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UNC Team Breast aka UNC Resident Breast Block Rotation (revised July 2018)Welcome to the Breast Division. We are a dynamic service emphasizing first person learning. Your involvement is very important to the imaging workflow, quality of patient care, and especially, your learning. We are pleased to have you on service. Block schedule and resources for self study including suggested articles, education modules and short videos (new!) are available on the rads.web.unc.edu UNC radiology website. The following are 4 high-yield recommendations to enhance your learning & end-of-block evaluation:Review orientation materials during the first weekTrack your learning progress using the milestones-adapted checklist Complete recommended reading assignments as they are assignedBe proactive during the work daySeek feedback. There will be a mid-block check in but please inquire if more is needed. Orientation materials:UNC Diagnostic Breast ProtocolsBI-RADS? Atlas 5th edition – Mammography, Ultrasound, MRI, Medical AuditBI-RADS? Reference card for easy reference during dictationsAdditional (on-line textbooks) available at phone numbers:Workflow technologist (diagnostic): Intercom 234Workflow technologist (procedures): Intercom 225Diagnostic RR: 984-974-8123 Hillsborough RR: 984-215-2258rads.web.unc.edu Resident Workflow tab for more department numbersTeaching:You will notice recurring themes for breast differentials, management algorithms, procedure techniques, patient counseling. We emphasis shoulder-to-shoulder learning and at-the-monitor education sessions. Study materials may be furnished to you in emails as you encounter a topic on service; these are available 24/7 on the department education website rads.web.unc.edu.In addition, there are 2 ‘teaching computers’ with preloaded educational modules, ideal for downtime, quick reference, homework. The modules include (but are not limited to) overview, US, MRI, Screening, Breast IR, Inflammatory Disease, LN, Male Breast and moreAttire:You will be giving patients imaging results, performing physical exams & diagnostic ultrasound, and consenting for and executing procedures. Therefore, please dress in professional attire and have your ID badge plainly visible. White coats are optional. On Block Mandatory Conferences (THREE):What: Resident ConferenceWhen: M-F, noon Where: Radiology resident conference room, basement of Women’s hospital Attendance at resident noon conference is mandatory. Please touch base with the attending prior to leaving for conference at 10 min ‘til noon. Sign out any studies in-progress with the fellow or attending on service with you. Please let me know if any particular attending keeps you regularly through noon conference so that I may remind them of this ACGME requirement. What: RADPATHWhen: Tuesday 8-10am Where: Mammo reading room: Learning preparation: Review sequential course of study power point educational modules (R2P2) prior to conference each week. This is an opportunity for residents to show their knowledge.Go to rads.web.unc.eduBreast TabBreast Rad Path (wk 1-4) IMPAX worklist scheduled ‘RADPATH CONFERENCE’ scribed alphabetically.IMPAX worklist scheduled ‘MDC CONFERENCE’ scribed in conference list order, exclude metastatic patients. What: MULTIDISCIPLINARY (412 breast conference)When: Wednesday 8-9:30amWhere: Sanofi Conference room Ground floor Cancer HospitalFellows and occasionally mini fellows to present conference patients. Diagnostic Service: (2 trainee PACS stations)Reference Tools: Diagnostic breast protocols, BI-RADS reference cardPACS worklist/ Chart cart: IMPAX worklist Radiology ‘EPIC DIAG TODAY MAMMO-not approved’ New diagnostic mammo cases will be placed by the workflow technologist in a RED folder in the diagnostic cart.Patients presenting for diagnostic ultrasound only (no mammo) will be in a GREEN folder and will not show up on the PACS worklist. You will only be aware that they are present by checking the cart itselfTake cases (this can either be one in progress or a new one). The folder in the front of the cart is the one you should look at first (this is the patient who has been in the department the longest) After previewing the case, FIRST make any observations and decide what you would do next. THEN check out with the attending. If the attending is unavailable (in ultrasound), preview another case but consider pre-dictating the one you have already looked at. Please don’t idle while waiting for additional images on a single study. Deliver interpretation results (verbal and written) to patients. Daily goal number of diagnostic cases is 10 cases for R1. Help coordinate same day biopsies for patients with BI-RADS? 5 lesions by speaking with your attending and the workflow coordinator (intercom 225)Help answer the phoneLearn how to perform (and interpret) ultrasound.Know the indication for breast or axillary ultrasoundReview the mammographic abnormality (if applicable) prior to ultrasoundRequest a chaperone from the technologist work area (male residents)Explain to the patient why an ultrasound is neededPerform a pre-scan physical exam Adjust/modify ultrasound scanning parametersFreeze and take pictures (R1s, do not send images to PACS until after reviewing with attending) Brief guidelines for diagnostic (and procedure) US images:- Accurate notation should be placed at the bottom of the image + include the following:Your initials/attending initials, side, clock face and distance from the nipple, a pictogram with the location as well as probe orientation- Center the US finding in the middle of the images. - Adjust gray scale gain, focal zone to optimize image - US modifiers: compound imaging, harmonics, landscape view for certain lesions. Procedure Service: (1 trainee (soon 2) PACS station in main reading room)Review Radsweb education resources : procedure video youtube link + Mahoney articleDay before: Populate the scheduled worklist ‘MAMMO PROCEDURES’ bucket with the next day’s patients. A paper patient schedule is posted on the procedure alternator, by our workflow coordinator by 2pm or can be found on EPICReview the patient’s diagnostic imaging Verify correct physician order/laterality & confirm this during ‘timeout’.Surgical Pathology Order: Specify type of biopsy, location side, clock face on procedure US images as well as in surgpath orderInclude ordering provider and attending radiologist to receive pathology resultsThese are picked up daily at 3pm from the reading room. Specimens obtained after 3pm need to be walked over to pathology on the 3rd floor of women’s and childrensHematology Pathology Orders: Walked to 3rd floor of the cancer hospitalType in Lab5500Microbiology orders:Type in Aerobic, Type in anaerobic and select fluid typeTube to station 82 from Children’s tube station on 1st floor of cancer hospital3 patient stickers: one placed into reading room procedure log, one on grey sheet, and one for your own procedure logDrag procedure patient names into next week’s IMPAX RadPath conference bucket listTrack and addend your patient’s biopsy resultsPath Addenda are done each Tuesday after conference and should include: 1) the date of the addendum 2) pathology copied from EPIC, 3) concordance or discordance and 4) follow up recommendation from conferenceBiopsy simulation workshops offered each block usually in week 3 First time residents (overview and practice)Senior residents are expected to facilitate/ contribute to teaching of junior residents in breast procedureScreens & Breast MRI Service: (1 trainee PACS station in the screening reading room)ScreensReview screening video module rads.web.unc.eduLook at the block schedule and note days you are scheduled to be on screens.Each screening session constitutes between 30-70 studies and maybe read in real time from IMPAX standard worklist ’Mammo Screens done today’ worklist or on your assigned day from IMPAX standard worklist ‘Mammo Screens new’ (reading yesterday’s studies) *Note, screening exams are often read in real time by the attending when time allows therefore, I strongly suggest reading screens the day before you are scheduled (most days the service tapers down considerably at 4pm and the remainder of the day is used to clean up reports/ for add on patients etc). Breast MRIProtocol breast MRI’s on the EPIC MR worklist Dictate with procedure attendingDynacad log in (available on all workstations): DynacadOther Breast Imaging resources applicable for resident education/Core exam preparation:What’s in the medical audit?Coordinate a 1 hour MQSA session with Heather Moser our QC technologist. RSNA Physics modules especially for R1 and R2.education/Under Education tab:Education Resources >>RSNA/AAPM Physics Modules >> Learn about important concepts in physics as identified in the AAPM physics curriculum designed for radiologists and radiology residents.Highest yield modules for Breast Imaging are:Fundamentals (4)Projection X-ray Imaging (6)Ultrasound (4)RADEXAM - End of block test what you’ve learnedTesting your knowledgemyTIPreport real time feedback if desired.We are delighted to have you on service. Thank you, in advance, for your hard work and help! Please feel free to email or call me if you have any questions or feedback. Sincerely,Sheila Lee, M.D.Clinical Assistant Professor of RadiologyBreast ImagingDivision Education liaison ................
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