Changes in postgraduate medical education and training in clinical radiology
Faculty of Clinical Radiology, Royal College of Radiologists, London, United Kingdom
Postgraduate medical education and training in many specialties, including Clinical Radiology, is undergoing major changes. In part this is to ensure that shorter training periods maximise the learning opportunities but it is also to bring medical education in line with broader educational theory. Learning outcomes need to be defined so that there is no doubt what knowledge, skills, attitudes and behaviours are expected of those in training. Curricula should be developed into competency or outcome based models and should state the aims, objectives, content, outcomes and processes of a training programme. They should include a description of the methods of learning, teaching, feedback and supervision. Assessment systems must be matched to the curriculum and must be fair, reliable and valid. Workplace based assessments including the use of multisource feedback need to be developed and validated for use during radiology training. These should be used in a formative and developmental way, although the overall results from a series of such assessments can be used in a more summative way to determine progress to the next phase of training. Formal standard setting processes need to be established for �high stakes� summative assessments such as examinations. In addition the unique skills required of a radiologist in terms of image interpretation, pattern recognition, deduction and diagnosis need to be evaluated in robust, reliable and valid ways. Through a combination of these methods we can be assured that decisions about trainees� progression through training is fair and standardised and that we are protecting patients by establishing national standards for training, curricula and assessment methods. � 2008 Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Postgraduate; radiology; training; education
Postgraduate medical education and training is undergoing
major changes in many countries around the world. The old model of learning
through an apprenticeship relationship, with one or more senior clinical colleagues
over very long working hours and seeing large numbers of normal and
pathological cases, is being challenged. With limits on the hours that can be
worked and shortened training as much time as possible at work must be used for
learning. There also needs to be an appropriate assessment system to evaluate
A seamless process is required to take students through
their basic undergraduate medical training into their early general
postgraduate training and then on to specialist training or training for
general practice. The process aims to produce fully trained doctors who can
improve the healthcare of the population that they serve. The process does not
stop there but continues with maintenance of those skills and development of
new skills. This process should be demonstrable to the public.
There is a wealth of educational theory about how best to
deliver training and how to assess the training outcome but this is less well
developed when applied to medical education than in other spheres of education,
although this situation is changing now.
The principles of good medical education and training
encompass many different elements. Selection processes at whatever level, where
there is open competition, need to be valid, open, objective and fair. Clear
learning outcomes should be outlined so that there is no doubt as to what
knowledge, skills, attitudes and behaviours are expected of those entering
The assessment systems must closely match the curriculum
and should be fair, reliable and valid. The curricula should reflect the
skills, knowledge, care and behaviour expected of doctors. Those who deliver
teaching and training should have the appropriate skills and attitudes and
standards should be determined for these skills. All of these elements should
be regularly assessed and quality assured to ensure that they meet the
pre-determined standards for each component of medical education.
In addition, medical education and training should reflect
the diversity of the society in which the doctor is practising. This includes
patient-focused care, learner-focused learning and making access to education
and training as well as clinical care equally available to those from different
parts of that society. There should also be equal opportunities for those with
The syllabus and curriculum need to be distinguished. A
syllabus is simply a list of topics to be studied. Much has been written in the
literature about the different types of curriculum  but in practice, the
curriculum states the aims, objectives, content, outcomes and processes of a
training programme. It includes a description of the methods of learning,
teaching, feedback and supervision. It should describe the knowledge, skills,
attitudes and behaviours that the learner will achieve.
In the United Kingdom, curricula are based on the General
Medical Council�s �Good Medical Practice� criteria  as well as the subject
matter of the individual specialty. These criteria include good clinical care,
maintaining good medical practice, relationships with patients, working with
colleagues, teaching and training, being honest, sincere and having strong
moral principles and being in good health.
Shortened working hours mean that training needs to be more
formally structured to ensure full coverage of the curriculum in a shorter time
period. Previously long hours allowed exposure to many different clinical
conditions almost irrespective of the formal training but at the expense of
fatigue, which has potentially detrimental effect on patient safety as well as
Curricula should ideally be developed into competency or
outcome-based models which can include generic elements related to
�professionalism� and other specialty-specific educational components.
In the United Kingdom, the Postgraduate Medical Education
and Training Board (PMETB) has defined eight standards for curricula  i.e.,
the rationale, the learning content, the model of learning, the learning
experiences, supervision and feedback, the management of curriculum
implementation, the process of curriculum review, and update and conformity of
the curriculum with equality and diversity legislation.
All curricula must demonstrate compliance with these
standards before they can be approved by the PMETB. The rationale for the
curriculum should explain the purpose of the curriculum, how it was developed
and the appropriateness to the stage of learning and the particular specialty.
It must set out the general professional and specialty-specific content to be
covered, the intended learning outcomes and recommended learning experiences.
There must be mechanisms for ensuring appropriate supervision of and feedback
on learning to individual trainees. There should be regular curriculum review
and revision where appropriate.
At the present time, most countries have a core radiology
curriculum covering the breadth of general radiological experience supplemented
by sub-specialty curricula based primarily on body systems. This model fits
best with the radiologist becoming an equal member of a multidisciplinary team.
As more and more clinicians acquire diagnostic imaging interpretative skills,
radiologists need to ensure that their skills are better in order to justify
their inclusion in the team. At the same time, �super� specialisation runs the
risk of �de-skilling� in non-specialist areas. For this reason, the challenge
of a curriculum is to deliver the knowledge, skills and attitudes not only
appropriate to the specialist area but also to ensure competence in the core
areas of emergency radiology. This is particularly important wherever
radiologists are in short supply to ensure that all sub-specialty areas are
There needs to be an assessment system, which is matched
directly to the curriculum, that not only acts as a developmental tool for
those in training but also as an assurance of competence in intended areas of
The Assessment Methods
It is in the area of assessment that trainees and trainers
will notice the greatest differences in the future. The apprenticeship method
of learning, with a number of exams during the course of training to act as a
stimulus to the acquisition of knowledge as well as hurdles to be crossed at
variable times during training, is not sufficient on its own in an era of
shortened training periods and greater public accountability.
Continual assessment, both formative and summative, is now
the norm with the objective of ensuring clinical competence. Much of the
terminology used by medical educationalists is new to many doctors and at times
threatening because it is poorly understood. Schuwirth  uses the useful
analogy of seeing assessment as a measurement of medical competence and then
regarding examinations as the diagnostic tools for �medical incompetence�. As
with all diagnostics, examinations have false positive and false negative
results with the result that some competent trainees fail while some
incompetent ones pass. These errors need to be minimised as much as possible as
their consequences are serious. One way of doing this is to calculate the
reliability and evaluate the validity of an examination or other assessment
Reliability and Validity
High reliability of an assessment process means that it
would reach the same conclusion if it were possible to administer the same test
again to the same individual in the same circumstances or at the very least
that the ranking of best to worst scoring students would not change. The
assessment must be reproducible. Reliability is expressed as a co-efficient
varying between 0 (no reliability) to 1.0 (perfect reliability).
Many assessments will state their �Cronbach alpha�
coefficient as an indicator of their reliability . An appropriate cut-off
for high stakes assessments is usually taken as greater than 0.8. One factor to
improve reliability is to increase the testing time to ensure wide content
sampling and sufficient individual assessments by different assessors. It has
been shown that the reliability of multiple choice questions (MCQs) increases
from 0.62 after one hour of testing to 0.93 after 4 hours while that of an oral
exam, from 0.50 after one hour to 0.82 after 4 hours. Immediately, it can be
seen that we now work in an era of the psychometrician and statistician guiding
us in developing robust assessments.
Validity on the other hand, is a conceptual term which
cannot be measured but is an indicator of whether the assessment tests what it
is meant to test. A number of different facets of validity has been described
 implying that multiple sources of evidence are required to evaluate the
validity of an assessment.
As well as evaluating the reliability and validity of an
assessment system, the educational impact, cost efficiency, acceptability and
feasibility should also be evaluated. Optimising an assessment method is about
balancing these six components. High stakes pass or fail examinations need high
reliability and validity whereas a formative developmental assessment relying
more on feedback to a trainee can focus more on educational impact and less on
Formal standard setting processes need to be developed for
summative assessments. Standard setting is the process used to establish the
level of performance required by an examining body for an individual trainee to
be judged as competent. It is in effect the pass mark. Many methods of standard
setting have been described . Relative standards are based on a comparison
among the trainees taking that examination, and they pass or fail in accordance
with how they perform in relation to each other. For example, the top 80%
always pass the examination.
The preferred standard is an absolute one where trainees
pass or fail according to their own individual performance irrespective of how
others perform. For this, a formal standard setting process is required and
probably the best known is the Angoff method . Assessors are asked to make
judgements, as subject experts, as to the probability of a �just passing�
trainee answering a particular question or performing the indicated task
correctly. The assessors� mean scores are used to calculate a standard for the
In determining the form of assessment to use, it must be
decided whether knowledge, competence or performance is being assessed.
Miller�s Pyramid  (Figure 1) is a useful way of describing levels of
competence. This describes the progress from �Knows�, which reflects applied
knowledge through to �Knows How�, which requires more than just knowledge to �Shows
How�, which requires an ability to demonstrate a clinical competency through to
Each stage requires a different form of assessment and,
ultimately, a test of clinical performance at the �Does� stage, which reflects
what the doctor actually does in the workplace. There is much debate about the
format of question that is the best in testing medical competence but, in fact,
if the content of the items is similar, it has been shown that the question
format is almost completely unimportant . In practice, MCQs tend to be used
to test factual knowledge with workplace observations of practice being used in
a formative way to feedback to the trainee their developmental needs. In
parallel, an assessment of behaviours and attitudes is best undertaken through
multi-source feedback. Presentations and oral exams also have their place but
their relatively low reliability means that high stakes decisions should not be
based solely on their results.
Workplace-based assessment methods have been used in a number
of medical specialties. The mini-Clinical Evaluation Exercise (mini-CEX) was
developed in the United States to assess the clinical skills that trainees most
often use in real clinical encounters. Trainees are observed directly by an
assessor when they are undertaking tasks such as history taking, clinical
examination and communicating with patients. Each encounter takes 15 to 20
minutes and should be repeated on a number of occasions in different clinical
situations with different assessors.
The mini-CEX has been shown to have good reproducibility,
validity and reliability in general medicine. It has been shown that for a
given area of performance at least four assessments are needed if the trainee
is doing well and more than four if the trainee is falling below the required
standard. Directly Observed Procedural Skills (DOPS), which has been developed
by the Royal College of Physicians in the United Kingdom, requires an assessor
to observe directly a trainee undertaking a procedure and then grade the performance
of specific pre-determined components of the procedure. These include generic
skills such as consent and communication as well as the practical aspects of
the procedure itself. An example to be piloted in the United Kingdom is appended (Figure 2).
In a Case-Based Discussion (CBD) a selection of the
trainee�s cases are discussed in a standardised and structured oral assessment.
A trained assessor questions the trainee about the care provided in pre-defined
areas � problem definition (diagnosis), clinical thinking (interpretation of
findings), management and anticipatory care (treatment and care plans).
Multi-source feedback (MSF) is an objective systematic
collection and feedback about an individual�s performance derived from a number
of people (�raters�) working with individuals from a variety of different
backgrounds e.g., clinical colleagues, nurses, radiographers and clerical
staff. This method permits an assessment of generic skills such as
communication, leadership, team work, teaching, punctuality and reliability.
The responses from about 15 �raters� are required to
ensure a reliable assessment of the individual�s attitudes and behaviours. The
raters are asked whether they have no concerns, some concerns or major concerns
about the individual in areas such as showing respect for patients� opinions,
privacy, dignity and confidentiality, giving appropriate and understandable
information to patients, respecting other team members� roles and working well
as part of a team, and being readily available and accepting of responsibility
for his/her actions. Some MSF will also assess specialty-specific attitudes and
behaviours. Other possible workplace-based assessment methods include audit,
presentation and teaching assessments, and patient satisfaction questionnaires.
Although workplace-based assessments are primarily
formative developmental processes, the accumulated knowledge of a trainee's
performance in these assessments can feed into the formal summative assessments
that determine the progress of a trainee from one stage of training to another,
and ultimately as being �licensed� for independent practice through whatever
process exists in the host country for certification. Such decisions require
information from a variety of different sources, the so-called triangulation of
evidence, to be robust. This means that information from workplace-based
assessments, multi-source feedback, examination results, evaluation of audit
and teaching skills, outcomes data, patient questionnaires and reports from
educational supervisors, or at least some of these, are required.
What does this all mean for Radiology?
The questions for radiology are how much of this applies
to the specialty and what adaptations need to be undertaken to suit the
uniqueness of the specialty?
In many ways radiology is different to other specialties.
Trainees are protected in their early years by working in a close
apprenticeship relationship with their trainers and their knowledge and skills
in the workplace are being assessed on a daily basis by their trainer but this
may not be done in a standardised way and it may not be formally documented.
Radiologists require different skills such as perceptual
and observational skills and the ability to recognise patterns or
abnormalities. Having made such observations, they need to make appropriate
deductions from those observations and from the clinical information available
to them to reach a differential and possibly a definitive diagnosis, and
finally they need to make appropriate recommendations for further investigation
or management. In addition, they require practical skills to undertake
diagnostic and interventional procedures.
Many of the diagnostic skills are assessed on an on-going
basis during training through the use of �film viewing tests� and other
interactions with their trainer. The weakness of such assessments is that they
are usually locally derived and there are usually no national standards. There
is a considerable amount of radiology teaching material available through
e-learning resources, and on DVDs and CDs.
In the United Kingdom, the curriculum for the first three
years is available to UK trainees through an electronic learning database, a
joint project between the Department of Health and the Royal College of
Radiologists. This permits learning pathways to be developed and also a degree
of self assessment, which can be recorded through a learning management system.
It is hoped that the next phase of this project will be to complete a large
archive of validated cases, which should permit the standardisation of
assessments for both trainees and trained specialists, who may need to
demonstrate on-going competence.
In the interim, those responsible for radiology curricula
should define the core diagnostic skills in each area of the curricula for each
stage of training on which assessments can be based. Workplace-based
assessments such as Directly Observed Procedural Skills (DOPS) lend themselves
ideally to the assessment of diagnostic and interventional radiological
procedures and with some adaptation so do mini-CEX and CBD. MSF and the
assessment of audit and teaching skills are generic to all specialties. The
knowledge base, which underpins a competent radiologist, is vast and MCQs in
the format of single best answer appear to be the most reliable and valid way
of assessing this.
The film viewing components of any radiology examination
need to move to a digital format ideally allowing image manipulation, where
appropriate, in order to simulate the workplace as closely as possible. An electronic
examination should allow more candidates to be examined on the same material to
ensure better standardisation. Oral examinations suffer from having poor
reliability and are disappearing from the assessment processes of many medical
It can be argued that in radiology oral examinations are
being used to assess something unique that cannot be assessed in any other way.
They are assessing the day-to-day interactions that take place between a
radiologist and a clinician where the radiologist interprets an imaging test on
the basis of a certain amount of clinical information and from that may reach a
diagnosis or may need to obtain more clinical information from the clinician to
do this or to recommend further investigation.
The oral exam allows simulation of this interaction and
allows the examiner to assess the level of confidence that a candidate has in
reaching a diagnosis. The challenge is to ensure that as many candidates are
examined on the same material as is possible, and that they are examined over
as broad a spectrum of the curriculum as is possible to ensure as high a
reliability as is achievable with this form of assessment.
Radiology is in a unique position to combine what was best
in the past, in terms of the close mentoring and apprenticeship of trainees,
with what is the best of the new methods in terms of workplace-based
assessments, examinations and multi-source feedback. Combining these various
assessments assures us that decisions about trainees� progression through
training is fair and standardised, and that we are protecting patients by
establishing national standards for training, curricula and assessment methods.
Figure 1 Miller�s Pyramid
Figure 2 Radiology Direct Observation of Procedural Skills
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|Received 30 November 2007; received in revised form 26 February
2008, accepted 7 April 2008
Correspondence: Warden, Faculty of Clinical Radiology, Royal College of Radiologists, 38 Portland Place, London W1B 1JQ, United Kingdom. E-mail: email@example.com (David Lindsell).
Please cite as: Lindsell D,
Changes in postgraduate medical education and training in clinical radiology, Biomed Imaging Interv J 2008; 4(1):e19