DOI:10.2214/AJR.05.2139
AJR 2007; 188:W9-W14
© American Roentgen Ray Society
Preclinical Medical Student Training in Radiology: The Effect of Early Exposure
Barton F. Branstetter, IV1,2,
Laura E. Faix1,
Allen L. Humphrey3 and
John B. Schumann3
1 Department of Radiology, University of Pittsburgh School of Medicine, 200
Lothrop St., PUH Rm. D132, Pittsburgh, PA 15213.
2 Department of Otolaryngology, University of Pittsburgh School of Medicine,
Pittsburgh, PA 15213.
3 Department of Neurobiology, University of Pittsburgh School of Medicine,
Pittsburgh, PA 15213.
Received December 14, 2005;
accepted after revision February 14, 2006.
Address correspondence to B. F. Branstetter IV
(bfb1{at}pitt.edu).
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. The purpose of this study was to determine whether an
integrated radiology curriculum in the first year of medical school changes
medical students' attitudes toward radiology or affects their knowledge of
radiologic principles.
SUBJECTS AND METHODS. The first-year medical curriculum of a medical
school was revised between the 2003 and 2004 academic years to introduce more
didactic radiology teaching. Dedicated radiology lectures were introduced, and
radiology consult sessions became integral to problem-based learning sessions.
A survey was administered between the first and second years of training to
assess first-year medical students' attitudes toward radiology and their
knowledge of basic radiologic principles. Students who had undertaken the
revised curriculum (class of 2008) were compared with students who had
undertaken the traditional curriculum (class of 2007). Survey responses were
compared with Mann-Whitney rank sum tests.
RESULTS. Students exposed to the new curriculum stated that they
were more familiar with radiology as a specialty and believed that radiology
had greater importance to the overall practice of medicine. They stated that
they were more likely to select radiology as a clinical elective, and more of
them were considering radiology as a career option. The students who had been
exposed to radiology performed better on the test of basic radiologic
knowledge. All results were statistically significant.
CONCLUSION. Exposing students to radiology in the first year of
medical school improves their impression of radiology as a specialty and
increases their interest in radiology as a career. Follow-up surveys will
determine whether this effect persists through the clinical years of training
and improves the overall impression of radiology within the medical
community.
Keywords: medical student education • patient-based learning • radiology education
Introduction
In most traditional medical school curricula, radiology is not formally
introduced to students until their clinical rotations
[1,
2]. Even then, radiology is
often not part of the core curriculum. It may be relegated to incidental
exposure during medical or surgical rotations, or it may be included only as
an optional elective after the core clinical clerkships have been completed.
Few documented curricula formally incorporate radiology teaching into the
first year of medical training, and this exposure tends to be limited to short
sessions [3]. To our knowledge,
investigators [4,
5] who have pursued a more
thorough curriculum in radiology have not attempted to assess changes in
medical student attitudes toward radiology.
The role of academic radiologists in early medical student education has
received greater focus in recent years
[6]. The advent of
problem-based learning (PBL) in particular has provided radiologists with an
opportunity to interact with students in the preclinical years
[7,
8]. This exposure to the field
of radiology, however, is within the context of medical and surgical problems
rather than radiology as a distinct specialty.
It is likely that greater exposure to radiology for all medical students,
not only those interested in radiology as a career, is advantageous to the
specialty [9]. The attitude of
other physicians toward radiology may be prejudiced by a lack of exposure to
radiologists during the formative years of medical school
[10]. Thus radiology teaching
may have benefits beyond increasing the likelihood of students choosing
radiology as a career.
Previous work on radiology in the medical student curriculum has focused on
objectives for the clinical years of training or on the utility of radiology
in PBL modules [11,
12]. To our knowledge, no
studies have quantitatively measured the effect of preclinical radiology
teaching in both didactic lectures and PBL modules. The purpose of this study
was to quantify changes in medical student attitudes toward radiology after
introduction of an integrated radiology curriculum in the preclinical years of
medical school.
Subjects and Methods
Changes in Medical School Curriculum
The curriculum for the first-year students at the University of Pittsburgh
School of Medicine includes basic science courses such as medical anatomy,
microbiology, genetics, and immunology. These courses are interspersed with
patient care courses such as ethics, medical interviewing, and medical
decision making and with pathophysiology courses such as neuroscience. These
courses traditionally have been taught without input from radiologists.
Although radiographs occasionally have been used to emphasize anatomic
relations or to visualize pathologic conditions, lectures have not been
dedicated to radiology, and radiologists have not been available to confirm
correct evaluation of the images.
Between the 2003 and 2004 academic years, changes were made in two courses
(medical anatomy and neuroscience) to provide greater exposure to radiology.
Medical anatomy is a 12-week course and is the first course taught to medical
students. In medical anatomy, a 1-hour radiology lecture focusing on
radiologic techniques and radiologic anatomy was added in the first week of
the 7-week course. In addition, a 45-minute radiology consult session focusing
on relevant anatomy and appropriate use of imaging was added to each of the
four PBL modules [7,
12]. The PBL modules were
supplemented with complete cross-sectional patient examinations presented with
the same PACS interface used in the clinical setting
[13]. Neuroscience is an
8-week course beginning in February of the first academic year. In the
neuroscience course, three half-hour radiology lectures focusing on radiologic
neuroanatomy and frequently encountered pathologic conditions were given in
the first week of the course. In addition, a 1-hour radiology consult session
to review pertinent case-based imaging findings was provided with each of the
three PBL modules. In both courses, the radiology consult sessions consisted
primarily of student-directed discussions interspersed with brief didactic
monologues. All of these lectures and consult sessions were taught by the same
academic radiologist.
The class of 2007, which was in its first year of medical school in
academic year 2003, had 146 students (74 women, 72 men) and was exposed to the
traditional curriculum. The class of 2008, which was in its first year of
medical school in academic year 2004, had 149 students (76 women, 73 men) and
was exposed to the new curriculum. Thus the class of 2007, who received no
formal radiology instruction in the first year, served as a control group, and
the class of 2008 was the experimental group.
Medical Student Survey
A survey was developed to measure medical students' attitudes toward and
knowledge of radiology. Six multiple-choice questions were focused on
attitudes toward radiology, and five multiple-choice questions were used to
test knowledge of basic radiologic principles (Appendix 1). The latter
questions were designed to measure conceptual knowledge of the practice of
radiology, as would be expected of a referring clinician, rather than
knowledge that would be expected of a radiologist. The knowledge questions
varied in difficulty from questions that any medical student would be expected
to answer to questions that might be difficult for experienced clinicians.
Administration of the survey was approved by the medical school curriculum
committee after review by the steering committee.
The survey was administered online to each group of students in the summer
between their first and second years of medical school. The online system was
structured such that respondents could not return to previous questions once
they had answered them. This precaution prevented respondents from using
knowledge gained in later questions to assist with earlier questions. Every
question had to be answered for a survey to be considered complete. Incomplete
surveys were discarded. Participation in the survey was voluntary, and Web
access to the survey was provided within the medical school.
To invite participants, a bulk e-mail was sent to the entire medical
student class. One week later, a second bulk e-mail was sent as a reminder.
One week after that, personalized e-mails were sent to every student who had
not yet responded to the survey. One week after that, a second personalized
e-mail was sent, warning that the survey was closing soon. One week after that
(4 weeks after the initial e-mail), the survey was closed. This procedure was
followed for both the class of 2007 and the class of 2008. There was no
response threshold for closing the survey.
Statistical Analysis
In the section on attitudes toward radiology, the answers to each question
constituted an ordered, categoric data set. The distribution among the five
ordered categories was not necessarily expected to be parametric, so
nonparametric statistical tests were selected. The Mann-Whitney rank sum test
was applied to each of the attitude questions to compare the class of 2007
with the class of 2008. For the knowledge section of the survey, the
percentage of correct answers was calculated for each respondent, and a
Mann-Whitney rank sum test was used to compare the scores for the two groups.
Thresholds for p value were set at 0.05. To determine whether
response rates were different between the two classes, a 95% CI for
differences of percentages was calculated.
Results
Survey response rates were not statistically different between the two
groups. The response rate was 81% (118/146) for the class of 2007 and 88%
(131/149) for the class of 2008. For each of the six survey questions
regarding medical student opinions toward radiology, statistically significant
improvement in attitude was found in the group that had been exposed to the
new curriculum. As expected, students in the experimental group answered they
were more familiar with radiology as a specialty and that they had been
exposed to more radiology in their first year of medical school. These
students were also more interested in radiology as a field, were planning to
take more elective rotations in radiology, and were more likely to consider
radiology as a career. Specifically, the percentage of students who answered
that radiology was intrinsically interesting increased from 42% to 73%. The
percentage of students considering a clinical radiology elective increased
from 67% to 84%. The percentage of students who answered that they might
consider radiology as a career increased from 38% to 54%. Students in the
experimental group answered that radiology has a substantial influence on
other areas of medicine. These results are summarized in
Figure 1.
The responses to the five knowledge questions are summarized in
Figure 2. The class of 2007 had
an average score of 3.21 (64%), whereas the class of 2008 had an average score
of 3.79 (76%). This difference was statistically significant.
Discussion
The results of this study show that medical student attitudes toward
radiology are significantly affected by early exposure to didactic teaching in
radiology and by radiologist involvement with PBL modules. Students who have
been exposed to more radiology in their first year of medical school are more
interested in radiology and have a higher opinion of the specialty.
Recent applicants to radiology residencies have represented the top
academic tier of medical students. Therefore some radiologists may question
the need for increased participation in undergraduate medical education.
Medical student interest in any specialty fluctuates, and current first-year
medical students may begin their residencies at a time when interest in
radiology has waned. Furthermore, early exposure to radiology may prompt
medical students to pursue research within the field instead of arriving at a
career decision late in training, after opportunities for in-depth research
have passed.
Another advantage of early exposure is the opportunity to confirm career
choice. Medical students who are aware of radiology earlier in their training
may choose to observe radiologists in the reviewing room or angiography suite.
These students would be less likely to choose radiology careers for
misunderstood or imagined reasons, such as a relaxed lifestyle or a lack of
direct patient care.
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Fig. 2 —Survey responses on knowledge questions for class of 2007 (no
formal radiology) and class of 2008 (new curriculum). Overall scores are
statistically significantly different. Asterisks indicate correct answer.
|
|
Although academic radiologists may be primarily interested in persuading
medical students of the benefits of a career in radiology, there are ancillary
benefits to the specialty when students who are destined for other specialties
have an improved understanding of radiology. One benefit is more appropriate
use of diagnostic tests, which can improve the delivery of efficient patient
care. Another potential benefit is improved relationships with referring
clinicians. The stereotype of the radiologist with an undemanding schedule and
overly high reimbursement may be effectively controverted. It is unclear to
what degree improved radiologist-clinician relationships may reduce political
battles or turf wars with other specialties
[10].
One of the questions in our survey addressed the perceived importance of
radiology to other areas of medicine. Of the medical students exposed to
radiology, 46% answered that imaging is as important as or more important than
physical examination, compared with 27% in the control group. This difference
suggests that the importance of radiology was clearer to students in the
experimental group and may indicate more respect for radiology as a specialty,
regardless of career interest.
Incorporation of radiology in the preclinical curriculum requires a
substantial time commitment from academic radiologists. Several hours of
preparatory time are needed for each hour of lecture or consult session
presented. (Educational material can be reused over several years to improve
the return on the time invested.) Furthermore, a radiologist ideally should be
a member of the course design and PBL design committees for each course to
which radiology is pertinent. Such time commitments detract from research and
clinical commitments and from postgraduate teaching. Promotion committees
often underestimate the importance of medical student teaching. The results of
this study suggest, however, that radiologist commitment to medical student
teaching may result in substantial benefits for the field of radiology and for
medicine in general.
Although didactic lectures require substantial time commitments for
preparation and delivery, radiologists can become involved in PBL modules with
less disruption to their schedules
[12,
14]. In addition to moderating
PBL sessions, radiologists can make themselves available to answer questions
posed during the sessions. Radiologists' broad knowledge of surgical options
and diagnostic pathways may be particularly appealing to medical students
trying to obtain an overview of a particular disease process.
It may not be surprising that students who received didactic lectures about
radiology were more knowledgeable about radiology. Nevertheless, we considered
it important to document that first-year medical students have sufficient
medical background to comprehend the clinical ramifications of the subject
matter. It might be argued that radiology is best taught after students have
had exposure to substantial clinical training so that the radiologic
manifestations of disease can be better appreciated. Our results and those of
others [4] suggest that medical
students, even in their first year, are able to incorporate information about
radiology that enriches their understanding of normal and pathologic anatomy
and disease processes.
There were several limitations to this study. It is possible that there was
an underlying trend toward more interest in radiology across the 2 years of
the study regardless of the increased didactic exposure. However, given the
current popularity of radiology residencies, the theory of regression to the
mean suggests that students should be less interested in radiology over time
not more interested, as in our results. It is also possible that the
differences in this study were the result of idiosyncratic differences between
two medical school classes. The magnitude of the differences between classes
and the consistent statistical significance across all survey responses,
however, suggest that the effect is the result of the intervention.
An individual teacher occasionally can produce a positive response from
students that is then attributed to the subject matter rather than the
teacher. This phenomenon is particularly true of a physician-professor
teaching during the preclinical years, when medical students avidly seek
clinical teaching amid their basic science courses. Because only one
radiologist was involved in the medical student teaching in our study, the
merits of this individual teacher may have confounded our results.
Nevertheless, it is expected that among radiologists, the stronger teachers
would be more likely to volunteer for medical student teaching, so our results
may be reasonably generalized. In previous teaching of radiology to medical
students in their second through fourth years, the radiologist-educator in our
study had not received specific teaching awards and had not demonstrably
affected student attitudes. Thus we attributed the changes in attitude at
least in part to the placement of lectures in the first year of training.
Response bias is a potential limitation in the analysis of any survey
responses. Students interested in radiology may be more likely to complete a
survey on the subject. Because our response rate was very high (84% overall)
and did not differ significantly between groups, response bias is not likely
to have been a substantial confounder in this study.
The results of this study apply only to attitudes of medical students at
the end of their first year of training. It is unclear whether these changes
in attitude will persist throughout medical school, whether these students
will be more likely to choose radiology as a career, or whether students who
eventually choose clinical careers will have a higher opinion of their
radiology colleagues. We intend to continue following this cohort of students
and to specifically address these questions in future studies.
In conclusion, dedicated medical student teaching from an academic
radiologist during the first year of medical school increases students'
interest in and appreciation of the field of radiology. Further study is
needed to determine whether these changes in attitude persist through the
clinical years of training and are predictive of students' career choices.
APPENDIX 1. Medical Student Survey
This survey was administered to medical students between their first and
second years of training. In part II, an asterisk indicates the correct
answer.
Part I: Opinions
- How much do you know about the specialty radiology?
- I've never heard of radiology.
- I have barely been introduced to radiology.
- I am about as familiar with radiology as with any other specialty.
- I know a lot about radiology.
- I know more about radiology than any other specialty.
- How much radiology have you been exposed to in the first year of medical
school?
- None
- Only in passing
- Peripherally, as a minor part of another course
- One or two dedicated lectures
- Several lectures and study sessions
- How interesting is the subject matter in radiology?
- It is worthless to me.
- It is dull but important.
- It is interesting only as it relates to other areas of medicine.
- It is interesting in its own right.
- It is downright fascinating.
- Are you considering radiology as a career?
- Not a chance
- Probably not
- Unsure
- I'm considering it.
- It's my top choice.
- Will you take a radiology elective in your fourth year?
- Not a chance
- Probably not
- Maybe one radiology elective
- Definitely one radiology elective
- Probably several radiology electives
- How much of an impact does radiology have on other areas of medicine?
- Minimal impact
- Occasionally changes patient care
- Often changes patient care
- Just as important as physical examination
- More important than physical examination
Part II: Knowledge
- Which of the following is not a technique in radiology?
- Magnetic resonance imaging (MRI)
- Computed tomography (CAT scan)
- Ultrasound (sonography)
- Brachytherapy*
- Nuclear medicine
- Which of the following is usually most expensive?
- Magnetic resonance imaging (MRI)*
- Computed tomography (CAT scan)
- Ultrasound (sonography)
- Conventional radiography (plain films)
- Which of the following is safest for patients who undergo many studies?
- Magnetic resonance imaging (MRI)*
- Computed tomography (CAT scan)
- Catheter angiography
- Conventional radiographs (plain films)
- Which of the following involves breaking through the patient's skin?
- Magnetic resonance imaging (MRI)
- Computed tomography (CAT scan)
- Catheter angiography*
- Conventional radiography (plain films)
- Ultrasound (sonography)
- All of the following procedures are commonly performed by radiologists
except:
- Biopsy of deep structures
- Irradiating cancer*
- Treating brain aneurysms
- Draining abscesses
- Treating vertebral fractures
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Abstract
Introduction
