainty and provides reassurance to the patient and to the GP, should also not be underestimated by the radiologist [ 13 ].

However, radiological investigations available to GPs must be determined by local radiologists in consultation with their GP colleagues as availability of new, often complex investigations may be limited in some countries and areas.

Electronic transfer has also developed rapidly over the last few years and the transmission of images and reports between radiology departments and surrounding GPs is now easily undertaken.

Closer working relationships with GPs and a stronger involvement of imaging in primary care will also increase contact of radiologists to their patients and particularly raise public awareness.

Maximising the use of resources

There has been a tendency in teaching and large regional hospitals for subspecialty services to pursue the development of satellite departments isolating radiologists from each other. While this may be essential in some clinical situations such as emergency departments, it potentially reduces the interaction between sub-specialist radiologists to the detriment of their wider knowledge and technological development. It may also reinforce the desire for clinicians to set up their own units and encourages the concept of radiologists working in clinical groups rather than providing a comprehensive imaging service. Radiologists should work towards a single strong well-staffed and funded department which is able to accommodate those clinicians who justifiably need prompt access to expert imaging [ 3 ].

The world of radiology is changing rapidly and radiologists have to be proactive in this process to survive. The subject is now too broad and complex for an individual to remain a comprehensive provider. As a result radiologists need to group themselves as specialists in particular systems or disease-based areas while finding a mechanism to provide a high-quality service. Radiologists must also be clinicians and understand the clinical features, natural history and treatments of the diseases that they are requested to investigate. Therefore, if radiologists want to add value to the chain of healthcare they need to sub-specialise to a greater or lesser extent according to their working circumstances. Teleradiology services may be appropriate for small and rural practices as part of an area network especially during nights and weekends and for interaction with GPs and patients. Radiologists must also interact more directly with patients and primary care physicians to provide a comprehensive diagnostic and advisory service prior to the patient entering the secondary care service by managing the investigations of the patients themselves. This will increase efficiency, clinical effectiveness of the service and speed up the referral process. Radiologists in the teaching hospitals will also need to specialise to a higher degree in order to provide a tertiary referral service, communicate and advise clinical experts and to conduct and drive imaging research as true experts in their field.

Recommendations

Sufficient radiologists are in training to ensure that the workforce is large enough to undertake the workload.
System- (or disease-) based subspecialisation or the development of system- (or disease-) based areas of special interest is essential for all radiologists to respond to the complexity and technological advances of imaging.
Encouraging radiologists to build strong networks with clinicians. In order to achieve this, all radiologists should have sufficient clinical knowledge in order to understand the fundamentals of clinical presentations, natural history, treatment and prognosis of all common and/or severe diseases. They should also obtain a more in-depth clinical knowledge of particular diseases related to any subspecialty in which they wish to practice. This may involve a number of strategies, but subspecialty and special interest curricula should ensure that trainees participate in clinical rounds, multidisciplinary meetings and provide opportunities for interaction with relevant clinicians.
Wide clinical experience should be obtained before entering radiology. In such circumstances further clinical experience may only be required in a chosen subspecialty and to a level dependent on previous experience.
Expanding consulting activities of radiologists with clinical specialists in multidisciplinary conferences.
Intensifying relations with GPs offering diagnostic management of their patients including referral to clinical specialists if needed or full work-up in conjunction with the GP.
Communicating with the patient and discussing options particularly in cases of primary care (patient referred by GP).
Making use of teleradiology services in a proactive way through local area networks under the control of radiologists to incorporate general and sub-specialist radiologists in a comprehensive coverage of clinical scenarios.
Ensuring that all radiologists involved in such networks keep close contact with referring physicians through both personal interaction and video conferencing.
Encouraging radiologists to network with interventional radiologists to learn the basic aspect of the techniques, indications and imaging follow-up in order to increase the quality of care to patients and the potential referral to both.
Ensuring that radiologists are conversant with the technical aspects of the equipment they are utilising and that sub-specialists involve themselves where possible in the development and implementation of new innovations.
Reinforcing the clinical role of radiologists to use resources to increase day-case work, to make decisions regarding imaging strategies, and to explain the results and further examinations to the patients.
Reinforcing the status of the radiologist with special interests.
Training programmes are always subject to country by country variations but should be structured with these principles in mind. Possible combinations include:
System- or disease-oriented sub-specialisation during the last 2 years of residency training (3+2). This may be followed by an additional 1 year fellowship training where appropriate.
Additional clinical experience fitting to the radiological sub-specialisation within the subspecialty training period and fellowship.
System- or disease-oriented training in two areas of special interest in the final 2 years of residency. This may be followed if appropriate by an additional 1 year fellowship training gaining further experience which may include an understanding of general practice medicine.

Acknowledgement

Paper prepared on behalf of the European Society of Radiology by Professor Iain McCall. Approved by the Executive Council 2009.

Most Popular Topics in Radiology 2023

Taking a look at current trends in radiology research topics.

Research is critical to the future growth of radiology. The specialty has a rich history in innovation and today’s investigators ensure a bright future for radiology by uncovering new discoveries and advancing radiologic research. Innovations in radiology have led to better patient outcomes through improved screening, diagnosis and treatment. The first step to develop a research project is identifying an interesting topic. These are just a few topics that are currently garnering interest in the field.

Medical Imaging AI

AI solutions to work seem to permeate every sector today, including radiology. These applications promise to transform the way radiologists work in the future by triaging images to help manage ever growing workloads. AI tools have the potential to enhance practice efficiency and improve diagnostic accuracy. Research into applications of AI in medical imaging continues to focus on solving specific diagnosis across all subspecialties. Radiologists are also starting to understand how AI might be incorporated into radiology workflows. RSNA leads the way in medical imaging AI research by publishing and funding research, helping radiologists learn practical applications of the technology and developing AI challenges to help create tools and harness the vast amounts of data needed. Learn about RSNA’s available resources and training in medical imaging AI.

Health Care Equity

Disparities in access to health care and screening are important to address and researchers are looking into barriers to screening for various populations and discrepancies in health outcomes across demographics. An important step toward improving care is expanding the diversity of the health care team. Populations historically underserved have been shown to have less trust in the health care system. A provider team that looks more like its patient population helps build trust. More than 50 presentations at RSNA 2022 focused on diversity, equity and inclusion topics, demonstrating the demand for continued research in the area. Find valuable resources and current health equity research here.

Photon Counting Detector CT

One popular topic in clinical radiology research, photon counting detector CT (PCD-CT), is gaining attention for its ability to reduce radiation dose while maintaining or even improving image quality. PCD-CT systems demonstrate several advantages over standard CT , including reduced electronic noise, improved spatial resolution, and lower radiation dose. The technique converts X-rays to electrical signal, facilitating small detector pixel designs, thus increased spatial resolution, without losing dose efficiency. These advances in diagnostic techniques that reduce the required radiation dose show promise for improved patient care.

COVID-19

Interest in the effects of COVID-19, both short- and long-term, continues to be strong. Research into health complications resulting from infection and disparities in access to care is a popular topic. As a growing population is diagnosed with long COVID, interest in the effects of this condition has increased. This was also a hot topic at the RSNA annual meeting with late-breaking research on the topic presented throughout the science sessions and in the Learning Center Theater. Read original research and access tools and guidelines for managing COVID-19 on the RSNA COVID-19 Resources page.

RSNA Advances Radiology Research

Once you have identified an interesting topic to research, RSNA’s Research Development Guide will help you expand on your idea and develop it into a project. The RSNA R&E Foundation funds promising research projects across all radiology subspecialties. In 2022, the Foundation introduced Emerging Issues grants , which are designed to rapidly and effectively address urgent issues that threaten the health and well-being of disparate populations.

The RSNA annual meeting is a great place to showcase your research results. Become a member to enjoy the benefits of presenting at the largest medical imaging conference and to gain access to R&E Foundation grants .

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Throughout its history, the Stanford Department of Radiology has worked continuously to develop the infrastructure necessary to expand interdisciplinary research efforts in anatomic imaging, instrumentation development, molecular imaging, nanotechnology, information sciences, systems biology, and interventional therapeutic advances. Coupling this rich biomedical imaging foundation with an energetic, forward thinking, and creative faculty and staff, we are able to introduce leading-edge imaging solutions and technology to other research communities and into clinical practice.

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Open access
Published: 19 August 2024

Radiology education for medical students: a qualitative exploration of educational topics, teaching methods and future strategies

Frederike S. Harthoorn 1 , 2 ,
Sascha W. J. Scharenborg 1 , 2 ,
Monique Brink 2 ,
Liesbeth Peters-Bax 2 &
Dylan Henssen 2

BMC Medical Education volume 24 , Article number: 891 ( 2024 ) Cite this article

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Metrics details

Imaging techniques play a central role in modern medicine and therefore it would be beneficial for all medical students to incorporate radiology education in medical school curricula. However, a formal undergraduate radiology curriculum with well-defined learning objectives remains lacking in The Netherlands. This study aims to qualitatively ascertain opinions from clinicians (radiologists and non-radiologists) with regard to radiology education in the medical school curricula, including topics, teaching methods and strategies.

A qualitative study with in-depth semi-structured interviews was conducted. Inclusion was carried out until saturation was achieved, after which 2 additional interviews were held. Interviews were conducted using open-ended questions, following a predefined topic list. The constant comparative method was applied in order to include new questions when unexpected topics arose during the interviews. All interviews were transcribed verbatim and coded using a thematic analysis approach. Codes were organized into categories and themes by discussion between the researchers.

Forty-four clinicians were interviewed (8 radiologists, 36 non-radiologists). The three main themes that were derived from the interviews were: (1) expectations of indispensable knowledge and skills on radiology, (2) organization of radiology education within the medical curriculum and (3) promising educational innovations for the radiology curriculum. The qualitative study design provides more in-depth knowledge on clinicians’ views on educational topics.

Conclusions

The themes and statements of this study provided new insights into educational methods, timing of radiology education and new topics to teach. More research is needed to gain consensus on these subjects and inclusion of the opinion of medical students with regard to radiology education is needed.

• Radiology education in medical curricula was considered important by all interviewees

• Integrating radiology and anatomy in Longitudinal learning communities (LLC’s) could be a promising educational strategy

• Integration of ultrasound education in medical curricula should be investigated further

Peer Review reports

Imaging technologies play a central role in the practice of modern medicine. Therefore, it is not surprising that previous studies suggest that all medical students would benefit from (basic) knowledge concerning medical imaging technologies and radiology [ 24 , 37 , 63 ]. However, radiology education is not well integrated in the medical curricula [ 21 , 25 , 29 , 37 ] and students’ lacking knowledge can be potentially dangerous [ 19 , 63 ]. In turn, medical students (including interns) and residents reported a lack of confidence when interpreting radiology examinations, including (chest) radiographs [ 19 , 48 ]. Moreover, lacking radiological knowledge was found to be correlated with an overutilization of medical imaging services [ 27 ], leading to increased societal healthcare-related expenses. Consequently, a need for radiology education in medical schools is recognized among teachers, medical students and curriculum designers [ 1 , 29 , 37 , 42 , 44 , 47 , 48 , 52 , 61 ]. Albeit, the learning objectives of such a radiology curriculum remains a topic of debate [ 61 ]. Therefore, proper identification of useful learning objectives for radiology education in medical curricula should be carried out [ 23 , 54 , 60 , 61 ]. The first step of defining learning objectives is to determine which educational topics are important to teach [ 26 , 34 , 60 , 5 ].

When defining these, it is important to identify the opinions of both clinicians (radiologists and non-radiologists) and medical students since both groups influence which topics are considered important to teach during medical school [ 39 ]. Opinions on this topic diverse, due to the fast technological developments in this broad field, which covers nearly every medical discipline for diagnostic and therapeutic purposes [ 23 , 34 , 63 ]. Several studies have previously aimed to determine radiology curriculum topics by questioning different groups of physicians (both radiologists and non-radiologists) and educational experts using questionnaires [ 32 , 36 , 48 , 53 , 53 , 54 , 55 , 55 , 61 ]. Overall, these studies provided lists of interpretative and non-interpretative skills that respondents agreed on what should be taught in medical school regarding radiology. The most commonly mentioned interpretative skill concerned the systematic approach of reading chest radiographs [ 32 , 36 , 48 , 53 , 53 , 54 , 55 , 55 ]. Suggested non-interpretative skills were more diverse and included (a) the basic physical mechanisms of ionizing radiation, including knowledge on radiation risks [ 32 , 36 , 53 , 53 , 54 , 55 , 55 , 61 ], (b) the principles of justification of procedures (e.g., knowing when to use intravenous contrast agents) [ 32 , 36 , 48 , 53 , 53 , 54 , 55 , 55 , 61 ], and comprehension of the role, indications and limitations of diagnostic imaging (and interventional) techniques [ 32 , 36 , 48 , 53 , 53 , 54 , 55 , 55 , 61 ].

Nevertheless, the aforementioned studies used a survey-based approach in which rather pre-determined information is collected from a large group of participants [ 32 , 36 , 48 , 53 , 53 , 54 , 55 , 55 ]. This study aimed to build on this work by employing an inductive, qualitative approach, allowing for the opportunity to acquire participants’ opinions without any influence of preset questions and to explore these answers to gain more detailed information on a broad range of topics [ 22 , 58 ]. Therefore, it is possible to gain a more accurate insight into the wide diversity of current ideas on education on imaging technology that are continuously changing. Limitations of qualitative research, on the other hand, concern the labor-intensive nature of such studies, which explains why in most fields, qualitative data are lacking. Also, qualitative data are more subjective than quantitative data as the interviewee has more control over the content of the data. Therefore, unnecessary quantification of qualitative data should be avoided as it falsely suggests objective, statistically proven results [ 10 , 38 ].

Consequently, there is a recognized need for enhanced radiology education in medical schools among teachers, students, and curriculum designers. This study aimed to 1) Identify key topics that should be included in a radiology curriculum, 2) Determine effective teaching methods for radiology education and 3) Propose strategies for integrating radiology education into existing medical school curricula. Therefore, we qualitatively investigated the perspectives of clinicians (both radiologists and non-radiologists) on radiology education in medical curricula.

An exploratory inductive qualitative study focusing on the role of radiology education in medical curricula was performed. A pragmatic qualitative approach was used with the aim to identify topics in radiology education that clinicians considered important to embed in the medical curriculum. A sample of clinicians involved in medical education in the Netherlands was asked to provide their insights using in-depth semi-structured interviews. Interviews were performed following an inductive iterative process using the constant comparative method [ 31 ]. This implies that if new topics arose during interviews, it was possible to explore these topics and thereby allowing new topics to be added to the interview guide during the experiment. The interview guide is provided in Table 1 . After interviewing, a thematic approach was used to analyze the data.

Relevant scientific literature was reviewed on learning objectives and teaching methods in radiology education in medical school. After reviewing the available literature, two researchers (F.H. en D.H.) constructed a topic list. An inductive iterative interviewing process was carried out using the constant comparative method [ 51 ]. Therefore, new topics could be added to the topic list during the interviews.

Participants

A list of eligible clinicians was constructed by reviewing hospitals and general practitioners within the training region of the university medical center in the east of The Netherlands (OpleidingsRegio Oost-Nederland). The contact person of each practice or department that provided a mandatory internship within the medical curriculum or an elective internship in radiology was contacted by e-mail in order to recruit eligible clinicians. Only clinical specialties embedding radiological imaging in their daily clinical practice were deemed eligible. Therefore, clinicians of the department of psychiatry, dermatology and ophthalmology were excluded from this study. The remaining clinicians were eligible if they participated in any medical curriculum in the Netherlands, regardless of being involved in the Bachelor’s or Master’s phase. Additionally, clinicians needed to be board-certified and actively working medical specialists, general practitioners or residents in radiology. Moreover, board-certified radiologists of the same training region who were involved in (any) medical curriculum in the Netherlands were included to provide more insight into what these “imaging experts” considered important to teach. Eligible clinicians were contacted by use of e-mail. After no initial response, the eligible clinicians were contacted again two weeks later. A third reminder was sent after a longer period of time, which varied from two weeks to three months. If no response was received, the participant was excluded from further inclusion.

Ethical statement

This study was approved by the ethics committee of the Netherlands Association of Medical Education (NVMO, case number 2023.2.9). Before being interviewed, clinicians confirmed to participate in the study. Informed consent was obtained from all clinicians prior to the interview in which the clinicians consented to have the interview audio-recorded for further analyses. Moreover, all methods were carried out in accordance with relevant guidelines and regulations. All recorded data was stored on a secured disc, to which only one researcher (F.H.) had access. Transcribed data was stored and analyzed anonymously.

Individual semi-structured interviews were conducted by one of the researchers (F.H.). Clinicians decided in which way the interviews were held: in person, via electronic telecommunication software (i.e. Skype version 8.65.0.78; Skype Technologies, Luxembourg City, Luxembourg Palo Alto, CA, United States) or by telephone. In addition, four clinicians provided extensive answers to interview questions via e-mail. These data were also used in the data analysis. The interviews started with a short introduction of the research content followed by an open question on the participant’s thoughts on this matter. During the interviews, the interviewer used open-ended questions and encouraged the clinicians to speak openly and express their opinions, thoughts and considerations. The interviewer explained that there were no relations with the board of examiners, the university medical center educational board or the educational management team. In order to ensure reliable data, all interviews were audio-recorded and transcribed verbatim afterwards. Each transcript was thereafter analyzed using direct content analysis [ 30 ]. Starting after the first interview had taken place; transcriptions were coded line-by-line, through which a code list was created. Coding was continued after each interview. Inclusion of new participants was halted when no new topics and codes arose from this process, indicating that data saturation occurred. To confirm data saturation, two additional interviews were held. When confirmed, inclusion of new participants was stopped.

Data analysis

The interview transcripts were analyzed qualitatively. The first four transcripts were independently analyzed by two researchers (F.H. and B.v.W.). Coding results were compared and discrepancies were resolved by discussion. If necessary, a third more experienced investigator (D.H.) could be asked to help resolve issues. Since there were no major discrepancies, further coding and analysis were carried out independently by one of the researchers (F.H.), who met periodically with one of the other researchers (D.H.) to discuss codes and themes until consensus was reached. The coding process was performed using Atlas.ti software, version 8.2.29.0 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). The constructed codebook was organized into categories and themes which arose after discussion of all the different codes between two of the researchers (F.H. and D.H.). Categories were used to group codes, which were then grouped into several themes. The categories and themes were shared with the other researchers in order to assess their validity.

A total of 97 eligible clinicians (radiologists; 10.3% and non-radiologists; 89.7%) were contacted by one of the researchers (F.H.) via e-mail between July and October 2020 (Table 2 ). Non-responders were excluded after a period of six months after the first e-mail was sent ( n = 44). Clinicians were also excluded if they expressed to have no active involvement in medical curricula ( n = 3) (Fig. 1 ). Of the included clinicians, four reactions were received via e-mail, while the other forty respondents provided their input by participating in an interview. The interviews lasted between 17 and 59 min. Participant characteristics are displayed in Table 2 .

Selection of the clinicians. 1 Six clinicians were not available due to lack of time . 2 Three contacted clinicians were excluded since they no longer worked for the specific training region

Ten categories of items were distilled from the transcribed codes, which were arranged in the following three themes (Fig. 2 ).

An overview of the subcategorized themes. Three themes accompanied by ten categories were derived from the interviews during the analysis after qualitative exploration of the opinions of clinicians and general practicioners on imaging technologies in medical school curricula

Theme 1: Expectations with regard to educational topics in radiology education

Anatomical knowledge.

Interviewees advocated that students need to be able to identify important anatomical landmarks and gross anatomical structures on the different radiologic imaging techniques. Knowledge of anatomy was believed to be the foundation of understanding a radiologic image by both radiologists and non-radiologists.

“It starts with that [knowledge of the human anatomy], as this forms the foundation of radiology. Then, you can also start interpreting medical images” – General Practitioner

“… but I sense that there is little attention for forming an idea on the anatomical relations. And in the end, that is the essence…” – Surgeon

Conversely, Computed Tomography scans (CT-scans) and Ultrasound (US) were suggested as ideal tools to teach anatomy in medical school. This was believed to benefit both anatomy education and radiology education. This combination provides clinical significance to anatomical structures as well as a three-dimensional insight into the anatomy. Furthermore, it would lead to early exposure to medical imaging in the curriculum. Magnetic Resonance Imaging scans (MRI-scans) were both suggested and dissuaded as a teaching tool because of their complexity.

Skills in interpretation

Interviews with both radiologists and non-radiologists revealed that the ability to interpret a wide range of radiological studies should not be included as a learning objective in medical school. Learning to interpret specific radiological studies (e.g., CT study of the thorax, brain MRI) should be incorporated in post-academic education for residents in training, as there is a greater exposure to these specific radiological studies during this period. Nevertheless, interviewees stated four things a medical student should be able to do concerning radiographs: (1) distinguish abnormal from normal (recognizing gross abnormalities), (2) identify some very common pathologies (e.g., pulmonary infiltrates, common bone fractures, joint luxation, pulmonary edema, hemorrhage, ischemia and malignancies), (3) identify acute diagnoses (e.g., vertebral fractures and pneumothorax on radiographs) and (4) acquire a systematic approach when reading radiographs (both chest radiographies and musculoskeletal radiographies). The extent to which these skills should be mastered under supervision was scarcely discussed and varied greatly.

Basic technological knowledge

Knowledge on the techniques of the four major different imaging modalities (radiography, CT, MRI and ultrasound) was regarded important as this provides knowledge on (contra-)indications and strengths and weaknesses of each imaging modality. It can also help a student interpret medical images as it helps to understand which structures are visible and why they are displayed in the way they are (e.g., the differences in size while comparing an AP- and PA-radiograph). It could also help students to understand the content of a radiological report (e.g., helping to understand why radiologists discuss patient positioning in their reports).

“You have to know the basics. You can order radiographs, a CT-scan, or an ultrasound or an MRI-scan. And the reason why you would choose one option or another is always different, but you always visualize something with it. I consider it important to know what a specific imaging technique shows you.” – Emergency doctor.

More specifically, it was considered important to have knowledge on the basics of ionization radiation, including its hazardous effects. For MR imaging, knowledge of the basic differences between T1-weighted-, T2-weighted-, and fluid-attenuation inversion recovery (FLAIR) sequences were disclosed as important subjects to master for medical students.

In addition, the impact that a radiological examination has on a patient (both mentally as well as physically) should also be embedded in the medical curriculum. This would also help future healthcare professionals to inform their patients properly in order to achieve well-informed consent.

“...I think that it is good to know because we receive a lot of questions from patients about radiologic studies” – General Practitioner

Comprehension of the role, indications and limitations of diagnostic imaging techniques

The most common (contra-)indications and limitations of the most frequently used modalities are seen as imperative knowledge which a student should acquire in medical school. This includes insights in accuracy rates of different radiological imaging methods and how these rates are influenced by other factors, as well as the costs of the different modalities. It should be noted that some clinicians mentioned that keeping up with the quickly changing indications could be a challenge and another participant did not find knowledge in indication important. All believed that you should always consult a radiologist when in doubt.

The benefits and drawbacks of the use of contrast agents, especially in CT imaging, and its (contra-)indications are worth emphasizing, for it has been mentioned multiple times in the interviews and is apart from one explicit modality.

“I believe that it is very important that you know which radiological examinations are available and what you can use each one of them for. I also believe that it is very important that students are aware of the costs of the different imaging modalities and that they also take this into account when making a decision. And that they realize which study is useful for a specific question” – General Practitioner.

Implications of radiology use in clinical practice

As each medical specialty has some level of experience with certain radiological imaging methods, it is important that students learn which techniques are used in various settings.. This was reported as a learning goal which should be achieved through experience-based learning (i.e., during internships). Also, clinicians expressed that it was paramount that students learn to write a concise though complete request for radiological imaging. In addition, students need to learn to look critically and should learn how to implement the radiologist's conclusion in the clinical setting for further medical management and/or follow-up.

Finally, students should also learn to consult the radiologist when questions arise regarding the most optimal imaging method or the radiological conclusion and how to interpret it.

“Radiological findings are subjected to interpretation: someone sees an abnormality and expects it to be something. And those expectations are supported or undermined by the clinical presentation and you have to either provide this knowledge to the radiologist or have to take this into account yourself”—ENT-specialist.

“I noticed that they [students and junior doctors] have no comprehension of contrast agents and therefore just follow guidelines which state to ‘Check renal function’. They have no idea why and whether they have to order for contrast agents” – Radiologist.

Theme 2: Teaching strategies with regard to radiology education

Timing and emphasizing responsibilities.

Most interviewees were convinced that during the Bachelor’s phase (i.e., the first three years of the university curriculum), imaging technology education needs to focus on the differences between modalities from a technical point of view. During those three years, radiological images should be used to help students understand the technical basis of imaging and recognize anatomical structures. This should gradually evolve into using radiological images to recognize simple pathology at the end of the Bachelor’s phase (e.g., bone fractures, pneumonia, pneumothorax). During the Master’s phase (last three years of university curriculum), the interviewees considered applied radiology as an important learning goal. This education could then be combined with recapitulating the anatomy.

“I think that it should definitely be addressed in the Bachelor’s phase, but that the subjects in radiology that are embedded in an internship should be addressed in more detailed and specific way before that internship. I am actually getting thrilled by that idea”—General practitioner.

It was believed that students will get more familiar with radiology when learning about imaging technologies is combined with anatomy and repeated over the years. Doing this while emphasizing different aspects of radiology during different learning phases of students, was also believed to result in a greater feeling of competence for medical students, especially with regard to chest radiographs and musculoskeletal radiographs. Therefore, radiology education during the Master’s phase of medicine should also focus on basic, structured interpretation of chest radiographs.

Assessment during internships of other disciplines

Interviewees suggested incorporating Entrusted Professional Abilities (EPAs) for radiology in the internships, so that radiology knowledge can be reviewed and improved continuously. Therefore, the knowledge of radiology can be monitored during the internships in the same way the discipline of radiology is integrated through all the different specialisms in medicine.

Theme 3: Promising educational strategies in radiology education

Longitudinal subject planning.

The idea of Longitudinal Learning Communities (LLCs) in radiology was discussed during all interviews. LLCs were defined as a community-based approach to learning during a time period of more than 1 year, encouraging meaningful student interaction and small-group learning as well as peer-group evaluation. LLCs were believed to help students to develop a collaborative approach to clinical practice, particularly in radiology. Clinicians believed that a timely repetition of anatomical and radiological knowledge before an internship would result in an improved learning experience.

Three clinicians, all non-radiologists, did not support more radiology education in already overcrowded medical curricula. One participant explicitly expressed that an LLC in radiology would take up too much time. Other interviewees (both radiologists and non-radiologists), however, considered radiology to be important enough to devote attention to, for example by use of LLCs. One participant also suggested saving time by combining the LLC with anatomy and physiology education throughout the medical curriculum. The learning materials used in such LLCs on radiology education were discussed as well. Suggested teaching methods included e-learnings and interactive workgroups. Additionally, the use of clinical cases during education as a form of applied radiology was expressed by many. Nevertheless, discrepancies remained with regard to the different teaching forms. Proposed forms were interactive teaching forms, clinical cases, lectures, computer orientated education, e-learnings, workshops, self-study, seminars, learning during the internships themselves (via specific educational moments, multidisciplinary meetings, during consulting hours at the outpatient department, radiology meetings, before surgery or via assignments). Clinicians expressed that they found it difficult to decide which educational methods would create the best learning environment for students.

Some additions to the described LLC were mentioned during the interviews. Several clinicians, both radiologists and non-radiologists, suggested adding practical ultrasound education to the LLC’s. One participant highlighted the importance of recapitulation shortly before practical education, also called in-time learning. This person believed that students would benefit more from good references, so they would know where to look when they need it and have clear learning objectives for radiology during their internships.

‘…I strongly believe that just in time learning would be a valuable option. If you simply teach students in-time where to find specific knowledge on radiology, they will use it when they need it the most. Then, all they need to do is practice their knowledge” – Geriatrician.

‘If you learn about radiological examinations relevant in the clinical practice that you are about to embark in, you will learn the basics just prior to your internship and the clinical context will help you to complete the picture. Together, I would consider this a rich learning experience for students” – Radiologist.

Internship in radiology

Due to a lack of time in the medical curriculum, most of the interviewees would not opt for the incorporation of a mandatory internship in radiology. Nevertheless, it was considered an important elective internship. Only one participant believed it was important to create time for a mandatory internship.

On the other hand, interviewees expressed that some practical experience in radiology for all medical students would be beneficial to: (1) gain insight into the tasks of a radiologist, (2) become aware of one’s own strengths and limitations regarding reading radiological examinations and (3) learn how to establish an optimal collaboration between radiologist and clinician. It was mentioned that such “intern days” could be integrated into the proposed LLCs in radiology or in various internships such as emergency and internal medicine or surgery.

“I consider it a good idea to offer it as an internship for choice, apart from the LLC”- Internal medicine doctor

Intracurricular primary radiologic skills

There was some discussion with regard to learning the skill of interpretation of a chest radiograph and the skill to perform a point-of-care ultrasound (POCUS). Chest radiography in itself takes a prominent place in radiology education and was believed to deserve a specific view on learning goals. There is an emerging use of POCUS in health care and the opinions on what should be taught on this subject diverse widely. Some interviewees thought that integrating POCUS as an intra-curricular learning goal would take up too much time to really let students master this skill. On the other hand, others were eager to implement teaching POCUS in the medical curriculum as it could serve as an extension on the physical examination with immediate results, low costs and high mobility with hand-held devices. It was mentioned that since so little is taught on ultrasound, there is so much to gain out of a bit more education.

“If you ask me, we will all throw out our stethoscope and let everyone have an ultrasound machine and I do believe that time will come. I just do not know how soon” – Emergency doctor

This study elucidated the views of both radiologists and non-radiologists and grouped these views in three themes: 1) Expectations with regard to educational topics in radiology education; 2) Teaching strategies with regard to radiology education; and 3) Promising educational strategies in radiology education.

These findings are largely corroborated by others. For example, Subramaniam et al. [ 53 , 55 , 55 ] also showed that radiology education should include the teaching of (contra-)indications for different imaging techniques, skills to systematically review chest and musculoskeletal radiographs, skills to identify gross abnormalities on radiographs and teaching students how to fit important findings in the clinical setting. However, contradictory to the studies of Subramaniam et al., interviewees did not express the reading of abdominal radiographs as an educational topic, which can be explained by the ongoing development of radiology in the clinical setting [ 2 , 57 ]. At the time of the publication of the papers of Subramaniam et al., abdominal radiographs had a more prominent clinical role than today.

Integration of radiology and anatomy education

Interviewees in this study stated that basic anatomical knowledge is needed to fully comprehend imaging studies. However, as less time is being assigned to anatomy education in medical curricula [ 18 , 35 , 4 ], learning about radiological examinations could become more complicated for students. Also, as Kourdioukova et al. [ 33 ] mention in their paper, Problem Based Curricula create a building block approach in which radiology and radiologic anatomy is relatively underrepresented in examinations. Integration of applied anatomy and applied radiology has been commonly suggested to optimize quality of anatomy and radiology education in modern medical curricula, [ 4 , 14 , 28 , 36 ]. This was also objectified as radiology small group teaching significantly improved anatomy scores [ 8 , 9 ] and radiology skills [ 40 ]. Additionally, combining radiology and anatomy education has been described to be easily implementable in existing preclinical curricula, because it requires few additional resources [ 62 ]. Integration of radiology education with other disciplines has also been suggested [ 42 ]. Interestingly, in the current study, MRI sequence which were considered basic knowledge comprised T1-weighted images, T2-weighted images and FLAIR images, whereas other sequences were not mentioned. Fat suppression techniques were not discussed, although several advantages are well-known in for example neuroradiology [ 56 ] and imaging of the musculoskeletal system [ 16 ]. Also, the use of diffusion-weighted imaging was not mentioned as part of the basic knowledge that a medical student must obtain. Possibly, clinicians omitted these sequence as the physical concepts are somewhat more complex to explain to students during rotations. However, the exact motives remain elusive. Together with the positive feedback to the LLC in the interviews of this study, a balanced integration of radiology education in various subjects of teaching could be a promising next step for radiology educators.

Other innovative teaching methods which might play a role in the future of anatomy and radiology education, such as augmented reality, virtual reality and combined use of these techniques with radiological data were not mentioned during the interviews. Nevertheless, several publications point out the possible advantages of each individual technique [ 6 , 3 , 12 , 13 , 41 ].

Radiology education topics: reading chest radiographs and practical teaching of ultrasound skills

Although in this study chest radiographs were considered an important educational topic in medical school, there was a wide diversity in opinion to what extent a student should master this subcategory of imaging technologies. Even though this study was not able to provide results to what extent of supervision level or entrusted professional activity a medical student should master this skill, this study was the first that objectified this wide diversity in opinions. We believe this should be investigated more profoundly to be able to create a properly adjusted learning objective on this topic. Especially since Eisen and colleagues found that only 15% of their study population, consisting of medical students, interns, residents and fellows, felt capable to interpret chest radiographs independently in an academic medical center setting [ 19 ]. This lack of confidence has been found by others as well [ 7 , 11 ].

Lastly, teaching ultrasound was a topic of debate in our study, which was widely discussed among the interviewees. This observed discrepancy is in line with literature on this topic [ 36 , 50 ]. Although ultrasound has been described as an educational tool to improve anatomy knowledge, physical examination skills, increase diagnostic accuracy and advance patient safety, the evidence regarding the effects of ultrasound education on these outcomes is very limited [ 20 ]. Nevertheless, various studies reported that medical students consider ultrasound education as valuable [ 15 , 17 , 46 , 49 , 59 ]. Despite this increased demand of ultrasound education in medical school, studies showed that hands-on education of ultrasound is taught at a minority of universities in Europe and the United States [ 43 , 45 ]. More research is needed to either create insight into the learning objectives of ultrasound in medical curricula or to chart the potential benefits of teaching ultrasound in medical school. Additionally, the effects of using ultrasound for educational goals on learning outcomes should be studied as well.

Strengths and limitations

The major strength of this study was the qualitative study design as a recent review highlighted that quality research is needed to investigate when and how radiology should be included in medical education [ 8 , 9 ]. A second strength concerns the exploration of the thoughts and opinions of a wide variety of clinicians included in this study. The sparse availability of recent scientific literature on the teaching of a dynamic subject like medical imaging illustrates that this is a relatively understudied domain and, simultaneously, shows the importance of the present work. This work, however, is not without its limitations. One limitation of this study was formed by the strictly defined inclusion criteria which only allowed clinicians from one region within The Netherlands to participate. The ideas on this topic within this region can differ from others since every training region has its own personal and cultural view on certain subjects and specific spearheads. This limitation regarding generalizability of the reported themes might also exist for the clinicians’ views on radiology education in countries other than The Netherlands. Secondly, this study population cannot be considered as a generalizable population of clinicians which are involved in medical education. For example, the number of radiologists participating in this study was larger as compared to the number of general practitioners (Table 2 ). Therefore, radiologists were overrepresented in the study population. In addition, some medical disciplines, such as psychiatry, ophthalmology and dermatology were excluded from this interview study due to the fact that these clinicians do not frequently encounter radiology. However, the risk of potential bias is limited as the nature of this study and research question did not warrant the inclusion of these clinicians. Furthermore, a limitation of the qualitative study design concerns the relative subjectivity of the results as participants hold control over the content of the data. This prevents quantification of the results and warrants future studies to investigate the statistical significance of the here described findings [ 10 , 38 ]. Additionally, it must be noted that clinicians are no education experts. Future implementation of these results should be carried out in close collaboration with education experts.

This qualitative study provided more in-depth knowledge on well-known topics with regard to radiology education in medical curricula. More knowledge with regard to educational methods, timing of radiology education was distilled and several new topics arose. This includes thoughts on educating ultrasound skills to undergraduates and the views on a longitudinal learning community in radiology in order to integrate imaging technologies in a problem based medical curriculum. It was recommended that radiology education should be more embedded in the medical curriculum and various educational strategies and topics to achieve this were suggested. Nevertheless, to which extent these educational topics should be mastered, what resulting learning objectives will need to entail and how to evaluate them need further research.

Availability of data and materials

The dataset generated from the interviews and analyzed during the current study are not publicly available since individual privacy could potentially be compromised but are available from the corresponding author on reasonable request.

Abbreviations

Longitudinal learning community/curriculum

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Acknowledgements

The authors would like to acknowledge Beau van Woudenberg, MSc, for his help with coding the interviews and with his valuable insights into qualitative research methods. No potential conflict of interest was reported.

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FH contributed to the design of the study, the acquisition, analysis and interpretation of data and drafted the work. SS and MB have substantively revised the work. LPB designed the study and substantively revised the work. DH supervised the whole project and consequently contributed to the design of the study and to revisions of the work. All authors approve the submitted version of this article and have agreed to both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved and the resolution is documented in the literature.

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Harthoorn, F.S., Scharenborg, S.W.J., Brink, M. et al. Radiology education for medical students: a qualitative exploration of educational topics, teaching methods and future strategies. BMC Med Educ 24 , 891 (2024). https://doi.org/10.1186/s12909-024-05879-0

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