Associat ion of Program Directors in Radiology Lee B. Talner, MD, Editor

Chairperson's Rounds for Radiology Residents

Thomas J. Cusack, MD

I am confident that most department chairpersons, when asked to submit a list of the attributes of their

position as the department chair, would not include "sufficient time to do everything that I want to" among them. Department chairs are constantly trading off time

spent on one aspect of their department for time spent on another. From time to time, major crises such as turf battles, faculty problems, or funding difficulties can be

distracting for weeks on end. The result is that expand- ing administrative duties tend to erode the very aspects

of their careers that led to the attainment of department chair status: teaching ability, research involvement, and direct patient care activities. Although most department chairs resist these erosive tendencies and generally

guard and retain as many Of these activities as possible, this is almost never accomplished as well as had been projected when these individuals accepted their admin-

istrative positions. When the chairperson occasionally does realize the need or desire for increased teaching activity and sets aside time to engage in it, a format may not be in place that enables maximum efficiency and use of that time.

For the residency programs, all of these forces acting on the chairperson's time tend to form an aggregate loss. The compromised ability of the chair to communi- cate directly to the residents his or her global perspec- tive on new developments in radiology, political issues

in radiology, and lessons learned in his or her own career experience cannot be accomplished by delegat- ing to more junior faculty. It is clear from comments

heard at recent national meetings that senior radiology

residents today are highly distressed and concerned about their future in radiology. They need the guidance

and role-modeling and encouragement of successful individuals in their field. This requires relationships with those role models, and successful development of those relationships requires time and the proper setting.

The purpose of this article is to provide a f ramework for solving these problems and to describe two exam-

ples of successfnl solutions. The most important factor in the solution is the for-

mat that is developed. The pressures that currently are competing for the chairperson's time will not diminish

and likely will intensify. It is not enough to make a good-faith effort to institute a solution; the format must be designed so that it is sustainable in the face of con- tinuing time pressures.

To be sustainable, the format must have certain attributes. It must be time efficient, educationally effec- tive, and, most important, rewarding for the chair.

Finally, the net result should be positive for the resi- dency. This last attribute implies that there are some trade-offs (discussed later). If any of these attributes are missing, I consider the program nonsustainable.

In the remainder of this article, I describe a format

that has proved successful in our department. The chairperson has two 1-hr sessions per week with the residents. The first hour is devoted to the differential diagnosis (DDX) format, and the second hour is a text- book review.

From the Department of Radiology, University of Illinois College of Medicine, Peoria, IL

Address reprint requests to T. J. Cusack, MD, Department of Radiology, University of Illinois College of Medicine, Box 1649, Peoria, IL 61656-1649.

Received March 14, 1995, and accepted for publication after revision June 27, 1995.

Acad Radiol 1995;2:1021-1025 © 1995, Association of University Radiologists

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CUSACK Vol. 2, No. 11, November 1995

FORMAT 1: THE DDX EXERCISE

In these sessions, the residents are shown an image with an obvious abnormality, such as a pulmonary nod- ule or intracranial calcification or cystic adnexal mass. The image may be shown in film format, projected from a textbook illustration, or projected on a slide.

After a brief study of the image by the residents, the nature of the abnormal finding is briefly discussed so that everyone understands what the finding is and what the DDX should be based on. At this point, the resi-

dents write, on a triplicate form designed specifically for this conference, the DDX for the abnormal finding.

This can be done along the lines of the chair's prefer- ence for pathologic groupings or can be left for each resident to develop his or her own pathologic group-

ings. I generally use the pathologic groupings in the American College of Radiology's (ACR's) teaching file coding system as the template for the pathologic cate-

gories. After an appropriate amount of time (usually 3-

7 min), the residents tear off the bot tom sheet of the triplicate form and hand in the top two sheets.

A general discussion of the DDX then ensues, led by the chairperson but contributed to by all of the resi-

dents, particularly the more senior residents who may have a better understanding of the finding as it relates to the newer modalities than the chairperson himself or herself. The discussion of the DDX is focused on orga-

nization. Published DDX lists are reviewed, and the res- idents are encouraged to make comments and critique these published lists. The residents can make additional

notes on their copy of the DDX that they have retained. There are advantages to having the residents express

their DDXs in written form rather than verbally. Many residents, particularly early in their careers, are much better at expressing themselves in written form than ver-

bally. In teaching conferences, it is often a waste of time to have the entire group wait while a junior resident struggles with an unfamiliar DDX; it is for this reason

that junior residents are sometimes not given the oppor- tunities to demonstrate their knowledge as often as more senior residents. Written lists of DDXs for senior resi- dents also are valuable in that the residents are unable to

finesse information from the case presenter, by noting the subspecialty of the case presenter, the presenter's current rotation, or even the patient's surname. Finally, written DDXs can be graded, compared, and repeated at

a later time to determine how the resident is progressing. It is reasonable to have a higher expectation for inclu- siveness in written tables of DDXs because the resident

is able to review what has already been covered and add additional items that might have been omitted. Although I have no data to support this, I have wondered whether experience at developing written tables of DDXs may be helpful to some residents in later assembling the DDXs

in verbal form. Sometime after the conference, the chairperson briefly

reviews the written DDXs and makes a quick assessment

of the residents' responses and grades them on a 5-point system (O [5], S+ [4], S [3], S- [2], and U [1]; O = outstand- ing, S = satisfactory, U = unsatisfactory). Because the

expectations for residents will vary depending on their level of training, there is a section at the top of the page for residents to indicate what month of training they are in. Occasionally, along with the overall grade, written

comments from the chair also may be appropriate (e.g., the resident overlooked an entire area of pathology in

his or her response). The department secretary then returns one of the "graded" copies to residents; the remaining copy is kept in the department files. Quar-

terly, these are summarized by the department secretary, listing all residents' names, all DDXs that they attempted during the quarter, and their respective grades.

The advantage of this format is that it emphasizes to residents the importance of developing DDXs for various radiographic findings early in their career. It also empha-

sizes the need to be able to recount these, in a somewhat orderly fashion, at any time and without prior warning. It enables residents whose manual dexterity or verbal skills may not be outstanding to express themselves in writing.

Occasionally, residents demonstrate considerable knowl- edge and organization in written form that are much less obvious in verbal communication.

The DDX exercise allows the department chair to con-

stantly review common and important tables of DDXs. It enables him or her to relate directly to the residents and to recount his or her experiences in these areas and the pitfalls that he or she might have encountered in the

past. Most important, it enables the chair to interact directly with each of the residents on a weekly basis, emphasizing some of the fundamental concepts Of diag- nostic radiology. The DDXs are periodically repeated. In this way, clear, written documentation of residents'

progress or lack of progress can be developed. Persistent difficulty in composing appropriate DDXs indicates a major problem that will seriously affect the resident's career unless it is corrected or compensated for.

The logistics of the pattern that I have found most useful and time effective are to obtain a standard text-

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book of radiology and to cut out the illustrations that have the findings to be used in the exercise. These are then taped on an 8.5 x 11 inch piece of paper and kept

in a notebook. Attached to each of these is the caption for the photograph; frequently, a paragraph or two photocopied from the textbook also is attached. Photo-

copies from recent editions of "gamut" books and other tables of DDXs are also included and are reviewed dur- ing the discussion phase of the exercise. These cases are then coded with the ACR teaching file code and are

incorporated into a table of contents. Perusal of the table of contents by the chair will quickly indicate the number and type of each exercise that has already been presented and will be valuable in identifying

additional exercises so that the entire spectrum of med-

ical imaging is covered. A variation of the DDX format is the designated diag-

nosis format. In this format, several images of a disease state are shown (e.g., Down's syndrome, neurofibroma-

tosis). It is expected that the senior residents will be able to identify the disease state in most instances. The residents are asked to write down the condition that is being shown and to describe the condition in whatever

detail they can, including pathophysiology and medical

imaging findings.

FORMAT 2: TEXTBOOK REVIEW

The other hour of the chairperson's rounds is a text-

book review. This practice is well established in many departments. I will review the logistics of the exercise that have been developed so that they conform to the attributes of formats identified earlier in this article.

Currently, we use a 1,200-page textbook and cover it

each year by requiring approximately 30 pages of read- ing per week for a total of 40 weekly sessions (allow- ance is made for vacations, holidays, the annual meeting of the Radiological Society of North America, and other weeks when no session is held). At each ses-

sion both the chair and the residents read the assigned pages, and the chair quizzes the residents on the mate-

rial presented. Each response is graded on the 5-point

system described earlier. To facilitate these verbal quizzes, the chair not only

reads the assigned pages but also dictates study notes

excerpted from the textbook relating to the assigned pages. These study notes are constructed so that the diagnosis (or finding or term of interes0 is listed along the left-hand side of the page and the appropriate

response is on the right-hand side of the page. In this manner, a set of questions is readily available that covers

the material. Small Post-it Notes are then placed along the extreme right-hand margin of the paper prior to the session and the chair writes down, next to the questions,

the initials of the resident to w h o m he or she is going to pose the question. The grade of the resident's response is then written next to the resident's initials, and the Post- it Notes are left in place after the conference. The depart- ment secretary subsequently reviews the chair's note- book and transcribes all of the answers into a computer data bank, which contains the resident's name, the ques-

tion the resident was asked, and the grade for that ques- tion. These are also summarized quarterly and are available for review by the chair.

Following questions on the material covered for that

week, approximately 10-15 rain are devoted to asking questions from previous sessions during the year, which also have been highlighted with Post-it Notes.

This requires residents to always be prepared for all of the information in the chairperson's notes.

The study notes for the chair are photocopied and

given to all residents. At the end of the year, the resi- dents have a fairly complete set of notes on the text- book. In our program this constitutes a major portion of

the core knowledge that the residents are expected to have mastered. The requirement to dictate study notes makes the first year of the textbook review much more

labor-intensive for the chair. However, the ability to read a current general textbook of radiology cover to cover carefully enough to construct study notes is a

luxury that most chairpersons will enjoy if they can jus- tify the time commitment. This format provides that jus-

tification. Generally, the time required to review the indicated pages and excerpt the appropriate study notes is approximately 60-75 min per session.

The major purpose of this format is to provide the

residents with a core knowledge of radiographic infor- mation and to repeatedly drill them on that knowledge. This will be valuable to them in clinical situations and when they take the boards. It will give them confidence that they have broad knowledge that has been tested frequently and is recallable. In attaining this goal, the residents and the chair are methodically involved in a broad review of medical imaging of all modalities as it

relates to pathology in all major organ systems. One of the most valuable aspects of this entire exercise

emerged as a very pleasant surprise. The quarterly print- outs of residents' scores have been extremely valuable,

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CUSACK vol. 2, No. 11, November 1995

particularly from the residents' viewpoint. An example of the DDX scoring for a resident is shown in Table 1. In this example there are no outstanding (5/0) grades, only

one above-average (4/S+) grade and only one unsatisfac- tory ( l /U) grade. The majority of the scores are in the average (3/S) to below-average (2/S-) range. If this were a first-year resident, it would indicate that the resident is

learning the discipline on a broad fi-ont, a fairly reassur- ing report. If this were a second-year resident, it would be worrisome that there are no outstanding (5 /0 ) grades

and only one above-average (4/S+) grade. If this were a third-year resident, it would indicate clearly that the level

of knowledge is far too superficial and that immediate corrective action is needed.

The real-life grades from the textbook review (Table 2) show alternating groupings of outstanding ( 5 / 0 ) and

TABLE 1: Resident's Scoring in a Differential Diagnosis Conference

Quarter Subject Reference Grade

Summer 1994 Adrenal masses 86-01 3/S Summer 1994 Psoriatic arthritis 43-01 3/S Summer 1994 Secondary hyperparathyroidism 81-01 2/S- Summer 1994 Pseudopseudohyoparathyroidism 89-01 1/U Summer 1994 Esophageal web 71-01 3/S Summer 1994 Bull's-eye lesion 77-01 2/S- Summer 1994 Intralobar sequestration -68-01 3/S Summer 1994 Dandy-Walker malformation 10-01 2/S- Summer 1994 Mediastinal mass 67-01 3/S Summer 1994 Angiomyolipoma 81-04 3/S Summer 1994 Ureterocele 82-01 2/S- Summer 1994 Hydronephrosis 85-01 4/S+ Summer 1994 Polycystic kidney disease 81-03 3/S

S = satisfactory, U = unsatisfactory.

TABLE 2: Resident's Scoring in the Textbook Review

Quarter Subject Reference Grade

Winter 1995 Eggshell calcification P&J/27 4/S+ Winter 1995 Cobalt lung P&J/27 1/U Winter 1995 Radiopaquedust pneumoconioses P&J/27 1/U Winter 1995 Maple-bark disease P&J/27 4/S+ Winter 1995 Industrial and war gases P&J/27 4/S+ Winter 1995 Paraquat lung P&J/27 1/U Winter 1995 Vinyl and polyvinyl chloride exposure P&J/27 1/U Winter 1995 Anomalous left coronary artery P&J/32 1/U Winter 1995 Aberrant left pulmonary artery P&J/32 1/U Winter 1995 Adenocarcinoma P&J/29 5/O Winter 1995 Bronchioloalveolar carcinoma P&J/29 5/0 Winter 1995 Pancoast tumor P&J/29 5/0 Winter 1995 Pancoast syndrome P&J/29 5/0 Winter 1995 Malignant histiocytosis P&J/29 5/0 Winter 1995 Round atelectasis P&J/30 5/O

S = satisfactory, U = unsatisfactory, O = outstanding.

unsatisfactory ( l / U ) readings. This indicates not only that the resident is not reading the assignment regularly, but also that when the resident does not read the assign-

ment there is no core knowledge to fall back on. This resident is therefore developing a core level of knowl- edge with major gaps, and this needs to remedied.

This type of objective scoring of residents is not easy to obtain in our program and, I suspect, in many others. Although residents are graded on their clinical rotations by faculty members who make a good-faith effort, the

shortcomings of this type of evaluation are well-known.

Problem residents are not identified early enough. The evaluations tend not to indicate to the residents signifi- cant areas of weakness. Finally, and most important, res-

idents are frequently not positively recognized for excellence in the performance of their duties. Although

some external examinations (e.g., the in-training exami- nation for diagnostic radiology residents offered by the ACR) are helpful, annual feedback is too infrequent.

Quarterly sessions with each of the residents to review their performance on the DDX conferences and textbook review have been uniformly gratifying for the

chair and helpful to the residents. In response to a resi- dent 's concern that much of the textbook scoring is

based on very current reading and may not indicate long-term knowledge, a variation has been instituted in which questions on the current material will be kept separate in the printouts from review questions that are

asked at each session. By comparing these two scores, then, somewhat of a "retention index" can be deter- mined. The residents have observed, tongue-in-cheek,

that the amount of knowledge that is not shown on the initial testing of current material can be used to calcu- late a "resistive" index.

DISCUSSION

The results have been very encouraging. The residents genuinely seem interested in these conferences and do not like to see them canceled, particularly for minor rea-

sons. Initially, there was some uneasiness about turning in written "tests" and having records kept of the chair's grades for individual responses to specific questions. This has not been a continuing problem. The younger residents, in particular, are anxious to demonstrate how well they are progressing. For the more advanced resi- dents, it is increasingly difficult to be impressive on the

upside and increasingly possible to demonstrate a major gap in their knowledge that is embarrassing.

The major advantage of this program is that it involves the department chair directly with the residents in an

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area (teaching) in which most department chairs have previously demonstrated considerable ability. It enables the department chair, in a fairly nonthreatening manner, to continue to learn about new modalities. It enables the department chair to stress the importance of the funda-

mental radiographic findings and the basic approach to medical imaging that he or she has found useful in his or

her own life. Although not intended to be an undermin- ing process, it does, in fact, enable the chair to more quickly pick up on attitudes of the residents toward their

learning process and difficulties that the residents may be having within the department than would otherwise

be obtained. Moreover, it also enables the department chair to assess any areas of weakness in the department 's educational activities by giving him or her an opportu-

nity to routinely review the entire spectrum of pathology

with the residents. In this era of medicine, it is particularly important for

residents to be exposed to the chairperson's perspec- tive on new developments in radiology, political issues

in radiology, and career experience interacting with other radiologists, referring physicians, and administra-

tors. The chair frequently has a different perspective on many issues than do program directors and other fac- ulty members, and it is valuable to have in place a set- ting that exposes the residents to that perspective.

Finally, it is heartwarming for a department chair to see the residents progressing month by month and to feel that he or she is not only an indirect but also a

direct influence on that progression.

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