Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

^IMaster's Degree in Medicine by Universidade Federal do Rio de Janeiro, Chief for the Unit of Computed Tomography at Instituto Nacional de Cardiologia de Laranjeiras
^IIDoctor in Medicine by Faculdade de Medicina da Universidade Federal do Rio de Janeiro
^IIIDoctor in Medicine by Universidade Federal de São Paulo, President of Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, Chief for Services of Radiology of Hospital Nove de Julho and Hospital Paulistano
^IVTitular Professor for Department of Radiology at Universidade Federal do Rio de Janeiro and Course of Post-Graduation at Pontifícia Universidade Católica do Rio de Janeiro

Mailing Address

INTRODUCTION

Medical residency is a specialization post-graduation coursedirected to physicians, utilizing the in-service-training as themain teaching procedure⁽¹⁾. The availability ofan appropriate infra-structure, a sufficient dynamics of servicesin health, and a well elaborated pedagogical program areprerequisites for an institution to offer a medical residencyprogram.

The basic criteria for the education of resident physicianshave been widely discussed by several institutions in manycountries. Among these criteria, it is important to highlight therecommendations from the Accreditation Council for GraduateMedical Education – ACGME) in 2002⁽²⁾,regarding inclusion in the curriculum of not only the theoreticalfundamentals and training applied to every field of the medicalpraxis, but also, opportunities for the development of thenecessary attitudes considered as of great relevance for theaccomplishment of future professional activities by theresident-physician. Additionally, these recommendations considerthe necessity of establishing a basic program and consolidating,among the resident-physicians, an attitude towards a constantlearning habit, especially for those who are attending programsin radiology and diagnostic imaging, considering the hugedevelopment of this specialty in the lastyears^(3,4).

A minimum programmatic content must be developed on the basisof a set of priority topics defined by means of a carefulanalysis performed by representatives of institutions involved inmedical residency programs as well as associations and agenciesrepresenting the specialty. The Association of Program Directorsin Radiology – APDR, in the United States, has developed theprograms to be accomplished by resident-physicians in radiologyand diagnostic imaging, in radiological anatomy and systems ordiagnostic methods, including head and neck, chest,cardiovascular, gastrointestinal; genitourinary, breast,musculoskeletal, neuroradiology, andultrasonography^(2,5).

In Brazil, the Comissão Nacional de ResidênciaMédica (CNRM) (National Commission for Medical Residency)has established standards and criteria for accreditation ofmedical residency programs, and the Colégio Brasileiro deRadiologia e Diagnóstico por Imagem (CBR) (BrazilianCollege of Radiology and Diagnostic Imaging) has defined minimumrequisites⁽⁶⁾ for the services to be able tooffer a training in this specialty. Most recently, still at thenormative level, some significant resources, like elaboration ofbrochures for qualification in physics⁽⁷⁾ andmammography⁽⁸⁾, have been implemented with thesupport of CBR. However, both institutions have not determined apedagogical program with clearly defined objectives.

In this study, the authors suggest a basic program forresident-physicians education in radiology and diagnosticimaging.

MATERIALS AND METHODS

The authors have performed a literature review and criticalanalysis about curricular norms and minimum programmatic contentregarding medical residency in radiology and diagnosticimaging.

The currently effective CBR and CNRM norms have been analyzedand compared, the essential topics being identified and includedin the present proposal.

RESULTS

According to the currently effectivenorms^(6,9), the length of the training periodis three years. The resident-physician is entitled to a 30-dayvacation period per year. The CBR recommends that,preferentially, the whole training should be accomplished in asingle accredited institution. However, in cases where theaccredited institution has not a determined equipment ordiagnostic resource, consent is given by CBR for the trainee toundergo up to 4-month training period in a service indicated bythe accredited institution.

The CBR basic program determines that the resident-physicianshould be trained in conventional radiology, ultrasonography,nuclear medicine, computed tomography, magnetic resonanceimaging, bone densitometry, and, also, in the following areas:neuroradiology, head and neck radiology, chest, digestive system,genitourinary system, musculoskeletal system, gynecology andobstetrics, breast, pediatrics, and interventional radiology(biopsies, drainage, vascular procedures).

The minimum criteria established by CNRM⁽⁹⁾for accreditation of programs in this specialty determine thatthe training should be in general and contrast radiology,ultrasonography, mammography, computed tomography, bonedensitometry, magnetic resonance imaging, interventionalradiology, examination techniques, urgencies and emergencies,respecting a minimum 80% of the annual full-time load. Thetraining in nuclear medicine is considered as optional, and theinstitution must offer mandatory courses in medical physics andradiological protection, and cardio-respiratory reanimation.

Ten to twenty per cent of the annual full-time load should bereserved for complementary theoretical activities, includinganatomoclinical sessions, discussions on scientific papers,clinical-radiological sessions, clinical-laboratory sessions,courses, lectures and seminars. These activities mustobligatorily include themes associated with bioethics, medicalethics, scientific methodology, epidemiology, andbiostatistics⁽⁹⁾.

In the present study, the model developed is didactically divided into modules, in compliance with CBR and CNRM recommendations. The module includes stages in different modalities of investigation by diagnostic imaging, whenever possible focusing on an organ of the system. This kind of division is aimed at organizing the acquisition of theoretical knowledge, allowing an appropriate transposition into the practice. Modules based on stages in diagnostic methods like bone densitometry, nuclear medicine, computed tomography, magnetic resonance imaging and ultrasonography, also are scheduled to allow a more comprehensive experience in the global practice of the specialty. Each module will have a mean duration of one month, these modules being harmonically distributed throughout the three-year period, according to the content extent, in an attempt to familiarize the resident-physician with the all the specialty domains (Table 1).

Considering the cumulative character of the knowledges andschedules, the training in conventional radiology initiated inthe first year will remain as an integral part of the schedulesin the subsequent years, with a proportional part-time load, asthe other diagnostic methods are added.

During the stage in these modules, the resident-physicianshould be offered training in different diagnostic methods, in aschedule with progressive complexity. The chest module, initiatedwith conventional radiology during the first year of training. Inthe second year, although this activity remains as a part of theschedule, more time will be dedicated to computed tomography; andin the third year, stages in magnetic resonance imaging andcardiovascular system radiology (echocardiography, computedtomography and magnetic resonance imaging) will be developed.

A performance evaluation must be undertaken by means ofpractical and theoretical tests applied by the work team andpreceptor. It is important to note the necessity of establishingpreviously defined models for these tests, aiming at allowing anevolutive and comparative analysis both at individual andcollective levels along the years. The results of suchevaluations should be utilized as material for reflection andeventual adjustments in the program.

At each module, the resident-physicians will be evaluated asto their acquisition of practice competences involving not onlyexaminations performance but also their interpersonalrelationship both with patients and the health team. The modelfor practical evaluation is of easy implementation and should beperformed during the daily routine, including all the steps ofthe examination since the first contact with the patient up tothe elaboration and discussion of the medical report.

The theoretical test should be applied every quarter, asrecommended by CNRM⁽⁹⁾.

The evaluation of the resident-physician attitudes must beundertaken by members of the health team other than thepreceptor, who should analyse the evolution of theresident-physician relationship both with patients and healthteam, establishing an arbitrary classification of sufficient,regular, or insufficient.

The preceptor's evaluation consists of a global appreciationon the level of competences in five domains: patients care,medical knowledges, interpersonal relationship and communication,learning from practice and professionalism.

At the end of each module, the resident-physician must writedown a maximum two-page report, summarizing his/her experience,difficulties, and suggestions for improvements, besides aself-evaluation. This report must be delivered to the preceptorresponsible for the module for appreciation.

In case of lack of local availability of determined equipmentnecessary for the resident-physicians training, the accreditedinstitution should enter in a formal agreement with anotherinstitution or service which can offer such a training modality.This institution must assign a preceptor as responsible for thispart of the training, including evaluation, besides presenting aprogram with defined objectives.

For discussions of themes regarding bioethics and medicalethics, didactic material available in the Regional and FederalMedicine Councils can be utilized⁽¹⁰⁾, besidesattendance at events periodically held on these themes. It isrecommended that during the learning of these themes, situationsexperienced by resident-physicians and their preceptors arediscussed in ethical-clinical sessions⁽¹¹⁾.

Activities associated with scientific, biostatistical andepidemiological methodologies may be developed in the form ofexpositive classes, discussions on scientific papers, or even bymeans of discipline approaching these three themes.

Proposal for distribution of practical and theoreticalactivities for each of the years of residency

1 – The first year (R1) – From the conceptual point ofview, the first year of medical residency is a landmark in thetransition between the phase of graduation and the commencementof the medical specialty practice. The main objective of thisstage is to allow that the resident-physician acquires goodhabits for the development of his/her career on a solid basis offundamental concepts.

Activities to be developed:

• Course on radiation physics, Imaging and radiologicalprotection.

• Bioethics and medical ethics, aiming at allowing theacquisition of good habits of clinical practice, and improvementof the interpersonal relationship with patients and healthteam.

• Hospital infection control, according to CNRMrecommendations⁽⁹⁾.

• Scientific methodology and epidemiology.

• Study of radiological anatomy and development ofperception of normal and abnormal structures.

• Radiological semiology: to consolidate a model oforganized analysis of structures in the several diagnosticmodalities. To recognize and classify the signs associated withconditions.

• Norms for an appropriate utilization of equipment andmaterials for diagnostic investigation, as well as notions ofcosts involved in each procedure.

• Learning of routine of examinations and reportselaboration.

• Learning of theoretical bases for attendance inemergency situations, including training in cardiorespiratoryreanimation.

• The training must give priority to conventionalradiology and ultrasonography.

• Clinical-radiological, anatomo-radiological sessions,and discussion on specialty-related scientific papers selected bythe preceptors. These papers should be, preferably, ofstate-of-art or review-type, adapted to the training complexitylevel.

Proposal for organization and distribution of trainingschedules:

First half year – Chest radiology, digestive system radiology,musculoskeletal system radiology, radiology in rheumatology andbone densitometry, radiology in emergency medicine and breastradiology.

Second half year – Ultrasonography, computed tomography,neuroradiology, urology (including the male genital system),pediatrics.

Vacations – 30 days.

2 – The second year (R2) – The objectives of this stageare; basically, to consolidate and deepen the learned concepts,advancing in the training in other diagnostic methods.

Activities to be developed:

• Courses of physics and imaging applied to computedtomography and ultrasonography, including Doppler.

• Learning of interventional radiology techniques.

• Training in medical emergencies in the form of shifts.This training must be developed in public health services,according to CNRM recommendations⁽⁹⁾.

• Activities related to medical ethics and bioethics.

• Clinical-radiological, anatomo-radiological sessions,and discussion of specialty-related scientific papers, selectedby the training preceptors.

• The in-service training must include conventionalradiology, ultrasonography, Doppler, endocavitary probes, andcomputed tomography.

• In some institutions with magnetic resonance imagingfacilities, the training in this modality can be initiated duringthis stage.

Proposal for organization and distribution of trainingschedule:

First half year – Radiology in gynecology, chest radiology,digestive system radiology, musculoskeletal radiology, head andneck radiology, radiology in pediatrics.

Second half year – Ultrasonography, computed tomography,neuroradiology, interventional radiology, breast radiology.

Vacations – 30 days.

3 – The third year (R3) – The main objective of thethird year is to allow that the resident-physician graduallyprogress to an independent posture, like that to be adopted inhis/her professional life.

Activities to be developed:

• Course of physics and imaging applied to magneticresonance imaging and nuclear medicine. Principles of protectionin nuclear medicine.

• Training in methods of higher complexity ininterventional radiology.

• Training in medical emergencies in the form ofshifts.

• Activities associated with medical ethics andbioethics.

• Clinical-radiological, anatomo-radiological sessionsand discussions on specialty-related scientific papers. Theselection of papers must be made by the resident-physician underthe preceptor's supervision.

• Full training in all diagnostic modalities, includingmagnetic resonance imaging and nuclear medicine.

Proposal for organization and distribution of trainingschedules:

First half year – Diagnostic imaging in obstetrics, chestradiology, digestive system radiology, musculoskeletal radiology,neuroradiology, nuclear medicine.

Second half year – Magnetic resonance imaging (two months),neuroradiology, interventional radiology, head and neckradiology.

Vacations – 30 days.

DISCUSSION

For more than a decade, both CBR and CNRM have demonstrated aclear interest in defining a set of essential competences whichshould be necessarily incorporated into the education ofresident-physicians in radiology. In 1989, in the city ofSão Paulo, the Fundação Nacional deDesenvolvimento e Apoio à Pesquisa (National Foundationfor Research Development and Support) promoted an importantseminar on organization of medical residency programs inradiology⁽¹²⁾. This seminar was held with theactive participation of CBR and CNRM members, as well asinnumerable preceptors of medical residency programs from severalstates of the country. The annals of this meeting, among its mainconclusions, indicates the necessity of establishing the minimumknowledges and skills required for a competent practice of thespecialty.

In this context, specific requisites for a program of medicalresidency in radiology and diagnostic imaging were carefullydefined on the basis of worldwide consolidated experiences inprogrammatic organization like the North-Americanone⁽¹³⁾. Their program has been widely acceptedand has been implemented throughout the United States. Annualmeetings of APDR are held for following-up the development ofthis program, allowing its coordinators to keep updated with theACGME guidelines. Additionally, a norms and procedures manual hasbeen issued and periodically updated to inform coordinators oneventual modifications⁽¹⁴⁾.

The rapid technological and scientific development in thisspecialty has caused a significant accumulation of information.Changes in the teaching-learning system have become necessary tocope with this new reality⁽⁴⁾. This requires teachingstrategies capable of deliver a model of hierarchicalorganization of knowledge acquisition, assuring the learning ofbasic and essential concepts. The resident-physician, at the endof the training, must be able to utilize in a critical way allthe resources which will allow him/her a continuous improvementalong his/her professional life.

The elaboration of minimum programmatic contents for eachspecialty or diagnostic method is aimed at organizing a set ofpriority topics to be obligatorily learned. Parallelly, otheractivities like bioethics, medical ethics, epidemiology andbiostatistics should be offered to supplement the education ofradiologists.

Material resources should not be limited to utilization ofequipment, since IT resources for reference to data banks anddigital images processing and filing systems are essentialelements in the modern practice ofradiology⁽¹⁵⁾. Resident-physicians should begiven access to an updated library, and to the main periodicalsof the specialty.

Evaluations are essential tools not only to attribute valuejudgement on knowledge acquisition by the resident-physician, butalso to allow reflections and eventual adjustments in the offeredprogram. Such evaluations should be performed within a modelalong the three-year period to allow the comparison of resultsand analysis of the effectiveness of the implemented changes. Theevaluations results must be always discussed with theresident-physician to allow his/her improvement.

A nationwide medical residence program adjusted to theBrazilian reality will allow a greater integration of the severalprograms and a more homogeneous education of future specialistsin radiology and diagnostic imaging.

CONCLUSION

The adoption of a basic program for medical residency in radiology and diagnostic imaging will allow the future implementation of a program for quality control in the education of the specialist in radiology and diagnostic imaging.

REFERENCES

1. Brasil. Decreto nº 80.281, 1977. Regulamenta a residência médica, cria a Comissão Nacional de Residência Médica e dá outras providências. Brasília: Diário Oficial da República Federativa do Brasil, 6/9/1977. Seção 1, pt 1, p. 11787.        [  ]

2. Program director's reference guide to ACGME and RRCs. [cited 2004 Jul 17]. Available from: http://www.acgme.org        [  ]

3. Collins J, Herring W, Kwakwa F, et al. Current practices in evaluating radiology residents, faculty, and programs: results of a survey of radiology residency program directors. Acad Radiol 2004;11:787–794.        [  ]

4. Goske MJ, Reid JR. Define a national curriculum for radiology residents and test from it. Acad Radiol 2004;11:596–599.        [  ]

5. Collins J. Program documents: policies and guidelines. Acad Radiol 2003;10(Suppl 1):S21–S23.        [  ]

6. Colégio Brasileiro de Radiologia. Programa básico de residência médica ou curso de especialização para formação em radiologia: credenciamento (requisitos mínimos). [citado 4/4/2005]. Disponível em: http://www.cbradiol@cbr.org.br        [  ]

7. Colégio Brasileiro de Radiologia. Princípios básicos de física em radiodiagnóstico. São Paulo: CBR, 2002.        [  ]

8. Colégio Brasileiro de Radiologia. Programa para treinamento em mamografia. Coordenador do projeto: Hilton Augusto Koch. São Paulo: CBR, 2004.        [  ]

9. Brasil. Ministério da Educação. Secretaria de Educação Superior. Comissão Nacional de Residência Médica. Resolução nº 4 de 2 de julho de 2003. Dispõe sobre os critérios mínimos para credenciamento de programas de residência médica e dá outras providências. Brasília: Diário Oficial da União, 29/12/2003.        [  ]

10. Conselho Federal de Medicina. Programa de Educação Médica das séries Bioética, Medicina Brasileira e Práticas Médicas. [citado 16/7/2005]; Disponíveis em: http://www.educaçãomedica@ cfm.org.br        [  ]

11. Sousa EG. A discussão de temas de bioética e de ética médica em programas de residência médica na especialidade de radiologia e diagnóstico por imagem. Rio de Janeiro: Informativo da Radiologia, 2003;77.        [  ]

12. Fundação do Desenvolvimento Administrativo (Fundap). Seminário. Requisitos mínimos de um programa de residência médica: competências em radiologia (editorial). Rev Imagem 1991:13:1–8.        [  ]

13. Rao VM. Radiology curriculum guidelines 1999/2000. [cited 2005 Feb 5]. Available from: http:// www.apdr.org        [  ]

14. Collins J, Chew FS. Radiology residency program directors' manual. Acad Radiol 2003;10(Suppl 1).        [  ]

15. Chew FS. Educational infrastructure for radiology residency programs. Acad Radiol 2003;10 (Suppl 1):S92–S96.        [  ]

Mailing Address:
Dra. Ana Luiza Boéchat
Instituto Nacional de Cardiologia de Laranjeiras
Rua das Laranjeiras, 374
Rio de Janeiro, RJ, 22240-006, Brazil
E-mail: alboechat@incl.rj.saude. gov.br

Received March 15, 2006. Accepted after revision June 5, 2006.

* Study developed as a Master's Degree Dissertation at Department of Radiology of Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.