Curriculum for Abdominal Section

OVERTON BROOKS VAMC CARDIOTHORACIC Rotation

Goals and Objectives

The goal is for each resident to achieve independent competency and acquire tools with which to continue self-education and life-long learning. The level of practice should be consistent with national community standards as outlined in the American College of Radiology (ACR) Practice Guidelines.

Emphasis throughout the four-year residency program is on understanding the pathophysiology of diseases and disorders, and its appearance across all different imaging modalities.

Patient Care

FIRST YEAR RESIDENTS (PGY-2):

1. Demonstrate knowledge of the basics of radiation safety. Understand radiation dose from chest radiographs and chest CT.

2. Demonstrate knowledge of and ability to use electronic patient information systems, including the radiology information system and appropriate use of electronic systems to obtain patient laboratory data, etc., to integrate with imaging findings to assist in an accurate diagnosis.

3. Understand the indications for each imaging examination performed and the specific indications for any examination performed on an individual patient. Ability to protocol CT examinations appropriately according to indication, and with attention to reducing patient risk from radiation and contrast exposure.

4. Demonstrate the ability to use the internet as a tool for teaching and learning, including access to information to improve knowledge in patient care situations.

SECOND YEAR RESIDENTS (PGY-3):

1. All of the objectives listed for first year should be attained with increased mastery. 2. Organized and efficient approach to thoracic procedures, including planning the procedure, informed consent, performing the procedure, immediate post-procedure care, followup of patients with tubes in place, and communication with clinicians. Followup on procedures to obtain results of biopsies. THIRD YEAR RESIDENTS (PGY-4):

1. All of the objectives listed for first and second years should be attained with increased mastery. 2. Teaching of the above objectives to medical students and junior residents.

FOURTH YEAR RESIDENTS (PGY-5):

1. All of the objectives listed for earlier years should be attained with increased mastery.

Medical Knowledge

During the first year, residents are expected to learn indications for common radiologic procedures, the technique for performing these procedures, and normal findings. These include:

a.i.1. Residents should become familiar with interpretations of standard chest radiographic studies and chest CT, including CT angiography for aortic and pulmonary vascular disease. a.i.2. Normal anatomy on CXR and CT should be understood. a.i.3. Basic familiarity with the most common pathologies should be demonstrated: edema, pneumonia, pulmonary embolism, cardiac chamber enlargement, aortic vascular disease, lung cancer, lung nodules, . a.i.4. The principles of use of radiographic contrast material should be understood. This includes indications for application of contrast, contraindications to use of contrast, considerations in choice of particular contrast material, and recognition and treatment of adverse reactions to contrast material. a.i.5. The principles of performing image-guided thoracic procedures should be understood. a.i.6. Specific knowledge objectives appended.

1. All of the objectives listed for earlier years should be attained with increased mastery. 2. Specific knowledge objectives appended.

THIRD YEAR RESIDENTS (PGY-4):

1. All of the objectives listed for first and second year residents should be reviewed with increased mastery.

2. Demonstration of the knowledge associated with first and second year objectives

2 should be demonstrated with teaching to medical students and junior residents.

1. All of the objectives listed for first, second, and third year residents should be reviewed with increased mastery. 2. Teaching of the above objectives to medical students and junior residents should be increasingly emphasized.

Interpersonal and Communication Skills

1. Work to structure written reports of imaging studies to accurately and effectively transmit results and recommendations to referring clinicians. 2. Demonstrate appropriate phone communication skills. 3. Begin to develop skills in obtaining informed consent, focusing on effective communication skills with patients, including discussion of alternatives and possible complications of procedures. 4. Effective and appropriate communication with technologists and other staff.

1. Demonstrate increasing skill in clearly and concisely communicating via the radiology written report. 2. Demonstrate ability to discuss cases with clinicians. 3. Demonstrate refinement in skills related to obtaining informed consent, including use of interpreters when language barriers exist. 4. Demonstrate leadership role in communications/interactions with technical personnel and patients, including explanation of delays related to emergencies.

1. All of the objectives listed for first and second year residents should be reviewed with increased mastery.

2. Improved ability to discuss cases with clinicians

3. Demonstration of the knowledge associated with first and second year objectives (in this document and rotation specific objectives) should be demonstrated with teaching to medical students and junior residents.

3 FOURTH YEAR RESIDENTS (PGY-5):

1. All of the objectives listed for first, second, and third year residents should be reviewed with increased mastery. 2. Demonstrate increased ability to communicate effectively with providers at all levels of the health care system as well as those in outside agencies. 3. The senior resident should model by action as well as directly teach the above objectives to medical students and junior residents.

Professionalism

1. Demonstrate understanding of broad principles of medical ethics. 2. Demonstrate understanding of the principles of patient confidentiality by compliance with the HIPAA Privacy Rule. 3. Demonstrate completion of medical records, including review/signoff of radiology reports, according to departmental/hospital guidelines. 4. Demonstrate positive work habits, including punctuality and professional appearance. 5. Demonstrate honesty with patients and all members of the health care team. 6. Enthusiastic participation as a member of the patient-care team.

1. All of the objectives listed for first year residents should be reviewed with increased mastery. 2. Demonstrate altruism (putting the interests of patients and others above own self- interest). 3. Demonstrate organized and efficient approach to managing workload.

1. All of the objectives listed for first and second year residents should be reviewed with increased mastery. 2. The resident should teach the above objectives to medical students and junior residents directly as well as by modeling behavior consistent with these objectives.

1. All of the objectives listed for first, second, and third year residents should be

4 reviewed with increased mastery. 2. The senior resident should increasingly supervise and mentor medical students and junior residents in achieving these objectives.

Practice-Based Learning and Improvement

1. Analyze practice experience and perform practice-based improvement in cognitive knowledge, observational skills, formulating a synthesis and impression, and procedural skills. Demonstrate this by active review and performance modification related to on-call discrepancies and active participation in morbidity and mortality/ misses conferences.

2. Demonstrate use of multiple sources, including information technology, to optimize life long learning and support patient care decisions.

3. Familiarity with internet resources, including PubMed, chestxray.com, etc.

1. All of the objectives listed for first year residents should be reviewed with increased mastery. 2. Demonstrate increasingly critical assessment of the scientific literature in journal clubs as well as other clinical and conference environments. 3. Review recent key papers supplied by thoracic faculty

1. All of the objectives listed for first and second year residents should be reviewed with increased mastery. 2. Familiarity with thoracic radiology material recently published in Radiology, Radiographics and AJR.

1. All of the objectives listed for first, second, and third year residents should be reviewed with increased mastery. 2. Demonstrate awareness of resources available to practicing radiologists for lifelong learning, including print, CD-ROM, and internet products of the ACR. 3. Demonstrate knowledge of the above objectives by supervision of medical students and junior residents as well as by directly teaching these objectives.

5 Systems-Based Practice

1. Begin to acquire knowledge regarding the costs of imaging studies and impact of costs on appropriate choices for clinical use. 2. Demonstrate knowledge of the examination system of the American Board of Radiology and importance of board certification.

SECOND, THIRD AND FOURTH ROTATIONS (PGY 3-5):

1. All of the objectives listed for first year residents should be reviewed with increased mastery. 2. Demonstrate the ability to design cost-effective imaging strategies/care plans based on knowledge of best practices. 3. Demonstrate knowledge of how decisions about timing/availability of imaging studies may affect hospital length of stay, referral patterns for specific examinations and use of diagnostic studies outside the Department of Radiology. 4. Demonstrate knowledge of hospital-based systems that affect physician practice, including physician code of ethics, medical staff bylaws, quality assurance committees, and credentialing processes. This includes knowledge of how these processes may affect the scope of practice of any one physician and competition among practitioners.

Year 1 (first 4-week rotation)

Goals: After completion of the first thoracic radiology rotation, the resident will be able to:

1. demonstrate learning of the knowledge-based objectives (1/4 of the total topics). 2. understand standard patient positioning in thoracic radiology. 3. obtain pertinent patient information relative to radiologic examinations. 4. accurately and concisely dictate a chest radiograph report. 5. communicate effectively with referring clinicians and supervisory staff. 6. demonstrate knowledge of the clinical indications for obtaining chest radiographs and when a chest CT or MR may be necessary.

6 7. know basics of the IV contrast agents 8. be familiar with CT anatomy of the respiratory and cardiovascular tract.

9. perform basic image-guided procedures of the chest. 10. prepare the resident to be able to safely practice while on call by the end of the first year.

Knowledge Based Objectives:

1. Review the thoracic anatomy including: chest wall, lungs, pleura and mediastinal organs.

2. Understand the normal imaging appearance of thoracic organs including cardiovascular and respiratory tracts using plain film radiography, computed tomography (CT).

3. Identify and describe cardiothoracic diseases on plain films.

Technical Skills:

1. Be familiar with fluoroscopic techniques and safe operation of the fluoroscopic unit.

2. Interview patients prior to radiographic contrast injection.

3. Compose a concise dictated a plain film report report.

4. Begin to function as a consultant to referring physicians and patients.

References for 1st Year:

1 Felson's Principles of Chest Roentgenology

2 Chest radiology: plain film patterns and differential diagnoses. James C. Reed.

3 Fraser and Pare's Diagnosis of Diseases of the Chest

7 4 Fundamentals of Body CT (Webb, Helms, Brant)

5 ACR Contrast Manual

Year 2

Goal: After completion of the second thoracic radiology rotation, and in addition to those goals listed for Year 1, the resident will:

1. demonstrate advances of the knowledge-based learning objectives (½ of the topics) . 2. continue to build on chest radiograph interpretive skills. 3. Develop detailed knowledge of contrast agents and allergic reactions. a. Be prepared to answer patient and staff questions concerning when contrast media should or should not be utilized and how to treat contrast reactions. 4. develop skills in protocoling, monitoring, and interpreting chest CT scans. 5. demonstrate an ability to generate and interpret basic multiplanar reconstructions (MPR) and volume-rendereing images of CT. 6. understand normal MRI findings related to the respiratory and cardiovascular tracts.

7. Acquire more confidence during calls.

8. Perform simple image-guided biopsies and drainage procedures with instruction and under the direct supervision of the Interventional radiology Faculty.

Knowledge Based Objectives:

Contrast Material:

1. Understand the physical properties and composition of standard contrast agents and the physiologic mechanisms of contrast media excretion.

8 2. Learn to screen patients who are at risk from injection of intravascular radiographic contrast material. Understand the classification, symptoms, and signs of contrast reactions and clinical management including appropriate use of pharmacologic agents and their mode of administration and doses after appropriate patient assessment.

3. Understand the indications for premedication and the appropriate regimen to premedicate contrast sensitive patients including dosages, and dose scheduling.

1. Refine comprehension of physics as it applies to patient medical radiation dose, and radiation safety.

2. Expand understanding of the causes and effects of Cardiothoracic and respiratory tract diseases.

3. Understand diagnosis, classification, and management of trauma.

4. Attend department case conferences and didactic presentations, including interdepartmental conferences, grand rounds, guest lecturers, etc.

References for 2nd year:

1. ACR Practice Guidelines for the Use of Intravascular Contrast Media, Version 5.0

2. CT and MR of the Chest (Naidich, Webb, Muller)

3. High Resolution CT of the Lung (Webb, Muller, Naidich)

Year 3: Goal: Add to general knowledge acquired in the first two years and learn more advanced and less common techniques and disorders.

9 Objectives:

1. Increase awareness of the CT and MR manifestations of cardiothoracic disease:

a.i.1.a. Learn about the different types of thoracic traumatic injuries and their classification as well as recommended non-surgical and surgical management and injury prognosis.

a.i.1.b. Understand of inflammatory diseases as seen on CT and MR and their clinical management.

a.i.1.c. Learn staging of thoracic neoplasms

2. Use the independent workstation for more advanced applications and image reconstruction on CT. 3. develop skills in protocoling, monitoring, and interpreting chest MR studies, including cardiovascular MRI. 4. demonstrate an ability to generate and interpret multiplanar reformatted (MPR) or three-dimensional images MRI studies as appropriate. Reference for 3rd year: See 1st and 2nd years

Year 4 Goal: Review all the knowledge and skills you have accumulated in the first three years and fill the gaps in your knowledge.

1. demonstrate learning of the knowledge-based objectives. 2. refine skills in interpretation of radiographs, CT and MRI scans. 3. correlate pathologic and clinical data with radiographic, CT and MRI findings. 4. become a more autonomous consultant and teacher. 5. get as much case management experience as possible.

10 Knowledge Based Objectives:

1 Review cases in the ACR teaching file and peer reviewed teaching files available on the internet. The best sites should present as unknown cases, asking for you to make a diagnosis and suggest recommended imaging and clinical management, summarizing the correct diagnosis and management at the end.

2 Attend available department case conferences or other didactic presentations, including interdepartmental conferences, grand rounds, guest lecturers, etc. Emphasize independent thinking before seeking direct staff supervised patient management.

3 Understand the basic principles of radiofrequency ablation, thermocoagulation, and other minimally invasive procedures, along with the appropriate imaging guidance and post treatment surveillance.

Reference for 4th year: See 1st and 2nd years

Assessment/Evaluation of Residents

1) Electronic evaluation by attending faculty each month after the rotation and Written evaluation

every 6 Months with the Program Director

2) ACR in-training examination

3) OSCE evaluation twice per year

4) Written ABR exam

5) Oral ABR exam

List of didactic lectures:

 Thoracic anatomy 11  CXR: Basic interpretation and findings

 Signs in thoracic radiology

 Interstitial lung disease

 Alveolar lung disease

 Atelectasis, airways, and obstructive lung disease

 Pulmonary infection

 Mediastinal masses

 Solitary pulmonary nodules

 Benign and malignant neoplasms of the lung

 Congenital lung disease

 Thoracic vascular trauma

 Thoracic non vascular trauma

 Non traumatic aortic emergencias

 Pulmonary embolism

 Congenital heart disease

 Ischemic heart disease

 Myocardial disease

 Cardiac valvular disease

 Pericardial disease

References:

University of Colorado (uchsc.edu)