Reducing interruptions during duty radiology shifts, assessment of its benefits and review of factors affecting the radiology working environment.

AIM: To investigate and reduce the number of inappropriate interruptions to the duty radiology registrar, as well as subjectively assess the effect of reducing interruptions and identify other methods of improving the duty working environment. MATERIALS AND METHODS: A pre- and post-intervention prospective quantitative study and post-intervention retrospective qualitative study of duty radiology registrars was performed at a tertiary referral centre. The first cycle of the quantitative study was performed prior to implementation of a telephone triage system. The second cycle and qualitative study were performed afterwards. RESULTS: The average number of interruptions per day dropped by 43.7% after the intervention. Moreover, inappropriate interruptions dropped from one in three to one in five interruptions. Improvement was demonstrated following the intervention for perceived patient safety, workload, reporting efficiency, reporting accuracy, work satisfaction, and stress. The most common hindrance to a good working environment was interruptions (36%). The most common suggestion for improvement was improved comfort (33%). CONCLUSION: The present study demonstrates that a telephone triage system can substantially reduce the number of interruptions to the duty radiologist. It also demonstrates that reducing interruptions in radiology has the potential to improve the working environment in many ways.

Erdheim-Chester disease: 25-year history with early CNS involvement.

We report a case of Erdheim-Chester disease (ECD) with a 25-year history following initial presentation with diabetes insipidus and brainstem involvement. The exceptionally long history is particularly notable, given that ECD is a life-threatening disorder and there is a recognised association between central nervous system involvement and poor outcome. The case is a timely reminder of the presenting features of the condition, given the emergence of potential new treatment options.

Pitfalls in imaging the frail elderly.

The number of older people in the UK is rising and will continue to increase. Furthermore, there is evidence that (i) the number of investigations on the oldest patients is disproportionately increasing, (ii) inappropriate and/or futile radiological investigations are commonplace and (iii) the requests are coming from the most junior doctors. In this article, we argue that the approach to investigating the frail elderly is different and complex. Careful thought and discussion is necessary to safely and compassionately investigate treatable conditions without causing unnecessary distress and suffering.

The Bristol Radiology Report Assessment Tool (BRRAT): developing a workplace-based assessment tool for radiology reporting skills.

AIM: To review the development of a workplace-based assessment tool to assess the quality of written radiology reports and assess its reliability, feasibility, and validity. MATERIALS AND METHODS: A comprehensive literature review and rigorous Delphi study enabled the development of the Bristol Radiology Report Assessment Tool (BRRAT), which consists of 19 questions and a global assessment score. Three assessors applied the assessment tool to 240 radiology reports provided by 24 radiology trainees. RESULTS: The reliability coefficient for the 19 questions was 0.79 and the equivalent coefficient for the global assessment scores was 0.67. Generalizability coefficients demonstrate that higher numbers of assessors and assessments are needed to reach acceptable levels of reliability for summative assessments due to assessor subjectivity. CONCLUSION: The study methodology gives good validity and strong foundation in best-practice. The assessment tool developed for radiology reporting is reliable and most suited to formative assessments.

Acceptability of oral iodinated contrast media: a head-to-head comparison of four media.

OBJECTIVE: To assess the palatability of iodinated oral contrast media commonly used in abdominopelvic CT and CT colonography (CTC). METHODS: 80 volunteers assessed the palatability of a 20-ml sample of a standard 30 mg ml(-1) dilution of Omnipaque® (iohexol; GE Healthcare, Cork, Ireland), Telebrix® (meglumine ioxithalamate; Guerbet, Aulnay-sous-Bois, France), Gastromiro® (iopamidol; Bracco, High Wycombe, UK) and Gastrografin® (sodium diatrizoate and meglumine diatrizoate; Bayer, Newbury, UK) in a computer-generated random order. RESULTS: Gastrografin is rated significantly less palatable than the remaining media (p<0.005). Omnipaque and Telebrix are significantly more palatable than Gastromiro. No difference existed between Omnipaque and Telebrix. 39% of participants would refuse to consume the quantities of Gastrografin required for a CTC examination compared with Telebrix (7%) and Omnipaque (9%) (p<0.05). CONCLUSION: Omnipaque and Telebrix are significantly more palatable than both Gastromiro and Gastrografin, with participants more willing to ingest them in larger quantities as well as being less expensive. ADVANCES IN KNOWLEDGE: Omnipaque and Telebrix are significantly more palatable iodinated oral contrast media than both Gastromiro and Gastrografin, which has potential implications in compliance with both abdominopelvic CT and CTC.

Diagnostic accuracy of radiographer reporting of computed tomography colonography examinations: a systematic review.

Computed tomography colonography (CTC) is the primary radiological test for the detection of colorectal tumours and precancerous polyps. Radiographer reporting of CTC examinations could help to improve the provision of this expanding service. We undertook a systematic review to assess the accuracy with which radiographers can provide formal written reports on intraluminal disease entities of CTC examinations compared to a reference standard. Data sources searched included online databases, peer-reviewed journals, grey literature, and reference and citation tracking. Eligible studies were assessed for bias, and data were extracted on study characteristics. Pooled estimates of sensitivities and specificities and chi-square tests of heterogeneity were calculated. Eight studies were eligible for inclusion with some risk to bias. Pooled estimates from three studies showed per patient sensitivity and specificity of reporting radiographers was 76% (95% CI: 70-80%) and 74% (95% CI: (67-80%), respectively. From seven studies, per lesion sensitivity for the detection of lesions >5 and >10 mm was 68% (95% CI: 65-71%) and 75% (95% CI: 72-79%) respectively. Pooled sensitivity for detection of lesions >5 mm in studies for which radiographers reported 50 or less training cases was 57% (95% CI: 52-61%) and more than 50 cases was 78% (95% CI: 74-81%). The current evidence does not support radiographers in a role involving the single formal written reporting of CTC examinations. Radiographers' performance, however, did appear to improve significantly with the number read. Therefore, when provided with adequate training and experience, there may be a potential role for radiographers in the reporting of CTC examinations.

The FRCR 2B oral examination: is it reliable?

AIM: To investigate the reliability of the oral component of the Fellowship of the Royal College of Radiologists (FRCR) 2B examination. MATERIALS AND METHODS: Anonymized candidate test scores were analysed from nine consecutive sittings of the FRCR 2B oral examination covering the period from spring 2006 to spring 2010. Interobserver reliability was assessed using weighted Kappa coefficient, intraclass correlation coefficient, and a modified Bland-Altman plot. RESULTS: During the study period, 2235 candidates sat the FRCR 2B examination. Eighty-five point one percent of candidates obtained paired oral assessment scores within one mark of each other. This figure rises to 95.7% for paired scores within 1.5 marks of each other. Mean difference in scores was 0.67 (95% CI: 0.65-0.70). Agreement rises at the extremities of mean score. Reliability coefficients for the FRCR 2B oral examination were calculated as 0.27 (weighted Kappa) and 0.44 (intraclass correlation coefficient). CONCLUSION: The calculated reliability coefficients indicate fair to, at best, moderate interobserver reliability in the FRCR 2B oral examination. These findings are disappointing but are comparable with other oral assessment reliability studies. There is scope for improvement, although further work to measure the combined reliability of all the components of the FRCR 2B examination is desirable. Measures that could potentially increase reliability must be carefully considered against any negative impact on test validity, acceptability, and cost.

Development of medical imaging technologies is the best way to advance clinical diagnostic accuracy and there is no such thing as VOMIT.

We recently published a commentary on the impact of blood biomarkers in clinical decision-making. In this issue we shift to a similar contemporary debate surrounding over-reliance on imaging technologies to make diagnoses, often without a clinical rationale other than to rule out pathology. This strategy is not without harm to patients as illustrated by both of our experienced contributors. The place and responsibility for missed or irrelevant diagnoses following imaging will often rest on little more than inept clinical targeting, although as McCoubrie points out, the skilled radiologist may have some role in tempering everything from overzealous interpretation to simple error. Given that many techniques are based on (albeit falling) X-ray exposure and involve vastly expensive (and routinely redundant) technologies operating almost continuously, the role of skilled radiological input is more essential than ever for reducing VOMIT. Can we control inadequate imaging request strategies?

Radiology curriculum for undergraduate medical studies--a consensus survey.

AIM: To establish an expert consensus of what, when, and how the teaching of radiology should be incorporated into the core undergraduate medical curriculum. METHODS AND MATERIALS: This Delphi survey consisted of four iterative rounds, with feedback given at the start of each successive round in the form of the results of the previous round. The participants consisted of both radiologists and non-radiologists with significant interest and involvement in radiology and undergraduate/Foundation training. The study addressed the questions of how, where, when, and by whom radiology should be taught. RESULTS: The number of responses in rounds 1-4 was 20, 23, 41, and 25 (25, 22, 31, and 61% response rate, respectively). There was good consensus amongst the responders on the following: radiology teaching must be delivered in conjunction with anatomy and clinical case-based teaching, if possible in the department of radiology on picture archiving and communication system (PACS) workstations, and the teaching should be delivered by a competent and credentialled individual. Case-based assessment was the most agreed method of assessment. The majority of the responders concurred that the curriculum should include general indications for commonly requested radiological investigations, consent and safety issues around radiological tests, and their basic interpretation. CONCLUSION: The consensus points reached by the present study not only serve as directive principles for developing a more comprehensive radiology curriculum, but also places emphasis on a broader range of knowledge required to promote the best use of a department of radiology by junior doctors in an attempt to improve patient experiences and care.

Evaluation of two minimal-preparation regimes for CT colonography: optimising image quality and patient acceptability.

OBJECTIVE: To compare a 2 day bowel preparation regime of barium, iodine and a mild stimulant laxative with a 1 day iodine-only regime for CT colonography (CTC). METHODS: 100 consecutive patients underwent CTC. The first 50 patients (Regime 1) ingested 1 bisacodyl tablet twice a day 3 days before CTC and 1 dose each of 50 ml of barium and 20 ml of iodinated contrast per day starting 2 days before CTC. The second 50 patients (Regime 2) ingested 3 doses of iodinated contrast over 24 h prior to CTC. Volumes of residual stool and fluid, and the effectiveness of stool and fluid tagging, were graded according to methods established by Taylor et al (Taylor S, Slaker A, Burling D, Tam E, Greenhalgh R, Gartner L, et al. CT colonography: optimisation, diagnostic performance and patient acceptability of reduced-laxative regimens using barium-based faecal tagging. Eur Radiol 2008; 18: 32-42). A 3 day low-residue diet was taken by both cohorts. Questionnaires rating the side-effects and burden of the bowel preparation were compared to a control cohort of patients undergoing barium enema. RESULTS: The proportion of colons producing none/scattered stool (score 1) was 90.3% with Regime 1 and 65.0% with Regime 2 (p<0.005). Any residual stool was significantly better tagged with Regime 1 (score 5), with 91.7% of Regime 1 exhibiting optimum tagging vs 71.3% of Regime 2 (p<0.05). No significant differences in side-effects between the bowel preparation regimes for CTC were elicited. Bowel preparation for barium enema was tolerated significantly worse than both of the CTC bowel preparation regimes. CONCLUSION: Regime 1, containing a 3 day preparation of a mild laxative, barium and iodine, produced a significantly better prepared colon, with no difference in patient acceptability.

The radiology report--are we getting the message across?

The radiology report is the primary method of communication between radiologist and referrer. Despite this, radiologists receive very little formal training regarding the structure of the radiology report and also its importance as a medico-legal document. We present a review of radiology reporting, highlighting the importance of report structure and language with the purpose of helping radiologists improve the clarity, brevity, pertinence, and readability of reports. We encourage radiologists to avoid hedging and strive to improve communication with referring clinicians.

The FRCR 2B examination: a survey of candidate perceptions and experiences.

AIM: To survey the views of recent candidates of the Fellowship of the Royal College of Radiologists (FRCR) 2B examination with reference to assessment validity, reliability, and acceptability. MATERIALS AND METHODS: One thousand, two hundred and four UK radiology trainees and consultants were invited to complete an automated internet questionnaire regarding their experiences and perceptions of the FRCR 2B examination. The questionnaire was informed by a review of the literature. Eligible participants were candidates who had taken the examination within the previous 3 years. RESULTS: Four hundred and ninety-seven out of 1204 (41%) responses were received; of which 258/497 (52% of respondents) were eligible for inclusion into the study. The rapid reporting component is perceived to be significantly fairer than the oral section (82 versus 70% agree; p<0.001). The oral component fared poorly in perceived performance-reducing anxiety levels but well in questions relating to validity and reliability. Female candidates are more likely to find the FRCR 2B unfair (p=0.01) and experience performance-reducing anxiety (p<0.001) than males. No gender differences were observed in first-time pass rates (p=0.6). Candidate first language did not affect anxiety levels (p=0.9) or first-time pass rates (p=0.06). Only 12% of candidates agreed that the oral examination should move to an objective structured clinical format. CONCLUSION: Candidates score the FRCR 2B examination well in test validity with little desire for change to the oral examination format. Efforts to help reduce anxiety levels in the oral component would improve perceived fairness.

Workplace-based assessment in radiology-where to now?

Assessment of doctors is in a state of flux. Traditional methods of assessment have been critically examined and found inherently limited. The wholesale shift towards outcome-orientated education in the last 10 years has led to the relatively rapid development of a radically different method of assessment. This method focuses on assessing what doctors do in everyday practice rather than written or practical simulations. Known collectively as "workplace-based assessment" tools, these have been embraced in North America, whereas they have been more cautiously adopted in the UK. However, many of these assessment tools have not been rigorously studied and, moreover, few have been specifically developed for assessing radiologists. However, they are likely to be incorporated into radiology training in the near future. This paper critically analyses both the underpinning assumptions behind this method and the evidence behind existing tools, and looks at the work that is required to develop, adopt or adapt such tools for use in radiology.