The Importance of Medical Training - Literature review Example

Literature Review One of the important aspects of medical training is that of image interpretation and techniques. Imaging of all kinds – CT, radiography, MR imaging, sonography and nuclear imaging – are “essential to the practice of modern medicine and surgery” (Rogers, 2003). According to Dawes et al. (2004), specific training in the uses of medical imaging techniques improves medical student performance in image interpretation (Dawes, 2004, p. 775). They divided students into two groups, and, during the first week of clinical training, the students were asked to interpret five of ten images, each image accompanied by examination findings and history. The images themselves included ultrasound, CT, MRI, nuclear medicine and plain films. The students were then subjected to 26 weeks of clinical training, both formally at hospitals and informally at clinical firms. After the clinical training, 133 students saw 10 radiological cases, including five that they were presented before and five new cases. Before the clinical training, the students only got a median of 8% correct when reviewing the images. After the clinical training, the median shot up to 43%, which is considered to be highly significant. Both groups of students also performed “significantly better” on the both the images they had seen before and the new images. This study showed that training significantly improved interpretation accuracy. The limitation of the study was that it was unclear if radiological teaching improved the accuracy, or that exposure to clinical practice is responsible for this (Dawes, 2004, p. 775). Unfortunately, even though Dawes et al. demonstrated the importance of training in this field, most medical students do not get enough formal training, because of the fact that courses in radiology are not mandated and the courses that are offered are “soft” - no tests, no meaningful assignments, and most are offered pass/fail, where you basically pass as long as you show up to class. Many medical schools rely upon informal training in radiology, through rounds and conferences, which means that radiological training is “anecdotal, haphazard, unstructured, and untested and therefore woefully short of the structured educational experience required to prepare students for the proper use of imaging” (Rogers, 2003). Radiological courses are not given the proper importance in a medical school curriculum because there are so many other disciplines that need to be covered. This has resulted in “imaging illiteracy” among many medical students. One of the results of this “imaging illiteracy” is that doctors and medical professionals are making inaccurate image readings. This changes the management of the patients medical issue in up to 11% of cases (Eisen et al., 2008, p. 460). Eisen et al. (2008) conducted a study of medical staff and house officers. This study concerned the competency in chest radiography (CXR). Echoing the concerns of Rogers (2003), Eisen et al. found that training in CXR interpretation, and radiology in general, is not stressed at most medical schools, with only 29% of medical school having a required clerkship in diagnostic radiology and that specific training in CXR is “not mandated for undergraduate medical education” (Eisen et al., 2008, p. 463). Moreover, CXR imaging is not a required procedure to know for many board, such as those for pulmonary medicine, cardiology and critical care medicine, and competency in CXR is not required by the American Board of Internal Medicine. However, even though this training is not emphasized in most individuals medical training, it is still necessary, as “house officers are expected to interpret CXR and make clinical decisions before a formal reading by a radiologist” (Eisen et al., 2008, p. 463). The result of this underemphasis on CXR was that 91% of the study participants misdiagnosed a pneumothorax emergency, 74% misplaced a central venous catheter and 54% misdiagnosed a pneumoperitoneum emergency (Eisen et al., 2008, p. 463). The participants also had difficulty interpreting the normal CXR, which led to inappropriate medical decisions, as the participants interpreted the normal CXR as abnormal (Eisen et al., 2008, p. 463). To combat this “imaging illiteracy”, Gunderman and Stephens (2008) have proposed a curriculum that is important to teach all medical students and students in the medical field. Their proposal introduces a rigor that is missing in many medical schools and will prepare students in the medical field to tackle all aspects of imaging (Gunderman & Stephens, 2008, p. 859). According to Gunderman and Stephens (2008), the earlier a student starts learning radiology, the better. “Evidence shows that those who receive early instruction in radiology enter their clinical years with heightened familiarity and comfort with ordering radiologic studies, take a greater interest in the field, are more likely to enroll in radiology electives in the future, and have a deeper understanding of basic ideas and concepts that are central to radiology” (Gunderman & Stephens, 2008 p. 859). The proper curriculum in radiology would encompass physics courses, the history of radiologic imaging techniques, the costs involved in radiologic imaging, how to orient themselves to various images, appropriate test ordering, the basics of contrast ordering, the vocabulary of radiologic imaging and the “common clinical uses of each imaging technique” (Gunderman & Stephens, 2008, p. 860). The first important skill that students in medical fields should master is that of physics, as it relates to imaging. Understanding ultrasound beams, x-rays, gamma ray detection and production, imaging parameters and TI relaxation times of human tissues depends upon a sound basis in physics knowledge. Additionally, the physics of the effects of ionizing radiation is a topic that is little understood, with 9% of ER physicians and 3% of patients understand the increased risk of cancer associated with radiology, and only 13% of radiologists and 22% of ER physicians can accurately estimate the radiation associated with one CT scan compared to a chest radiograph (Gunderman & Stephens, 2009, p. 860). The effect of ionizing radiation, including which of the imaging techniques provide the greatest exposure, how physicians can lower exposure and how to talk to patients about the risk are all subjects that should be studied in-depth. History is another topic that should be on the radiological curriculum. According to Gunderman & Stephens, learning the history of radiology and the contribution of the Curies, Wilhelm Roentgen and Godfrey Hounsfield puts the material into context and makes it more meaningful, therefore more memorable. It also prepares students to also become innovators (Gunderman & Stephens, 2009, p. 860). Students also need to understand the true costs of ordering images, and understand that the lowest-cost alternative is not always the correct one, even though wasteful spending must be curtailed. Students need to understand the costs of the various procedures and be able to take cost into account when ordering tests, but not let it be the deciding factor on whether or not a certain test is necessary (Gunderman & Stephens, 2009, p. 860). Orienting themselves to images is another skill that must be taught. Students need to be oriented as to the images that they are seeing, such as being able to tell which is the patients left or right side, understanding standard imaging planes and labeling of images, and how the monitor changes when the transducer position changes. If a student feels lost when he or she examines an image, than that student is less likely to order a radiologic examination and is more likely to make “less-effective use of imaging in the care of their patients” (Gunderman & Stephens, 2009, p. 860). Students must also know the uses of the different imaging techniques, such as when to order a CT and the appropriate images to order after chest pain or trauma. In this way, appropriate test ordering is even more important than proper image interpretation (Gunderman & Stephens, 2009, p. 860). Inherent in this knowledge is the knowledge of the strengths and weaknesses of the various tests, which techniques offer the greatest spatial resolution and the most physiologic information, and that sonography is appropriate for soft-tissue lesions but not appropriate for other medical issues, such as subcortical bone or an aerated lung (Gunderman & Stephens, 2009, p. 861). Another way that students can become more proficient in medical imaging is by the use of simulations. Simulations are real-world problems that are mimicked by the use of trained persons, devices, contrived social situations and lifelike virtual environments (Issenberg, 2005, p. 11). Because these simulations mimic the real environment, students act as if they are in the real environment. The conditions under which students learn in a simulated environment include repetitive practice, in which the learner repetitively learns skills in a controlled environment; curriculum integration, in which simulated situations are integrated into the coursework of students, as opposed to be a stand-alone curricula; range of difficulty level, where learners are engaged in simulations that are different degrees of difficulty; multiple learning strategies, where different learning strategies are incorporated to facilitate learning; capturing clinical variation, in which the simulations capture a wide variety of problems; controlled environment, in which students are able to make assessments without adverse consequences; and individualized learning, where learners are active participants, not passive by-standers (Issenberg, 2005, pp. 13-19). In short, students are, by and large, not prepared to handle imaging in the real world. Curricula typically short-changes the practice of imaging, and patients are paying the price, as demonstrated by Eisen et al. However, if schools can adopt a rigorous program, modeled after Gunderman & Stephens, combined with medical simulations, as proposed by Issenberg, the problem of under-prepared students with regards to radiology and imaging can be combatted. Read More