Biomed Imaging Interv J 2006; 2(2):e5
© 2006 Biomedical Imaging and
Electronic teaching files and continuing
professional development in radiology
Lim1, MBBS, MMed (Diag Radiol), FRCR,
GL Yang2, MS
1 Department of Neuroradiology, National Neuroscience Institute,
2 Biomedical Imaging Laboratory, Agency for Science Technology
and Research, Singapore
Education in diagnostic
radiology employs medical images extensively, and case-based
teaching files of actual patients are useful to illustrate pertinent
teaching points. In the era of digital radiology, there is great
potential to use the ready source of patient material from Picture
Archive and Communication Systems (PACS) and initiatives such
as Medical Imaging Resource Center (MIRC) on the World Wide
Web for teaching and for Continuing Professional Development
(CPD). As mandatory CPD becomes the reality in medical practice,
computerised solutions that support the creation of electronic
teaching files in the midst of busy clinical workflow would
be very valuable. This paper will explore the features of image-based
CPD, the various ways in which medical images can be used for
self directed learning and the challenges that face the radiology
profession. © 2006 Biomedical Imaging and Intervention
Journal. All rights reserved.
Keywords: Radiology education; radiology information
systems; medical imaging resource centre
Continuing Professional Development (CPD) is becoming increasingly
important for medical professionals. In the 1990’s,
Continuing Medical Education (CME) initiatives were in their
infancy and served to enable practicing physicians to keep
up with current advances and state-of-the-art practice of
medicine. With growing public attention and awareness, there
has been increasing pressure to maintain standards of patient
care and for regulation and oversight of the medical profession
[1-6]. Physician performance
and outcome measurements are of interest to the profession
and increasing concern to the public as well as to external
organisations such as the Joint Commission on Accreditation
of Healthcare Organisations. In many countries, CME programmes
have developed and changed to become professional revalidation
and maintenance of certification programmes. In the United
States, mandatory maintenance of re-certification (including
an examination), has resulted in increased demand for programs
and infrastructure for lifelong learning and self-assessment
In order to deliver CPD effectively in the context of busy
medical practice, on-demand remote or distance learning initiative
would be desirable, particularly exploiting the advantages
of computerisation and the World Wide Web. Like other subspecialties,
diagnostic radiology also faces demands from CPD. However,
the unique features and challenges of education in diagnostic
images make this at the same time a daunting task and an unparalleled
RADIOLOGY EDUCATION AND TEACHING
Medical education in diagnostic radiology is heavily image-intensive.
In order to distinguish the subtle differences between diseases,
diagnostic radiologists need to learn and master a large template
of abnormal findings, normal features, and normal findings
that mimic disease. Visual “Aunt Minnies” (like
your own aunt, it may be easier to recognize her than to describe
her), with unique features that allow immediate diagnosis
of a certain disease are another highlight of radiology learning
The ability to identify and appreciate the subtle nuances
in the difference between diseases that often have similar
imaging findings but vastly different treatments and outcomes,
is honed by continued exposure to a large number of representative
images. This has traditionally been accomplished during radiology
specialty training by rotating through various imaging departments.
It would be desirable to distil this accumulated experience
and training into an organised body of images with educational
value, which is in the form of radiological teaching files.
Such case based teaching files can be derived from images
from real patients that illustrate a particular teaching point,
diagnostic pitfall or unexpected outcome. Most radiology departments
in teaching hospitals already maintain a collection of teaching
files that comprise, at the most basic level, a number of
medical images, and pertinent information about the clinical
details, diagnosis, outcome and perhaps a short discourse
on the nature of the disease and its associated imaging findings.
This may be supplemented by appropriate references and suggested
reading, differential diagnosis and pearls of wisdom. In the
past, these teaching files would be stored as hard copy film
and paper and filed according to a classification system such
as the American College of Radiologists index of radiological
ELECTRONIC TEACHING FILES AND PACS
Hardcopy films have several drawbacks in that they are prone
to physical degradation, can be used by only one person or
one group at a time, occupy physical space, and are apt to
be misplaced. With the advent of computers and the digital
age, the acquisition of natively digital radiological images
(such as computed tomography and magnetic resonance images
that were created by computer processing as opposed to analogue
film-screen exposure) has become an irresistible trend. Such
data can be manipulated, archived, and transmitted with much
greater ease and convenience in the digital realm, and Picture
Archive and Communication Systems (PACS) are impacting radiology
workflow, cost and productivity. Although the advent of PACS
will result in the decline (and demise) of the physical film
library, to date there have been no commercial PACS vendors
that have developed a full-functional teaching file solution.
Several workarounds have been proposed, and resources and
authoring tools are available for making “teaching folders”
or exporting relevant images [9-15].
WORLD WIDE WEB EDUCATIONAL RESOURCES
There are many online repositories of electronic radiology
educational material available on the World Wide Web [16-19],
with several sites offering teaching files as “Case
of the Day”. More sophisticated initiatives on the World
Wide Web include the search engines such as Medical Image
Repository Center (MIRC) of the Radiological Society of North
America (RSNA) [20-22].
This initiative goes beyond merely offering a collection of
radiological images, and establishes a set of electronic schema
(based on Extensible Markup Language, or XML) to define electronic
teaching files for search engines. Any MIRC site can function
as a query service or storage service or both. In the query
service, a MIRC web portal will be able to search all the
linked MIRC storage websites for medical images (for instance
based on free text search). The storage service will then
respond and return links to matching electronic teaching files.
The MIRC project envisages a worldwide community of radiologists
that will share medical images (conforming to the schema),
enabling seamless communication of images for education and
research purposes. A number of institutions and internet-based
teaching files are currently linked to MIRC (Figure 1).
[View this figure]
|Figure 1 Medical Imaging Resource
Center (MIRC) web portal (http://mirc.rsna.org/mirc/query)
of the Radiological Society of North America. This
query service links multiple participating MIRC
sites, allowing users to search for electronic teaching
In order to take advantage of the rich source of images afforded
by PACS  and the potential of an internet
search engine of MIRC, our group has developed Medical Image
Repository Interface with PACS (MIRIP) .
This solution is essentially a computer server running a database
programme, an image server and a web server that enables users
to generate an electronic teaching file from an existing patient’s
images in PACS. To conform to relevant privacy laws 
and patient confidentiality, all images are anonymous. Teaching
files generated by MIRIP are in conformance to the MIRC schema
and may be viewed on World Wide Web and can participate in
the RSNA search engine (Figure 2).
[View this figure]
|Figure 2 Example of a MIRC electronic
teaching file created on MIRIP using images from
PACS (see text).
In addition to the enterprise-wide MIRIP designed for large
teaching hospitals, our group has also built a range of teaching
file authoring tools, including a “lite” version
for personal use as a radiologist’s case library ,
as well as an online submission system for radiologists who
do not have either the MIRC enterprise or personal versions,
but who would like to participate in creating electronic teaching
files on the World Wide Web . In this
way, we have created a Singapore National MIRC initiative which
is linked to RSNA MIRC (Figure 3).
ELECTRONIC TEACHING FILES FOR CPD
Although electronic teaching files may be useful for self-directed,
on-demand learning in an institutional intranet, further development
is required in order to turn them into a validated (i.e. assessed)
distance learning programme for CPD on the World Wide Web.
Examples of validated CPD programmes would include self-assessment
modules or SAMs for the American Board of Radiology ,
and assessments by CME providers who will issue pass/fail
points. Teaching files form an excellent backbone for any
radiology CPD programme when several cases of a particular
condition or similar conditions are clustered together to
form the nucleus of a learning module, for example focal lung
nodules caused by tuberculosis, bronchial carcinoma, hydatid
cyst. Furthermore, images in MIRC teaching files can be used
for validated test questions in a distance learning CPD programme
in combination with an electronic learning management system
[View this figure]
|Figure 4 Example of a multiple-choice
question based on radiological image from electronic
Such learning management systems typically comprise a database
of candidates with appropriate security features (such as
password restricted access), and the ability to mark the candidates’
tests and decide on a score. In Singapore, efforts are being
made to establish a system for radiology teaching files to
participate in the CME Category 3B verifiable self-assessment
distance learning programme . Picture-based
questions can be asked and the answers immediately assessed
by the CME learning management system (Figure 5). The main
advantage of using electronic teaching files created on systems
such as MIRIP would be lack of copyright issues. One of the
limiting factors of distance learning programmes has been
the copyrighted peer-reviewed or validated content. The copyright
of the teaching file in terms of images and text, however,
will belong to the creator (or the institute), and such “home-grown”
material would be easier to work with than copyrighted articles
or image sets, which might be prohibitively expensive. An
additional benefit of producing our own teaching files would
be increasing expertise and improved standards of education
and professional pride in the creation of high-quality intellectual
[View this figure]
|Figure 5 Distance learning program
validated self-assessment. Display of answers to
multiple choice questions is immediate and, combined
with a learning management system, can support online
MULTIMEDIA: BEYOND STATIC TEACHING
Although electronic teaching files may be desirable as a
first step in CPD, they are not entirely adequate for teaching
all the skills required of radiological practice. For instance,
merely teaching the final diagnosis limited to a static picture
may not take into account the process of detection, deduction
and further management inherent in all diagnostic radiology
interactions. Failure to arrive at the correct multiple choice
answer of the correct diagnosis may be the result of breakdown
anywhere in the chain of reasoning that is taken for granted
by radiologists. These include failure to detect the abnormality,
to think through the different possibilities in order to rank
the appropriate likely cause, or to incorporate additional
non-imaging clinical information (for example, the differential
diagnosis of similar-appearing nodules would be ranked differently
depending on whether the patient was a sheep farmer with a
fever or a smoker who works the asbestos industry).
To overcome the electronic limitations of teaching with static
pictures, multimedia teaching files have been developed, representing
the first step in dynamic and interactive electronic radiology
teaching. Multimedia files can be used to demonstrate and
explain not just the features of a particular diagnosis but
also the step-wise process of arriving at such a diagnosis,
making use of audio as well as moving graphics on a radiological
image . Furthermore, this can be applied
on the World Wide Web as a discussion forum and may even be
potentially useful as a form of viva voce practice for candidates
preparing for an examination.
CHALLENGES FACING RADIOLOGICAL
As in all worthwhile endeavours, the usefulness and success
of radiology CPD depends on the willing contribution of participants.
In this case, the task would be to ensure a continuous supply
of expert content, using the tools that have been developed.
Despite the availability of a ready source (in PACS) and destination
(in WWW and MIRIP) of images, it still requires human effort
and intelligence to bring order to the information, not a
trivial task in today's world of radiology staff shortage
and time pressure. In many countries (some with existing shortages
of radiologists) there is barely enough manpower and time
to cover the ever-increasing service demands, let alone participate
in CPD. To encourage healthy contribution of material, there
should be CPD credit, not just for passing the assessment
tests, but also for the content providers, peer reviewers
and programme directors. The reality is that CPD requires
participation from the whole community of practising radiologists
(particularly in small communities such as in Asia), and should
not be limited to those radiologists involved in teaching
in University centres. The challenge before us is how to promote
'buy-in' from radiologists of today to perpetuate the admirable
ethos of 'see one, do one, teach one' for the radiologists
In summary, CPD is becoming an integral part of medical
practice, and the radiology community faces challenges in
manpower and time. With appropriate tools and mechanisms exploiting
digital images, PACS and the World Wide Web, radiologists
will be equal to the task of using CPD to enhance the quality
of medical care.
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|Received 30 August 2005; accepted
17 September 2005
Correspondence: Department of Neuroradiology,
National Neuroscience Institute, 11 Jalan Tan Tock Seng,
Singapore 308433. E-mail: firstname.lastname@example.org
Please cite as: Lim CCT, Yang GL, Electronic
teaching files and continuing professional development in
radiology, Biomed Imaging Interv J 2006;2(2):e5
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