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Opinions |
1 From the Department of Radiology, Columbia University, Milstein Hospital Bldg, 3rd Floor, 177 Fort Washington Ave, New York, NY 10032 (S.C.); and Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (R.B.G.). Received April 6, 2004; revision requested June 18; revision received August 6; accepted September 29. Supported in part by a grant from the RSNA Research and Education Foundation. Address correspondence to S.C. (e-mail: sc56{at}columbia.edu).
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ABSTRACT |
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© RSNA, 2005
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INTRODUCTION |
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One conventional answer adopted by many radiology departments can be paraphrased by the energetic response: Yes, this can be done by working harder and harder. Many astute observers have noted that this answer has resulted in longer clinical hours for a large proportion of academic radiologists, with a concomitant decrease in time spent in research and educational pursuits. In this situation, many junior faculty members might find it more difficult to make the traditional sacrifices to spend occasional evenings and weekends on research projects or educational presentations, when they are already spending several evenings and one or two weekends of every month on call. If they make that sacrifice, then they risk the development of seriously unbalanced lives and the problem of burnout. Finally, the lure of higher-paying private practice jobs may be more difficult for erstwhile academic radiologists to resist if the academic radiologist's job becomes increasingly similar to that of a private practice radiologist. Therefore, it seems that the solution of working harder, as attractive as it may seem in the short term, is fraught with long-term problems for academic radiology and may actually aggravate the shortage of academic radiologists.
We contend that academic radiology needs to come up with better long-term answers. Finding such answers will require a search for innovations in strategy (3) that improve the prospects for both academic radiologists and the departments in which they work. To address the issue of insufficient numbers of academic radiologists, we need to step back and recognize that this issue represents a strategic problem for the entire profession of radiology. If academic radiology departments continue to devote most of their resources to the clinical mission at the expense of the research and educational missions, then there are potentially serious consequences. In the research arena, there may be a vacuum created by the lack of scientifically minded radiologists capable of exploring and developing new imaging technologies. It has often been said that "the failure to do the research today will lead to the loss of control of tomorrow's imaging technologies" (4). In the educational arena, there will be fewer individuals who can not only teach the necessary details of everyday clinical radiology but also inspire trainees to develop the important skills and professional behaviors that are the hallmark of the superior radiologist. Such individuals also are needed to help provide the environment of intellectual stimulation and inquiry conducive to professional learning and to motivate more trainees to consider academic radiology as a serious career pathway. Therefore, a persistent shortage of academic radiologists is likely to lead to a long-term crisis that has implications for not only academic radiology but also the entire profession of radiology.
Such a crisis may be viewed in two different but highly complementary ways. First, we learn from Kuhn that the existence of a crisis is a necessary precondition for the successful development of new ways of thinking that replace older ways of thinking and doing—a phenomenon that he labeled a "paradigm shift" (5). As the word paradigm has been bandied about in the popular literature in many ways, we will use a specific definition offered by Barker: "A paradigm is a set of rules and regulations (written and unwritten) that does two things: (a) it establishes or defines boundaries; and (b) it tells you how to behave inside the boundaries in order to be successful" (6). In this article, we articulate some of the central strategic themes of the "old" paradigm of academic radiology and venture to identify key strategic themes of the "new" paradigm.
Second, we note that the existence of a crisis is not inherently a bad condition. In this light, we refer to the etymology of the character for the Chinese word for "crisis," which is composed of two radicals; the left-hand radical means "problem," and the right-hand radical means "opportunity" (Fig 1). In our view, the shortage of academic radiologists should lead all of us in academia to question basic assumptions about our work and place in society and how we are actually carrying out our mission. Specifically, we should use this opportunity to refocus our attention on the central questions at the heart of academic radiology: What are the main functions of the academic radiologist? How should academic radiologists be organized to maximize their productivity? To respond effectively to the changes in the health care environment, we need to develop a deeper appreciation for the nature of the work of the academic radiologist and a fuller understanding of physician productivity. These insights would help academic radiology departments determine how to help academic radiologists increase their productivity, whether by working smarter, organizing their professional work better, or helping them make more effective decisions. Success in this arena will be determined by the ability of an individual academic radiology department to transform itself in ways that promote overall productivity, support the motivation of radiologists to do their best work, and attract energetic and suitably trained individual professional contributors and collaborators.
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STRATEGIC ISSUES FOR ACADEMIC RADIOLOGY: WHO IS THE ACADEMIC RADIOLOGIST? |
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After briefly describing the dominant strategic themes of the 20th century, we then present emerging strategic themes that help "make sense" of these central issues. According to one expert on strategy, Mintzberg (8), emergent strategy is defined as a strategy that arises from "a series of ad hoc initiatives, reactions, decisions, and choices that executives and managers make in response to daily pressures, without guidance from a pre-existing planned strategy." He also posits that as much as 90% of an organization's actual strategy is based on emergent strategy. For the purpose of this article, the advantages of adopting this overall strategic approach are twofold. First, identification of emerging strategic themes allows radiologists to use the same language in discussing upcoming changes in academic radiology and, thereby, affords them the opportunity to make sense of the changes that are occurring around them (9). Second, this approach encourages academic radiologists to look outside their own profession to identify new concepts, methods, or initiatives that may lead to successful adaptation to environmental change. In exploring these themes, we find that there is much to be learned from the disciplines of operations management, human resources management, knowledge management, and adult learning. These three emerging strategic themes epitomize ways of meeting the upcoming crisis and, potentially, enable an individual academic radiology department to increase productivity in all three academic missions.
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THE RADIOLOGIST AS KNOWLEDGE WORKER |
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Academic radiologists extend this knowledge work into both their research and educational missions. In the research realm, academic radiologists use their knowledge and skills to derive scientific hypotheses, design experiments, provide imaging data, analyze results, and draw accurate conclusions. In the educational realm, academic radiologists use their deep subspecialty knowledge along with their teaching skills to facilitate the learning of other individuals in regard to the appropriate use of imaging technologies, the evaluation of diagnostic images, and the clinical decision making about the meaning and significance of the test results.
The recognition of the radiologist as knowledge worker is critical to the achievement of maximal productivity. This is because the measurement of the productivity of knowledge workers is quite different from that of the productivity of manual laborers. As pointed out by Zaslove (12), the productivity of manual laborers can be evaluated on a quantitative basis. The number of satisfactorily constructed widgets can be divided by the number of hours required to produce them to derive a productivity measurement. In knowledge work, however, productivity is associated with not only the number of things produced but also their quality. Some suggest that, at the higher levels of knowledge work, the importance of quality exceeds that of quantity. Zaslove proposed a modification of this simplistic equation to demonstrate how productivity measurement in clinicians may be performed; we have adapted this model to show how radiologists' productivity could be measured similarly (Fig 2).
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We face problems of even greater difficulty with respect to measurement of research productivity and assessment of educational productivity. Although we can produce relevant quantitative figures for research productivity (such as the number of published papers and the number of funded grants) and educational productivity (such as the number of teaching sessions and the teacher ratings), the measurement of quality is not clear in these arenas. For example, in research, although one can argue that publication of a report in a renowned and widely read journal is worth much more than publication of it in a highly subspecialized journal with limited circulation, one would not know how to assess the differences in quality. To assess the differences, should we use journal impact factors, number of citations, or expert panel ratings? In educational circles, it is often stated that the success of an educational intervention is related to the change in knowledge, attitudes, and behavior inculcated in the learners. Although teacher ratings represent a method by which to access feedback of the learners about their view of the educational intervention, other factors may cloud the relevance and importance of these ratings, such as differences in popularity among educators. Also, assessment of educational scholarship by university promotion committees requires ongoing documentation of scholarly teaching activities, a process that often receives substantially less attention than it deserves (15).
Another important consequence of the recognition of the radiologist as knowledge worker is that radiologists have the means of production within their heads. Therefore, radiology departments have to treat these individuals carefully, as these resources are physically mobile. During a time of a surplus of radiologists, this fundamental attribute of knowledge workers simply means that the organization suffers the loss of time and expense related to hiring a substitute radiologist, as well as the specific knowledge, skills, and experience that the original radiologist had learned on the job at that institution. In the past, academic radiology departments readily tolerated the effects of the mobility of academic radiologists, as they could readily recruit others who would bring new ideas, knowledge, and skill sets to them. In a period of a shortage of academic radiologists, however, radiology departments will need to retain their radiologists because of increased difficulty in finding satisfactory replacements. Departments faced with prolonged periods of understaffing are likely to experience growing levels of dissatisfaction among those who have to shoulder the extra work, and this burden of extra work leads to the possibility of further attrition. This could lead to a "death spiral" in which a whole division or even a whole department dissolves and has to be rebuilt from scratch. Given the shortage of academic radiologists, this is very difficult to accomplish. Even in the absence of such cataclysmic developments, there is a discernible economic deficit to any organization that loses valuable knowledgeable radiologists because of the loss of human capital and attendant turnover costs (16).
The view of the academic radiologist as a knowledge worker indicates that academic radiology departments should be looking for more than experience in a clinical subspecialty in the evaluation of the knowledge and skill sets of an academic radiologist. It is obvious that there are highly important well-defined bodies of knowledge, such as molecular medicine, tissue engineering, and medical informatics, that need to be imported into radiology. Radiologists with the background and the skills in these areas are likely to be in great demand. Equally important are the skills that are not so readily identifiable. These include the facility to increase the clinical productivity of one's colleagues, the ability to mentor junior faculty members about how to initiate and conduct research successfully, and the capability of promoting smooth and productive collaborations with departmental colleagues, as well as with members of other academic departments and disciplines. To address such issues, academic radiology departments must examine the following: (a) the identification of key bodies of knowledge and knowledge-producing processes (specific for each individual department); (b) the organizational processes that promote the sharing of that knowledge and thus maximize its benefits; and (c) the availability of sufficient slack (ie, time and resources) to allow academic radiologists and others to take advantage of the opportunities associated with dissemination of valuable knowledge. Proper attention to these issues on a department-wide level may lead to a vision of how work will be accomplished in each academic domain during the 21st century.
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MODELS OF ACADEMIC PHYSICIANS |
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The viability of the triple-threat model, however, was scrutinized in the 1980s, as many began to doubt that it was possible for any but the most talented academic physicians to achieve excellence in all three academic arenas at the same time (17). Therefore, the "dual-platoon" model was proposed, whereby academic physicians were divided into clinician-educators and laboratory-based physician-scientists. In the 1990s, this model further evolved into a "three-platoon" model, with the growth of a new group of academic physicians known as clinician-scientists (18). This group of physicians is skilled not only in clinical medicine but also in the performance of scientifically rigorous clinically based scientific studies. Typically, these physicians have training or experience, or both, in important disciplines in public health, including biostatistics, epidemiology, technology assessment, health services research, and evidence-based medicine. In radiology, there has been overt recognition of the importance of this third-platoon model. Important initiatives in this regard include the development of Radiological Society of North America research grants targeted for academic radiologists early in their careers and the initiation of the General Electric–Association of University Radiologists Radiology Research Academic Fellowship targeted for radiologists who are developing expertise in technology assessment and health services research.
In the 21st century, which, if any, of these models of an academic physician should academic radiologists pursue in their careers? We suggest that the way that individual academic radiology departments answer this question will have a substantial impact on the future welfare of academic radiology. There is one cardinal principle that will underlie any effective solution in the 21st century: It will not be necessary for each academic radiologist to develop a complete background in each sphere of academic activity for work in that arena. In the early history of academic radiology, it may have been possible for a number of individuals to cross over routinely as an expert from one radiology subspecialty to another. The trend toward knowledge explosion in each subspecialty, however, as well as the trend toward an increasing number of radiology subspecialties, now makes that phenomenon a relatively rare accomplishment. Instead, we posit that the academic radiology department should be searching for ways that promote greater collaboration, teamwork, and sharing of knowledge among all of its members (19). For example, for a junior radiologist to perform a health services research project, he or she need not first become an expert in health service research to perform one or even a few studies in this field. Instead, we suggest that an academic radiology department will need to develop the social structure and culture that allow this individual to feel free to team up with other individuals who do have the requisite sets of skills and knowledge in that field. Of course, this also implies that the academic radiology department is structured in a way that allows and encourages the skilled expert to have the time and motivation to share his or her expertise with the more junior individual (who might be one of several individuals requiring the expert's attention). In the best-case scenario, this department has anticipated the need for the sharing of knowledge and has afforded that expert some discretionary time, that is, "free time" away from reading clinical radiologic studies. Of course, we are highly conscious that in an economically competitive environment, slack is one of the first job features to disappear. As DeMarco (20) points out, however, organizations tend to become more efficient by sacrificing their ability to change, and the judicious use of slack is the key ingredient in promoting change, innovation, and reinvention. We maintain that academic radiology departments need to create slack to promote the development of new professional initiatives that meet local and institutional needs. For example, such initiatives may involve the creation of new imaging services, the invigoration of a research community, or the development of new educational programs that meet accreditation requirements. Judicious investment in these initiatives could facilitate a "positive feedback" cycle in which further successful initiatives could be supported.
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THRESHOLD COMPETENCIES AND JOB COMPETENCIES OF ACADEMIC RADIOLOGISTS |
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On the other hand, Boyatzis (22) defined a threshold competency as "a person's generic knowledge, motive, trait, self-image, social role, or skill which is essential to performing a job, but is not causally related to superior job performance." An example of a threshold competency for an academic radiologist is the body of knowledge of general radiology as applied to everyday clinical work. The ability to interpret commonly requested images such as conventional radiographs, cross-sectional images of the head and body, and nuclear medicine images of the bones, lung, and abdomen is highly valued in today's academic radiology department. It is generally acknowledged, however, that this particular competency is not one that will differentiate a superior academic radiologist from an average one.
What were some of the critical job competencies in academic radiology during the 20th century (Table)? In the clinical realm, deeper knowledge of a subspecialty discipline within radiology (as exemplified by fellowship training and further postgraduate experience) has been a job competency for academic radiologists (23). In the research realm, knowledge of experimental design, coupled with personal attributes of persistence, imagination, and clarity of thought, have been hallmarks of a successful radiology researcher. In addition, the ability to write scientific articles in a clear and thorough fashion has been a job competency. In the educational realm, job competencies include excellent communications skills, use of a wide variety of teaching cases, and a learner-oriented value system. Certainly, the ability to entertain and captivate audiences during oral presentations has been an important job competency for a number of academic radiologists who are in high demand as speakers.
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WHY 20TH-CENTURY THRESHOLD COMPETENCIES WILL NO LONGER SUFFICE IN THE 21ST CENTURY |
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In vernacular form, we could refer to this set of generally accepted (though previously unarticulated) 20th-century strategic themes as "quality, individuals, and instruction." In the 21st century, however, each of these aforementioned competencies will be insufficient to meet the demands of rising needs as determined by the surrounding health care environment and by society. These needs require academic radiology departments to provide the following: (a) a higher volume and a wider array of diagnostic imaging services, many of which are associated with greater complexity; (b) the researchers who can discover, define, or establish appropriate uses of imaging technology in ways that provide greater clinical effectiveness and lower health care costs; and (c) an educational milieu that not only provides the mechanism for helping trainees establish initial competency in diagnostic radiology but also guides them in the development of intellectual tools and mind-sets that will help them to maintain competency as postgraduates. We identify three new strategic themes that have emerged recently at various academic radiology departments. These new domain-based themes include the throughput (or overall service speed from start to finish) of clinical radiologic operations, the formation of interdisciplinary research teams with a high-performance ethic, and the emphasis on self-directed learning as the educational process to achieve and maintain professional competence. These themes pithily may be referred to as "throughput, teams, and self-directed learning" (Fig 3).
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THROUGHPUT: NEW STRATEGIC THEME FOR THE CLINICAL MISSION |
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There is a plethora of information and experience from both manufacturing and service industries about ways to increase service speed. Basic texts in operations management cover essential concepts such as process throughput, limiting resource (or "bottleneck"), and capacity utilization. Furthermore, during the 1980s and 1990s, it became strikingly evident in diverse industries that reduction of service time resulted in substantial competitive advantage for those companies that were able to deliver their products and services with the requisite quality in a markedly shorter time frame (27). In addition, the full array of process improvement technologies that are inherent in total quality management, reengineering, and six sigma programs have yet to be applied on a broad basis to the service operations of most academic radiology departments. Regardless, speed alone will not solve the problems of the academic radiology department because the typical academic radiology department tends to offer a wider array of complex services than does the typical private group practice; many of these diagnostic services require subspecialist involvement. How can this set of problems be approached?
We suggest that the new strategic theme for the clinical mission is throughput. Operationally, throughput is the rate at which the system generates output over unit time and is often expressed as a ratio between output and input. More prosaically, throughput is defined in The Goal by Goldratt and Cox (28) as the rate at which the system generates money through sales. (That bottom-line orientation helps to focus otherwise "over-erudite" academic discussion.) In academic radiology, throughput can be viewed as having two different components, both of which have a distinctive value component. First, the operational production of a diagnostic test in a patient starts from the time the patient is scheduled and does not conclude until the time when the referring physician (or patient) has the appropriate test results available to him or her. For the radiology department, however, this process is not finished until the appropriate financial remuneration for performance of the study has been collected. This entire process is referred to as the "value-chain." Throughput can be increased by augmenting the capacity of the entire process at the rate-limiting flow step, which is known as the bottleneck. For example, if the bottleneck for performing MR imaging procedures is related to the number of technologists available to process the work, then hiring more MR imaging technologists is likely to result in improved throughput. The emphasis on throughput as opposed to speed implies that improvement efforts are directed mainly to the bottleneck, and not to each individual step of the work process, unless a particular step, or series of steps, can be eliminated completely.
Second, in the case of certain imaging studies that comprise hundreds to thousands of source images, such as computed tomographic (CT) angiographic scans, functional MR images, and screening lung CT scans, there is a huge amount of information that requires viewing and interpretation by a subspecialty-trained radiologist. Hence, we could conceive of the interpretation process itself as a measurable value-added component and can relate this process to the knowledge work that radiologists perform, as discussed in an earlier section. One may anticipate that images obtained with these kinds of intensive cross-sectional studies may require increasing amounts of visual effort and time, compared with the clinical CT scan of the late 20th century. In addition, the likelihood of exponential growth of such studies is high, as knowledgeable baby-boomers demand such services; however, the continued shortage of such skilled radiologists is likely to make speedy service difficult. Therefore, in this regard, we can already perceive the beginning of a long-term bottleneck in which advanced studies await completion of interpretation by an already overworked expert radiologist. Siegel and Reiner (29) perceived some of the professional and technologic issues inherent in this paradox, and with colleagues at the Society for Computer Applications in Radiology, they have helped spearhead a new initiative called Transforming the Radiological Interpretation Process. The focus of this initiative is on defining ways in which images obtained with such intensive and complicated studies can be most expeditiously viewed and interpreted by radiologists, while taking into account the factors that result in perceived loss of quality. These could be related to previously unsuspected imaging findings, organ system findings that are beyond the expertise of the radiologist in a given subspecialty, or other forms of observation or technology-related error. In this example, if one discovered that the bottleneck for performing high-volume intensive cross-sectional studies and interpreting images obtained with them existed at the level of the subspecialty radiologist, then one could improve throughput for the entire work process by finding ways for radiologists to interpret these kinds of images more expeditiously.
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TEAMS: STRATEGIC THEME FOR THE RESEARCH MISSION |
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The word team conjures up many views of a team, whether beneficial or harmful, and many ideas of what actually constitutes a team. In this regard, Katzenbach and Smith (31) emphasize the inextricable connection between teams and high performance. They define a team as "a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable." To paraphrase this wisdom, a team that is not associated with high performance is not truly, or not yet, or no longer a team, according to their definition. Such a group might properly be termed a potential team or a working group instead. The skills required for academic radiologists to be effective team members are not automatically acquired during residency and fellowship; in fact, they are not necessarily developed during the course of a career in academic radiology. In management and organizational behavior, there is one interesting line of research about the phenomenon of "skilled incompetence" in which experienced executives use "practiced routine behavior (skill) to produce what they do not intend (incompetence)" (32). Similarly, given their highly developed expertise in a sophisticated technologic field, radiologists need to be aware of the possibility of skilled counterproductive behaviors in dealing with colleagues and team members.
Teamwork skills would best be developed early in one's academic career. Although there are several excellent texts about developing facility with these skills, practice, experience, and self-awareness are really the critical factors in promoting team skills (33–35). In addition, the presence of valued role models with substantial multidisciplinary team experience—especially mentors and colleagues inside or outside the academic radiology department—would be valuable in professional development of faculty. Finally, it would be useful for academic radiologists and others to recognize that the same skills used in teamwork can be more broadly applied to networking, which can often be helpful in getting organizational work done, and thereby help to promote professional success in research and other spheres of academic endeavor.
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SELF-DIRECTED LEARNING: STRATEGIC THEME FOR THE EDUCATIONAL MISSION |
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We note that the instructional program has always been supported by the regular textbook reading that the typical radiology resident would do for at least 1 or 2 hours on several nights during the week. The actual substance of the reading typically would be determined by the individual resident, with guidance from fellow residents and the occasional advice of the attending staff. This framework worked well in the 20th century in producing residents who could pass the board certification examinations and function as practicing radiologists after residency; however, we note that the traditional framework is threatened by several 21st-century trends. First, the shortage of academic radiologists, particularly in academic programs that are small or short-staffed, threatens to limit the amount of time and effort available to provide instruction, as well as the time to upgrade instructional material and to develop new instructional presentations. Second, in the 21st century, there is increasing likelihood that some radiology faculties may have certain gaps in their collective knowledge; for example, one could imagine that, 5–10 years from now, some academic institutions may still have no individual with real expertise in molecular imaging. Third, the adoption of the picture archiving and communication system by academic medical centers has changed the work patterns of the radiology resident, with possible loss of experience-based learning. Some authorities suggest that this has served to diminish that individual's role from "being an assistant radiologist" to "observing a radiologist" (36). If so, then an unintended consequence of picture archiving and communication system technology is to undermine the education one receives at the viewing station during clinical readout sessions.
Although instruction-based education will remain a mainstay of resident-based radiology education, we suggest that greater emphasis be placed on the individualized study that residents accomplish during their training. In fact, this individualized study may represent an early stage of self-directed learning; that is, such individualized study may be a learning process by which individuals "assume ownership of their thoughts and actions" (37). This process is one that residents will continue to use after completion of residency to meet professional challenges in their future and to maintain their competencies for continued board certification. For postgraduate radiologists, study will remain a critical component of their self-directed learning. Another critical component of self-directed learning is inquiry (38). Although the curriculum of radiology residency constrains the breadth of topics that a typical radiology resident will cover, postgraduate radiologists will need to decide about what topics they want or need to learn more and how to do so. In other words, these skills require that the individual decide what the questions are, rather than that the individual just find the answers. For radiology residency programs, we suggest that more attention be paid to self-directed learning, with development and refinement of skills in study and inquiry. This will require radiology educators to rethink their educational goals and methods (39) and, perhaps, to engage in their own self-directed learning programs about teaching (40).
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ENHANCING THE VALUE OF STUDY: ESSENTIAL COMPONENT OF SELF-DIRECTED LEARNING |
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In promoting the value of study, we do not mean to increase the average amount of time that radiology residents already spend in studying, whether in developing their initial knowledge base, sets of skills, and competencies or in honing them for the board certification examinations. Instead, what we mean is to increase the value of the time and effort already spent in studying on the previous nights. To enhance the value of studying, there are several explicit steps that radiology educators could take. First, radiology residents need to have an idea about the kinds of knowledge and skills they are expected to have acquired after completing a set of rotations in a given subspecialty of radiology. Along these lines, there already have been substantial valiant efforts to develop curricula for radiology residents in various subspecialties (42–44). In addition, attending staff in various divisions could decide what material they think should be covered by residents who pass through their clinical rotations. Second, educational resources, whether they be books, articles or reviews, or technology-based media, ought to be identified as starting points or new lead-in points for the resident's own study program. In various residency programs, residents pass on the knowledge to one another about which books are best for a 1st-year resident to review as opposed to those sources that are better for a more senior resident to review. There is no reason why the dissemination of such "informal knowledge" cannot be encouraged even further and even systematized and incorporated into a residency database. Third, the judicious and timely application of new educational technologies will help facilitate resident training, although we need to be aware of the possibility that the mindless substitution of any given technology-oriented educational initiative for a more traditional form of education may fail for any number of reasons. Knowledge of instructional design would help to ameliorate such difficulties (45). In our view, one example of useful educational technology is a simulation program designed specifically for radiologists about how to handle sedation, analgesia, and contrast medium issues (46). This program requires residents to act on their knowledge in real time with a simulated patient.
Radiology educators can help to make knowledge recently acquired by a resident during the course of study "come alive" in a systematic fashion in a number of ways. This can be done with time-honored methods, such as using short small-group presentations during their subspecialty rotations or preparing resident-oriented conferences and quiz sessions where they can talk and show one another what was just learned. Alternatively, such knowledge can be shared with the use of communications technology through which tough cases can be shared and questions and answers about various radiology topics can be discussed. In addition, attending physicians who are on clinical coverage with the resident could be encouraged to inquire into the learning points that were recently covered, and perhaps could even contribute his or her own experience, as well as provide occasional case material. Finally, educators can facilitate effective study by recognizing that there are various kinds of cognitive methods to promote memory. Although less effective methods (eg, rote memorization or "shame and embarrassment") may have been used in the past to promote memory retention and to improve performance, recent work indicates that knowledge acquisition and memory retention are improved by the use of "cognizing" techniques aimed at enhancing functional recall of explicit knowledge (47). These techniques include the following: (a) acquisition of knowledge, followed by use in a situation where it is needed; (b) acquisition of knowledge in continuity with prior knowledge (scaffolding); (c) promotion of genuine reflection; (d) use of divergent opinion and discussion; and (e) location of "hooks" within material to increase intrinsic interest in the topic.
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PROMOTING THE SPIRIT OF INQUIRY: THE OTHER CRITICAL ASPECT OF SELF-DIRECTED LEARNING |
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e.e. cummings (48)
The shift from the instruction-based paradigm to the self-directed learning paradigm requires that the radiology residency program provide an environment that is truly conducive to the residents' education. The radiology residency program has to provide a supportive learning and work environment that is designed to support the residents' study programs. This includes guidelines for the curriculum, recommendations on educational source material, opportunities for periodic guidance with the residency program director and other faculty members, support of the educational infrastructure and media, and a set of learning mechanisms through which the process of study can be made more effective. These learning mechanisms may include various educational media, image libraries, study guides, or other materials that help to promote memory retention, to facilitate active learning, or to broaden the underlying knowledge base. Even more important, the Accreditation Council for Graduate Medical Education program requirements indicate that diagnostic radiology residency programs need to provide what they describe as follows:
an environment of inquiry [italics added] and scholarship . . . [in which] both faculty and residents must participate actively in scholarly activity. . . . [Scholarship includes] active participation of the faculty in clinical discussions, rounds, journal club, and research conferences in a manner that promotes a spirit of inquiry and scholarship (49).
Although all faculty members would agree about the importance of maintaining the intellectual richness of the academic medical environment, it is more difficult for all of us to remember that it is the job of each faculty radiologist to promote the "spirit of inquiry" on a daily basis.
The focus on inquiry also serves to undo the pernicious effects of the overemphasis on accuracy during 20th-century radiology education. Although the continual improvement in accuracy in radiologic diagnosis helped to promote the field during the 20th century, the heavy reliance on yesterday's answers tended to foster attitudes that inhibited critical thinking and learning, both of which will be required of 21st-century radiologists. As a mental habit, academic radiologists learn how to search for scientific questions that hold sufficient promise of increasing knowledge about the mechanisms of disease, the understanding of biological phenomena, and the quality of patient care. This pattern of thinking requires a process of scientific inquiry. Along similar lines, practicing radiologists of the 21st century will continually need to assess not only what knowledge they do possess, but also what knowledge they do not possess and then how to go about acquiring the necessary knowledge and skill sets. These capabilities also require experience in scholarly inquiry. In the future, we believe that radiology residents will need to learn not only to recognize the "Aunt Minnies" and to generate the list of leading differential diagnoses but also how to acquire, evaluate, and use information and knowledge about various diseases and imaging technologies. In an era of information explosion, the value of developing these skills will become self-evident as the 21st century progresses. The Accreditation Council for Graduate Medical Education recognized this competency as the capability for lifelong learning. For radiologists, this competency will include the core skill of scientific assessment of medical evidence about new technologies and applications (50).
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CONCLUSION |
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ACKNOWLEDGMENTS |
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References |
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ABSTRACT
INTRODUCTION
