Ideal Exposure: Integrating Imaging Interpretation into a

PA Program Curriculum

John Grosel, MD Associate Professor, Marietta College PA Program Radiologist, Riverside Radiology and Interventional

Associates, Inc.

“This is bad, right? I need to call the neurosurgeon, right? Can’t find anyone!!!”

ObjectivesAt the conclusion of this session

participants will:

1. Understand how a radiologist has integrated radiology education and imaging interpretation throughout a PA program.

2. Understand and be able to implement teaching methods that will help PA programs provide basic imaging interpretation.

3. Be aware of frequently overlooked, but very important, aspects of effective imaging interpretation education and how to implement these into a PA program curriculum.

PA student and Radiology

• Utilization of imaging resources – When to order what

• Interpretation of images – Preliminary

interpretations – Final interpretations?

• Ability to clearly articulate findings to collaborating clinicians

Why spend time on imaging interpretation?

• Improves patient care – Utilization of imaging, especially advanced imaging

techniques like CT and MRI, have more than tripled since 1995

• X-ray interpretation on PANCE • Compliments and reinforces anatomy, physical

exam, pathophysiology, and clinical medicine • X-Ray Interpretation: how well are you prepared

in this skill? • Marietta College PA Program evaluation question

Overview

• The basics • Normal radiographic anatomy

– In conjunction with 9 week cadaver anatomy course

• Identify abnormal (and figure out what it is) – Lectures in Clinical Medicine course – “Unknowns” – Individual or small group review at workstation

with radiologist – Life long learning

• Look at studies ordered

The Basics• 5 x-ray densities • Basics of each imaging modality with

emphasis on plain film and CT scans, but also significant unique features of other imaging modalities – No radiation in ultrasound, physiologic imaging

with nuclear medicine, etc. – Enteric and IV contrast

• Presented in conjunction with cadaveric anatomy

“Normal”

• “Within normal limits” • Extensive normal plain film and CT scan

exposure during summer cadaver anatomy – Spine, knee, shoulder, ankle and brain MRI as

well • Lecture with constant classroom interaction • Small group reviews with instructor

– Numerous plain films examples available on view box

– CT scans on computer monitors • All resources available 24/7 for individual review • “Practice test’

R. paratracheal stripe

Azygos

Trachea

Carina

R. diaphragm

L. hilumR. hilum

Aortic arch/knob

AP window

Main pulmonary a./t.

L. diaphragm

L heart border (left ventricle)

R. heart border (R. atrium)

R and L costophrenic angles

WHAT VIEW IS THIS?

PA CHEST X RAY

Head CT

9

R

Head CT

10

L. Frontal lobeFrontal (anterior) horn L lateral ventricle

Head of L caudate nucleus

L Basal ganglia

White line: Internal capsule

L. Temporal lobeAtrium of L lateral ventricle

L. thalamusL. Occipital lobe

R

Assessment of “Normal”

• 15% of Anatomy grade is radiology – 10% practical exam – 5% written exam

“Abnormal”

• Must know normal – Review of pertinent normal

radiographic anatomy at beginning of Clinical Medicine radiology lectures

– Radiologic anatomy questions posed to the class during other lectures

Identify abnormal

• Clinical Medicine radiology lectures – Follows our systems approach

• Review anatomy, physiology, pathophysiology while reviewing images

– Moderate student interaction – Emphasize typical features of common

abnormalities – My approach to each modality

Intracranial hemorrhage imaging

• CT best (hematoma increased attenuation – whiter than brain)

• Location (parenchymal, subarachnoid, subdural, epidural, or intraventricular)

• Clinically pt. have headaches (HA) – Red flags – worst headache of life,

different character of HA, associated with abnormal physical exam

• If suspect stroke clinically, CT to R/O bleed in the stroke prior to anticoagulation

Intracranial hemorrhage imaging

• If bleed, look for mass effect, herniation • Hypertensive headaches – basal ganglia

hemorrhage – If bleeding is in the brain parenchyma, but not in

the basal ganglia, evaluate for underlying mass or AVM – brain MRI with gadolinium (may need to wait a month or two)

• Nontraumatic subarachnoid hemorrhage (SAH) = ruptured berry aneurysm until proven otherwise – Sulci

Intracranial hemorrhage imaging

• Subdural hematomas due to tearing of bridging veins – seen in elderly with atrophic brains – Crescentic and cross sutures

• Epidural hematomas seen after trauma – tear of middle meningeal a. with bony FX – Lenticular and stop at sutures

Examples of each.

L BASAL GANGLIA HEMORRHAGE

17

R R

Identify abnormal“Unknowns”

• Few days after Clinical Medicine lecture • 30-40 cases

– Plain film and CT • Laser pointer gets passed around amongst

the students – “Present” the case formally

• Emphasized in chest, bone, neuro – Some abdominal, renal cases

• Also done as a break in other lectures

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Assessment of “abnormal”

• 7-12% of Clinical Medicine grade – Each system exam has 3-8 (out of 50-60)

radiology questions – 2 or 3 will be interpreting radiographic images

• Second year end of rotation exams • Objective structured clinical examination

(OSCE) station • Comprehensive exam

Next step: Putting it all together• Sit at workstation with radiologist during

didactic phase and on rotations – Important to be able to identify the few abnormal

cases interspersed amongst many normal cases • Often easier to interpret abnormal cases than

normal ones • Good to hear what the radiologist is thinking • Emphasizes importance of good history and

rapport with radiologist • Use of scroll function at the workstation

• Initial preliminary interpretations

Lifelong learning

• Always look at images ordered – Helpful to the patient – Helpful to the clinician

Text from one of our graduates who has been working for 5 months: “This is bad, right? I need to call the neurosurgeon, right? Can’t find anyone!!!”

Sources of radiology instructors and cases

• Friendly neighborhood radiologist • Radiology teaching program - residents • To recruit radiologists/residents need to

show benefits: – Enjoyment of teaching, sharing good cases – Training future clinicians – Academic prestige – College benefits, title – Monetary compensation

• Various on-line materials

Textbooks

• Mettler JR, Fred A. Essentials of Radiology 3rd Ed. Philadelphia, PA: Elsevier Saunders; 2014.

• Goodman, Lawrence R. Felson’s Principles of Chest Roentgenology: A Programmed Text 4rd Ed. Philadelphia, PA: Elsevier Saunders; 2015.

• Helms, C. Fundamentals of Skeletal Radiology, 4rd edition. Philadelphia, PA: Elsevier Saunders; 2013.

References1. Saha A, Roland R, Hartman M, Daffner R. Radiology Medical Student

Education. Academic Radiology. 2013;20(3):284-289. 2. Sendra-Portero F, Torales-Chaparro O, Ruiz-Gómez M. Medical

students’ skills in image interpretation before and after training: A comparison between 3rd-year and 6th-year students from two different medical curricula. European Journal of Radiology. 2012;81(12):3931-3935

3. Straus C, Webb E, Kondo K et al. Medical Student Radiology Education: Summary and Recommendations From a National Survey of Medical School and Radiology Department Leadership. Journal of the American College of Radiology. 2014;11(6):606-610.

4. Dettmer S, Schmiedl A, Meyer S, Giesemann A, Pabst R, Weidemann J, Wacker F, Kirchhoff T. Radiological Anatomy - Evaluation of Integrative Education in Radiology. Fortschr Röntgenstr. 2013;185(09):838-843.

5. Dawes T, Vowler S, Allen C and Dixon A. Training improves medical student performance in image interpretation. BJR. 2004;77:775-776.