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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

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