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| Journal of the New Zealand Medical Association,
28-October-2005, Vol 118 No 1224
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Radiology knowledge in new medical graduates in
New Zealand
Rathan Subramaniam, Tim Hall, Tina Chou, Dale Sheehan
In the current era of modern organ imaging, radiological
investigations play a central role in patient management. However, although
radiology has undergone significant changes during the last two or three
decades, this has not translated fully into medical school curricula. Despite
the enormous change in medical practice, radiology is still only taught as an
adjunct subject in the final year (trainee intern year) medical school curricula
rather than as one of the core subjects
Final year medical students (trainee interns) at the
University of Auckland have a ‘radiology elective week’ as part of
their curricula but there is no other organised formal radiology teaching. It is
expected that Auckland students learn radiology from their attachments in
medicine, surgery, general practice, psychiatry, and obstetrics &
gynaecology during final year. At the University of Otago, there is also no
organised radiology teaching during the final year (trainee intern) of medical
school. Indeed, students are expected to learn by ‘osmosis’ from
their attachments in other specialities.
The purpose of this study was to establish the level of
knowledge of first year house officers in New Zealand (as a cohort group) about
common radiological investigations as well as to measure their ability to
request the most appropriate and cost-effective radiological investigations for
common clinical conditions.
MethodsA test was developed and administered anonymously to a
sample of first year house officers in 4 of 5 large training centres and at a
provincial centre. The goal was to sample about 25% of the 2002 new medical
graduate cohort group. The test was administered at Waikato, Christchurch,
Rotorua, Auckland, and Dunedin hospitals during the first month of the new house
officer year (November 2002) with the assistance of education co-ordinators at
each centre.
To ensure national consistency in administering the
test, co-ordinators were briefed on the purpose of the test and were asked to
administer it during the first month of the new first year house officer
intake.
There were four sections in the test (Appendix 1). The purpose of the first section was to
determine how many first year house officers actually observed common
radiological investigations during their medical school training. The second and
third sections tested their practical knowledge and risks of these
investigations. The fourth section tested their ability to select the most
appropriate and cost-effective investigations for common clinical scenarios.
The content of the test was reviewed (for content and
face validity and readability) by a group of academic clinicians: a consultant
radiologist, a consultant physician, a consultant surgeon, and a medical
education specialist
The test was validated among a group of graduating
medical students at the Waikato Clinical School, University of Auckland in 2001.
About 20 graduating students at the Waikato Clinical School took the test. The
feedback about the standard of the test, suitability of the topics examined, and
readability of the test was incorporated into the final form of the test. A mark
scheme was prepared to ensure scoring reliability and fairness across marking
answers for all the questions and all the candidates. The principal investigator
was the only marker so that the inter-rater reliability was not an issue as
there was no second marker.
Participation of the house officers was voluntary,
anonymous, and consented and all participants were given 30 minutes to respond
to the test without access to any radiological resources. Co-ordinators from
each centre returned the completed tests to the principal investigator.
Responses from all the centres were marked by the principal investigator and
analysed at the Waikato Clinical School, University of Auckland using Microsoft
Excel v10 software (Microsoft Corporation, Washington, USA).
ResultsSixty-two first year house officers participated; 59 (22% of
total first house officers in 2002)1 were graduates of New Zealand medical
schools (Auckland 24 and Otago 35) and 3 were from overseas institutions. Six of
the participants have done radiology selective (a period of 4 weeks for advanced
study in a field of choice by students in their fifth year of medical school in
the University of Auckland) or elective
and three were involved in radiology research.
The following percentages of respondents never observed the
respective examination during their medical school training (also see Figure 1):
Figure 1. Percentages (vertical axis) of first year
house officers having never observed selected radiological investigations
as medical students
 InvestigationsThe mean score for practical knowledge about common
investigations was 50% (95% CI: 48%–52%); for knowledge about risks
involved in common investigations including radiation it was 47% (95% CI:
45%–49%); and for selecting the appropriate clinical investigations, the
mean score was 53%(95% CI 52%–54%) (Figure 2).
Only 42% (95% CI 38%–46%) of the respondents thought
they had adequate radiology teaching in their medical school training to work as
house officers.
Figure 2. Mean scores (percentages) of first year house
officers’ radiology knowledge
 DiscussionThe ultimate aim of medical student radiology teaching is to
produce a clinician who would be aware of the indications for, values, and
limitations of radiology in the clinical management of patients.
In order to produce a clinician who can critically see the
role of radiology in patient care, we need to provide a well-structured
radiology teaching programme to our medical students especially to those in the
final year (trainee interns) of medical school.
The practice of diagnostic radiology has changed
considerably in both technique and application within the last 15 years. With
advancement of technology, the practice of radiology includes not only
conventional methods but new imaging processes such as multi-detector computed
tomography (MDCT), and MRI.
In Australia, while the population has increased by 20%
during the last 15 years, the use of diagnostic imaging services has doubled and
the services rendered per 1000 population has increased by 80%.2 The challenge
for all medical educators is to educate the future medical profession about
cost-effective application of new diagnostic and therapeutic imaging
procedures.
The vast majority of today’s medical student
population will be physicians of general practice and non-radiology
specialities, and will request a wide spectrum of radiology investigations or
procedures in their professional life. But there are no organised radiology
teaching programmes for candidates in non-radiology training programmes in New
Zealand. This underlies the importance of providing a basic knowledge of
radiology to all medical students. Hence, radiology education should be
appropriate and effective for a medical student who will soon to be a
non-subspecialised junior medical officer.
One of the most important objectives for medical student
radiology education is that junior doctors and general practitioners need to
understand the value, indications, and limitations of radiological
investigations.3 In general, students need to know what information radiology
investigations and procedures can provide with accuracy and what their
limitations are. This will allow the future clinicians to have a meaningful
discussion about the suitability of an investigation with the radiologists and
use them as a resource. In addition, they are expected to obtain informed
consent for the investigations explaining the tests and risks to their patients
for noninterventional or noninvasive radiological investigations such
as CT, US, and MRI. (This is usually
done at the time of requesting the investigation rather than at the time of the
examination performed in the radiology department.)
Informed consent is becoming increasingly important in the
current medicolegal environment. To understand the above issues, ideally the
student observes such an investigation or procedure during their educational
experience at medical school. It is clear from our study that about 75% of
respondents never observed a barium enema or IVU. This may be due to the
declining use of these two tests due to their replacement by CT colonography and
CT urogram.
Despite being very common imaging investigations, about 25%
of the students never observed an ultrasound examination or CT scan. This is
reflected in their low mean scores of 50% and 47% about the practical knowledge
and risks of common radiological investigations and procedures, respectively. It
is important, therefore, that medical schools design curricula that allow all
students to have an opportunity to observe these common radiological
investigations and to understand the benefit and risks.
To use imaging investigations appropriately and cost
effectively, students need to be taught evidence-based imaging. Some of the
examples of these evidence based guidelines include:
This will encourage evidence-based
practice in the use of established imaging guidelines.
Only 42% of the respondents agreed that they had adequate
radiology teaching during their medical school training. This further elaborates
the need for organised radiology teaching in our medical schools, especially in
the final year (trainee intern). An integrated weekly radiology teaching with
other speciality attachments throughout the final year of medical school would
contribute enormously to the students’ understanding of radiology and its
role in day to day patient management. This along with the ‘radiology
elective week’ would provide the practical knowledge adequate to work as
house officers.
Assessment forms an integral part of learning processes. One
of the oldest and most robust findings of educational research is that the
assessment is the major influence on what gets learned. Examination results in
practical areas do not always match the work based evaluations of students by
those who work with them.9 Hence both summative and formative assessment methods
are necessary.
The summative assessment can take the form of a radiology
Objective Structured Clinical Examination (OSCE) at the end of the student
period of learning in the trainee intern year. It has been shown that students
improved OSCE performance after additional clinical exposure.10 This suggests
that OSCEs would be suited for testing integration of radiological and clinical
knowledge learned.
The formative assessment from radiologists and tutors
throughout the radiology teaching can provide insight into aspects of
professional competence including the ability to work in a team, attitudes, and
commitment that escape attention of summative examiners. For a summative
radiology examination to be most powerful, it needs to be incorporated into a
student’s final year of training (trainee intern year).
One limitation of this study is that only about 25% of the
2002 cohort of graduating final year medical students from New Zealand medical
schools took part in this voluntary study, and this sample cohort represents a
‘self selected’ group of house officers—this may have skewed
the results more favourably.
Providing a structured teaching programme and appropriate
assessment in radiology in our medical schools is important, as radiology
threads through patient care in almost every medical speciality.
Author information:
Rathan M Subramaniam, MRI Fellow and Senior Clinical Lecturer;1,2,3 Tim Hall,
Senior House Officer;1 Tina Chou, Senior House Officer;1 Dale Sheehan, Senior
Lecturer, Clinical Teaching, Christchurch College of Education,
Christchurch
1Department of Radiology, Waikato Hospital, Hamilton
2Department of Radiology, Waikato Clinical School,
University of Auckland, Hamilton
3Current address: Department of Medical Imaging, The
Canberra Hospital and the Australian National University, Canberra,
Australia
Acknowledgements:
The authors acknowledge the
contributions of Drs Barbara Hochstein, Brett Lyons, and Stephen
Child in reviewing the content of the
test and in co-ordinating the administration of the test at their respective
centres. We also thank Bruce Shadbolt who provided statistical analysis.
Correspondence: Dr
Rathan Subramaniam, The Canberra Hospital, Yamba Drive, Garran, ACT 2605,
Australia. Fax: +61 2 62443824; email: rathan67@hotmail.com
References:
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