OPINION
Role of Emergency Radiology in Patient Care: Educating Medical Students and New Trainees in Emergency Medicine Waqas Shuaib, MD, Jamlik O. Johnson, MD, Faisal Khosa, MD Our department occasionally holds learning sessions for new emergency medicine trainees and rotating medical students, who often admit knowing little to nothing about emergency radiology and the services it provides before attending these sessions. The most common question asked is “Why is there a need for a dedicated emergency radiology department?” Although somewhat surprising despite the nighthawk and the off-hour radiologic services we provide, it is our understanding that a vast number of students and new trainees do not take dedicated radiology courses [1-4] and therefore have little opportunity to learn about how emergency radiologists (clinically skilled, in combination with excellent radiology competence) contribute to the care of critically ill and injured patients. To understand the current demand and the growing need for dedicated emergency radiology departments in the near future, it is worth mentioning that the 2010 National Hospital Ambulatory Medical Care Survey reported 129.8 million emergency department (ED) visits nationwide [5]. With the Patient Protection and Affordable Care Act signed into law in 2010, EDs nationwide anticipate an increased patient load, along with more complicated cases [6]. In anticipation of handling large patient volume, EDs rely heavily on emergency radiology to provide value-based imaging, which can translate into smooth patient throughput. Faisal Khosa is the 2013-2015 American Roetgen Ray Scholar
A typical ED provides 50% to 70% of admissions to a hospital. This creates an imaging volume and a diagnostic challenge for emergency radiologists, who must collaborate with the ED to facilitate the decision of which patients to admit. After interpreting the initial images, recorded findings and recommendations for further examinations or evaluations are communicated to the ED in written form. This plays an important role in determining the disposition, workup, and treatment of patients both during and after their ED encounters. The most apparent contribution of emergency radiology practice is in the area of diagnosis. This contribution is greatly valued by EDs, as these radiologic assessments have great implications for patient outcomes. For example, when a referring physician requests imaging with a certain diagnostic hypothesis in mind, such as “sudden-onset umbilical pain radiating to right iliac fossa: assess for acute appendicitis” or “worst headache of my life: rule out cerebral aneurysm,” in this scenario, the radiologist’s duty is to confirm, disconfirm, or provide a different diagnosis. Imaging in trauma cases is diagnostic. Other valuable services of emergency radiology are demonstrated in patients who may present with vague symptoms and in whom the results of physical examinations and medical, social, and surgical histories may be nonspecific, equivocal, or misleading. In this situation, depending on the type of ED imaging study performed (x-ray, CT, MRI, or angiography), a trained
ª 2013 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.026
emergency radiologist will conduct a careful review of all the images, probing for any abnormality pertaining to the patient’s symptoms to formulate a diagnosis. In addition to managing emergency cases, depending on the institution, emergency radiologists are also in charge of preoperative films, “stat” readings, and teleradiology studies sent from other institutions. At our institution, the emergency radiologists are always on the front lines of patient care, at all hours of the day and night. This 24/7/365 coverage allows referring physicians to use more advanced studies (ultrasound, CT, and MRI) to make appropriate diagnoses. This is helpful in resolving many expected and unexpected cases. In one such unexpected case, a woman refusing CT was referred for abdominal ultrasound to rule out a potential case of acute appendicitis; however, the emergency radiologist found an adnexal mass suggestive of ectopic pregnancy. Similarly, in another unexpected case of a young female patient with right lower quadrant pain, abdominal CT was performed to assess for suspected appendicitis, but an engorged ovary indicated a diagnosis of ovarian torsion. Although it is the responsibility of an emergency radiologist to satisfy referring physicians’ queries, emergency radiologists are physicians first and then radiologists, which makes providing the correct diagnosis their top priority. The importance of having openended communication between the ED and emergency radiology ultimately improves patient care. For 1
2 Opinion
example, while constructing an imaging plan for aortic injury, the decision to order conventional radiography or CT scanning as the appropriate screening examination can be a challenge for new trainees because the literature on both modalities makes compelling arguments, one of time efficiency (radiography) and the other of image accuracy (CT). Ordering both studies is an excessive use of resources and can also translate into a longer turnaround time for the patient. In such cases, dedicated emergency radiologists make important contributions as consultants by providing valuable feedback on the most efficient and effective imaging option because particular patient profiles may not match the diagnostic algorithms. Therefore, creating an interdepartmental dialogue improves the likelihood of excellent patient care. Emergency radiologists ensure the best patient care by providing dictated radiologic results to referring physicians. In case of urgent diagnoses (hemothorax, pneumo-
thorax, flail chest, malpositioning of the endotracheal tube), timeliness is crucial, and therefore the radiologist may also convey the results via telecommunication. Furthermore, an emergency radiologist is an effective team member willing to create dialogue with referring physicians regarding unwarranted study requests. This is driven mainly by concerns for medical cost containment, excessive resource utilization, lengthy hospital stay, and, most important, protecting patients from any unnecessary imaging that may expose them to additional radiation. Emergency radiology also makes significant contributions to the science of imaging through teaching (during grand rounds and call) and research programs that educate students, residents, and fellows to advance and improve the radiologic aspects of emergency care. For students interested in emergency radiology, the awareness of this subspecialty as a distinct body of radiologic knowledge both nationally and internationally along, with the growth of the American Society
of Emergency Radiology, portends an exciting future for this emerging field. For the new trainees who have already chosen emergency medicine as their field of practice, being informed about the clinical importance of this subspecialty can help them make effective and efficient choices about the use of its resources. REFERENCES 1. Branstetter BF, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007;188:W9-14. 2. Dobre MC, Maley J. Medical student radiology externs: increasing exposure to radiology, improving education, and influencing career choices. J Am Coll Radiol 2012;9:506-9. 3. Holt NF. Medical students need more radiology education. Acad Med 2001;76:1. 4. Nyhsen CM, Steinberg LJ, O’Connell JE. Undergraduate radiology teaching from the student’s perspective. Insights Imaging 2013;4: 103-9. 5. Centers for Disease Control and Prevention. Emergency department visits. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed November 11, 2013. 6. Yox SB. The Affordable Care Act—an update for clinicians. Available at: http://www. medscape.com/viewarticle/808532.
Waqas Shuaib, MD, Jamlik O. Johnson, MD, and Faisal Khosa, MD, are from Emory University, Atlanta, Georgia. Waqas Shuaib, MD, Emory University, 550 Peachtree Street, Atlanta, GA 30308; e-mail: [email protected].
Role of Emergency Radiology in Patient Care: Educating Medical Students and New Trainees in Emergency Medicine Waqas Shuaib, MD, Jamlik O. Johnson, MD, Faisal Khosa, MD Our department occasionally holds learning sessions for new emergency medicine trainees and rotating medical students, who often admit knowing little to nothing about emergency radiology and the services it provides before attending these sessions. The most common question asked is “Why is there a need for a dedicated emergency radiology department?” Although somewhat surprising despite the nighthawk and the off-hour radiologic services we provide, it is our understanding that a vast number of students and new trainees do not take dedicated radiology courses [1-4] and therefore have little opportunity to learn about how emergency radiologists (clinically skilled, in combination with excellent radiology competence) contribute to the care of critically ill and injured patients. To understand the current demand and the growing need for dedicated emergency radiology departments in the near future, it is worth mentioning that the 2010 National Hospital Ambulatory Medical Care Survey reported 129.8 million emergency department (ED) visits nationwide [5]. With the Patient Protection and Affordable Care Act signed into law in 2010, EDs nationwide anticipate an increased patient load, along with more complicated cases [6]. In anticipation of handling large patient volume, EDs rely heavily on emergency radiology to provide value-based imaging, which can translate into smooth patient throughput. Faisal Khosa is the 2013-2015 American Roetgen Ray Scholar
A typical ED provides 50% to 70% of admissions to a hospital. This creates an imaging volume and a diagnostic challenge for emergency radiologists, who must collaborate with the ED to facilitate the decision of which patients to admit. After interpreting the initial images, recorded findings and recommendations for further examinations or evaluations are communicated to the ED in written form. This plays an important role in determining the disposition, workup, and treatment of patients both during and after their ED encounters. The most apparent contribution of emergency radiology practice is in the area of diagnosis. This contribution is greatly valued by EDs, as these radiologic assessments have great implications for patient outcomes. For example, when a referring physician requests imaging with a certain diagnostic hypothesis in mind, such as “sudden-onset umbilical pain radiating to right iliac fossa: assess for acute appendicitis” or “worst headache of my life: rule out cerebral aneurysm,” in this scenario, the radiologist’s duty is to confirm, disconfirm, or provide a different diagnosis. Imaging in trauma cases is diagnostic. Other valuable services of emergency radiology are demonstrated in patients who may present with vague symptoms and in whom the results of physical examinations and medical, social, and surgical histories may be nonspecific, equivocal, or misleading. In this situation, depending on the type of ED imaging study performed (x-ray, CT, MRI, or angiography), a trained
ª 2013 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.026
emergency radiologist will conduct a careful review of all the images, probing for any abnormality pertaining to the patient’s symptoms to formulate a diagnosis. In addition to managing emergency cases, depending on the institution, emergency radiologists are also in charge of preoperative films, “stat” readings, and teleradiology studies sent from other institutions. At our institution, the emergency radiologists are always on the front lines of patient care, at all hours of the day and night. This 24/7/365 coverage allows referring physicians to use more advanced studies (ultrasound, CT, and MRI) to make appropriate diagnoses. This is helpful in resolving many expected and unexpected cases. In one such unexpected case, a woman refusing CT was referred for abdominal ultrasound to rule out a potential case of acute appendicitis; however, the emergency radiologist found an adnexal mass suggestive of ectopic pregnancy. Similarly, in another unexpected case of a young female patient with right lower quadrant pain, abdominal CT was performed to assess for suspected appendicitis, but an engorged ovary indicated a diagnosis of ovarian torsion. Although it is the responsibility of an emergency radiologist to satisfy referring physicians’ queries, emergency radiologists are physicians first and then radiologists, which makes providing the correct diagnosis their top priority. The importance of having openended communication between the ED and emergency radiology ultimately improves patient care. For 1
2 Opinion
example, while constructing an imaging plan for aortic injury, the decision to order conventional radiography or CT scanning as the appropriate screening examination can be a challenge for new trainees because the literature on both modalities makes compelling arguments, one of time efficiency (radiography) and the other of image accuracy (CT). Ordering both studies is an excessive use of resources and can also translate into a longer turnaround time for the patient. In such cases, dedicated emergency radiologists make important contributions as consultants by providing valuable feedback on the most efficient and effective imaging option because particular patient profiles may not match the diagnostic algorithms. Therefore, creating an interdepartmental dialogue improves the likelihood of excellent patient care. Emergency radiologists ensure the best patient care by providing dictated radiologic results to referring physicians. In case of urgent diagnoses (hemothorax, pneumo-
thorax, flail chest, malpositioning of the endotracheal tube), timeliness is crucial, and therefore the radiologist may also convey the results via telecommunication. Furthermore, an emergency radiologist is an effective team member willing to create dialogue with referring physicians regarding unwarranted study requests. This is driven mainly by concerns for medical cost containment, excessive resource utilization, lengthy hospital stay, and, most important, protecting patients from any unnecessary imaging that may expose them to additional radiation. Emergency radiology also makes significant contributions to the science of imaging through teaching (during grand rounds and call) and research programs that educate students, residents, and fellows to advance and improve the radiologic aspects of emergency care. For students interested in emergency radiology, the awareness of this subspecialty as a distinct body of radiologic knowledge both nationally and internationally along, with the growth of the American Society
of Emergency Radiology, portends an exciting future for this emerging field. For the new trainees who have already chosen emergency medicine as their field of practice, being informed about the clinical importance of this subspecialty can help them make effective and efficient choices about the use of its resources. REFERENCES 1. Branstetter BF, Faix LE, Humphrey AL, Schumann JB. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol 2007;188:W9-14. 2. Dobre MC, Maley J. Medical student radiology externs: increasing exposure to radiology, improving education, and influencing career choices. J Am Coll Radiol 2012;9:506-9. 3. Holt NF. Medical students need more radiology education. Acad Med 2001;76:1. 4. Nyhsen CM, Steinberg LJ, O’Connell JE. Undergraduate radiology teaching from the student’s perspective. Insights Imaging 2013;4: 103-9. 5. Centers for Disease Control and Prevention. Emergency department visits. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed November 11, 2013. 6. Yox SB. The Affordable Care Act—an update for clinicians. Available at: http://www. medscape.com/viewarticle/808532.
Waqas Shuaib, MD, Jamlik O. Johnson, MD, and Faisal Khosa, MD, are from Emory University, Atlanta, Georgia. Waqas Shuaib, MD, Emory University, 550 Peachtree Street, Atlanta, GA 30308; e-mail: [email protected].
