GOALS &OBJECTIVES - SATIN



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Diagnostic Radiology

McGill University

Goals and Objectives for PGY 1

Revised : March 2017

Table of Contents

1) Requirements for PGY1 year (13 PERIODS) 7

2) Program Goals 8

3) General CanMEDs Roles for PGY 1s 8

Medical Expert/Clinical Decision-Maker 8

Communicator 8

Collaborator 8

Leader 8

Health Advocate 8

Professional 9

Scholar 9

4) ROTATION: Emergency Medicine 10

Overall Goal 10

Medical Expert 10

Communicator 10

Collaborator 10

Leader 11

Health Advocate 11

Scholar 11

Professional 11

5) ROTATION: Internal Medicine – CTU 12

Overall Goal 12

Medical Expert 12

Communicator 12

Collaborator 12

Leader 12

Health Advocate 12

Scholar 13

Professional 13

6) ROTATION: General Surgery 14

Overall Goal 14

Medical Expert 14

Communicator 14

Collaborator 14

Leader 14

Health Advocate 15

Scholar 15

Professional 15

7) ROTATION: Gastroenterology 16

General Objectives: 16

Specific Objectives: 16

Medical Expert 16

Communicator 16

Collaborator 16

Leader 16

Health Advocate 17

Scholar 17

Professional 17

8) ROTATION: ICU 18

Overall Goal 18

Medical Expert 18

Communicator 19

Collaborator 19

Health Advocate 19

Leader 20

Scholar 20

Professional 20

9) ROTATION: Obstetrics and Gynecology 20

Overall Goal 20

Medical Expert 21

Knowledge 21

Skills 21

Communicator 21

Collaborator 21

Leader 21

Health Advocate 21

Scholar 22

Professional 22

10) ROTATION: Orthopedic Surgery 23

Overall Goal 23

Medical Expert 23

Communicator 23

Collaborator 23

Leader 23

Health Advocate 23

Scholar 24

Professional 24

11) ROTATION: Pediatrics 25

Overall Goal 25

Medical Expert 25

Communicator 25

Collaborator 26

Leader 26

Health Advocate 26

Scholar 26

Professional 26

12) ROTATION: Respiratory Medicine 27

Overall Goal 27

Medical Expert 27

Communicator 27

Collaborator 27

Leader 28

Heath Advocate 28

Scholar 28

Professional 29

13) ROTATION: Urology 30

Overall Goal 30

Medical Expert 30

Communicator 31

Collaborator 31

Leader 31

Health Advocat 31

Scholar 31

Professional 31

14) ROTATION: Float (Periods 12 & 13) 33

Medical Expert 33

Communicator 33

Collaborator 33

Manager 33

Health Advocate 33

Professional : 33

Scholar : 33

Specific Objectives: 34

Medical Expert : 34

On Call Responsibility : 35

Lectures : 35

Requirements for PGY1 year (13 PERIODS)

Surgery: (For periods 1-6)

General Surgery 2 periods

SICU 1 period

Orthopaedics 1 period

Emergency 1 period

Elective 1 period (Obstetrics/Gynecology or Urology)

(For periods 7-11)

General Surgery 2 periods

SICU 1 period

Orthopaedics 1 period

Elective 1 period (Obstetrics/Gynecology or Urology)

Medicine: (For periods 1-6)

CTU 1 period

Emergency 1 period

GI 1 period

Neurology 1 period

Pediatrics 1 period

Respirology 1 period

(For periods 7-11)

CTU 1 period

GI 1 period

Neuro 1 period

Pediatrics 1 period

Respirology 1 period

Emergency*

*The Emergency rotation is now optional and depending on availability of GI or Neuro trainees can opt to do Emergency rotation.

Vacation: 1 period

Periods 12 & 13 Radiology Float (revised-February 2015)

Program Goals

This clinical, postgraduate year has two overriding broad objectives that should be kept in mind. The first objective is to provide the opportunity to experience clinical medicine and broaden your medical background.

The second objective is to gain a better understanding of the relevance of diagnostic imaging for a variety of medical disciplines and therefore, provide appropriate imaging during your career as a radiologist. This must be integrated in a graded fashion with the Royal College of Physicians and Surgeons Objectives of Training and Specialty Training Requirements in Diagnostic Radiology.

You are encouraged to remember that you will be a future radiologist. Therefore, seek knowledge and information from each rotation that is relevant to your future. You should strive to review all diagnostic imaging for your patients and understand the rationale behind acquiring imaging for your patients. You are encouraged to make use of the personnel and facilities of the Medical Imaging Departments during your clinical year. Inform the Radiologists of your presence, your interest in Radiology rounds and your interest in Radiology procedures. However, please remember that the duties and responsibilities of your other PGY-1 rotations take precedence over the activities in the Medical Imaging Department

General CanMEDs Roles for PGY 1s

Medical Expert/Clinical Decision-Maker

▪ Knowledge of anatomy, physiology, and pathology of the relevant systems during each specific rotation (given to resident by respective departments in Medicine and Surgery)

▪ Ability to assess, treat and follow up patients for their acute or chronic illnesses.

Communicator

▪ Able to communicate with colleagues (medical / paramedical).

▪ Able to consult with referring physicians

▪ Demonstrate effective communication skills when dealing with patients, during interview, consent and procedure.

▪ Able to explain the procedure and findings in terms that the patient and family can understand.

▪ Able to construct well organized patient notes and discharge summaries.

Collaborator

▪ Demonstrate adequate consultation skills when interacting with other physicians & health team members

▪ Interact appropriately with others demonstrating a team-based approach to managing patients.

▪ Contributes to Multidisciplinary Rounds and Conferences

Leader

▪ Consider advantages and disadvantages of various available diagnostic tests, and advise work up accordingly

▪ Demonstrate awareness of the indications for various interventional modalities

▪ Consider advantages and disadvantages available of operative versus interventional techniques.

▪ Grasp of the limitations of the public health care system

▪ Able to manage a reasonable clinical caseload during each rotation.

Health Advocate

▪ Recognize and consider consent issues, patient comfort and other patient-related issues,

▪ Recognize and consider radiation doses when recommending, approving and performing diagnostic or interventional cases

▪ Understand the principles of Health Advocacy as it pertains to the individual patient as well as the population at large.

▪ Promote screening examinations and regular health care provider visits

Professional

▪ Demonstrate integrity, honesty and compassion.

▪ Ability to show sensitivity and care to the patient and the patient’s family.

▪ Practice understanding of ethical and medical-legal requirements of all physicians

▪ Demonstrate awareness of one’s own limitations.

Scholar

▪ Set personal learning goals & objectives during rotation(s).

▪ Take a leadership role in learning from others, with teaching/supervision of junior residents on rotation, elective students, off-service residents.

▪ Create Teaching Cases for use by future trainees.

▪ Read journals regularly and attend Journal Club

▪ Attend Wednesday PM protected teaching in the Radiology Department during the PGY 1 year.

ROTATION: Emergency Medicine

Overall Goal

This rotation in Emergency Medicine is designed to expose the resident to common problems encountered in the emergency medicine patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

The radiologist will encounter emergency imaging on a daily basis in their practice, and as such a good understanding of the common emergency presentations and their appropriate work up, particularly the role of diagnostic imaging, is crucial.

As well, the radiologist can encounter acutely ill patients in the imaging departments in the context of complications from procedures, allergic reactions to contrast media, and general interventional radiology. The resident should be comfortable with recognizing the acutely ill patient and with basic management skills of emergency treatment.

Medical Expert

▪ Demonstrates an understanding of the pathophysiology of disease and injury and the natural history of disease and illness

▪ Understands the requirements for follow up care

▪ Develops increased competency in patient care and decision making for the emergency patient

▪ Demonstrates the prompt recognition of acute illness and injury

▪ Demonstrates an understanding of the principles of resuscitation, investigations, and diagnosis and management decisions

▪ Perform a clinical assessment and collect all appropriate information, including interpretation of relevant imaging studies

▪ Develop appropriate differential diagnosis and initiate management of:

▪ Acute illness/injury

▪ Traumatized patients

▪ Acute age related disorders

▪ Pediatrics

▪ Geriatrics

▪ Toxicological disorders

▪ Environmental disorders

Communicator

▪ Completes the emergency chart in a comprehensive and legible manner

▪ Communicates effectively and compassionately with the patient and family

▪ Understands the importance of a multidisciplinary team and interacts in an appropriate and effective manner with consultant physicians, nurses, and other health professionals

Collaborator

▪ Functions as a member of the emergency team and understands the roles of other health professionals.

▪ Demonstrates an understanding of the relationship of the emergency department with the EMS

▪ Demonstrates an ability to interact collegially and professionally with other physicians and all specialties

Leader

▪ Understands the basics of department management with respect to the function of the patient board and the role of the charge nurse.

▪ Understands the principles of quality assurance, risk management, and standards of care

Health Advocate

▪ Develop an understanding of the support services in the community, such as CCAC (Homecare), homeless shelters, detox services for patients being discharged from the ED

Scholar

▪ Attends the PGY 1 educational sessions, except when on booked vacation days

▪ Demonstrates self directed learning, with study and review of material appropriate for rotation.

▪ Demonstrates ability to identify gaps in knowledge and expertise.

▪ Apply best practice to patient care decisions, based on critical appraisal of relevant literature

Professional

▪ Demonstrates a responsible work ethic, interest and enthusiasm for learning

▪ Demonstrates professional work habits: punctual, dressed appropriately (greens acceptable), discharges duties in timely fashion

▪ Recognizes their limitations and seeks assistance when necessary.

▪ Responsive to feedback.

ROTATION: Internal Medicine – CTU

Overall Goal

This rotation in Internal Medicine is designed to expose the resident to common problems encountered in the general medical patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

Many of the acute and chronic illnesses encountered in internal medicine require imaging for diagnosis and management. Knowledge of these diseases and their treatment as well as potential complications of treatment will improve the radiology resident’s skills in interpreting studies in these patients.

Medical Expert

▪ Able to perform an organized, accurate and complete patient history and physical examination

▪ Orders tests appropriately and utilizes/interprets results effectively in patient assessment and development of management plan

▪ Interprets and integrates clinical information and test results, in order to develop and appropriately update patient care plans

▪ Demonstrates good medical knowledge base

▪ Demonstrates good judgment when setting management priorities

▪ Able to assess and start initial management in an acute emergency.

Communicator

▪ Establishes a therapeutic relationship and professional rapport with patients and families.

▪ Clear, concise and legible problem-oriented medical records

▪ Able to communicate effectively with health care team members, including technical staff, support staff, supervisors and colleagues.

▪ Can obtain an informed consent

▪ Provides clear instructions and checks whether the patient/family understands

▪ Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting

Collaborator

▪ Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise

▪ Able to request and provide consultations with clear understanding of question being asked

▪ Takes on appropriate share of team assignments and assists others as required

Leader

▪ Utilizes health care resources effectively to balance patient care, learning needs and outside activities.

▪ Utilizes information technology to optimize patient care and life-long learning

▪ Displays organizational skills with effective time-managemen

▪ Identifies and addresses issues related to discharge planning

Health Advocate

▪ Identifies the important determinants of health affecting patients.

▪ Recognizes and responds to those patient care issues where patient advocacy is appropriate.

▪ Identifies situations where patient advocacy is required.

▪ Acts as a patient advocate.

Scholar

▪ Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.

▪ Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students

▪ Attends and contributes to rounds and other learning events

▪ Accepts and acts on constructive feedback

Professional

▪ Practices medicine ethically, demonstrating integrity, honesty and compassion.

▪ Recognizes limitations and seeks advice and consultation when needed

▪ Discharges duties and assignments dependably and in a timely fashion

▪ Maintains appropriate boundaries in work and learning situations

▪ Respects diversity of race, gender, disability intelligence and socio-economic status

ROTATION: General Surgery

Overall Goal

This rotation in General Surgery is designed to expose the resident to common problems encountered in the general surgical patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

Understanding of surgical indications, surgical anatomy of common procedures and the potential post-surgical complications is crucial to proper interpretation of pre and post-operative imaging.

Many surgical techniques will have relevance to the practice of interventional radiology procedures, such as the use of sterile technique, obtaining informed consent, and instrument manipulation.

Medical Expert

Demonstrates knowledge of:

▪ The principles of wound healing

▪ The principles of resuscitation, stabilization, and disposition

▪ The natural history and progress of surgically related disease in the pediatric, adult, pregnant, and geriatric population

▪ The indications and limitations of investigative modalities

▪ The indications and limitations, mechanisms of action, interactions, and complications of pharmacologic agents

▪ The indications, techniques, and complications of manipulative procedural skills

Communicator

Resident is expected to demonstrate communication skills in both verbal and written manner with:

▪ Establishes a therapeutic relationship and professional rapport with patients and families

▪ Able to explain surgical disease and management plan in clear understandable fashion

▪ Can obtain an informed consent

▪ Presents the patient’s problems clearly, concisely and clearly, correctly in the clinical setting both verbally and in patient’s medical record

Collaborator

▪ Participates in interdisciplinary teams, considering and respecting the opinions of other team members

▪ Identifies and understands the roles, expertise and limitations of all members of an interdisciplinary team

▪ Works with the other members of the interdisciplinary team to develop a plan for the general surgery patient; this may include preoperative and postoperative investigations, treatments and continuing care both in hospital and in ambulatory settings.

Leader

▪ Demonstrates knowledge and awareness of appropriate resource allocation

▪ Organizes the workload appropriately and demonstrates effective time management

▪ Demonstrates knowledge of the principles of Quality Assurance in clinical practice

▪ Gives due attention to details

Health Advocate

▪ Able to identify operative risk factors in individual patients

▪ Identifies risk factors for Gastrointestinal tract disease, Breast disease, and factors that deleteriously affect operative risk factors and counsels patients accordingly

▪ Aware of guidelines of care for both prevention of disease, as well as treatment of established disease

Scholar

▪ Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature

▪ Reads around consults seen in the ER, clinics, ward setting

▪ Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students

▪ Attends and contributes to rounds and other learning events

▪ Accepts and acts on constructive feedback

Professional

▪ Interacts with patients, families, nurses and other health care personnel in a professional, respectful and ethical manner

▪ Demonstrates a good work ethic

▪ Examines and resolves any interpersonal difficulties in a professional manner

▪ Strives to balance personal and professional roles and responsibilities, and demonstrate ways to resolve conflicts in these areas

▪ Constantly evaluates her/his knowledge, skills and abilities, and recognize the limits of her/his professional competence

ROTATION: Gastroenterology

General Objectives:

These rotations take place under the main supervision of gastroenterologists. During the rotation, the residents will spend time on the inpatient and outpatient consult service. This is to allow exposure to the full breadth of gastrointestinal disease seen in the hospital setting. Residents will generally be involved in endoscopic procedures performed on patients they have seen in consultation. Residents will also spend time in ambulatory care clinics and endoscopy clinics under direct staff supervision. Therefore, the main objective of this rotation is to gain a solid grounding in all aspects of the practice of gastroenterology.

Many patients with diseases of the GI tract require medical imaging. It is important for the radiology resident to have an understanding of the clinical nature of these diseases and the role of imaging in the diagnosis and management of these patients.

Specific Objectives:

Medical Expert

▪ Acquire a thorough knowledge of the range of clinical problems in the Gastroenterology.

▪ Develop clinical skills required to accurately assess patients with GI disorders.

▪ Demonstrate appropriate choice of lab, radiologic, endoscopic, and other investigations in diagnosis of GI disorders.

▪ Function effectively as a consultant in the GI inpatient service and in ambulatory clinics.

▪ Recognize ones limits by seeking appropriate consultation when required.

Communicator

▪ Display the ability to communicate effectively with patients and families and thereby establish a therapeutic relationship.

▪ Learn the importance of actively involving patients so that they are partners in their on-going care.

▪ Elicit relevant information, not only from patients but from their families and other professionals in order to develop a shared plan of care.

▪ Synthesize and convey patient information succinctly and accurately to GI staff in order to develop an appropriate management strategy.

▪ Synthesize and convey patient information succinctly and accurately in a written format in the hospital chart an in clinic consultation reports.

Collaborator

▪ Work collaboratively with other in hospital services, particularly medicine and general surgery for the betterment of patient care.

▪ Work collaboratively with radiology in choosing and arranging investigations.

▪ Work collaboratively with pathology in the interpretation of endoscopic and liver biopsy results.

▪ Work collaboratively with nurses in the endoscopy unit to ensure timely completion of endoscopic tests.

Leader

▪ Learn to manage time effectively on a busy inpatient consult service.

▪ Learn to appropriately allocate finite hospital resources such as inpatient admissions, radiologic and endoscopic investigation. Learn to prioritize patients needing endoscopy in an appropriate fashion.

▪ Serve in a leadership role as junior staff on the inpatient consults service.

Health Advocate

▪ Engage in health promotion where appropriate. For example counsel smoking cessation in patients with Crohn’s. Counsel alcohol cessation in patients with liver disease.

Scholar

▪ Learn to search and critically appraise the literature as it relates to questions of patient care.

▪ Use clinical material seen in this rotation to present at divisional rounds, academic half day an M&M rounds.

▪ Use clinical material seen in this rotation to develop a research question for research block.

▪ Take a leadership role in the education of junior residents and medical students on the inpatient consult service.

Professional

▪ Demonstrate a commitment to patients, the profession and society through the provision of ethical, honest, compassionate care

ROTATION: ICU

Overall Goal

The radiologist will encounter imaging of the critically ill patient on a daily basis in their practice, and as such a good understanding of the common ICU diagnoses and their appropriate work up, particularly the role of diagnostic imaging, is crucial.

As well, the radiologist can encounter acutely ill patients in the imaging departments in the context of complications from procedures, allergic reactions to contrast media, and general interventional radiology. The resident should be comfortable with recognizing the severely ill patient and with implementing basic management skills of emergency treatment.

Many technical skills, such as vascular access, will be relevant to the radiology resident’s training in interventional radiology procedures.

Medical Expert

At the end of the rotation, the resident must be proficient, but is not limited to,

o acute respiratory failure

o hemodynamic instability

o sepsis

o acute renal failure

o overdoses and poisonings

o acute neurologic insults

o acute electrolyte and endocrine emergencies, and coagulation disorders

▪ For less common problems, the trainee must gain a knowledge base that allows them to formulate a differential diagnosis, initiate a management plan, and request appropriate consultations.

▪ The resident must become familiar with strategies to prevent such failures in the high-risk patient.

▪ The resident is also expected to have mastered the fundamental aspects of technical procedures commonly used in the treatment of critically ill patients.

▪ Emphasis will be placed on the ability to recognize, investigate, and stabilize acute critical illness.

▪ The resident must demonstrate the ability to collect and synthesize relevant data, to formulate an appropriate differential diagnosis, and offer an initial investigational and management plan.

▪ Cost effective use of laboratory and radiological investigations are expected

▪ As Critical Care is a multi-specialty discipline, the resident must have gained exposure to a wide variety of patients from a mixed population of medical, surgical, and obstetrical patients.

▪ All residents must develop an appreciation for the future interaction between the Critical Care Unit, themselves, and their medical discipline

▪ Relate and apply a sound fund of basic science knowledge to patient care in the majority of cases.

▪ Accurately interpret the results of common lab and diagnostic tests.

▪ Make judgments that are usually complete and sound. Arrive at decisions appropriately with appropriate use of available information.

▪ Demonstrate the ability to handles most common problems independently, while appropriately asking consultants for help with specific questions in more complex questions.

▪ Develop an ability to immediately recognize acute life-threatening illness and institute immediate life sustaining supportive therapy. Display appropriate leadership of the team, utilizing resources in an effective manner.

▪ Demonstrate adequate knowledge of monitoring techniques for the critically ill patient to allow for appropriate management.

▪ Consistently use appropriate preventative measures and apply knowledge in a prospective manner so as to anticipate potential problems and attempt to prevent them.

▪ Demonstrate an ability to perform an appropriate consultation assessment to and answer a question or request from another health care provider. Be able to present well-reasoned, well-documented assessments and recommendations in written and oral form in response to a request from another health care provider.

▪ Demonstrate competency in performing essential procedures with appropriate skill and manual dexterity for level of training. Carries out techniques correctly and efficiently with appropriate knowledge of indications and risks.

Communicator

▪ To provide humane, high-quality care, establish effective relationships with patients, other physicians, and other health professionals.

▪ Obtain and synthesize relevant history from patients/families/communities.

▪ Discuss appropriate information with patients/families and the health care team, particularly limitation of therapy and institution of comfort care in the ICU.

▪ Inter-professional Relationships; demonstrate an ability to work well with other services, using appropriate communication skills, resulting in a constructive environment.

▪ Communication with other allied health professionals; demonstrate an ability to communicate well with other members of the health care team. Specifically, able to provide a clear outline of the plan for patient care.

▪ Communication with Patients; demonstrate an ability to consistently achieve good rapport with patients and gain patient respect and confidence, and to clearly explain diagnosis and treatment options in an understandable fashion. Develop communication skills with patients on a ventilator.

▪ Communication with Families; demonstrate an ability to gain the respect and confidence of family members, to create a supportive and helpful environment, and to deliver information to families in a humane manner that is understandable and encourages discussion.

▪ Written communication & Documentation; demonstrate an ability to write records/reports that are usually complete, orderly, systematic, generally support management, and allow a physician unfamiliar with the patient to identify the relevant daily issues.

Collaborator

▪ Demonstrate abilities to become an active member of the Intensive Care Unit team who is able to work well with other team members.

▪ Demonstrate an ability to give and follow appropriate instructions with nurses and allied staff, and to develop rapport, resulting in a constructive working environment.

▪ Deal effectively with issues and achieve good results even in difficult situations without antagonizing others.

▪ Consult effectively with other physicians and health care professions.

▪ Contribute effectively to other interdisciplinary team activities.

Health Advocate

▪ The resident must be able to:

▪ Educate the families of critically ill patients on the life-style and health issues that have led to the illnesses of their family members

▪ Identify the important determinants of health affecting patients

▪ Contribute effectively to improved health of patients and communities

▪ Recognize and respond to those issues where advocacy is appropriate

Leader

▪ Participate in bed management issues and enable efficient care of the critically ill patient by using investigations appropriately.

▪ Effectively organize work in such a way that priorities are established and that coordination occurs with the other members of the team ensuring total, acute, and continuing care of patients.

▪ ability to prioritize and effectively execute tasks through teamwork with colleagues, and make systematic decisions when allocating finite health care resources

Scholar

▪ Self-education skills; demonstrate up-to-date knowledge in major clinically applicable developments. Display effective skills in continuing education.

▪ Demonstrate an ability to identify gaps in knowledge and develop a strategy to fill the gaps.

▪ Critical Appraisal of the Medical Literature; Demonstrate ability to seek out, locate and judge the strength of the evidence in the literature. Able to pose an appropriate patient-related question, execute a systematic search for evidence, and critically evaluate medical literature in order to optimize clinical decision making

▪ Scientific Interest; Participates in the scientific activities offered in the program. Contributes actively to discussion and teaching. Able to add to and elevate the level of discussion. Incorporates a spirit of scientific enquiry and use of evidence into clinical decision-making.

▪ Teaching Skills; Available, approachable. Effectively shares knowledge. Helps others to develop their potential.

▪ Oral Presentation Skills; Able to give a clear, concise, effective oral presentation concerning a clinical or scientific topic with appropriate use of audiovisual aids.

▪ Identify clinical problems in surgical critical care.

▪ Recognize and identify gaps in knowledge and expertise around the problem.

▪ Formulate a management plan.

▪ Consult others (physicians and other health professionals) in a collegial manner.

Professional

▪ Residents must be able to demonstrate their professionalism in the following ways;

▪ Integrity and honesty; demonstrate an honest, straightforward approach that is respectful of others, and deserves the respect of others.

▪ Responsibility and self-discipline; Dependable, reliable, honest and forthright in all information and facts; prompt, appropriate follow-up of patients. Non-clinical responsibilities, (e.g. rounds, teaching, etc.) are similarly dealt with.

▪ Bioethics; Sensitive to bioethical issues and demonstrates a reasonable approach to them. Performs in an ethical manner with other health care professionals, patients and families.

▪ Self-Assessment; demonstrates appropriate awareness of own limitations; seeks assistance and/or feedback to overcome/ compensate for limitations, and accepts advice graciously.

▪ Receptiveness to Feedback Responds constructively to new suggestions and ideas.

ROTATION: Obstetrics and Gynecology

Overall Goal

This rotation in Obstetrics and Gynecology is designed to expose the resident to common problems encountered in the prepartum, intrapartum and postpartum patient. The resident will further enhance their skills in the assessment, diagnosis and management of the fetus and female patient population.

Many obstetric and gynecologic patients require medical imaging. It is important for the radiology resident to have an understanding of the clinical nature of both the normal imaging of pregnancy and of OB/GYN complications and diseases and the role of imaging in the diagnosis and management of these patients.

Medical Expert

Knowledge

▪ Demonstrates basic interpretation skills in (FHR) fetal monitoring

▪ Demonstrate working knowledge of normal female and fetal development

▪ Understands the complications of pregnancy and their initial emergent management and need for referral/consultation, including the first, second and third trimester

▪ Demonstrates basic knowledge of indications and utility of imaging in the assessment of normal pregnancy and high risk patients

Skills

▪ Assess and write appropriate orders for low risk antepartum, intrapartum and postpartum patients

▪ Assess and manage common post-operative/post-delivery problems and initiate the workup/therapy in more complex situations with supervision

▪ Assess and manage common gynecologic problems presenting to E.R. and out patient office

Communicator

▪ Establishes a therapeutic relationship and professional rapport with patients and families.

▪ Formulates and completes clear, concise, legible and timely problem-oriented written/dictated consultation notes and discharge summaries

▪ Able to communicate effectively with patients, families and health care team members

▪ Can obtain an informed consent

▪ Provides clear instructions and checks whether the patient/family understands

▪ Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting

Collaborator

▪ Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise

▪ Able to request and provide consultations with clear understanding of question being asked

▪ Takes on appropriate share of team assignments and assists others as required

Leader

▪ Utilizes health care resources effectively to balance patient care, learning needs and outside activities.

▪ Utilizes information technology to optimize patient care and life-long learning

▪ Displays organizational skills with effective time-management

▪ Identifies and addresses issues related to discharge planning

▪ Able to set urgency priorities with respect to referrals

Health Advocate

▪ Identifies the important determinants of health affecting patients

▪ Recognizes and responds to patient care issues where patient advocacy is appropriate, including within the treatment team and outside services/agencies

▪ Recognizes impact of societal factors on patient health (housing etc)

Scholar

▪ Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.

▪ Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students

▪ Attends and contributes to rounds and other learning events

▪ Accepts and acts on constructive feedback, developing a plan to correct gaps in knowledge or skills

Professional

▪ Practices medicine ethically, demonstrating integrity, honesty and compassion.

▪ Recognizes limitations and seeks advice and consultation when needed

▪ Discharges duties and assignments dependably and in a timely fashion

▪ Maintains appropriate boundaries in work and learning situations

▪ Respects diversity of race, gender, disability intelligence and socio-economic status

ROTATION: Orthopedic Surgery

Overall Goal

This rotation in Orthpedic Surgery is designed to expose the resident to common problems encountered in orthopedics, including emergency, inpatient and outpatient settings. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

Understanding of surgical indications, surgical anatomy of common procedures and the potential post-surgical complications is crucial to proper interpretation of pre and post-operative imaging.

Many surgical techniques will have relevance to the practice of interventional radiology procedures, such as the use of sterile technique, obtaining informed consent, and instrument manipulation.

Medical Expert

▪ Demonstrates anatomical and orthopedic knowledge base appropriate for level

▪ Able to perform a focused, accurate and complete history and physical examination

▪ Understands the indications and limitations of various investigative imaging modalities (X ray, US, CT, MRI)

▪ Demonstrates an understanding of the basic principles of fracture management, joint replacement and musculoskeletal injury

▪ Able to synthesize clinical information, imaging and tests results for development of appropriate differential diagnosis and management plan for a variety of common problems in the orthopedic patient

Communicator

▪ Establishes a therapeutic relationship and professional rapport with patients and families

▪ Able to explain surgical disease and management plan in clear understandable fashion

▪ Can obtain an informed consent

▪ Presents the patient’s problems clearly, concisely and correctly in the clinical setting both verbally and in patient’s medical records

Collaborator

▪ Participates in interdisciplinary teams, considering and respecting the opinions of other team members

▪ Identifies and understands the roles, expertise and limitations of all members of an interdisciplinary team

▪ Works and consults with other interdisciplinary team members and clinical colleagues to develop a plan for the orthopedic surgery patient; this may include preoperative and postoperative investigations, treatments and continuing care both in hospital and in ambulatory settings.

Leader

▪ Demonstrates knowledge and awareness of appropriate resource allocation

▪ Organizes the workload appropriately and demonstrates effective time management

▪ Utilizes information technology to optimize patient care and life-long learning

Health Advocate

▪ Able to identify operative risk factors in individual patients

▪ Recognizes and responds to those patient care issues where patient advocacy is appropriate.

Scholar

▪ Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature

▪ Reads around consults seen in the ER, clinics, ward setting

▪ Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students

▪ Attends and contributes to rounds and other learning events

▪ Accepts and acts on constructive feedback

Professional

▪ Practices medicine ethically, demonstrating integrity, honesty and compassion.

▪ Recognizes limitations and seeks advice and consultation when needed

▪ Discharges duties and assignments dependably and in a timely fashion

▪ Respects diversity of race, gender, disability intelligence and socio-economic status

ROTATION: Pediatrics

Overall Goal

This rotation in Pediatric Medicine is designed to expose the resident to common problems encountered in the pediatric populations. The resident will further enhance their skills in the assessment, diagnosis and management of this unique patient population.

Medical Expert

▪ Able to demonstrate the unique communication skills necessary to obtain thorough, focused neonatal and pediatric histories from children, parents or other caregivers

▪ Able to perform a physical examination on infants and children, despite potential poor compliance

▪ Able to recognize the unique natural history of neonatal and pediatric diseases and use this information in reaching a diagnosis and management plan for care

▪ Able to individualize therapy, including drug therapy, nutritional, fluid and electrolyte needs, recognizing potential altered physiological states (such as immature hepatic and renal function) that affect therapy

▪ Able to recognize the normal range and wide variation with respect to diagnostic tests involving infants and children of different ages

▪ Able to diagnose and manage medical conditions presenting in the pediatric patient. Guidelines for study include:

▪ Newborn illnesses – including jaundice, sepsis, seizures, feeding problems, failure to thrive, hypoglycemia, prematurity and developmental concerns

▪ Respiratory illnesses – including asthma, croup, bronchiolitis, cystic fibrosis and pneumonia

▪ Cardiac disease – including innocent and pathologic murmurs, congenital heart disease, arrythmias, congestive heart failure and Kawasaki disease

▪ CNS disease – including seizures, headaches, acquired brain injury and specific diseases affecting development (e.g. cerebral palsy)

▪ Gastrointestinal diseases – including gastroenteritis and dehydration, malabsorption and constipation

▪ Infectious diseases – including all common viral and bacterial infections

▪ Dermatology – including eczema, urticaria and erythematous rashes

▪ Hematology – including anemia and thrombocytopenia

▪ Child neglect and maltreatment – including skeletal injuries, skin lesions, sexual abuse and shaken baby syndrome.

Communicator

▪ Establishes a therapeutic relationship and professional rapport with pediatric patients, parents and other family members

▪ Clear, concise and legible problem-oriented medical records, discharge summaries and consultations

▪ Able to communicate effectively with health care team members, including technical staff, support staff, supervisors and colleagues

▪ Provides clear instructions and checks whether the patient/family understands

▪ Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting

Collaborator

▪ Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise

▪ Able to request and provide consultations with clear understanding of question being asked

▪ Takes on appropriate share of team assignments and assists others as required

Leader

▪ Utilizes health care resources effectively to balance patient care, learning needs and outside activities.

▪ Utilizes information technology to optimize patient care and life-long learning

▪ Displays organizational skills with effective time-management

▪ Recognizes issues surrounding informed consent and refusal of treatment in children and adolescents and the right of adolescents to confidentiality

Health Advocate

▪ Identifies the important determinants of health, including injury prevention

▪ Recognizes and responds to those patient care issues where patient advocacy is appropriate

▪ Identifies situations where patient advocacy and preventative health awareness is required

▪ Recognizes the importance of giving accurate information with respect to immunizations, promoting safety in the home and on the street, counseling re smoking and substance abuse

Scholar

▪ Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.

▪ Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students

▪ Attends and contributes to rounds and other learning events

▪ Accepts and acts on constructive feedback

Professional

▪ Practices medicine ethically, demonstrating integrity, honesty and compassion

▪ Recognizes limitations and seeks advice and consultation when needed

▪ Discharges duties and assignments dependably and in a timely fashion

▪ Demonstrates awareness of the life-long significance of serious or chronic illnesses in children and the impact on their quality of life

▪ Respects diversity of race, gender, disability intelligence and socio-economic status

ROTATION: Respiratory Medicine

Overall Goal

Overall goal: Many patients with diseases of the respiratory tract require medical imaging. It is important for the radiology resident to have an understanding of the clinical nature of these diseases and the role of imaging in the diagnosis and management of these patients.

Medical Expert

Given a patient complaining of respiratory symptoms or with abnormal lab tests or chest radiograph, the resident will learn to take an appropriate history, perform an appropriate physical examination, and develop a suitable working diagnosis (and differential diagnosis, with appropriately justified ranking of alternative hypotheses).

The resident will:

▪ Order appropriate investigations in order to establish the diagnosis and assess severity of physiologic impairment.

▪ Be aware of the positive and negative predictive values of common respiratory investigations

▪ Be able to discuss the natural history of conditions that he/she has diagnosed, with and without treatment.

▪ Be able to manage the pharmacological and non-pharmacological aspects of treatment.

Given a patient with known chronic lung disease, the resident will:

▪ manage acute exacerbations and complications arising from the underlying disorder; also gain knowledge of preventative measures (e.g. vaccination) and rehabilitation available to that patient.

▪ The resident will take into account the indications and contraindications of these therapies; and will be able to explain the physiological effects that these therapies have on normal and abnormal pulmonary function.

Communicator

The resident will:

▪ Acquire the proper attitudes, interpersonal skills and strategies to behave as an effective consultant and learn how to provide effective verbal and written consultations.

▪ Communicate his/her clinical impression in a clear and concise fashion, in both written and oral form, to the referring physician and to other health care personnel.

▪ Be able to communicate his/her clinical impression to the patient and his/her family in a clear and compassionate way that takes into account the patient’s cultural values and education.

▪ Learn how to prepare patients, including how to obtain informed consent, for all respiratory procedures.

Collaborator

▪ Develop and display effective interactions with allied health care professionals in order to ensure optimal patient care, and efficient and safe discharges to the community.

▪ Learn and incorporate the role of a multi-disciplinary approach to the diagnosis and therapy of lung disease.

▪ He/she will develop and demonstrate an understanding of the importance of patient and family education in the management of acute and chronic disease.

▪ Demonstrate effective teamwork. This includes delegation to and guidance of more junior trainees, in a way that

▪ promotes learning;

▪ recognizes each team member’s strengths and skills;

▪ ensures patient safety and wellbeing at all times.

▪ Demonstrate and communicate respect for other health care workers (including respiratory therapists, nurses, physiotherapists, social workers, laboratory personnel, clerical staff, etc)—without exception, at all times.

Leader

▪ Develop and demonstrate the ability to set appropriate priorities in:

▪ His/her own daily clinical work

▪ Establishing the rapidity with which investigations, treatments and follow-up need to be undertaken for patients in diverse clinical settings

▪ Ensure consistent, timely review and follow-up of test results for his/her patients.

▪ Learn the approximate costs and risk-benefit ratios of diagnostic, therapeutic, and preventive interventions in the management of respiratory disease, and use these to help guide priority setting and resource allocation. Examples include

▪ CT scan of thorax (including without and with contrast; high-resolution),

▪ V/Q scans

▪ CT-PET scans,

▪ Pulmonary and bronchial angiography,

▪ MRI,

▪ medistinoscopy,

▪ thoracoscopy,

▪ pleural evacuation techniques,

▪ lung resection via thoracotomy,

▪ lung reduction surgery for COPD,

▪ lung and heart-lung transplant,

▪ routine pulmonary function tests and exercise studies,

▪ inhaled and parenteral corticosteroids and evolving anti-inflammatory therapies (e.g. leukotriene antagonists)

▪ bronchodilator therapy,

▪ anticoagulation therapy (including thromboprophylaxis, low molecular weight heparin, warfarin, and newer anticoagulants)

▪ tuberculosis management, including treatment of latent TB infection

▪ role of radiotherapy in management of lung cancer, role of common chemotherapeutic regimens in management of small cell lung cancer

▪ role of protocol therapies for all lung cancers.

Heath Advocate

▪ Recognize the importance of smoking cessation on an individual, community and at a national level. The resident will give stage-matched advice to smokers.

▪ Understand the importance of advocacy in the area of pulmonary rehabilitation and the management of chronic lung disease in the community.

▪ Demonstrate a gentle, caring and respectful attitude towards the patient at all times, with attention to patient’s rights and confidentiality, and to patient comfort

▪ Ensure that patients’ and families’ health concerns are handled appropriately and expeditiously.

Scholar

▪ Learn to incorporate evidence-based medicine, as well as the relevant ethical and legal precepts, into diagnostic and therapeutic plans

▪ Learn to review and synthesize relevant evidence and guidelines from the medical literature to address common and rarer respiratory conditions.

▪ Learn and model effective teaching of clinical clerks, residents, and attending physicians as well as other health professionals.

▪ Demonstrate the ability to access the medical literature effectively

▪ Demonstrate self-directed learning and a commitment to scholarship, with respect to all areas of clinical practice and to research in respiratory disease.

▪ Learn how to present an effective didactic teaching session at a medical conference (Grand Rounds format)

Professional

▪ Demonstrate exemplary professional and personal behaviour at all times. Recognize his/her limitations, and seek additional guidance when appropriate.

▪ Appropriately recognize, manage and communicate situations of diagnostic, therapeutic and/or prognostic uncertainty, including the use of controversial or potentially toxic interventions.

▪ Gain and model an understanding of medical ethics as applied to clinical practice, including issues of competence and informed consent/refusal, patient autonomy, end-of-life care, confidentiality, and protection of public health.

▪ Demonstrate empathy and support for patients and families coping with chronic and/or life-threatening illness.

▪ Demonstrate the ability to work effectively with patients and families under difficult circumstances, e.g.

▪ communicating bad news, discussing complications, disclosing medical error.

▪ Demonstrate the ability to understand, accept and learn from constructive feedback, and to improve accordingly.

▪ Demonstrate the ability to provide constructive feedback e.g. to junior trainees.

▪ Develop the ability to balance the demands of daily medical practice with other professional and personal goals, interests and commitments.

ROTATION: Urology

Overall Goal

Overall Goal: This rotation in Urology is designed to expose the resident to common problems encountered in urology, including emergency, inpatient and outpatient settings. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

Understanding of surgical indications, surgical anatomy of common procedures and the potential post-surgical complications is crucial to proper interpretation of pre and post-operative imaging.

Many surgical techniques will have relevance to the practice of interventional radiology procedures, such as the use of sterile technique, obtaining informed consent, and instrument manipulation.

Medical Expert

▪ Will have knowledge of the embryology, anatomy and physiology of the urinary system and the male genital system.

▪ Will have acquired basic knowledge of the patho-physiology of the urologic conditions encountered during the rotation.

▪ Will have understanding of specific microbiologic applications in Urology.

▪ Will become competent in pre-op assessment of the surgical patient including recognition and management of co-morbidity and risk, and the need for collaboration with other specialist colleagues.

▪ Will become competent in basic post-operative care of the surgical patient including

▪ fluid and electrolyte balance

▪ pain control

▪ wound care

▪ other post-operative complications

▪ Will become competent in recognition and management of particular and specific perioperative needs of urologic patients

▪ Will become familiar with recognition and management of urologic emergencies

▪ acute urinary retention

▪ difficult catheterization

▪ hematuria

▪ acute renal colic

▪ acute renal obstruction

▪ acute renal insufficiency

▪ acute urologic trauma

▪ acute scrotal conditions

▪ Will be competent to advise remote primary health care providers if and with what urgency a patient with a urologic emergency problem should be transferred to a secondary or tertiary care centre.

▪ Will become competent in assessing the signs and symptoms of a patient with urologic disorders and formulate a plan of investigation which is appropriate and cost effective.

▪ Will become familiar with the treatment plans for various urologic malignancies

▪ Will become familiar with the investigation and management of patients with voiding disorders and incontinence.

Communicator

▪ The resident in Urology will become competent in taking histories from patients and demonstrating an ability to overcome language and socio-cultural barriers frequently encountered in our multicultural milieu.

▪ The resident will learn to present cases at rounds in a concise and complete manner including all relevant data.

▪ The resident will record and recount patient data from consultations to an attending and/or senior resident in an equally concise and clear manner.

▪ Residents will chart in clear and concise manner patients’ daily progress notes, discharge summaries, operative reports and consultations.

▪ Residents will maintain clear communication with patients, and relatives where required.

▪ Residents will maintain clear communication with appropriate nursing staff and other.

Collaborator

▪ Residents will recognize their role as a member of a team which includes other MDs, nurses, and other care providers on the ward, in the operating room or the emergency room, or elsewhere in the hospital, and in the community.

▪ Residents will complete discharge summaries, consultation reports and other supporting documents to enhance communication with community partners.

Leader

▪ Residents will become proficient with the use of information technology.

▪ Residents will use consultations and tests to enhance the care delivered to the Urology patient and/or consultation.

▪ Residents will participate in discharge planning in concert with consultants, nurses, social services and other health care providers, both in hospital and post discharge in the community or long-term or palliative care facilities.

▪ Residents will understand the principles of cost-effectiveness, limited resources and evidence-based medicine.

Health Advocat

▪ Residents will provide prognostic information to patients and suggestions regarding actions to take or avoid to optimize outcome.

▪ Residents will encourage patients to adopt a healthy lifestyle and avoid unhealthy practices, i.e. smoking.

▪ Residents will be aware of health advocacy and support groups in the community and to examine their possible active roles with such groups.

Scholar

▪ Residents will demonstrate an interest in acquiring further knowledge of urologic and surgical facts and development. This, by independent research and questioning of associates, senior members of the team, teachers and mentors.

▪ Residents will learn to evaluate medical literature for fact, relevance, accuracy and validity.

Professional

▪ The resident will recognize emotional/psychologic needs of the patient.

▪ The resident will demonstrate sensitivity to gender, culture and ethnic differences.

▪ The resident will acquire and apply knowledge of the professional codes and norms of behavior that govern the behavior of physicians and surgeons in clinical practice.

▪ The resident will acquire and apply knowledge of the legal codes and norms of behavior that govern the behavior of physicians/surgeons in clinical practice.

▪ The resident will be able to recognize ethical issues in clinical practice, specifically those related to the critically ill patient and to the dying patient.

▪ The resident will be able to recognize and deal with unprofessional behavior in clinical practice.

▪ The resident will be punctual.

▪ The resident will maintain a respectful and courteous manner towards patients, colleagues and both professional and non-professional co-workers.

▪ The resident will perform all educational and clinical activities and evaluations as requested and expected

DIAGNOSTIC RADIOLOGY (PGY 1) - FLOAT

Goals and Objectives for periods 12 & 13

ROTATION: Float (Periods 12 & 13)

Medical Expert 

At the end of the rotation, the resident is able to:

▪ Identify principal anatomical structures on:

▪ Plain chest x-rays and CT

▪ Plain bone films and CT

▪ Plain abdominal x-rays and CT

▪ Brain CT

▪ Abdominal and pelvic US

▪ Recognize the features of the most common pathologies encountered in the Emergency Room: chest x-ray, bone films, US and CT-Scan

▪ Evaluate the technical quality of imaging examinations

▪ Discuss indications and contra-indications of contrast administration, discuss the different modalities of administration and prevent and treat their complications

▪ Recognize indications and basic principles of Ultrasonagraphy

▪ Aquire basic scanning techniques for abdominal, pelvic, and testicular ultrasound

Communicator

▪ Learn to formulate and begin to dictate a proper radiologic report.

▪ Demonstrate communication skills by interacting effectively with technologists, nurses and colleagues.

Collaborator

▪ 1) Develop appropriate consultant approach towards technologists, colleagues and clinical departments

▪ 2) Develop interdisciplinary approach.

Manager

▪ Identify urgent indications in radiology.

▪ Learn to prioritize examinations.

▪ Be familiar with different imaging modalities, their advantages and drawbacks.

▪ Be familiar with the different imaging resources in order to offer effective and efficient services.

Health Advocate

▪ Be sensitized to radiation protection and patient advocacy.

Professional :

▪ Demonstrate integrity, honesty and compassion.

▪ Be aware of her/his limitations.

▪ Know how to ask for help and have knowledge of available resources.

Scholar :

▪ To begin using log book and the portfolio.

▪ Establish an academic learning strategy: readings, case reviews

▪

Specific Objectives:

Medical Expert :

Chest and cardiac imaging

Anatomy : mediastinum, fissures, airway, vascular

Pathology : Pneumonia

Atelectasis

Pleural effusions

Pulmonary edema

Pneumothorax

Chest trauma

Acute aortic syndrome

Musculoskeletal imaging :

Plain films/CT : Trauma

- Describe common fractures and dislocations

Abdomen :

Anatomy : CT-US : know anatomy : liver, spleen, kidney, adrenals, pancreas, bowels,

gallbladder and biliary tree, aorta, IVC

Pelvis : urinary bladder, uterus, ovaries, prostate, seminal vesicles

Intraperitoneal and retroperitoneal spaces

Renal space

Main vascular structures: Aorta and main branches

Intestinal and systemic venous return

Pathology : Bowel obstruction

Pneumoperitoneum

Acute appendicitis, diverticulitis, etc

Intraperitoneal fluid

Organs trauma : liver, spleen, kidneys, pancreas

Identify an abscess

Identify an aortic aneurysm

Neurologic Imaging :

Anatomy : CT-scan

Ventricles, cerebral parenchyma

Posterior fossa : cerebellum, vermis, brainstem

Basal cisterns : prepontine, pontocerebellar, ambient, interpeduncular, Quadrigeminal and suprasellar

Sylvian fissure

Basal ganglia : caudate nucleus, globus pallidus, thalamus

Falx cerebri, tentorium cerebelli

Corpus callosum

Principal arteries : ACA, MCA., PCA, Circle of Willis

Basilar artery

Venous drainage and sinuses

White matter, grey matter

Corona radiata, centrum semiovale

Sella turcica , pituitary gland

Sinuses

Mastoïd

Pathology : Infarctions

Hemorrhage

Brain herniation, cerebral edema

Hydrocephalus

Mass effect

Ultrasound :

Anatomy : liver, gallbladder and biliary tree, spleen, kidney, adrenals, pancreas,

urinary bladder, uterus, ovaries, prostate, aorta, IVC, celiac trunk, SMA,

portal vein, hepatic veins

Pathology : Biliary stone

Free fluid; spaces: Morrison’s pouch, pelvic, right and left superior quadrant

Gross mass

Differentiate cystic with solid structures

Trauma

On Call Responsibility :

PGY 1 Resident during “float“ rotations (periods 12 &13) will do shadow call with a more senior resident in order to familiarize him/herself with the on call issues. The first month will consist of “passive shadowing”, observing a more senior resident on call. This will progress to “active shadowing”, where the resident will be reporting cases which will all be reviewed and signed off on by senior residents.

Lectures :

PGY1 residents will attend all 8AM and 12 PM teaching rounds at their base hospital as well as all IHVP and VP series. Special lectures on emergency radiology for the PGY1s have been created as an introductory series, given by the senior residents during core curriculum teaching.

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McGill

Diagnostic Radiology Residency Program

Programme De Résidence En Radiologie Diagnostique

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