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A Milestone-Based Approach to Breast Imaging Instruction for Residents

2014; Elsevier BV; Volume: 11; Issue: 6 Linguagem: Inglês

10.1016/j.jacr.2014.01.007

1558-349X

Jennifer A. Harvey, Brandi T. Nicholson, Carrie M. Rochman, Heather R. Peppard, Clinton S. Pease, Nicholas Demartini,

Advances in Oncology and Radiotherapy

Residency is historically an apprenticeship, learning through observation and instruction with varying degrees of structure. Since July 2013, the Next Accreditation System (NAS) of the ACGME has required the use of progressive milestones for each radiology residency rotation. The authors describe how a breast imaging curriculum can be structured to comply with the NAS. The breast imaging rotations move from basic recognition and management of suspicious findings, through the detection of more subtle findings and learning of biopsy skills, and finally to the synthesis and management of more advanced findings. Likewise, patient communication moves from sharing imaging findings to the more challenging situation of breaking the bad news of a cancer diagnosis. This progression of skills mirrors the objectives of levels 1 to 4 of the NAS. Learning objectives have been adapted to form very specific milestones for each rotation, which results in a shared responsibility between residents and faculty members. Using clear expectations may improve the uniformity of teaching, resident satisfaction, and facilitate performance review for residents who are struggling. Didactic lectures, case-based conferences, teaching file cases, and assigned readings provide different approaches to education, allowing variation in learning styles. Performance on the breast imaging section on the ACR Diagnostic Radiology In-Training examination at our institution has risen from below the 50th percentile to around the 80th percentile beginning in 2011. Residency is historically an apprenticeship, learning through observation and instruction with varying degrees of structure. Since July 2013, the Next Accreditation System (NAS) of the ACGME has required the use of progressive milestones for each radiology residency rotation. The authors describe how a breast imaging curriculum can be structured to comply with the NAS. The breast imaging rotations move from basic recognition and management of suspicious findings, through the detection of more subtle findings and learning of biopsy skills, and finally to the synthesis and management of more advanced findings. Likewise, patient communication moves from sharing imaging findings to the more challenging situation of breaking the bad news of a cancer diagnosis. This progression of skills mirrors the objectives of levels 1 to 4 of the NAS. Learning objectives have been adapted to form very specific milestones for each rotation, which results in a shared responsibility between residents and faculty members. Using clear expectations may improve the uniformity of teaching, resident satisfaction, and facilitate performance review for residents who are struggling. Didactic lectures, case-based conferences, teaching file cases, and assigned readings provide different approaches to education, allowing variation in learning styles. Performance on the breast imaging section on the ACR Diagnostic Radiology In-Training examination at our institution has risen from below the 50th percentile to around the 80th percentile beginning in 2011. The Next Accreditation System (NAS) Milestones Project developed by the ACGME [1Nasca T.J. Philibert I. Brigham T. Flynn T.C. The next GME accreditation system—rationale and benefits.N Engl J Med. 2012; 366: 1051-1056Crossref PubMed Scopus (1035) Google Scholar, 2Accreditation Council for Graduate Medical Education. The Next Accreditation System. Available at: http://www.acgme-nas.org. Accessed June 30, 2013.Google Scholar, 3Accreditation Council for Graduate Medical Education. The Diagnostic Radiology Milestone Project. Available at: http://www.acgme-nas.org/assets/pdf/Milestones/DiagnosticRadiologyMilestones.pdf. Accessed June 21, 2013.Google Scholar] evaluates programs and residents on the basis of educational outcome measurements. The milestones are competency based and range from level 1 to level 5. At level 1, a resident should demonstrate milestones expected of one who has had some education in diagnostic radiology. At level 5, a resident has advanced beyond performance targets set for residency, although some emergence of these skills may occur during training. The goal of our curriculum is to move residents from level 1 to level 4 as consistently as possible, with the final intention being to prepare physicians for the current practice environment.Radiology residencies were required to implement the NAS by July 2013. Transitioning current residency programs to a milestone-based approach may be challenging. A comprehensive curriculum is necessary to start. The Society of Breast Imaging has recently published an updated curriculum for resident and fellow training [4Monticciolo D.L. Rebner M. Appleton C.M. et al.The ACR/Society of Breast Imaging Resident and Fellowship Training Curriculum for Breast Imaging, updated.J Am Coll Radiol. 2013; 10: 207-210Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. The article provides a list of topics to be covered and context for teaching these topics. However, the translation of this curriculum into milestones may not be apparent. The purpose of this article is to provide an example, on the basis of our experience, of how a breast imaging curriculum can be structured for radiology residents using milestones.Residency Requirements for Breast ImagingThe Mammography Quality Standards Act, the ACGME, and the ABR require residents to have 12 weeks of instruction in mammography; the first two also require residents to interpret at least 240 mammograms within a 6-month period during the last 2 years of residency [3Accreditation Council for Graduate Medical Education. The Diagnostic Radiology Milestone Project. Available at: http://www.acgme-nas.org/assets/pdf/Milestones/DiagnosticRadiologyMilestones.pdf. Accessed June 21, 2013.Google Scholar, 5Mammography Quality Standards Act of 1992. Pub L No 102-539 (1992).Google Scholar, 6US Food and Drug AdministrationQuality mammography standards: final rules—21 CFR parts 16 and 900. Docket No. 95N-0192, RIN 0910–AA24 edition, 55925-55926. US Department of Health and Human Services, Washington, District of Columbia1997Google Scholar]. If a resident does not pass board examinations at the first opportunity, he or she must interpret 240 mammograms within the 6 months immediately preceding the date of qualification as an interpreting physician. The NAS also now requires that residents interpret a minimum of 300 mammograms during their residencies, effective July 2013 [3Accreditation Council for Graduate Medical Education. The Diagnostic Radiology Milestone Project. Available at: http://www.acgme-nas.org/assets/pdf/Milestones/DiagnosticRadiologyMilestones.pdf. Accessed June 21, 2013.Google Scholar].The ABR has recently shifted to a goal of residents' obtaining core knowledge within the first 3 years of residency so that the fourth year has focus time for subspecialization. Many programs now provide the 3 breast imaging rotations during the first 3 years of residency.Why Develop a Milestone-Based Approach to Teaching Breast Imaging?Residents assimilate knowledge through observation and reading on topics seen during the workday. Self-directed learning is a desirable skill that may foster an attitude of curiosity and investigation that leads to lifelong learning [7Collins J. Lifelong learning in the 21st century and beyond.Radiographics. 2009; 29: 613-622Crossref PubMed Scopus (47) Google Scholar] and is one of the milestones evaluated in the NAS.However, when self-directed learning is the primary form of teaching, lack of direction and inconsistent exposure to important topics may result in large knowledge gaps. Variability occurs in day-to-day patient presentations and between geographic regions. For example, residents in Virginia may never see a patient with a ruptured breast implant, as implants are more common in other areas of the country. Without a structured guide, residents may not have the fund of knowledge to develop and prioritize a list of topics for review that is appropriate to their level of training.The Diagnostic Radiology Residency Review Committee of the ACGME requires that learning objectives be provided for each rotation. These objectives can be adapted to become specific milestones. For example, a learning objective may state that residents should be familiar with the mammographic features of benign and suspicious calcifications. This can be adapted as a level I milestone stating that residents should know the differential diagnoses for amorphous, fine pleomorphic, and coarse heterogeneous calcifications. Adapting learning objectives into specific milestones makes expectations more defined.The Use of MilestonesTranslating expectations into very specific milestones transforms teaching and learning into a shared responsibility between residents and faculty members [8Kothary N. Ghatan C.E. Hwang G.L. et al.Renewing focus on resident education: increased responsibility and ownership in interventional radiology rotations improves the educational experience.J Vasc Interv Radiol. 2010; 21: 1697-1702Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Faculty members set specific goals for a rotation as milestones and provide the materials to meet those goals. It is the residents' responsibility to review the materials and achieve the objectives. The faculty members can regularly assess progress. For residents who are not making good progress during a rotation, sitting down to review deficiencies in the predetermined milestones makes the conversation tangible and defined rather than personal. The conversation can therefore be perceived as supportive rather than critical.Our resident curriculum and milestones are organized to produce residents who are competent and confident in their breast imaging skills. The 3 months in breast imaging are completed during the first 3 years of residency. The rotations move from basic recognition and management of breast cancer findings, through detection and biopsy, and then to the management of more advanced findings. Available teaching opportunities include assigned readings, in-house teaching cases, a 2-year rotating didactic lecture curriculum, resident case conferences, and division radiology-pathology conferences. Our goal is to build a strong knowledge base, instill confidence in study interpretation, and provide safe basic procedure skills in breast imaging for each resident.Students learn in different ways [9Hughes J.M. Fallis D.W. Peel J.L. Murchison D.F. Learning styles of orthodontic residents.J Dent Educ. 2009; 73: 319-327PubMed Google Scholar]. Most residents are excellent visual learners, which is a by-product of their chosen profession in imaging as well as being members of the millennial generation [10Slanetz P.J. Kung J. Eisenberg R.L. Teaching radiology in the millennial era.Acad Radiol. 2013; 20: 387-389Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. RadioGraphics has recently updated its website [11RadioGraphics for residents & fellows. Available at: http://pubs.rsna.org/page/radiographics/residentsfellows. Accessed November 27, 2013.Google Scholar] to include online identification of teaching articles with comments by trainees in response to the changing environment. Teaching at the workstation, case conferences, and assigned readings work well for most residents. However, a significant portion of teaching during residency is accomplished through verbal communication by feedback on daily work and in didactic lectures, which are biased toward auditory learners. Residents who are poor auditory learners may seem to be poor performers despite adequate or even high test scores. For these residents, directed reading, computer-based teaching cases, and written notes may improve performance. Providing several approaches to resident teaching allows each to apply his or her best learning skills.Resident RotationsOur first goal for residents is to become familiar with the varied imaging appearances of breast cancer as well as the correlative clinical findings. This will ready them for the detection of more subtle cancers on screening examinations during the second rotation, when they will also learn safe biopsy techniques and radiologic-pathologic correlation. In the third rotation, residents will synthesize information and learn advanced management strategies, including the evaluation of women with newly diagnosed or prior breast cancer. As residents progress through rotations, they will observe patient interaction, communicate basic information, and eventually learn how to have difficult conversations [12Harvey J.A. Cohen M.A. Brenin D.R. Nicholson B.T. Adams R.B. Breaking bad news: a primer for radiologists in breast imaging.J Am Coll Radiol. 2007; 4: 800-808Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar]. Of course, many of these skills are acquired simultaneously, so the defined goals may seem somewhat arbitrary. However, by stating specific expectations for each rotation, learning can be focused, and skills can mature. This progression from the more simple tasks of distinguishing normal from abnormal to the most complex synthesis of imaging and clinical data to create the best care for that patient mirrors the NAS milestone goals.Before beginning each rotation, a resident receives a document of expectations that mirror the NAS goals, reading assignments, a list of teaching cases to review, and a worksheet with blanks to fill in during the month (Appendices 1–3).Month 1: Diagnostic ServiceThe first day of a new rotation is often anxiety provoking. Setting solid expectations and communicating them effectively reduces anxiety. A brief conversation to orient residents will put them at ease and make them feel welcome.The goals of this first experience in breast imaging mirror level 1 for medical knowledge of the NAS, which is to make core observations, formulate differential diagnoses, recognize critical findings, and differentiate normal from abnormal (Table 1). Gaining experience with the varied appearances of breast cancer improves the pattern recognition required to discern benign masses, asymmetries, and calcifications from those that are potentially malignant. Spending this first month on the cancer-enriched environment of the diagnostic service provides many opportunities to see both screening-detected and symptomatic breast cancers. Residents are required to learn basic breast differential diagnoses and use the BI-RADS® lexicon [13American College of RadiologyBreast Imaging Reporting and Data System (BI-RADS).4th ed. American College of Radiology, Reston, Virginia2003Google Scholar] for reporting mammographic and breast ultrasound findings.Table 1Goals of breast imaging rotationsMonth 1•Observe a mammogram.•Learn basic breast differential diagnoses, including calcifications, masses, and architectural distortion.•Read and appropriately apply the BI-RADS lexicon for mammography and ultrasound.•Understand the indications for BI-RADS category 3 for mammography and ultrasound.•Understand the basic physics of breast imaging.•Evaluate abnormal screening mammographic results, review subsequent diagnostic images, decide if an important finding is present or not, and include the suggested next step or management plan such as views to localize a one-view finding.•Evaluate symptomatic patients, including obtaining a pertinent clinical history, targeted clinical examination, and appropriate selection of modality on the basis of patient age.•Perform targeted breast ultrasound, optimizing settings for near-field imaging.•Appropriately communicate diagnostic results to patients.Month 2•Read as many screening mammograms as possible. Obtain meaningful feedback and incorporate on a daily basis.•Learn breast cancer risk factors, and define who is at high risk appropriately.•Learn about nipple discharge and male breast disease.•Obtain informed consent and follow safe-practice standards.•Observe and then perform basic breast procedures, including wire localization, stereotactic and ultrasound-guided biopsy.•Recognize correct targeting of a lesion during biopsy and distinguish concordant from potentially discordant results.•Understand basic radiologic-pathologic correlation and the management of high-risk lesions.•Learn how to communicate biopsy results to patients.•Interpret breast MRI studies using the BI-RADS lexicon.•Present selected cases at tumor boards.Month 3•Perform more complex breast procedures.•Learn about breast implants.•Evaluate extent of disease and perform regional staging in women with new or suspected breast cancer using mammography, ultrasound, and MRI.•Understand the normal and abnormal appearance of the postoperative breast, including residual carcinoma after lumpectomy and local recurrence of breast cancer.•Present selected cases at tumor boards. Open table in a new tab While on the diagnostic service, residents will learn how to work up screening-detected lesions and evaluate women with symptoms, such as breast lumps or nipple discharge. This introduces the realm of level 2 of the NAS, which includes secondary observations, narrowing the differential diagnosis, and describing management options.Patient interaction is a large part of breast imaging practice. During the first rotation, level 1 and 2 NAS communication skills are taught that include the routine communication of results (level 1), as well as the communication of bad news such as need for biopsy (level 2).Month 2: Screening and ProceduresAfter the cancer-rich diagnostic experience, residents are ready to apply their skills to the recognition of more subtle findings of cancer on screening mammography and breast MRI. Having residents read screening mammograms during their first month, before they have solid experience in the recognition of breast cancer, is less productive. Although only 300 mammographic interpretations are required by the NAS, we encourage our residents to read as many screening mammograms as possible. This fulfills level 3 of medical knowledge of the NAS, which is to provide accurate, focused, and efficient interpretations, and also works toward level 4 of medical knowledge, which is to identify more subtle observations (Table 1).Basic breast procedural skills will be taught during this month. Because residents performed many breast ultrasound studies during their first rotation, they are now comfortable handling a transducer and are ready to gain experience with ultrasound-guided procedures. They typically pick up skills for stereotactic biopsy and mammography-guided wire localization very quickly. Review of percutaneous breast biopsy results in the context of the imaging findings teaches radiologic-pathologic correlation and the topic of concordant and discordant results. They will also learn about high-risk pathologies on core biopsy and management strategies. Finally, effective, sensitive communication of biopsy results is modeled for residents by faculty members. This fulfills NAS level 1 and 2 procedure skills and level 4 communication skills.The hands-on instruction of residents in breast procedures requires delicate feedback in the physical presence of an often very anxious patient. Residents will observe and then assist for several procedures of each type before taking a primary role. The physical geometry of ultrasound-guided biopsy can be reviewed during assigned reading. Each morning, the procedures for that day are reviewed, and specific trainees are assigned on the basis of level of experience, which helps residents know their roles in each procedure.Residents will also interpret breast MRI examinations. Residents may now better appreciate the context of MRI screening and diagnostic examinations within the fuller realm of breast care. Participating in the reporting of MRI studies allows residents to appreciate similarities and distinctions of MRI and mammographic BI-RADS descriptors.Month 3: Developing Management StrategiesThe goal of this last breast imaging rotation is to foster the synthesis of information, further participate in patient management, and develop confidence in evaluating advanced cases (Table 1). This month is split between diagnostic and screening and procedural services.Now that residents have seen and helped biopsy breast cancers, they are ready to establish the extent of disease and evaluate regional lymph nodes for staging. These skills are initiated during the earlier rotations, tumor board presentations, and lectures. However, this last rotation helps solidify this knowledge through clinical application of these skills to women on the diagnostic service with new or suspected breast cancer and on breast MRI. They will also evaluate for residual or recurrent cancer in women with prior breast malignancies. Additional experience with breast procedures will improve technique and confidence. Residents learn to synthesize information to present a cohesive case at breast tumor boards. With residents' increasing level of sophistication, discussion about emerging technologies and controversial topics such as tomosynthesis and screening breast ultrasound help them gain perspective in the subspecialty and critically evaluate new information. These skills reach into the level 5 realm of the NAS.Opportunities for LearningAssigned ReadingsSpecific chapters, textbooks, and articles are assigned for each rotation [14Berg W.A. Dorsi C.J. Jackson V.P. et al.Does training in the Breast Imaging Reporting and Data System (BI-RADS) improve biopsy recommendations or feature analysis agreement with experienced breast imagers at mammography?.Radiology. 2002; 224: 871-880Crossref PubMed Scopus (140) Google Scholar, 15Harvey J.A. March D.E. Making the diagnosis: a practical approach to breast imaging. Elsevier, New York, New York2013Google Scholar, 16Morris E.A. Breast MRI: diagnosis and intervention. Springer, New York, New York2005Google Scholar].Case-Based TeachingReview of teaching cases reinforces skills by applying knowledge. We have several types of teaching cases available:•Faculty-created teaching cases: Of our collection of more than 200 cases, about 45 are assigned for each rotation targeted to specific milestones. A sheet with fill-in-the-blank questions accompanies the assignments.•Resident-created teaching cases: For each rotation, residents prepare two teaching cases to submit to the departmental teaching file. Each case includes clinical information, pertinent images, two multiple-choice questions, and a summary that focuses on pathophysiology and typical imaging features. All cases are reviewed by an attending radiologist for accuracy.•Commercial teaching cases: Our department subscribes to the ACR's teaching file, RADPrimer. Residents are assigned teaching cases by month, and compliance with review can be audited.ConferencesFormal conferences fill gaps in knowledge and reinforce concepts:•Didactic conferences: Formal conferences are given at noon for all radiology residents. A rotating 2-year didactic curriculum is required by the ACGME. The Breast Imaging Division organizes 3 seminar weeks per year (Table 2). During the first year, emphasis is placed on screening findings and detection, while the second year emphasizes the evaluation of clinical findings. A physics lecture that includes practical applications is cotaught by a radiologist and a physicist. Ten to 12 topics are given each year because other conferences (eg, quality assurance) are also scheduled during the seminar weeks.Table 2Example didactic breast imaging curriculumYear 1: approach to screening BI-RADS mammography and ultrasound lexicon Breast anatomy and physiology Calcifications made easy Architectural distortion Asymmetries Detecting cancer in dense breasts Risk assessment and high-risk screening Nuclear imaging of the breast Breast core biopsy Talking with patients: breaking bad newsYear 2: evaluation of palpable findings Breast masses Imaging the woman with breast cancer The postoperative breast The augmented breast The male breast BI-RADS MRI lexicon/how to read a breast MR study Breast procedures II: wire localization, galactography The path is back: now what? Unusual breast cancers Physics of breast imaging Open table in a new tab •Case conferences: Forty-five-minute case-based conferences are given every morning. The Breast Imaging Division is responsible for two conferences per month. Typically these are formed around a theme, such as palpable lumps or the ultrasound lexicon. Focusing the cases to specific topics results in residents' walking away with a few specific teaching points. Each case conference includes 2 or 3 multiple choice questions so that residents become accustomed to this format for board examinations.Our division-specific conferences add to the learning environment:•Biopsy conference: a 1-hour biweekly review of all breast procedures performed since the prior conference (45–60 cases). The images are presented on a workstation. A brief differential diagnosis is discussed, and the pathology is announced. One or two teaching points are discussed per case (eg, lesion descriptors, differential diagnosis, pathologic concordance). This conference is well received by trainees because of the high volume of cases with immediate feedback of radiologic-pathologic correlation.•MRI conference: 1 hour every other month to review MRI-guided procedures. The format is similar to that of the biopsy conference. This conference allows trainees to review a large volume of positive cases in a short period of time.•Journal club: a division-specific 1-hour conference every other month to review both classic and recent articles. Each trainee presents an article, gaining experience in understanding how to apply current literature to his or her practice.•Tumor board: a weekly review of current breast cancer cases. Residents present 1 or 2 cases per week during the second and third rotations. This conference is especially helpful for senior residents, as it requires synthesis of information.Our OutcomesObjective evidence of our outcomes can be observed through results from the ACR Diagnostic Radiology In-Training examination. Between 2007 and 2010, percentile rankings for breast imaging on this examination mirrored total performance for level 2 residents at our institution (Fig. 1). However, beginning in 2011, the percentile ranking for breast imaging was significantly higher (range, 77th to 81st percentile) than for total examination performance (range, 40th to 62nd percentile). A confounding factor is that level 1 residents began rotating on breast imaging during their first year of radiology residency beginning in 2010. The improvement in scores may therefore be due to earlier exposure rather than an improved experience. However, neuroradiology, with a new division head in 2009 who also instituted a structured curriculum, was the only other subspecialty at our institution to experience a similar trend in higher percentile ranking during this time period.The Resident PerspectiveThe following is a summary of the perspective views of two residents who then became fellows in breast imaging at our institution (C.S.P., N.A.D.).Learning radiology is a daunting task and one that is not well appreciated by other physicians. The scope of material that one is expected to master is extremely broad. In almost no other field can a resident be asked to point to any one random location on a CT of the entire body, list 5-10 things that can go wrong in that spot, and what each of those different disease processes look like on various imaging modalities. Few other physicians will be expected to intelligently answer a detailed question from a neurosurgeon regarding a cranial nerve 10 minutes after answering an equally detailed and specific question from a gynecologist. While we as residents should consider ourselves as adult independent learners, a structured framework within which to operate is extremely helpful. With study time fit in between clinical service, call, and family responsibilities, a structured curriculum ensures that one's study time is maximized. The breast imaging curriculum combines clinical experience, didactic and case based lectures, and directed computer case based review. This structured approach ensures that the important learning objectives are met and leaves the resident with a solid foundation in breast imaging.Other comments from residents on confidential review of the rotation include the following:I thought it was a great rotation. As a first year I think the structure really helped me out.Attendings were very helpful in teaching. Teaching files were great. Handouts provided as well to help practice BI-RADS terminology and to learn the basic differentials.Great rotation. Lots of teaching and plenty of opportunity to practice our BI-RADS and clinical decision making skills. Attendings are all encouraging to the residents, while still remaining objective and attentive to the task at hand.ConclusionsOur trainees reflect our ability as teachers. Implementing specific objectives as milestones has been very helpful in ensuring that our residents have a well-rounded knowledge base, diverse experiences, and solid management strategies at the completion of the program.Take-Home Points•Learning objectives can be adapted for use as milestones specific to each rotation. This may result in improved consistency of teaching, resident satisfaction, and objective performance evaluations.•Learning on the breast imaging rotations progresses from recognition of findings and differential diagnoses, through the detection of more subtle findings and the development of biopsy skills, and finally to the synthesis and management of findings. This progression mirrors the NAS Milest