Program Goals

Patient Care

• The graduate will demonstrate competence in the use and interpretation of basic and advanced medical imaging techniques to include plain film, conventional and computed tomography, fluoroscopy, angiography, mammography, ultrasound, magnetic resonance imaging, nuclear medicine, and interventional radiology, sufficient to direct their appropriate use in patient care.
• The graduate will demonstrate understanding of the operation and maintenance of diagnostic imaging equipment, the performance of imaging examinations, and the procedures employed for image production to the extent that he or she can successfully supervise radiological and nuclear medicine technologists.  He or she will recognize common errors in technique and be able to recommend corrective action.
• The graduate will demonstrate understanding of the indications, use, and risks of various radiographic contrast agents commonly employed in clinical practice, to include air, barium sulfate, iodinated contrast media, and gadolinium chelates. He or she will competently recognize and treat anaphylactoid reactions to intravenously administered contrast agents.
• The graduate will demonstrate competence in the supervision of conscious sedation of radiology patients.
• The graduate will demonstrate competence to gather accurate, relevant patient information incident to the interpretation of radiologic examinations.
• The graduate will demonstrate potential to competently sustain day-to-day interpretation of clinical workload up to 12,000 assorted diagnostic radiology and nuclear medicine examinations per year without major error.
• The graduate will demonstrate competence in the performance of uncomplicated diagnostic arteriography, venography, vena-caval filter placement, image-guided biopsy and drainage procedures, image guided enteric and venous access placement and evaluation, myelography, arthrography, hysterosalpingography, retrograde cysto-urethrography, and related minimally invasive procedures without major morbidity or mortality.

Medical Knowledge

• The graduate will demonstrate sufficient knowledge of radiologic physics, radiobiology, radiation safety, and diagnostic radiology to pass both parts of the written board examination and the oral board examination on his or her first attempt.

Practice-based Learning and Improvement

• The graduate will demonstrate a working familiarity with the processes and procedures involved in clinical and scientific research design, execution, and critical analysis of data, publishing at least one scientific article or case report in a peer-reviewed journal.
• The graduate will demonstrate the ability to competently locate, appraise, and employ evidence from current radiology literature applicable to his or her practice.

Interpersonal and Communication Skills

• The graduate will demonstrate ability to create and sustain therapeutically and ethically sound relationships with patients and their families, and with other members of the health care team.
• The graduate will demonstrate ability to render clear, concise, organized, accurate, and clinically useful radiology reports. He or she will reliably notify referring providers of important or unsuspected imaging results in a timely fashion.
• The graduate will demonstrate proficiency in public speaking and oral presentation.

Professionalism

• The graduate will demonstrate understanding of, and uphold, traditional medical professional and military leadership values of honesty, integrity, respect, compassion, accountability, loyalty, continuity of care, and commitment to responsibility.
• The graduate will demonstrate understanding of, and uphold, the ethical principles of providing or withholding care, patient confidentiality, informed consent, and business practice.
• The graduate will demonstrate sensitivity and responsiveness to patients’ culture, gender, age, and disabilities.
• The graduate will demonstrate ability to provide appropriate teaching and mentorship to technologists, nurses, physicians-in-training, and professional colleagues.

Systems-based Practice

• The graduate will demonstrate sufficient knowledge of military operations, procedures, and administration to serve capably as a radiologist in the military healthcare system.
• The graduate will demonstrate a working familiarity with hospital organization and administration, resource management, and the tenets of cost-effective radiologic practice.

Basic Tenets of Resident Education

Modern paradigms of graduate medical education are based upon Sir William Osler’s late nineteenth century observation that the patient is the best teacher.  Applied to the specialty of radiology, it is the patient’s imaging examination that is the best teacher. Clinical activity must form the core of the radiology resident’s educational experience. Although this paradigm presumes that the resident will be tasked to perform much of the mundane work related to patient care in exchange for quality teaching, the Program Director’s intent is that residents be considered students first – not employees. Underpinning this mind-set are several educational values adapted from Jane Vella’s Learning to Listen, Learning to Teach. Academic section chiefs are directed to adopt these values in their development and execution of a training plan.

• Safety: The design of educational tasks and materials, the atmosphere in the room, and the relationship between residents and faculty must convey a sense that the experience will work for them. Objectives must be relevant and feasible, and residents’ efforts to attain these objectives must be affirmed. The educational environment must be non-judgmental; residents deserve the academic freedom to fail without recrimination unless an imminent threat to patient care is at stake.
• Sound relationships: Respect, affirmation, open communication, listening, and humility must transcend personal likes and dislikes.
• Sequence and reinforcement: Tasks must proceed from simple to complex, easy to difficult. Facts, skills, and attitudes must be repeated in diverse and engaging ways until they are learned.
• Praxis: Learning is in the doing and deciding. Residents must be given direct responsibility for patient care activities and be integrated into the workflow in accordance with their level of skill and ability. They must be offered constructive feedback and provided the opportunity to reflect, evaluate, and learn from their experience.
• Respect for learners: Residents are not objects to be used by faculty to accomplish work. Residents are a subject in their own learning, and in large part decide what occurs in the educational dynamic between residents and faculty. Residents should be granted leeway in directing the focus of their own education, commensurate with good patient care and the constraints of the residency program’s goals and objectives.
• Ideas, feelings, and actions: Resident education involves more than just medical knowledge. It involves the development of procedural and administrative skills, and attitudes about patients, technologists, professional colleagues, and the radiologist’s role in patient care. Resident training must address all of these.
• Immediacy: Teaching must provide residents with skills, knowledge, or attitudes whose immediate usefulness is readily apparent to them.
• Clear roles: The residents’ and faculty members’ expectations for each other must be articulated, not assumed. Their roles must be clearly defined, yet remain fluid enough to support both quality patient care and an appropriate educational relationship and dialogue.
• Teamwork: Residents and faculty must share responsibility for their service and work together, each with a stake in successful completion of the workload. This is not to say that the faculty should necessarily “pitch in”, but rather that the resident should perceive a clear sense of participation by faculty in a process which meets the needs of both the staff and the residents. “Books and a high volume of cases are no substitute for the staff/resident relationship, which has traditionally been the foundation of all medical education.” (Anonymous PGY-4, 2000)
• Engagement: Residents must be encouraged not only to partake in patient care activities but also to take ownership of their service: organizing, coordinating, and directing the workflow as their level of skill and ability allows.
• Accountability: Faculty must ensure the quality and sufficiency of their instruction. At the same time, residents must be accountable for their own education. Expectations and directives, once articulated, should be followed-up and enforced. Residents failing to meet reasonable performance expectations should be counseled and their deficiencies remedied first at the level of individual faculty before proceeding to the academic section chief or program director.

II. Academic Organization And Content

Clinical Rotations

The clinical curriculum is comprised of fifty-two, four-week rotations providing comprehensive experience in each of the nine radiology subspecialty sections: neuroradiology, musculoskeletal (MSK) radiology, vascular and interventional radiology, chest radiology, breast imaging, abdominal radiology, pediatric radiology, ultrasonography, and nuclear radiology.  In accordance with ACGME and ABR requirements, six rotations are devoted to nuclear medicine. Residents complete seven or eight rotations in abdominal imaging  depending on their year group (including gastrointestinal and genitourinary fluoroscopy, CT, and MRI), four or five rotations in pediatric radiology, and four rotations in each remaining subspecialty section. Residents should expect at least one rotation in each section every year. Rotations in emergency and acute care radiology and cardiac radiology supplement this experience. Furthermore, residents attend the Armed Forces Institute of Pathology’s Six-week Radiologic Pathology Course during their third year of training, complete one elective rotation during the second year, and three elective rotations during their senior year. Clinical and didactic curricula and service responsibilities for each rotation are detailed in section VI of this document. The academic schedule for SY 2005 is included in section VII.

The angiography and interventional radiology service, abdominal imaging rotation, and occasionally other services require resident coverage to ensure adequate patient care. The Chief Resident may adjust day-to-day resident assignments to meet these requirements.

First-year Curriculum

The focus of the first year curriculum is a broad exposure to basic clinical radiology emphasizing emergency radiology and responsibilities on-call. The year begins with an Introduction to Clinical Radiology short-course that includes didactic lectures, practical exercises, and hands-on clinical training. The rotation is designed to provide the new resident with basic, foundational knowledge, skills, and attitudes routinely employed in the production, interpretation, and reporting of medical imaging examinations. Residents review important and commonly occurring imaging issues and are provided with a core of knowledge and skills immediately useful in the performance of day-to-day clinical radiology. During the remainder of the year, residents rotate through each subspecialty section at least once, plus a rotation in emergency and acute care radiology. Angiography is deferred to the last half of the year. Emphasis is placed on basic interpretive and clinical practice skills, anatomy, imaging pitfalls, and common and important diseases.

Second-year Curriculum

The second year curriculum builds upon the foundation of the first year with at least one rotation in each subspecialty section and two in emergency and acute care radiology. An elective rotation and a rotation in cardiac imaging are also provided during the second year of training. Residents are expected to perform more efficiently and more independently than their first year counterparts and should be familiar with the imaging appearances of commonly occuring disease processes.

 Third-year Curriculum

Third-year residents continue core rotations in each subspecialty section, including two consecutive rotations (eight weeks) in pediatric radiology at Children’s Hospital & Regional Medical Center in Seattle , Washington . They also attend a six-week course in radiological-pathological correlation at the AFIP in Washington , D.C.

 Fourth-year Curriculum

Fourth-year residents complete core rotations in each subspecialty section and three elective rotations. Residents must declare their plans for elective time at least four weeks before the elective begins.

 AFIP Six-week Course

Third-year residents attend the Six-week Radiologic Pathology Course at the Armed Forces Institute of Pathology (AFIP) in Washington , D.C. This fully funded TDY assignment provides a comprehensive review of radiologic imaging with emphasis on the principles of radiologic-pathologic correlation. Lodging during the course is provided at the Malogne House for a specially contracted government rate. Lodging at alternative sites is not authorized. The AFIP requires participating residents to submit two, fully prepared, histologically confirmed cases that illustrate some aspect of radiologic-pathologic correlation. Cases must include:

 ·         Complete clinical, historical, laboratory, and pathological summaries

·         Original, representative images from all pertinent radiologic examinations

·         Color photographs of the gross pathology (with few exceptions)

·         Original tissue (paraffin) block or representative glass mounted microscope slides

 The Chief Resident maintains a record to ensure compliance with this requirement and to forestall submission of duplicate cases. Details of case submission, administrative and logistical requirements, and academic content of the course may be obtained by following the departmental information link at www.radpath.org.

Children’s Hospital & Regional Medical Center

Third year residents complete an eight-week rotation in pediatric radiology at Children’s Hospital & Regional Medical Center (CHRMC) in Seattle, Washington. Residents rotate under local orders with lodging provided at a nearby hotel in Seattle . There is no reimbursement for meals or transportation.

On the first day of their rotation, residents report to the Department of Radiology administrative offices, CS528, NLT 0745. Further information regarding daytime and on-call responsibilities is provided at that time. Residents take call at CHRMC, within MAMC institutional constraints, as determined by the faculty supervisor. Residents are excused from teaching conferences and weekday call at MAMC during their rotation, but may take weekend call at MAMC as determined by the Chief Resident.

Goals, objectives, and service responsibilities for the pediatric radiology rotation at CHRMC are detailed in Section VI of this document. Further information may be obtained by calling (206) 526-2166, or (206) 526-2134.

Electives

The academic schedule allots one elective to second-year residents and three elective rotations to fourth-year residents of good academic standing. Up to two of these may be used for research or independent study; at least one is to be a strictly clinical elective. Residents must submit goals and objectives for elective rotations to the program director at least four weeks before the elective is scheduled to begin. The program director may direct the resident to a particular subspecialty area for any elective rotation depending upon the strength of the resident’s academic record. Residents pursuing research or independent study are evaluated by the program director or a designated faculty mentor. Residents choosing a clinical elective are evaluated by the chief of the appropriate academic section.

Elective rotations at outside institutions are permissible, provided:

·         The elective complies with applicable institutional requirements.

·         The MAMC GMEC approves the rotation.

·         The resident is in good academic standing.

·         The resident assumes responsibility for coordinating all necessary administrative requirements.

Such rotations are usually limited to sites in the local community suitable for resident placement on local orders. They are never funded, and MEDCOM policy prohibits the use of permissive TDY for training in excess of 10 days. These rotations require considerable advanced notice to properly coordinate, and residents should plan at least three months ahead.

Multidisciplinary Clinical Conferences

The Department of Radiology supports several multidisciplinary clinical conferences convened to review and discuss the diagnosis, staging, and therapeutic alternatives for patients with malignant neoplasms. These conferences include tumor board, ENT tumor board, urology tumor board, thoracic surgery conference, mammography radiology-surgery conference, and the breast pathway conference. They serve important patient care needs and are not intended to be strictly academic in nature. Academic section chiefs establish requirements for rotating residents’ participation in the preparation and presentation of conference material. Beyond these requirements, residents are encouraged to participate to a degree appropriate for their level of training.

Reading Requirements

Academic section chiefs establish reading requirements in the curriculum for each rotation (section VI). Additional reading includes that required to prepare for journal club and Brant & Helms conference. Residents should expect to commit at least 15 hours per week to the independent study of teaching files, journals, and academic texts, but ultimately every resident must develop an individualized plan to meet expected performance objectives. Independent study should lead from general to more complex and highly specialized topics.

Resident Teaching Conferences

The resident conference schedule incorporates subspecialty-specific teaching conferences, formal didactic lecture, the instruction of various non-interpretive skills required by the ACGME, and elements of an OTSG-mandated military unique curriculum. MAMC teaching conferences meet in the Taylor Conference Room most Mondays through Fridays at 0730-0800 (morning report) and 1230-1300 (resident conference). Morning conference is coordinated by the program director and led by faculty.  Noon conference is coordinated by the Chief Resident and led by residents.  The conference schedule is suspended during the two-week period spanning the Christmas and New Year’s holidays. MAMC conferences are supplemented by lectures at the University of Washington Diagnostic Radiology Residency Program, meeting on Thursday afternoons, 1530-1800, September through May.

The program director publishes a monthly schedule during the last week of the preceding month. The Chief Resident (or his/her designee) will ensure that attendance at all conferences is accurately recorded. Attendance is mandatory for all residents and rotating clinical clerks with the following exceptions:

• Residents rotating on angiography/interventional radiology who are scrubbed into a case as the primary operator or first assistant will be excused from all conferences.
• The Chief Resident may use Thursday afternoons to attend to administrative responsibilities at his/her discretion, and will be excused from conferences at the University of Washington .
• Senior residents may use Thursday afternoons, February through May, to prepare for oral board examinations, and will be excused from conferences at the University of Washington .
• Residents participating in IRB-approved clinical investigations may, with prior approval from the program director, use Thursday afternoons to pursue research activities related to their protocol, and will be excused from conferences at the University of Washington .
• Residents attending the Six-week Course at the AFIP will be excused from all conferences.
• Residents rotating at Children’s Hospital & Regional Medical Center will be excused from MAMC teaching conferences, but will attend lectures at the University of Washington .
• Residents on leave, TDY, or at home due to illness will be excused from all conferences.
• Residents attending to exigent, life- or limb-threatening patient care needs will be excused from all conferences until their responsibilities are discharged.
• Residents who have passed the physics portion of the written board examination will be excused from physics lectures.
• Residents demonstrating good cause and who seek prior permission from the program director will be excused on a case-by-case basis.

Individual components of the conference curriculum follow.

Core Subspecialty Conferences

Each radiology supecialty section is responsible for a one-week block of the MAMC noon conference scheduled twice per year.  Faculty presentations are typically didactic during the first 6 months of the year and emphasize essential medical knowledge. During the last 6 months of the year, faculty presentations are more often case-based, simulating day-to-day clinical practice and emphasizing interpretive skills, differential diagnosis, and oral presentation. Residents are trained to think and communicate on the spot in preparation both for oral board examinations and for his/her professional role as an imaging consultant. Core conferences are supplemented by faculty lectures and case conferences at the University of Washington (q.v. p. 15).

Brant & Helms Conference

The residency program’s core text is the second edition of Fundamentals of Diagnostic Radiology, by William E. Brant and Clyde A. Helms. This is a required text and residents are expected to obtain a copy. Typically costing approximately $150.00, it may be purchased from a variety of commercial storefront and Internet booksellers as well as university-based medical bookstores. Brant & Helms Conference provides a forum for the weekly review and discussion of reading assignments. Residents may be required to take a written quiz. Conferences are typically scheduled on Mondays and are supervised by academic section chiefs with corresponding subject matter expertise.   Reading assignments are published with the monthly conference schedule.

Radiologic Physics

The Radiological Physics Program for Radiology Residents is designed to support basic clinical applications and provide a basis for understanding future advancements in radiology.  Participation is mandatory for first- and second-year residents, or for any resident who does not pass the American Board of Radiology’s written certification examination in radiologic physics. The program is based upon self directed reading assignments from the text The Essential Physics of Medical Imaging, 2^nd Ed. by JT Bushberg et al., beginning in October every year. The curriculum follows guidelines established by the American College of Radiology and includes lectures in the fundamental structure of matter, x-ray production, interactions of radiation with matter, screen-film concepts, film processing, image quality, mammography, fluoroscopic systems, computers and network applications in radiology, digital radiography, computed tomography, magnetic resonance, ultrasound, nuclear medical physics and camera systems, patient dosimetry, radiation protection, and radiation biology.  Mr. Jon Carter, a medical physicist certified by the American Board of Radiology in both diagnostic radiological physics and medical nuclear physics, coordinates the overall program and provides the majority of instruction in radiological physics.  A health physicist certified by the American Board of Health and board-certified radiation oncology physicians round out the program faculty. Residents meet weekly with an instructor as needed to review reading assignments and receive focused instruction on areas of concern.  Comprehension of course material is assessed through regularly scheduled quizzes. At the conclusion of the lecture series, residents preparing for the American Board of Radiology’s written certification examination take the RAPHEX examination.

In addition, the program provides funds to send PGY-3 residents to the University of California at Davis ’ radiological physics course, held in Sacramento , CA every August.

Resident Didactic Lectures

Residents prepare and present one 45-minute didactic lecture to their fellow residents each year. Residents must adhere to a true didactic format, utilizing text slides and illustrative digital images in a Microsoft PowerPoint® presentation. These lectures provide residents with practical experience in oral presentation, the review and appraisal of scientific literature, and the focused, in-depth study of current medical knowledge. Lecture content should be tailored to allow a thorough, thoughtful, and organized presentation of the assigned topic in 40-50 minutes.

The University of Washington

On Thursday afternoons, September through May, residents are released from clinical responsibilities at 1200 to attend teaching conferences at the University of Washington Diagnostic Radiology Residency Program. Lecture topics are available online at www.rad.washington.edu/residency. Residents provide their own transportation; there is no expense reimbursement. The Chief Resident (or his/her designee) records attendance and reports to the program director the following day. Whenever lectures at the University of Washington are not scheduled or are cancelled, MAMC residents may use this time for alternative academic endeavors.

Journal Club

This monthly conference provides a venue for instruction in some of the fundamental concepts of practice based-learning and improvement. Residents gain practical experience in the formulation and performance of a focused literature search, the critical appraisal of scientific literature for validity and applicability to current practice, medical-legal considerations, and the surveillance of literature for current trends in radiologic practice.

Difficult Case Conference

Difficult Case Conference partly fulfills ACGME requirements for resident participation in department Quality Improvement activities. Residents and faculty present diagnostically challenging cases, truly “missed” cases, and complications related to invasive procedures, particularly those related to patients who suffer “potentially compensatory events” (PCE’s). Faculty and residents review and discuss these cases in order to determine underlying causes for diagnostic or procedural error to improve future patient care. The Chief Resident maintains a record of the cases presented to document conference proceedings.

Visiting Faculty Conferences

The residency program routinely invites J. David Godwin II, M.D., and Professor of Radiology at the University of Washington , to provide monthly case conferences in thoracic radiology. These conferences are scheduled at the convenience of Dr. Godwin, usually on the first Friday of each month. The program occasionally invites other academic radiologists to lecture or provide case conferences, depending upon the availability of funds. Clinical faculty from other departments at MAMC will periodically provide conference instruction.

Interdisciplinary Teaching Conferences

The radiology residency program sponsors interdisciplinary teaching conferences with other residency programs and patient care services, including Emergency Medicine, Pathology, General Surgery, Developmental Pediatrics and Pulmonary Medicine. Some are incorporated into the resident conference schedule, while others are scheduled at a mutually convenient time. Radiology residents may be required to prepare, present, and discuss pertinent imaging examinations with support of radiology faculty.  Although current examinations of patients with active clinical problems may be presented, these conferences are primarily intended to provide a venue for academic interaction with clinical colleagues rather than a patient care conference per se.

Research & Scholarly Activities

Productive participation in scholarly activity is a requirement for graduation. Residents may select one or more of the following activities to fulfill this requirement:

•      Serve as principle or associate investigator in an Investigational Review Board (IRB)-approved clinical investigation. The resident drafts and submits research proposals in consultation with a faculty co-investigator, typically prior to completion of the first year of training. The resident conducts the protocol in accordance with IRB standards and policies, analyzes the results, and authors a manuscript suitable for publication in a peer-reviewed journal. The faculty co-investigator mentors the resident and coauthors the manuscript. The resident will submit an abstract of their scholarly activity for presentation at Madigan Research Day no later than the R-4 year.

•      Author an original manuscript, such as a book chapter or literature review, suitable for publication in a peer-reviewed journal. The resident will present their scholarly activity at the program’s research conference prior to February 1 of the R-4 year, and will submit an abstract for presentation at Madigan Research Day no later than the R-4 year.

•      Successfully publish a case report in a peer-reviewed journal. The resident will submit an abstract of their scholarly activity for presentation at Madigan Research Day no later than the R-4 year.

•      Successfully present a poster at a national meeting no later than February 1 of the R-4 year.

•      Present a scientific poster at a national meeting. The resident will submit an abstract of their scholarly activity for presentation at Madigan Research Day no later than the R-4 year.

The program strongly encourages joint research with other clinical services and institutions. All research proposals, irrespective of methodology or human use considerations, must undergo IRB approval. Proposals must be reviewed by the department chairman and department’s representative to the IRB prior to submission. The IRB representative reports the status of resident research to the program director at least semiannually.

MAMC’s Department of Clinical Investigation (DCI, 968-1160) provides robust support for resident research efforts, including assistance in protocol development, statistical analysis of actual data, and preparation of manuscripts. The DCI also sponsors a two-day long Introduction to Clinical Investigations Course offered each autumn. First year residents are required to attend this course, where they review the basic tenets of protocol design and data analysis. The DCI will be the sole source of TDY funding for presentation of research at a national society meeting or imaging conference.

For additional information please contact:

Director, Diagnostic Radiology
Madigan Army Medical Center ,
ATTN: MCHJ-R
Tacoma , WA 98431