Body Imaging Procedures Residents Curriculum

Description of Educational Experience

The clinical and academic educational experience incorporated into the Body Imaging Procedures rotation at University of Washington Medical Center and its affiliated institutions includes the formal clinical rotation on the dedicated procedures service, formal faculty-directed and self-directed didactic and individual study, and participation in multidisciplinary conferences.  Residents will learn to approve, plan, and perform interventional procedures and manage their complications with faculty supervision.  They will be expected to have the basic understanding of cross-sectional image-guided cervical, thoracic abdominal and pelvic interventions. Residents will be able to put biopsy and aspiration results into clinical context and will learn to relay results to the clinical colleagues along with recommendations given from a radiologist’s perspective.

Responsibilities:

The resident on Body Imaging Procedures is supposed to spend 50% of the rotation in Body CT and will be directly supervised by the Body CT attending and Procedures attending respectively.

1. The resident will share the procedures of the day with the procedures fellow according to the current arrangements within the Body Imaging section.
2. The resident arrives at the Procedures service at 12:30 pm after completing the morning responsibilities on Body CT, and leaves the service at 6:00 pm. Arrival times may vary, but should be early enough to accommodate a complete work-up including consent process prior to the actual procedure start time. On Tuesdays, when the procedures fellow is on academic, the resident will perform all procedures prior to 1:00pm, arrival time accordingly is 8am.
3. Gil Camero Jr., Procedure Service Coordinator (or sometimes the CT and US services) will contact the resident about any procedure requests (there is also a procedures inbox, where Gil will put in requests). The resident will share the cordless procedure phone (598-3725) with the fellow and has to be reachable to expedite and facilitate communication with Gil and other services.
4. The resident will review the appropriate images with the attending on the service and decide to whether to perform the procedure as well as to determine guidance modality.
5. The resident needs to communicate any concerns or issues to the referring clinicians and resolve potential problems.
6. If procedure is approved, the resident will fill out the necessary forms (see “approval package”) and return them to Gil or secretarial staff and arrange for out-patient admissions if necessary (alternatively place in approval outbox).
7. Core duties are to perform the BI procedures with the attending, to generate a report ON THE SAME DAY and to maintain the database. To ensure optimal patient care it is of paramount importance to have all reports of the day generated before the resident leaves for the day, outpatients and inpatients.
8. If no procedures are scheduled for a given day or time slot, the resident should pursue the following activities in this order:
1. Pursue teaching opportunities with your attending including specifically practice on the two biopsy phantoms and on the sample devices, depending on the personal level of training
2. maintenance of the procedure service database
3. helping out in US or CT with reading cases (please leave MR for designated trainees, unless agreed otherwise)
4. sharing interesting cases of the procedures service with other colleagues, specifically cases with discrepant rad-path correlation (educational activity)

Patient Care

Goal

Body Imaging residents must aim to learn to provide patient care related to image-guided interventions that is compassionate, appropriate, and effective for the diagnosis and treatment of these conditions and the promotion of health.

Competencies

1. Learn to perform CT and US guided procedures. This includes guidance of the patient, technical staff and radiology nurse before, during and immediately after the procedure. Procedures are performed under direct supervision of the procedure attending.
2. Learn to triage the requests for appropriateness, modality correctness and ability to see or reach the lesion to biopsy or aspirate with a specific modality.
3. Learn to order appropriate lab tests for procedures.
4. Learn to order any pre-medication and discontinuation of medication as required for the procedure.
5. Learn the appropriate follow-up of the patient after the procedure including retrieval of histologic and cytologic results and correlate them with the imaging findings.
6. Learn to handle and manage any complications that may arise during or after the procedure.
7. Learn to efficiently coordinate the daily workflow within the interventional service
8. Learn to function as a competent consultant to the clinical partner when requests for procedures come in and when radiological validation of histological results with regard to the acquisition of tissue sampling is required.
9. Learn to maintain the dedicated procedures database.

Objectives

The resident will complete the following during the rotations to attain the above expectations, all under direct supervision of radiology faculty:

1.       Review pertinent patient history, physical findings and any antecedent imaging studies to determine that the requested procedure is appropriate, and if not, take appropriate steps to contact the ordering physician.

2.       Practice on biopsy phantoms under guidance and supervision of a faculty member before working on the first patient if necessary and during the rotation if necessary.

3.       Improve or gain procedure skills (depending on training).

4.       Communicate real or potentially false negative biopsy results to the referring physicians in a timely manner and document relevant action and recommendations accordingly.

Assessment Methods

1.       Faculty evaluations

2.       Sonographer, CT tech and coordinator evaluations

3.       Patient evaluations (expected to be required by ACGME soon)

Medical Knowledge

Goal

Residents must demonstrate acquisition of knowledge of established and evolving radiology, clinical, and epidemiological sciences as they pertain to adult imaging and intervention, as well as the application of this knowledge to patient care.  On the procedures service, this competency has technical and cognitive components. 

Competencies

Technical and cognitive competency goals for this curriculum include:

Technical Knowledge

1.       Familiarization with the technical equipment (ultrasound and CT guidance tools) available to perform the various interventions performed on the service.

2.        Familiarization with the technical devices (biopsy and aspiration / injection devices) available to perform the various interventions performed on the service.

3.       Ability to perform ultrasound and CT guided procedures safely and expeditiously.

4.       Know how to optimize image quality when performing interventions and how to balance dose-related image quality to safely perform a procedure and manage radiation exposure on CT guided procedures

5.       Know the imaging changes induced by the interventional procedures

Cognitive Knowledge

1.       Ability to recognize pertinent anatomy of organs and body parts of interest and recognize abnormalities and target areas for interventions.

2.       Know how to diagnose common inflammatory, infectious and neoplastic conditions on various imaging modalities and be able to distinguish them from normal variants and posttraumatic and iatrogenic alterations that may mimic disease.

3.       Know the clinical changes induced by the interventional procedures.

4.       Recognize possible false negative biopsy results and relate to referring physician probability of false negative results.

Objectives

The resident will complete the following during the rotation to attain the above competencies, all under direct supervision of radiology faculty:

1.       Review equipment and devices with supervising faculty at the beginning of the rotation and again shortly before a new type of procedure.

2.       Review all requests for procedures under faculty supervision and decide on the action.

3.       Read the selected procedure-related scientific and educational articles available on the Body Imaging Section’s website before performing a new procedure.

4.       Practice on the available biopsy phantoms. 

5.       Perform all interventional procedures that occur during the rotation to gain technical and cognitive competency.

6.       Perform daily review of the biopsy results and put them in clinical context. Discuss results and technical circumstances related to the procedures with attending if results are suggestive of being false negative.

7.       Attend conferences which include radiology participation.

8.       Attend didactic lectures given by the radiology attendings on all imaging modalities.

9.       Prepare radiologic reports on all studies performed on the service.

Assessment Methods

1.       Daily interaction

2.       Global faculty evaluations

3.       End of rotation evaluation

4.       Sonographers’ and technologists’ (and if applicable radiology nurses’) evaluation of technical skills

5.       Sonographers’ and technologists’ (and if applicable radiology nurses’) evaluation of residents’ interaction with the patients.

Practice- Based Learning and Improvement

Goal

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.  Fellows are expected to develop skills and habits to be able to achieve competencies to:

• Incorporate formative evaluation feedback into daily practice
• Use information technology to optimize learning

Objectives

Technical competency:

1. Obtain evaluations from faculty, technologists, nurses and patients. Identify weaknesses as perceived by those providing the evaluations, and after correcting these weaknesses,  be evaluated again.
2. Obtain a practical test on biopsy phantom before the rotation.

Cognitive competency:

• Residents will be given a case-based oral test with requisitions for the daily practice to evaluate their ability to triage patients correctly for the appropriate procedure. 
• Specific questions related to the scientific and educational articles available on the website will be asked.

Systems Based Practice

Goal

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. 

Competencies

• Understand the impact of the procedure and the effect of accurate results on the total care of the patient.
• Understand that patient safety must be considered for all interventional procedures. If other resources can be used for diagnosis and management of the patient that do not require intervention, then those should be considered first.
• Work with other healthcare providers (such as surgeons, oncologists, endocrinologist, etc) to formulate the safest and most effective way to diagnose and management of the patient.

Assessment Methods:

1. Faculty evaluation documenting achievement of competency
2. 360 degree evaluation

Professionalism

Goal

The residents must remember that they represent the University of Washington Medical Center, Department of Radiology with all of their actions and communications while on this rotation.  The highest standards of professionalism must be maintained at all times, especially in interactions with patients or with other physicians.  The residents will be responsible for tracking duty hours and reporting them to the supervisory attending.  Competence in professionalism will be assessed by supervisory attendings, as well as by the 360-degree evaluation. Fellows must demonstrate a commitment to carrying out professional responsibilities and adhere to ethical principles.

Competencies

• Responsiveness to patient needs that supersedes self-interest
• Accountability to patients, society, and the profession

These are considered essential to the professional practice of radiology

Assessment Methods

1. Responsiveness to patient needs will be assessed by evaluations given to patients
2. Accountability will be assessed by evaluations of fellow performance by the sonographers, patient care coordinators[ok2] , technologists and radiology nurses.

Interpersonal and Communication Skills

Goal

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and forming a team with patients, their families, and professional associates. 

Competencies

The list below reflects competencies that fall under Interpersonal and Communication Skills:

• Presenting findings, differential diagnosis, most likely diagnosis, technical approach and communicating clearly with staff and affiliated colleagues is necessary.
• Competence in communication will be assessed by supervisory attendings, as well as by the 360-degree evaluation.

Assessment Methods

The measurable objective for this competency is:

1. Patient satisfaction reflected by interaction in the interventional suite and by the patient evaluation.
2. Evaluation of interaction with the sonographers
3. Evaluation of interaction with the technologists
4. Evaluation of interaction with the radiology nurses
5. Evaluation of interaction with the patient care coordinators

Teaching Methods

Residents will learn through active participation in the service and performance of procedures under the direct supervision of faculty members and through electronic online teaching material. Didactic conferences/teaching are also given to cover the spectrum of procedures across the two main guiding modalities.

Assessment Method

The resident’s performance on this rotation or educational experience will be measured by:

1. Faculty evaluations of resident’s perceptive, deductive, and diagnostic skills
2. Sonographer and technologist evaluation
3. Patient care coordinator evaluation

The effectiveness of this educational experience is measured by the resident’s evaluation of the rotation.  The rotation as well as individual faculty is evaluated and feed back provided to the program director and faculty.

All procedures and reports are done under direct supervision of a faculty member.

Educational Resources

Several articles are provided in the curriculum and on the section website to prepare the trainees for the rotation. Trainee should read the as an introduction the book chapter on “Image Guided Needle Based Procedures “, as it provides specific information on the interventions performed and devices used in the rotation. The specific articles related to the next day’s procedures, including articles related to the devices used, should be reviewed prior to the day of service. Additional material is available for review in the mini-library in the reading room.