Lifelong learning in radiology:all eyes on visual expertise

Radiological images, such as x-rays, provide invaluable information about the human body. However, radiological images are considered difficult to evaluate. Medical students, residents in radiology and senior radiologists have different levels of expertise in evaluating radiological images. Their learning experiences, therefore, also vary and should be supported differently. Students typically receive training on evaluating radiological images during medical school. Therefore, training should be as efficient and effective as possible. Radiology residents engage in workplace learning and evaluate medical images themselves. To foster their learning, additional and detailed sources of feedback are essential. Eye-tracking methodology objectively captures where, when and how long a resident has looked while evaluating images. Eye-tracking may therefore provide such feedback. Senior radiologists need to continuously adapt to new imaging techniques. To support their learning, it is necessary to aid the implementation of new imaging techniques into everyday medical practice

Reversal of the hanging protocol of Contrast Enhanced Mammography leads to similar diagnostic performance yet decreased reading times

Objectives: Contrast-enhanced mammography (CEM) was found superior to Full-Field Digital Mammography (FFDM) for breast cancer detection. Current hanging protocols show low-energy (LE, similar to FFDM) images first, followed by recombined (RC) images. However, evidence regarding which hanging protocol leads to the most efficient reading process and highest diagnostic performance is lacking. This study investigates the effects of hanging-protocol ordering on the reading process and diagnostic performance of breast radiologists using eye-tracking methodology. Furthermore, it investigates differences in reading processes and diagnostic performance between LE, RC and FFDM images. Materials and methods: Twenty-seven breast radiologists were randomized into three reading groups: LE–RC (commonly used hangings), RC-LE (reversed hangings) and FFDM. Thirty cases (nine malignant) were used. Fixation count, net dwell time and time-to-first fixation on malignancies as visual search measures were registered by the eye-tracker. Reading time per image was measured. Participants clicked on suspicious lesions to determine sensitivity and specificity. Area-under-the-ROC-curve (AUC) values were calculated. Results: RC-LE scored identical on visual search measures, t(16)= -1.45, p =.17 or higher-p values, decreased reading time with 31%, t(16)= -2.20, p =.04, while scoring similar diagnostic performance compared to LE-RC, t(13.2)= -1.39, p -.20 or higher p-values. The reading process was more efficient on RC compared to LE. Diagnostic performance of CEM was superior to FFDM; F (2,26)= 16.1, p <.001. Average reading time did not differ between the three groups, F (2,25)= 3.15, p =.06. Conclusion: The reversed CEM hanging protocol (RC-LE) scored similar on diagnostic performance compared to LE-RC, while reading time was a third faster. Abnormalities were interpreted quicker on RC images. A RC-LE hanging protocol is therefore recommended for clinical practice and training. Diagnostic performance of CEM was (again) superior to FFDM

Learning physical examination skills outside timetabled training sessions: what happens and why?

Lack of published studies on students’ practice behaviour of physical examination skills outside timetabled training sessions inspired this study into what activities medical students undertake to improve their skills and factors influencing this. Six focus groups of a total of 52 students from Years 1–3 using a pre-established interview guide. Interviews were recorded, transcribed and analyzed using qualitative methods. The interview guide was based on questionnaire results; overall response rate for Years 1–3 was 90% (n = 875). Students report a variety of activities to improve their physical examination skills. On average, students devote 20% of self-study time to skill training with Year 1 students practising significantly more than Year 3 students. Practice patterns shift from just-in-time learning to a longitudinal selfdirected approach. Factors influencing this change are assessment methods and simulated/real patients. Learning resources used include textbooks, examination guidelines, scientific articles, the Internet, videos/DVDs and scoring forms from previous OSCEs. Practising skills on fellow students happens at university rooms or at home. Also family and friends were mentioned to help. Simulated/real patients stimulated students to practise of physical examination skills, initially causing confusion and anxiety about skill performance but leading to increased feelings of competence. Difficult or enjoyable skills stimulate students to practise. The strategies students adopt to master physical examination skills outside timetabled training sessions are self-directed. OSCE assessment does have influence, but learning takes place also when there is no upcoming assessment. Simulated and real patients provide strong incentives to work on skills. Early patient contacts make students feel more prepared for clinical practice

What We Do and Do Not Know about Teaching Medical Image Interpretation

Educators in medical image interpretation have difficulty finding scientific evidence as to how they should design their instruction. We review and comment on 81 papers that investigated instructional design in medical image interpretation. We distinguish between studies that evaluated complete offline courses and curricula, studies that evaluated e-learning modules, and studies that evaluated specific educational interventions. Twenty-three percent of all studies evaluated the implementation of complete courses or curricula, and 44% of the studies evaluated the implementation of e-learning modules. We argue that these studies have encouraging results but provide little information for educators: too many differences exist between conditions to unambiguously attribute the learning effects to specific instructional techniques. Moreover, concepts are not uniformly defined and methodological weaknesses further limit the usefulness of evidence provided by these studies. Thirty-two percent of the studies evaluated a specific interventional technique. We discuss three theoretical frameworks that informed these studies: diagnostic reasoning, cognitive schemas and study strategies. Research on diagnostic reasoning suggests teaching students to start with non-analytic reasoning and subsequently applying analytic reasoning, but little is known on how to train non-analytic reasoning. Research on cognitive schemas investigated activities that help the development of appropriate cognitive schemas. Finally, research on study strategies supports the effectiveness of practice testing, but more study strategies could be applicable to learning medical image interpretation. Our commentary highlights the value of evaluating specific instructional techniques, but further evidence is required to optimally inform educators in medical image interpretation

Teaching Systematic Viewing to Final-Year Medical Students Improves Systematicity but Not Coverage or Detection of Radiologic Abnormalities

Purpose Systematic viewing of images is widely advocated in radiology; it is expected to lead to complete coverage of images and consequently more detection of abnormalities. Evidence on the efficacy of teaching systematic viewing to students is conflicting. The aim of this study was to investigate the effects of teaching systematic viewing to final-year medical students on systematicity of viewing behavior, coverage of the image, and detection. Methods Final-year medical students (n = 60) viewed 10 chest radiographs in a first series before training and another 10 radiographs in a second series after training. Between series, students were taught basic chest radiographic viewing, in either a systematic or a nonsystematic manner. With eye tracking, systematicity (Levenshtein distances), coverage (percentage of image viewed), and detection (sensitivity and specificity) were measured. Results In a mixed two-by-two design, significantly higher sensitivity was found after training compared with before training (F1,55 = 6.68, P = .012, ηp2 = .11) but no significant effect for type of training (F1,55 = 1.24, P = .30) and no significant interaction effect (F1,55 = 0.12, P = .73). Thus, training in systematic viewing was not superior to training in nonsystematic viewing. A significant interaction of training type and time of viewing was found on systematicity (F1,49 = 20.0, P <.01, ηp2 = .29) in favor of the systematic viewing group. No significant interaction was found for coverage (F1,49 = 0.43, P = .51) or specificity (F1,55 = .124, P = .73). Conclusions Both training types showed similar increases in sensitivity. Therefore, it might be advisable to pay less attention to systematic viewing and more attention to content, such as the radiologic appearances of diseases

Teaching Systematic Viewing to Final-Year Medical Students Improves Systematicity but Not Coverage or Detection of Radiologic Abnormalities

Purpose Systematic viewing of images is widely advocated in radiology; it is expected to lead to complete coverage of images and consequently more detection of abnormalities. Evidence on the efficacy of teaching systematic viewing to students is conflicting. The aim of this study was to investigate the effects of teaching systematic viewing to final-year medical students on systematicity of viewing behavior, coverage of the image, and detection. Methods Final-year medical students (n = 60) viewed 10 chest radiographs in a first series before training and another 10 radiographs in a second series after training. Between series, students were taught basic chest radiographic viewing, in either a systematic or a nonsystematic manner. With eye tracking, systematicity (Levenshtein distances), coverage (percentage of image viewed), and detection (sensitivity and specificity) were measured. Results In a mixed two-by-two design, significantly higher sensitivity was found after training compared with before training (F1,55 = 6.68, P = .012, ηp2 = .11) but no significant effect for type of training (F1,55 = 1.24, P = .30) and no significant interaction effect (F1,55 = 0.12, P = .73). Thus, training in systematic viewing was not superior to training in nonsystematic viewing. A significant interaction of training type and time of viewing was found on systematicity (F1,49 = 20.0, P <.01, ηp2 = .29) in favor of the systematic viewing group. No significant interaction was found for coverage (F1,49 = 0.43, P = .51) or specificity (F1,55 = .124, P = .73). Conclusions Both training types showed similar increases in sensitivity. Therefore, it might be advisable to pay less attention to systematic viewing and more attention to content, such as the radiologic appearances of diseases

Neural correlates of visual perceptual expertise:Evidence from cognitive neuroscience using functional neuroimaging

Functional neuroimaging is a useful approach to study the neural correlates of visual perceptual expertise. The purpose of this paper is to review the functional-neuroimaging methods that have been implemented in previous research in this context. First, we will discuss research questions typically addressed in visual expertise research. Second, we will describe which kinds of stimuli are employed and which functional-neuroimaging techniques are implemented in this kind of research, with a special focus on electroencephalography (EEG) and functional magnetic resonance imaging (fMRI). Third, we will summarize the outcomes of recent studies that addressed the neural correlates of visual expertise and will particularly focus on studies that examined the neural correlates of visual expertise in medical image diagnosis. Finally, the review closes with a discussion of the benefits, caveats, and future directions of cognitive-neuroscience research for studying visual expertise

The Neural Implementation of Surgical Expertise Within the Mirror-Neuron System : An fMRI Study

Motor expertise is an important aspect of high-level performance in professional tasks such as surgery. While recently it has been shown that brain activation as measured by functional magnetic resonance imaging (fMRI) within the mirror-neuron system (MNS) is modulated by expertise in sports and music, little is known about the neural underpinnings of professional, e.g., surgical expertise. Here, we investigated whether and (if so) how surgical expertise is implemented in the MNS in medical professionals across three levels of surgical qualification. In order to answer the more specific research question, namely, if the neural implementation of motor expertise develops in a linear or non-linear fashion, the study compares not only brain activation within the MNS related to action observation of novices and experts, but also intermediates. Ten novices (medical students), ten intermediates (residents in orthopedic surgery) and ten experts (orthopedic surgeons) watched 60 video clips (5 s each) of daily-life activities and surgical procedures each while their brain activation was measured using a 3-T fMRI scanner. An established localization procedure was followed to functionally define the MNS for each participant individually. A 2 (video type: daily-life activities, surgical procedures) × 3 (expertise level: novice, intermediate, expert) ANOVA yielded a non-significant interaction. Furthermore, separate analyses of the precentral and parietal part of the MNS also yielded non-significant interactions. However, post hoc comparisons showed that intermediates displayed marginally significantly lower brain activation in response to surgery-related videos within the MNS than novices. No other significant differences were found. We did not find evidence for the hypothesis that the brain-activation level in the MNS evoked by observing surgical videos reflects the level of surgical expertise in the professional task of (orthopedic) surgery. However, the results suggest a potential non-linear relationship between expertise level and MNS-activation level