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Is Technical School a Good Model for Radiology Residency?

¹ Division of Education, Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr., RI 1053, Indianapolis, IN 46202-5200.

Received February 20, 2001; accepted after revision April 17, 2001.

 
Address correspondence to R. B. Gunderman.

The reader's attention is directed to the commentary on this article that appears on the following pages.

Introduction

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Gentlemen, what I want are Facts.... Facts alone are what is wanted in life.

Dickens, Hard Times

Like journeymen in a skilled trade, radiology residents learn through an apprenticeship composed mainly of on-the-job training, with smaller additional components of independent study and formal instruction. As in technical school, radiology apprentices are usually not expected to conduct original investigation or to advance the field, but merely to assimilate an existing body of knowledge and skills and become adept at applying that repertoire to practical situations [1].

Operating in a technical mode, many of our residency programs treat residents as empty vessels, as if the essential function of the residency program were to pour knowledge and skills from full vessels (faculty) into empty ones (residents). Our 4-year mission, we seem to think, is to fill up those vessels with thousands and thousands of facts. The implicit message we send the residents is this: "What you need to know is defined by what we know. If we don't know it, you don't need to know it."

In many medical disciplines, including radiology, the technical model has dominated residency programs for decades. It exhibits a number of advantages. For one thing, such a program makes it relatively easy to specify what trainees need to learn; namely, they need to learn what the faculty tells them, or what their specialty's certification examinations cover. When disputes arise over the validity or relevance of a particular point, one need only repair to a textbook. Moreover, the technical approach makes it relatively easy to determine whether a particular trainee—or for that matter, a whole residency program—is doing a good job. One need merely administer a standardized test and measure how thoroughly the trainees have memorized the facts. Finally, this approach makes life relatively easy for both the faculty and the residents. By relying on the technical model, both are spared the more intense struggle of creative collaboration and mentorship that characterizes graduate study in higher level academic disciplines, where students are expected to do original work.

Error and Uncertainty

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In technical schools, mistakes are dealt with as defects, because they represent failures to adhere to established patterns of thought and practice. The implicit message of this system is simple: there are only two types of answers, right answers and wrong answers. Uncertainty is to be avoided at all costs.

Yet a deeply ingrained aversion to uncertainty is nearly antithetical to the creativity on which scientific and educational progress depends. Without a high tolerance for uncertainty, it is impossible to suspend judgment, to question the received view, to look at a problem from multiple perspectives, and to create new approaches. By implicitly promoting the mindset of a technical apprenticeship, many radiology residency programs undercut the impulse to become a self-critical and creative contributor to the field [2]. In short order, fact-laden radiology review manuals become the residents' bibles.

Science

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How do residents view science? Many express little or no enthusiasm for it. This disinterest arises in part from the fact that the curriculum discourages thinking like a researcher, and in part from the fact that many residents receive no meaningful exposure to research at any point in their training [3]. With the growing demands on radiology programs to increase clinical through-put, we rely more and more on residents for image interpretation; time for training in research has become a luxury that many programs believe they can't afford. Over time, many residents come to regard science as a received body of facts, a collection of information, the sum total of the contents of all the radiology textbooks.

In fact, nothing could be further from the truth. Science is not a received body of facts, but a struggle to understand, a determination to expose the false and inadequate, and a thirst to find out what we don't know. Scientists regard the information in textbooks not as their final goal, but as their springboard to discovery. Instead of trying to cram residents full of information, we should be trying to foster their curiosity, skepticism, creativity, and willingness to make mistakes. Residency should be conceived as an invitation to discovery in which it is not enough merely to know the right answers; it is no less important that one be capable of posing the questions that produced them.

Testing

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If we wish to nurture the intellectual integrity of residents during training, we must be prepared to stop our ears to the sirens of testability. The current system of testing and the incentives based on it exert a powerful influence both on how residents approach learning and on what they wish to know. When residents believe that their success or failure will be defined largely in terms of their scores on standardized examinations, they naturally modify their activities to conform to those expectations. When they discover that such examinations pay little heed to abilities such as critical thinking and creativity, they naturally redirect their attention to those parameters that the examinations test best; namely, the memorization of facts. In their quest to master facts, however, they become slaves to convention and relinquish their capacity to play a meaningful role in the pursuit of understanding.

Radiology residency programs should strive to create fertile minds. The noninterpretive skills program of the Association of Program Directors in Radiology and the American College of Radiology is an important step in this regard, but more work remains to be done [4,5,6,7,8]. We cannot afford to regard with complacency the fact that many of the most important lessons radiology residents should be learning are underrepresented in the curriculum precisely because it is difficult for the American Board of Radiology to figure out how to test residents regarding the lessons learned.

Facts are fine, but only to a point [9]. Beyond memorizing facts, residents need to be encouraged to question what constitutes a fact, where facts come from, and why some facts are deemed important and others are not. The tail of testability must never be allowed to wag the dog of what's really worth knowing. Cultivation of the capacity to distinguish what's really worth knowing from what isn't should be a primary mission of every radiology residency program.

Homogenization

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Radiology is fortunate to attract many bright people into its fold. But what starts happening to them as soon as they arrive? Do they become more interesting people as a result of their residency experience? Do they become more inquisitive, more creative, or wiser? Or, by inviting them to bury their noses for 4 years in radiology review manuals, are we inviting them to become less interesting, increasingly short-sighted, and more one-dimensional?

Many of our residency programs seem to be modeled after the dairy industry, where homogenization is king. If radiology is to flourish, however, it is vital that we encourage a diversity of perspectives. We should seek out people who can bring something different to the field, provide them ample opportunities to explore and develop interdisciplinary interests, and design our organizations to take advantage of their distinctive abilities to contribute.

History

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How can radiology residency programs foster the capacity to discern what's really worth knowing and play a creative role in its pursuit? Oddly enough, a significant part of the answer lies in an unexpected place. If radiology residents are to achieve the larger perspective on the field necessary for self-reflection and creativity, there is no better place to begin than history, the study of how things came to be the way they are.

It is in the study of a discipline's history that some of the most crucial lessons become apparent: the realization that things haven't always been this way, that today's facts weren't ready at hand in yesterday's textbooks, that such facts were born of questioning, that some of yesterday's lines of questioning led nowhere, and that it was only because skeptical people asked questions, rather than merely memorizing what they were told, that we are where we are today. Far from being ignored, as is so commonly the case in residency programs today, the history of radiology should become an essential ingredient in residency training, and national organizations should make the development of an intellectually rigorous curriculum of radiology history a high priority.

Professionalism

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Radiology programs should foster in both residents and faculty a sense of intellectual excitement and encourage them to approach clinical practice with equal doses of skepticism and creativity. Far from undermining individual programs or the profession as a whole, a skeptical and creative radiologist is their greatest ally. Only through the efforts of such people will we manage to winnow the wheat from the chaff, sort out what about the "facts" is true from what isn't, and propel ourselves beyond the modest boundaries of what we think we know today.

Confronted with such arguments, some program directors may respond that there is no time in the curriculum to address such noble objectives as critical thinking and creativity. As the volume of radiology information continues to expand exponentially, there isn't even sufficient time to teach residents all the basic facts about radiology. Far from contesting this statement, sober analysts of residency training should lend their hardiest assent.

There isn't enough time in the curriculum for residency programs to teach all the basic facts about radiology. In fact, there hasn't been for a long time. The question is, what is the appropriate response to this situation? Shall we simply lengthen the course of training from 4 years to 5? Shall we simply peddle ever harder in the same old direction, only to fall further and further behind? Or shall we rethink what the radiology residency should be all about in the first place, spending a bit less time on what to know (information), and a bit more on how to know, and why?

Practical Approaches

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At a practical level, what can residency programs do to achieve these objectives? Here are some suggestions for departments with the capability to implement them:

• First, radiology departments should provide their residents with regular conferences devoted to ongoing research, accompanied by an invitation to participate. If there is no research in radiology, then researchers in other disciplines, with whom radiologists might collaborate, should be invited to present their research, and both faculty and residents should attend.
  
• Second, residents should be encouraged to engage in research during their training, with time and resources set aside for that purpose [10]. Appropriate mentorship should be provided, and faculty should be evaluated in part in terms of the quality of research mentorship they provide. Resident participation in research should be acknowledged and rewarded.
  
• Third, residents should be given regular opportunities to present and critique one another's projects. Residents who are not involved in research should develop educational presentations that make them local experts in a specific aspect of radiology.
  
• Fourth, a journal club, in which residents are expected to read and critique the primary radiology literature, should become a regular part of every radiology residency program [11]. Occasional formal debates over such topics as "The Best Test for Pulmonary Embolism," "The Use of the Term `Infiltrate' in Chest Imaging," and "Who Should Control Vascular Sonography?" should become a part of the curriculum.
  
• Fifth, critical thinking should become a permanent feature of teaching at the view station. For example, faculty and residents should operate in a culture that encourages them, within limits, to challenge one another's assertions. Residents should be praised less for the facts they recite and more for the questions they raise.
  
• Sixth, research in nontraditional fields should be encouraged. These fields would include, but not be limited to, education, history, management, and health services research [12]. Such studies foster a wider perspective on the field and promote the formulation of new questions about it. Departments should provide time and resources to help committed residents find funding for graduate-level training in such fields.
  
• Seventh, radiology programs should encourage faculty to play an active service role in their departments, schools, and communities, and encourage residents to emulate the faculty. Both should strive to flourish not only as radiologists, but as human beings and citizens. Service achievements should be formally recognized by the department.
  
• Finally, these and other innovations in residency training should replace, not displace, some of the fact-based instruction in today's training programs. Residents already spend more than enough time memorizing information, and we cannot simply load more expectations on an already overstuffed curriculum. The goal here is to devote time and energy to the creation and development of new cognitive perspectives, and that requires time to think.
  

Conclusion

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If radiology is to flourish, it is imperative that we reexamine our residency programs in light of a larger vision of radiology excellence, one that esteems originality alongside authority, imagination alongside memorization, and vision alongside detection. We must focus less on the capacity to collect information, and more on the intellectual habits of mind we engender. We must place first in our deliberations the question, "What do we really need to learn?" and accord the question, "What can we test?" second place. We must be willing to make mistakes, and dedicated to learning from them. We must develop residents who address the question, "What have you amounted to?" not in terms of what they have managed to accumulate, but in terms of what they have contributed to their profession and their society. If we are to achieve these goals, we must prepare our residency programs for graduation from technical school.

Acknowledgments
 
I acknowledge the generous support of a visiting professorship of the Department of Radiology of Cincinnati Children's Medical Center, where the thoughts in this article were originally presented.

References

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