n Opinion
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
Reviews and Commentary
New Dogs, Old Tricks1
Richard I. Markowitz, MD Robert H. Cleveland, MD
Published online 10.1148/radiol.13131574 Radiology 2014; 270:642–643 1
From the Department of Radiology, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (R.I.M.); and Department of Radiology, Boston Children’s Hospital, Boston, Mass (R.H.C.). Received September 9, 2013; revision requested October 7; revision received October 12; accepted October 18; final version accepted October 29. Address correspondence to R.I.M. (e-mail: [email protected]). Conflicts of interest are listed at the end of this article. RSNA, 2014
q
642
L
ast June, the American Board of Radiology (1) administered its final large oral examination in diagnostic radiology for residents who had completed 4 years of a conventional diagnostic radiology residency. The next batch of trainees, having completed 3 years of training, recently took the so-called Examination of the Future, which was given on computer terminals at a testing center in Chicago, Ill. This replaces the former part I and physics portions of the old examination. It was curious to hear many of the examiners at the board examinations bemoan the passing of the old system, although many of the younger examiners were loath to share that opinion. Nevertheless, it was a common observation across the subspecialty examiner spectrum that the first-time examinees had much more confidence and success with cross-sectional modality imaging than with conventional radiographic studies, even though many of these cases showed classic findings of relatively common entities (personal communications). The “old dogs” in the group (ourselves included) naïvely thought that these would be the easy cases; they were not. It is true that when the old dogs were trained, there were not as many or even any of the new modalities, such as ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and molecular imaging. During our training years, we spent a lot of time and effort to learn the signs and tricks of conventional radiographic interpretation, which represented the bulk of clinical practice at that time. Modern diagnostic radiology trainees have so much more to learn. Also, the value of conventional radiography has been downgraded both in relative value units (2) and expected utility for many diseases and conditions. Why spend time on these conventional examinations when you could get the answer more easily
with CT or MR imaging? Although conventional radiography, which is cheaper and readily available, is often not specific enough, it is still widely used (constituting 58%–65% of our own case volume) and often provides a necessary overview that can direct further imaging. In fact, many diagnoses made at conventional radiography do not require further imaging. Thus it is still relevant and deserves as much expertise as ever. As the old dogs quickly realized, learning new tricks is just another part of professional life. The train of progress keeps moving; get on board or be left behind. And so we learned, practiced, and continued to add new tools and techniques to our stores of knowledge. The question, it seems, is not whether old dogs can learn new tricks (3); they have and will continue to do so. The real question is can new dogs learn old tricks? Will newly trained radiologists have the same abilities and experience to confidently master those skills that older and more experienced radiologists take for granted? Do we, as teachers, spend enough time to prepare trainees in what some consider the basics of our specialty? Or will physicians in other branches of medicine become more adept at plain film interpretation and therefore not require the services of a radiologist, who may be too busy performing MR examinations or other studies involving hundreds of images to pay much attention to the list of lower-technology examinations? At a June teaching conference for residents and fellows, one of us dug out of our file some oldies but goodies. The cases were on film. Do you remember those plastic sheets with a black background that you had to put in front of a bright light (ie, viewbox)? It was amusing and curious to watch the residents as they were handed the films and struggled to figure out which way they should
radiology.rsna.org n Radiology: Volume 270: Number 3—March 2014
OPINION: New Dogs, Old Tricks
hang them on the viewbox. They had to get up from their seats and walk to the front of the room to see the images clearly. They were up there alone in the dark room, with nothing but the films, no mag, no contrast enhancement, no localizer, no color Doppler—only their eyes and their brains. They did well, although they seemed a little uncomfortable, just like at the oral board examination. The remaining residents and fellows were very quiet, but stayed wide awake and paid rapt attention. They might be called upon next and asked for their opinion. This commonly used teaching format, similar to the now-retired oral examination, tries to simulate the real-life situation where we are called upon, day in and day out, for one modality or another, to render an expert opinion for the benefit of our patients and referring physicians. Clearly, the discomfort level was highest and the confidence level lowest when it came to conventional radiographic studies.
Markowitz and Cleveland
We are encouraged that it is not just us two old dogs who are uneasy about the fading of plain film interpretative skills, which we believe still constitute a major portion of current practice. Whether it may be the concern about radiation exposure from CT or the growing cost of medical imaging, there is a sense that radiology leaders are taking notice of the importance of the issue. This has recently been reflected in the interest that several national and international organizations have placed on renewing awareness of the power of plain film interpretation. Since the spring of 2011, these two authors alone have been invited to give presentations regarding the role of chest and abdominal radiography in modern imaging practice at six national and international venues. With both public pressure to reduce medical radiation exposure and the support of organized radiology, we think new dogs can and should learn old tricks.
Radiology: Volume 270: Number 3—March 2014 n radiology.rsna.org
We just have to show them how it is done and give them a little time and opportunity to practice. Maybe old dogs could even stick around and help out. There is always something new to learn. Disclosures of Conflicts of Interest: R.I.M. No relevant conflicts of interest to disclose. R.H.C. No relevant conflicts of interest to disclose.
References 1. American Board of Radiology website. http:// www.theabr.org/. Accessed September 9, 2013. 2. Sunshine JH, Burkhardt JH. Radiology groups’ workload in relative value units and factors affecting it. Radiology 2000;214(3): 815–822. 3. Cambridge Advanced Learner’s Dictionary and Thesaurus. Cambridge University Press website. http://www.cambridge.org/. Accessed September 9, 2013.
643
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
Reviews and Commentary
New Dogs, Old Tricks1
Richard I. Markowitz, MD Robert H. Cleveland, MD
Published online 10.1148/radiol.13131574 Radiology 2014; 270:642–643 1
From the Department of Radiology, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (R.I.M.); and Department of Radiology, Boston Children’s Hospital, Boston, Mass (R.H.C.). Received September 9, 2013; revision requested October 7; revision received October 12; accepted October 18; final version accepted October 29. Address correspondence to R.I.M. (e-mail: [email protected]). Conflicts of interest are listed at the end of this article. RSNA, 2014
q
642
L
ast June, the American Board of Radiology (1) administered its final large oral examination in diagnostic radiology for residents who had completed 4 years of a conventional diagnostic radiology residency. The next batch of trainees, having completed 3 years of training, recently took the so-called Examination of the Future, which was given on computer terminals at a testing center in Chicago, Ill. This replaces the former part I and physics portions of the old examination. It was curious to hear many of the examiners at the board examinations bemoan the passing of the old system, although many of the younger examiners were loath to share that opinion. Nevertheless, it was a common observation across the subspecialty examiner spectrum that the first-time examinees had much more confidence and success with cross-sectional modality imaging than with conventional radiographic studies, even though many of these cases showed classic findings of relatively common entities (personal communications). The “old dogs” in the group (ourselves included) naïvely thought that these would be the easy cases; they were not. It is true that when the old dogs were trained, there were not as many or even any of the new modalities, such as ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and molecular imaging. During our training years, we spent a lot of time and effort to learn the signs and tricks of conventional radiographic interpretation, which represented the bulk of clinical practice at that time. Modern diagnostic radiology trainees have so much more to learn. Also, the value of conventional radiography has been downgraded both in relative value units (2) and expected utility for many diseases and conditions. Why spend time on these conventional examinations when you could get the answer more easily
with CT or MR imaging? Although conventional radiography, which is cheaper and readily available, is often not specific enough, it is still widely used (constituting 58%–65% of our own case volume) and often provides a necessary overview that can direct further imaging. In fact, many diagnoses made at conventional radiography do not require further imaging. Thus it is still relevant and deserves as much expertise as ever. As the old dogs quickly realized, learning new tricks is just another part of professional life. The train of progress keeps moving; get on board or be left behind. And so we learned, practiced, and continued to add new tools and techniques to our stores of knowledge. The question, it seems, is not whether old dogs can learn new tricks (3); they have and will continue to do so. The real question is can new dogs learn old tricks? Will newly trained radiologists have the same abilities and experience to confidently master those skills that older and more experienced radiologists take for granted? Do we, as teachers, spend enough time to prepare trainees in what some consider the basics of our specialty? Or will physicians in other branches of medicine become more adept at plain film interpretation and therefore not require the services of a radiologist, who may be too busy performing MR examinations or other studies involving hundreds of images to pay much attention to the list of lower-technology examinations? At a June teaching conference for residents and fellows, one of us dug out of our file some oldies but goodies. The cases were on film. Do you remember those plastic sheets with a black background that you had to put in front of a bright light (ie, viewbox)? It was amusing and curious to watch the residents as they were handed the films and struggled to figure out which way they should
radiology.rsna.org n Radiology: Volume 270: Number 3—March 2014
OPINION: New Dogs, Old Tricks
hang them on the viewbox. They had to get up from their seats and walk to the front of the room to see the images clearly. They were up there alone in the dark room, with nothing but the films, no mag, no contrast enhancement, no localizer, no color Doppler—only their eyes and their brains. They did well, although they seemed a little uncomfortable, just like at the oral board examination. The remaining residents and fellows were very quiet, but stayed wide awake and paid rapt attention. They might be called upon next and asked for their opinion. This commonly used teaching format, similar to the now-retired oral examination, tries to simulate the real-life situation where we are called upon, day in and day out, for one modality or another, to render an expert opinion for the benefit of our patients and referring physicians. Clearly, the discomfort level was highest and the confidence level lowest when it came to conventional radiographic studies.
Markowitz and Cleveland
We are encouraged that it is not just us two old dogs who are uneasy about the fading of plain film interpretative skills, which we believe still constitute a major portion of current practice. Whether it may be the concern about radiation exposure from CT or the growing cost of medical imaging, there is a sense that radiology leaders are taking notice of the importance of the issue. This has recently been reflected in the interest that several national and international organizations have placed on renewing awareness of the power of plain film interpretation. Since the spring of 2011, these two authors alone have been invited to give presentations regarding the role of chest and abdominal radiography in modern imaging practice at six national and international venues. With both public pressure to reduce medical radiation exposure and the support of organized radiology, we think new dogs can and should learn old tricks.
Radiology: Volume 270: Number 3—March 2014 n radiology.rsna.org
We just have to show them how it is done and give them a little time and opportunity to practice. Maybe old dogs could even stick around and help out. There is always something new to learn. Disclosures of Conflicts of Interest: R.I.M. No relevant conflicts of interest to disclose. R.H.C. No relevant conflicts of interest to disclose.
References 1. American Board of Radiology website. http:// www.theabr.org/. Accessed September 9, 2013. 2. Sunshine JH, Burkhardt JH. Radiology groups’ workload in relative value units and factors affecting it. Radiology 2000;214(3): 815–822. 3. Cambridge Advanced Learner’s Dictionary and Thesaurus. Cambridge University Press website. http://www.cambridge.org/. Accessed September 9, 2013.
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