Clinical Rotations

Clinical Rotations

Body Imaging and GI/GU

Competency-Based Goals and Objectives

by level of training

(Pediatric abdominal imaging G&O are included in the pediatric rotations)

Rotation One

1. Medical Knowledge

Instrumentation and Protocols

·  Basic CT and MRI instrumentation

·  Common CT and MRI artifacts

·  Become familiar with on-line protocols

·  Types of oral and intravenous contrast

·  Contra-indications to contrast administration, pre-treatment regimens for at-risk patients, nephrogenic systemic fibrosis, and treatment regimens for contrast reaction

Abdomen

·  Liver: normal size, diffuse disease, (fatty infiltration, acute and chronic hepatitis, cirrhosis, edema), focal masses, metastases, granuloma

·  Gallbladder: normal appearance, acute cholecystitis (calculous/acalculous), sonographic Murphy’s sign, other etiologies of wall thickening

·  Bile ducts: normal intra- and extrahepatic bile duct diameters and dilatation

·  Pancreas: normal anatomy, pancreatic duct, mass

·  Spleen: normal size, focal masses, lymphoma, abscess, infarction, granuloma

·  Peritoneal cavity: ascites

·  Trauma: hemoperitoneum, pneumothorax, vascular injury, solid organ injury, mesenteric/bowel injury, active bleeding

Kidneys, urinary bladder and prostate

·  Normal renal anatomy, simple renal cyst

·  Ureters: hydronephrosis, pyonephrosis, hydroureter, stone

·  Urinary bladder: calculi, wall thickening

·  Abscess/pyelonephritis, perinephric fluid

·  Post-renal transplant collections: hematoma, urinoma, abscess, lymphocele

·  Complex renal cyst, adult polycystic disease and acquired renal cystic disease, renal cell carcinoma, angiomyolipoma

·  Urinary bladder: mass, infection, hemorrhage, wall thickening, bladder outlet obstruction,

diverticula, ureterocele

·  Trauma

Bowel

·  Inflammatory conditions including appendicitis, diverticulitis, inflammatory bowel disease, epiploic appendagitis

·  Infectious colitis

·  Ischemic bowel

·  Bowel perforation

·  Bowel obstructions and underlying etiology

·  Intussusception, volvulus, closed loop obstruction, incarcerated hernias, strangulation

Gynecology

·  Ovarian neoplasm: cystic/solid adnexal masses, cystadenoma/carcinoma, dermoid, fibroma, germ cell tumor, Doppler evaluation

·  Ovarian torsion appearance on CT

·  Pelvic inflammatory disease, tubo-ovarian abscess

Vascular

·  Abdominal aorta: normal appearance and measurement, aneurysm

·  Inferior vena cava: normal appearance, thrombosis

·  Lower extremity deep vein thrombosis

·  Hematoma

·  Pseudoaneurysm

·  Liver transplants, including hepatic artery stenosis or thrombosis, portal vein thrombosis, post-biopsy complications

·  Pancreas transplant: vasculature, fluid collections

·  Hemodynamics of cirrhosis, portal hypertension and varices, portal vein thrombosis

Assessment Methods

·  Faculty evaluations

·  Mock orals

·  ACR in-service examination results

2. Patient Care

·  Gather essential and accurate clinical information about patients relevant to the interpretation of the examination including correlation with prior radiological studies.

·  Communicate effectively and demonstrate caring, respectful behavior when interacting with patients and their families, answering their questions and helping them to understand the image-guided procedure as well as its clinical significance.

·  Use information technology to support patient care decisions.

·  Perform basic procedures such as thoracentesis and paracentesis with faculty guidance.

·  Start a procedure log for image-guided procedures

·  Protocol GI and GU examinations including CT and MRI with faculty guidance. Determine if additional imaging is needed before the patient examination is complete

·  Recognize CT findings of appendicitis, diverticulitis, cholecystitis, hydronephrosis, ureteral obstruction, bowel obstruction, volvulus, ischemic bowel, pneumoperitoneum, common traumatic injuries of the chest/abdomen, active extravasation, emphysematous inflammatory processes, bronchogenic carcinoma, pneumothorax, pulmonary embolus, aortic dissection, aortic rupture, traumatic vascular injury and common neoplasms.

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  Mock orals

·  Semi-annual review of procedure log

3. Practice-Based Learning and Improvement

·  Participate in self-directed learning including outside reading on anatomy and common pathology supplemented with information on emergency/trauma processes.

·  Participate in QA/QI activities.

·  Use information technology to access on-line medical information, and to facilitate self-directed learning.

Assessment Methods

·  Faculty evaluations

·  Learning portfolios (learning plan)

·  Mock orals

·  ACR in-service examination

4. Interpersonal and Communication Skills

·  Dictate prompt, accurate and concise radiological reports for basic studies.

·  Develop effective communication skills with patients, patients’ families, physicians and other members of the health care team.

·  Obtain informed consent for procedures with faculty guidance.

·  Promptly communicate urgent, critical or unexpected findings to residents, referring physicians or clinicians and document the communication in the radiological report.

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  Formal evaluation of resident dictations documented in resident learning portfolios

5. Professionalism

·  Demonstrate integrity, respect and compassion to patients, physicians, staff and other health care professionals.

·  Demonstrate positive work habits, including punctuality and professional appearance.

·  Demonstrate a commitment to the ethical principles pertaining to confidentiality of patient information.

·  Demonstrate a commitment to continuous professional development and lifelong learning through consistent conference attendance and participation.

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  semi-annual review of conference attendance

6. Systems-Based Practice

·  Understand how medical decisions affect patient care within the larger system.

·  Demonstrate knowledge of and apply appropriateness criteria and other cost-effective healthcare principles to professional practice.

Assessment Method

·  Faculty evaluations

Suggested References

·  Fundamentals of Body CT by Richard Webb

·  The Requisites in GI, GU

Rotation Two

1. Medical Knowledge

Abdomen

·  Liver: post-liver transplantation collections: hematoma, biloma, abscess

·  Gallbladder: inflammatory conditions, carcinoma

·  Bile ducts: bile duct stones, inflammatory disease, cholangitis, pneumobilia, neoplasm

·  Pancreas: neoplasm, cysts

·  Pancreatitis complications: abscess, pseudocyst and pseudoaneurysm, chronic pancreatitis

·  Peritoneal cavity: abscess, hemorrhage, omental mass, metastasis, carcinomatosis

·  Spleen: varices

·  Gastrointestinal tract: neoplasm, inflammatory conditions

·  Abdominal wall hernia, inguinal hernia

Kidneys, urinary bladder and prostate

·  Kidneys: xanthogranulomatous pyelonephritis, emphysematous pyelonephritis, congenital anomalies, pelvic kidney (see pediatrics section), medullary nephrocalcinosis

·  Adrenal glands: mass

·  Retroperitoneum: adenopathy, mass

·  Ureters: ureteral stone

·  Urinary bladder: ectopic ureterocele

·  Renal artery stenosis, renal vein thrombosis (see vascular section section)

·  Staging renal cell carcinoma

Gynecology

·  Cervix: mass, stenosis, endometrial obstruction

·  Fallopian tube: hydrosalpinx, pyosalpinx

·  Post-hysterectomy

·  Peritoneal inclusion cyst

·  Ovarian, cervical and endometrial cancer staging

Scrotal

·  Staging for testicular neoplasm

Vascular

·  Renal vein thrombosis

·  Mesenteric ischemia

·  Arterial stenosis and thrombosis

Assessment Methods

·  Faculty evaluations

·  Mock orals

·  ACR in-service

2. Patient Care

·  Screen and supervise more complex studies

·  Pre-procedural evaluation: coagulation laboratory studies, anticoagulation medication

·  Stratification of risk for percutaneous procedures

·  Techniques for image-guided invasive procedures: understanding important landmarks and pitfalls of percutaneous procedures, including recognition of critical structures to be avoided

·  Biopsy of soft tissue masses

·  Aspiration of fluid collections, cysts and catheter placement for abscess and fluid drainage

·  Post-procedural evaluation: radiographic studies, patient monitoring, management of complications

·  Maintain a procedure log

·  Fine needle biopsy versus core biopsy in specific application, such as focal liver mass, renal mass, thyroid/parathyroid mass, retroperitoneal lymphadenopathy

·  Determine the appropriate patient protocol/study and interact with the technologist on a regular basis.

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  Semi-annual review of procedure log

3. Practice-Based Learning and Improvement

·  Participate in self-directed learning with outside reading from Webb and the Case Review Series.

·  Demonstrate knowledge and the application of the principles of evidence-based medicine in practice.

·  Participate in QA/QI activities.

·  Facilitate the teaching of medical students.

Assessment Methods

·  Faculty evaluations

·  Learning portfolios (learning plan)

·  Mock orals

·  ACR in-service examination

4. Interpersonal and Communication Skills

·  Interact with residents and attending physicians in consultation to enhance clinical radiological correlation.

·  Dictate accurate and concise radiological reports for more complex studies with concise impression including diagnosis and/or differential diagnoses

Assessment Methods

·  Faculty evaluations

·  Direct observation by the faculty

·  Formal evaluation of resident dictations documented in resident learning portfolios

5. Professionalism

·  Demonstrate responsiveness to the needs of patients that supercedes self-interest (altruism).

·  Demonstrate a commitment to continuous professional development and lifelong learning through consistent conference attendance and participation.

Assessment methods

·  Faculty evaluations

·  360 evaluations

·  Semi-annual review of conference attendance

6. Systems-Based Practice

·  Effectively prioritize patients requiring cross-sectional imaging studies.

·  Participate in discussions with faculty regarding system challenges and potential solutions regarding radiological service and patient care.

Assessment Method

·  Faculty evaluations

Suggested References:

·  Fundamentals of Body CT by Richard Webb

·  Case Review Series for GI, GU

Rotation Three (and > months)

1. Medical Knowledge

·  Features that distinguish different types of benign and malignant hepatic masses on CT and MRI imaging

·  Features that distinguish different types of benign and malignant renal masses on CT and MRI imaging

·  Features that distinguish different types of benign and malignant pancreatic masses on CT and MRI imaging

·  Features that distinguish different types of benign and malignant adrenal masses on CT and MRI imaging

·  Biliary abnormalities on MRCP imaging

·  Expected post-operative findings with more complex bowel surgery

Assessment Methods

·  Faculty evaluations

·  Mock orals

·  ABR written examination results

2. Patient Care

·  Perform more complex image-guided procedures with faculty oversight

·  Screen and supervise, with increasing level of responsibility, most cross-sectional imaging studies.

·  Consistently provide safe patient care by minimizing the radiation dose when determining protocols for CT.

·  Recognize the MRI findings of common abdominal/pelvic neoplasms and causes of biliary obstruction, as well as the CT findings of less common thoracic/abdominal disease processes

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  Semi-annual review of procedure log

3. Practice-Based Learning and Improvement

·  Outside reading. Review radiology education web sites and teaching files including ACR CD-ROM.

·  Facilitate the teaching of medical students and more junior level residents.

·  Participate in QA/QI activities.

Assessment Methods

·  Faculty evaluations

·  Learning portfolios (learning plan)

·  Mock orals

4. Interpersonal and Communication Skills

·  Dictate accurate and concise reports for the most complex studies with concise impression including diagnosis and/or differential diagnoses as well as recommendations for further imaging and/or management, when appropriate.

·  Consult effectively with medical staff and attending physicians.

Assessment Methods

·  Faculty evaluations

·  Direct observation by the faculty

·  Formal evaluation of resident dictations documented in resident learning portfolios.

5. Professionalism

·  Demonstrate accountability to patients, society and the profession.

·  Demonstrate a commitment to continuous professional development and lifelong learning through consistent conference attendance and participation.

Assessment Methods

·  Faculty evaluations

·  360 evaluations

·  Semi-annual review of conference attendance

6. Systems-Based Practice

·  Understand indications for and cost-effectiveness of varying cross-sectional imaging modalities (Ultrasound versus CT versus MRI).

·  Practice cost-effective evaluation of patients requiring imaging studies that does not compromise the quality of care through the utilization of the ACR Appropriateness Criteria.

Assessment method

·  Faculty evaluations

Suggested References:

·  The Case Review Series: GI and GU

·  On-line teaching files