Da Inta Flashcards
Radiology training breakdown
ST1-3 - rotations through system and modality based attachments in various fields
(Breast, cardiac, thoracic, GI, molecular, radionuclide, paediatric, musculoskeletal, neuroradiology, head and neck, urogynae and core interventional)
Achieve core competency - what is expected of any radiologist performing acute and on call imaging
ST 4 - transition into area of special interest 60% general, 40% interest.
ST 5 - greater focus on specialist skills 60% special interest, 40% general
During these last two years it is expected to achieve level 1 competency in two specialist interest areas, or level 2 competency in one area (becoming an expert in a chosen field).
What is needed for CCT?
Certificate of Completion of Training
- Demonstration of CIPs (capabilities in practice - descriptors that demonstrate achievement of high levels of practice):
- Demonstration of adherence to GMCs good medical practice
- Understanding organisational and management systems
- Engage in reflection and QUIP
- Engage in evidence based medical practice
- Act as clinical teacher and supervisor
- Demonstration of working well in teams
What is SPECT imaging?
Single photon emission computed tomography (SPECT) is a nuclear medicine imaging technique that uses gamma rays to create 3D images of the body.
A patient is injected with a radioactive tracer
The tracer binds to specific molecules and targets in the body
The patient lies on a table while a gamma camera rotates around them
A computer generates 3D images from the data collected by the camera
Often combined with a CT
What it’s used for
Heart: To check blood flow and look for blockages in the coronary arteries
Brain: To show blood flow and help diagnose vascular brain disorders, seizures, and Parkinson’s disease
Other conditions: To help diagnose dementia, some psychiatric problems, and problems with bones or joints
What is hybrid imaging?
Hybrid imaging refers to the fusion of two (or more) imaging modalities to form a new technique. By combining the innate advantages of the fused imaging technologies synergistically, a new and more powerful modality usually comes into being.
What are critical training points in radiology training?
A critical progression point is a point in a curriculum where a learner transitions to higher levels of professional responsibility or enters a new or specialist area of practice, including successful completion of training.
Discovered Xrays
William RONTGEN
Royal college of radiologists does what?
Governs training and practise of radiologists in the UK.
- Set curriculum and exams
- Issue guidelines
- Represent radiologists in discussing national issues with the department of health
General problems from the RCR census
- Number of scans increasing
- Number of radiologists not increasing alongside this
- Increased outsourcing
HOT TOPICS
Outsourcing pros/cons
PROS
- Scans reported in a timely fashion
- Reduced burden on radiology departments and on-call team
- Increases capabilities of the in hours service
- Specific investigations eg CXRs can be outsourced leaving radiologists to concentrate on areas of interest
CONs:
- Reduce training opportunities for in house registrars
- Outsourced radiologists are not as easily contactable
- May not have access to as much clinical information
- Phenomenon of double-reporting can occur if scans viewed in the morning or before MDMS
- specialist work may be poorly reported
Generally speaking I agree with the RCRs statement that overall it is better for the patient if a scan is reported by a local radiologist who can speak directly to other clinicians.
HOT TOPICS
Skills mix/radiographer
PROS:
- Reduces workloads on radiologists, especially in high volume areas such as ED
- more cost effective for radiology departments
CONS;
- Difficult cases with need radiologist review leading to double-reporting
- Can impact on training for registrars
HOT TOPICS
Turf wars
Imaging being carried out by other medical or surgical specialties.
PROS
- Radiologist workload can be reduced
- Idea of better correlating clinical findings and following up the patients
CONS
- Risk of losing work and training opportunities
- Radiologists have a deeper knowledge of other body systems and therefore may find other pathology
- Radiologists have a deeper understanding of imaging modalities, limitations, and safety.
“Wars are not fought to decide who is right, but rather to decide who is left.”
Radiologists must:
- Maintain high training and education levels in their areas of expertise.
- Be available for night and weekend coverage, or form associations that can do so.
- Work to improve training for qualified technologists
- Set guidelines and accreditation standards
The two formats of radiology training?
- apprenticeship style vs academy training
Apprenticeship - basing the training within the radiology department from day one
- exposure to on call reporting
- working with senior radiologists and clinicians
I LIKE this style of training because I feel I learn best by having the opportunity to see decision making in action, and the ability to ask questions in real time, before then re reviewing subject material after and reflecting on the learning event
Academy training
- Aiming to standardise training
- Freedom to make mistakes early on and being exposed to an increased number of “cold cases”
- These cold cases are hand picked to show a variety of important pathologies
Negatives would be
- Reduced early exposure to HOT reporting
- Fewer opportunities for hands-on training such as intervention or ultrasound
- Less time spent with a variety of senior radiologists
Things in the radiology E-portfolio
Number of work-placed based assessments taking place in the forms of:
Mini- image interpretation exercises or mini-IPX - 6 needed a year
Radiology DOPS - direct observation of procedural skills - 6/year
Audits - 1/year
Teaching observation - 2/year
Multisource feedback - 1/year
MDT assessment - 2/year needed ST3 onwards
Clinical and educational supervisor meetings and ARCP - annual review of progression of competence
What radiology exams are there?
First FRCR exam: ST1
Anatomy and physics
Anatomy (90 minutes) and Physics (2 hours).
- The anatomy exam tests knowledge of anatomy necessary for interpreting imagery
- The physics exam consists of 40 true/false questions, each question with 5 components (so total of 200 questions).
- tests knowledge on the physics that underpins modern diagnostic imaging
Final FRCR exams, split into part A and B
FRCR Part A examination
Taken in ST3
Two 3 hour papers (each 120 questions) taken on one day. This exam asks questions on the following areas: Cardiothoracic and Vascular, Musculoskeletal and Trauma, Gastro-intestinal & Genito-urinary, Adrenal, Obstetrics Gynaecology and Breast, Paediatrics and Central Nervous System and Head & Neck.
FRCR Part B examination
Taken in ST4
Consists of three exams; a reporting session (75 minutes), a rapid reporting session (35 minutes) and an oral examination (60 minutes).
Upon completion of the final exams, you would become a fellow of RCR as opposed to a junior or associate.
Tell me about yourself
My name is Jonah Little
In terms of my clinical experience,
I am currently a bank doctor working in and around Brighton.
I had a broad range of medical experience in F1/2, with rotations in Geriatrics, gastroenterology, psychiatry, Paediatric surgery, obstetrics and gynaecology and respiratory medicine.
Since F1/F2 I have been working as a bank doctor. I believe this has broadened my knowledge hugely, as it has given me the chance to experience more specialties, which I did not get the chance to experience in F1/F2. I think this is very important for a career in radiology which necessitates a broad knowledge across multiple specialities.
In terms of academic achievements, I studied at Imperial College London, where I achieved 5 distinctions in my MBBS (clinical practice, clinical science, medicine, pathology and surgery), and a distinction star in obstetrics and gynaecology. In my fourth year I achieved a first-class BSc in respiratory sciences. I understand from speaking to radiology trainees that the FRCR exams are challenging and dedication to learning is key to ensuring success. I believe my past marks depict that I will be able to cope with the hard work needed.
In terms of management roles, I’ve worked as a production manager at a leading record label, recording music [2023-sep24]. During this time, I learned a lot. Ultimately managing lots of people, time management, attention to small details and the oversight and understanding of a process from start to finish, all of which I think are relatable to a career in radiology.
Lastly in terms of my personal interests I am a keen musician. I see lots of similarities with a career in radiology: in terms of the physics of recording musical instruments, manipulating sound waves with IT programmes and tools and in terms of playing in bands and being part of a team. Communication and listening are key elements in music, especially when improvising and listening for subtle cues. Overall, my interest in music depicts that I can balance my learning with extra-curricular activities. Across university I was working two jobs, playing in 4 bands, running music nights, but also managed to achieve high scores in my exams, of which I am really proud.
What is a clinical audit?
A clinical audit is a way of measuring the effectiveness of healthcare against proven standards for high quality. It involves taking action to bring practice in line with these standards, improving the quality of care and health outcomes.
The audit I did examined antibiotic compliance in paediatric appendicectomy cases. We retrospectively collected data on compliance to the antibiotic guidelines: including antibiotic combination, dose and duration, which is then tailored based on findings at laparoscopy. There were four instances of post-operative abdominal collections during this time. After this, we educated staff members in the weekly MDM, updated posters around A+E, on the wards and in theatres and sent out emails to colleagues. We then undertook a second prospective cycle, showing increased compliance and no post operative abdominal collections. Now, diagnostic imagery did not form a major part of this audit, but it did show that changes to protocols and education could impact the burden on radiology departments in terms of necessitating further imagery due to complications, for example in this case, paediatric US for abdominal collections.
Radiology is an exam heavy specialty, how have you demonstrated your commitment to study for these exams?
I was able to achieve high marks in my university exams, whilst balancing my interest in music. I’m the first doctor in my family, and I further had to balance university with working as a kitchen porter and in pubs to afford to study in London.
At university I learned the importance of early preparation, time management and ensuring structured and repetitive learning in a variety of formats. I would learn from didactic and passive methods, as well as active learning in PBL sessions and quizzes. I would consolidate this knowledge gleaned with structured repetition and the making of flashcards and testing my knowledge with multiple choice questions.
I did a course this year in Instructional Methods in teaching, which helped me to understand the pros and cons of all of these teaching methods - helping me to understand both as a learner and teacher, I can apply these to my future education.
I think all of this is important for radiology. It is exam heavy, and having spoken to radiology trainees I understand that hard work will be needed to achieve in the examinations and ultimately learn a new discipline.
Tell us about your teaching experience?
During my F1 year, I taught in the local transition to F1 course from February to March, and later mentored over 10 final-year students between June and August. During this time, I organised bedside teaching sessions where I helped students develop examination skills, enabling them to detect and present real clinical findings. I provided instruction on various critical areas, including escalation and emergency processes, discharge summaries, drug charts, and the interpretation of blood results, reports, and diagnostic tests, tailored to the expectations of an F1. We also worked on communication skills through discussion and practice. I was pleased that I received positive feedback during this time, that my sessions were relevant, comprehensive and well structured.
I have also taught saxophone and piano to children - which I think is unique, in that it involves describing more abstract theory and communicating aspects in a simple enough way to be understood, often to children with varying levels of communication skills.
I did a course this year in Instructional Methods in teaching, which helped me to understand the pros and cons of all of these teaching methods - helping me to understand both as a learner and teacher, I can apply these to my future education.
This experience highlights my commitment to teaching, a key element in a career in radiology, where teaching and mentorship play an important role throughout various stages of professional development.
What research experience do you have?
I did an intercalated degree in respiratory medicine and was based at the royal brompton.
I learned about:
Physiology and pharmacology
Pathophysiology
Genetics
Epidemiology of lung diseases
But further about the heirarchy of studies and how to critically appraise to a higher level. *****************
What is your greatest achievement outside of medicine?
I think my greatest achievement outside of medicine would be some of the recordings I have had the pleasure of playing on. I have played on records with a famous trombonist called Vin Gordon, who played on Bob Marley’s album exodus. My father is a DJ and has a record of an artist called Winston Reedy from before I was born. I have since been recorded on records with him too. I’m proud of my achievements in music, I have played on stages in front of thousands of people and have played at hundreds of music venues. Ultimately, this is due to my continued hard work in learning music and in my ability to have networked in the world of music. I believe that these are skills that help networking; being personable, approachable and a good communication are things which I will be able to take forward in a career in Radiology.
What is your greatest strength?
I think my greatest strength is my ability to communicate effectively with people of different backgrounds.
Before university I worked as a charity fundraiser - in order to persuade people to donate to charity I had to present the work of the charity in an understandable way, based on the person I was speaking to.
I’ve worked for a charity playscheme initiative called the hamlet centre for children with a “physical or mental impairments where I would look after and care for a child across the day, often with use of non-verbal prompts and simple language.
I’ve taught children how to play piano whilst I was at university which involves simplifying abstract theory.
As you can see from previous multi-source feedbacks or TABs, I’ve also had very positive feedback from colleagues in my medical career: consultants, junior doctors and nursing staff in my ability to communicate in a succinct and effective way.
In my current role as a bank doctor, I work across an array of specialties in three different hospitals and therefore work frequently alongside new colleagues and meet many patients.
I think this is all very important and necessary for a career in radiology which involves communicating with a broad range of specialities, ancillary staff, fellow radiologists and patients. Radiology involves choosing language carefully - ensuring reports contain relevant information but remain interpretable for more junior members of the teams that may be the first to act upon scan reports.
What is your main weakness?
I think my main weakness is that I can sometimes be overly cautious. In the past I have double-checked things a lot or would previously seek reassurance from seniors.
I have found by being systematic, taking clear notes and through becoming more experienced in general, I am trusting my decision making and instincts more and more.
I can forsee that initially I may be overly meticulous in reviewing images when starting out. While attention to detail is necessary in radiology, balancing thoroughness with efficiency is key, especially during high-volume shifts.
Do radiologists need good communication skills?
Good communication skills are fundamental for a career in radiology. It’s important to write reports in a clear and succinct manner, that is interpretable to clinicians at all levels. Furthermore, excellent verbal communication is vital when interacting with patients, for example during interventional procedures or ultrasonography. Radiologists of course also need to interact with and listen to clinicians, when acting on call as the troubleshooting radiologist in terms of negotiating scans, informing teams of urgent findings, or in the settings of multidisciplinary meetings.
I think an example of my good communication skills would be during my obstetrics and gynaecology rotation. On a daily basis I would need to perform multiple speculum examinations. This is an examination which can be very worrying or embarrassing for patients. I would always ensure I explained the procedure in full, answering and addressing any concerns the patient may have before the procedure, gaining consent and ensuring they understood I would be listening and acting upon any concerns during the procedure.
This sort of patient interaction is relevant for a career in radiology: for example for fluoroscopy patients, where it is important to effectively communicate what a patient can expect to happen and ensuring they feel comfortable before proceeding. I know from speaking to radiology trainees that performing fluoroscopy occurs in training as early as ST1.
What is fluoroscopy?
Fluoroscopy is the use of Xrays to form real time imagery, and often incorporates the use of contrast agents. It can be diagnostic an interventional.
Diagnostic examples include barium swallows and enemas and angiography.
Interventional examples include insertion of a catheter or stents, or needle biopsies.
Pros - real time visualisation, precision, dynamic studies
Cons - radiation exposure and need to monitor duration of procedures
What is risk management?
Can you work under pressure?
Risk management is the systematic process of assessing risk to either staff or patients, and employing techniques to minimise these risks.
Risk management is employed daily by healthcare workers. A notable rotation for me, where this was particularly important, was during obstetric and gynaecology night shifts. Overnight at the tertiary centre I worked in, it would only be myself and a registrar. I carried 3 bleeps, and between us we would cover the labour ward, pre and post natal wards, the gynaecology and gynaecology oncology wards, A and E referrals, Gynaecology assessment unit and the maternal assessment unit. As a result, it was an incredibly busy shift. I would be bleeped very frequently and need to prioritise tasks based on clinical importance, ensuring I had inquired enough information from the referring doctor or nurse in order to prioritise. Furthermore, I would have to escalate appropriately to the registrar and determine the urgency for this as frequently they would be in theatres. There would also be frequent obstetric emergencies throughout the night that would require me to promptly get to theatre to assist.
It was absolutely fundamental to maintain clear notes of tasks in order to prioritise what needed to be done. This job taught me how to cope under very stressful circumstances and I feel it will prepare me well for on-call shifts in Radiology. Having spent time with the trouble-shooting radiologist, I understand the importance of clear note taking and discussion with referrers to determine whether scans are clinically indicated and the urgency in which they need to be performed and prioritised.
What is a good team player?
A good team player is an individual that communicates and listens effectively. It’s important to recognise the limits of your understanding and experience, and knowing when it is important to escalate to a senior. Another key aspect is being flexible and adaptable. In the best teams I have worked for, an environment where everyone’s opinion can be listened to, is fostered.
An example of this in my practice would be during the first COVID wave, where I began working several months early due to increased pressures. For some of this time I worked on a ward with nurses and HCAs that had worked mainly in elective surgical day units in a different hospital entirely. The hospital had increased its bed capacity by nearly 50% and so senior support was spread thinly. During this time, I supported the nurses with tasks they were less familiar with, but also emotionally as we had many sick and deteriorating patients and it was a stressful environment. I also had to recognise the limitations of my own practice: that I was not well experienced at this time. I would escalate emergencies immediately, but also with any scenarios where I was not confident. Ultimately, it was incredibly stressful and busy and at times felt as though if I missed something it would not be brought to the attention of a senior who had limited time. We all got through this period by supporting each other, raising concerns immediately and not being afraid to recognise our own limitations and ask for help.
How do you organise your workload?
At the moment I work across many specialities as a bank doctor. I organise my work load by initially communicating with the nurse in charge to ascertain if there have been any acute issues overnight. Thereafter, I look up my patients NEWs scores and prioritise ill patients and those that are new to the wards. I see medically fit patients last. If there are urgent tasks, these may take president over seeing the next patient, depending on the level of urgency. Of course, in the event of a deteriorating patient, I will review them promptly. I ensure I keep neat and clear notes of what needs to be done after seeing patients. This then allows me to prioritise the remaining tasks based on clinical need.
What is a good leader?
I believe a good leader in healthcare is someone who is able to ensure good standards for patients, and further aim to improve those standards whilst empowering others to do so too. It’s important to drive standards to avoid the stagnation of healthcare.
Good qualities of leaders include: being a good listener and communicator and fostering an environment where people feel their opinions are valid. I feel a good leader will often have a vast level of experience they can draw on to help in situations and work out the best course of action, whilst being able to teach those who are experiencing a situation for the first time.
A scenario where I displayed good leadership would be when I lead an audit that examined antibiotic compliance in paediatric appendicectomy cases. We retrospectively collected data on compliance to the antibiotic guidelines: including antibiotic combination, dose and duration, which is then tailored based on findings at laparoscopy. There were four instances of post-operative abdominal collections during this time. After this, we educated staff members in the weekly MDM, updated posters around A+E, on the wards and in theatres and sent out emails to colleagues. We then undertook a second prospective cycle, showing increased compliance and no post operative abdominal collections.
Good leadership is essential for a career in radiology: which is constantly evolving in terms of the workload and workforce crises, innovations in interventional radiology and the use of AI.
STAR approach
Situation
Task
Action
Result
How to deal with conflict at work?
It is important during conflict to empathise with both sides and try to understand both perspectives. It’s essential to take on the role of a mediator as opposed to immediately taking sides. Ultimately there may be situations which need rectifying at the time, but it’s important to appreciate when emotions are high it may be suitable to defer this to a later time. Overall, it is important to encourage reflection for all parties involved.
One conflict that springs to my mind would be that an elderly 94 lady was admitted to hospital with a fractured neck of femur. She had been clerked in by a fellow foundation doctor and was in A+E majors. I was seeing a different patient on the ward, as the emergency buzzers went off. I attended the patient straight away, along with an IMT doctor who was also present. The lady was in cardiac arrest and did not have a valid DNAR. We commenced CPR and an arrest call was put out. The consultant arrived and we terminated CPR after several cycles as it was deemed to be unlikely to be successful and not in the patients best interests. The consultant at the time remarked about the fact that this was a very frail and comorbid lady, with a high chance of mortality and that a DNAR form should have been discussed with the patient and their son that was also present at the time. It was a very stressful situation for the team in general and the department was under exceptional pressures at the time. Whilst the consultant was ultimately right about the situation, the way in which they addressed it was very brash and made it more upsetting for the junior. I took the junior doctor aside, listened to them, provided them with tissues and suggested they take a short break to compose themselves. I then spoke to the consultant, who apologised to the junior for the way they had said it and in front of the whole team. This was all explainable because the whole department was under such stress, but ultimately was a key learning point.
Where is radiology headed?
We need to think about this in the short and long term. The RCR census is a great resource for understanding the pressures that radiology faces in general.
I have learned there is a huge workforce issue:
- Across the UK, there are 9.9 radiologists
(consultants, SAS and trainees) per
100,000 people, compared to the OECD
average of 12.8.
- There are also regional inequalities across the UK
The latest RCR census has three key recommendations:
- RECRUIT
- TRAIN
- RETAIN
The number of scans is increasing year on year.
The NHS spent £52m more on excess reporting between 22’ 23’.
This could fund 2,690 yearly consultant
salaries
The workforce shortfalls are increasing year on year. This leads to delays in scans for patients and bottle-necking. Ultimately this leads to increased morbidity and cost for the NHS.
There is a government lead drive for local diagnostic centres, but there hasn’t been an increase in necessary reporting capacity which places additional strains on radiology departments.
AI may help with the streamlining of reporting, however staff need the planning time and training
to consider their implementation and how
best to use it in the service - which is not possible with current service constraints.
With regards to AI, it is not about whether radiologists will be replaced by AI, but more about how best can it be used? An example would be using AI software to detect normal CT heads, allowing radiologists to concentrate on the reporting of scans with significant findings.
Interestingly with AI there are additional considerations, such as human factors and what legal implications could be.
How do radiologists learn from their mistakes?
Ultimately this is through departmental meetings called REALM (radiology events and learning meetings) or LDMs or learning from discrepancy meetings. These involve presentation of cases in which retrospective review or additional information differ from the report originally provided, and can affect patient outcome. These meetings act as a means of education, aiming to improve future reports. There is an emphasis on anonymising cases. Important points are whether the patient has been affected by the discrepancy and if so an incident report should be considered.
What is the role of a consultant radiologist?
The roles of a consultant radiologist can be subdivided into several key areas:
Clinical
- Reporting of scans
- Carrying out interventional work
- Running MDMs
Academic:
- Teaching registrars and medical students
- Completing audits and research
Management:
- Being in charge of budgets
- Organising rotas
- Appointing new staff
Personal:
- Supervision and mentoring roles
What will you miss as a radiologist?
I do really enjoy patient contact, and understandably with reporting there can be less patient contact than medical specialties.
However, with the rise in interventional procedures and other domains such as ultrasonography, guided biopsies and fluoroscopy, there is plenty of scope to have patient facing roles.
From my taster week I also saw that this contact can be incredibly meaningful, by providing patients with instant diagnoses in ultrasound, or interventions which can greatly improve someones quality of life such as angioplasty.
What does PACS stand for?
Picture archiving and communication systems. It is an IT system that allows transfer display and manipulation of digital images
What is RIS?
Radiology information systems, an IT programme used to generate reports and manage appointments.
What are the harmful effects of radiation?
Stochastic
- No threshold
- The probability of an effect occurring increases with the dose
- Effects occur generally with a time lag
Examples: malignancy, genetic mutations
Deterministic
- Appear above a given threshold
- The severity of the effect increases with the dose
- Effects occur within a short timeframe
- Examples: erythema, hair loss, cataracts
The most harm is caused by ionising radiation which either damages DNA directly through the breaking of bonds or indirectly through the production of free radicals
What is IRMER and IRR?
IRMER stands for ionising radiation medical exposure regulations and is regarding the protection of patients from ionising radiation.
Who has responsibility under IRMER? Overall the employer, but also the referrer (GP), practitioner (radiologist) and operator(radiographer).
IRR stands for ionising radiation regulations and protects staff members and members of the public.
There are two important roles:
RPA - radiation protection advisor - a medical physics expert who advises on all aspects of radiation protection.
RPS - radiation protection supervisor - a senior radiographer which is involved in upholding these standards.
How would you plan an audit?
- Define the Audit Purpose
Is it to evaluate the quality of clinical care, compliance with guidelines, or assess outcomes like patient satisfaction or safety? - Select the Area of Focus
For example medication management, referral times, mortality - Define Audit Criteria and Indicators
Audit Criteria: These are the standards or guidelines against which the performance will be assessed. - Determine the time frame or sample size
- Data Collection Methods
Patient notes, observation, patient or staff questionnaires - Set a timeline of when you would like things to have been done by
- Assign roles - who will do what?
- Collect the data
- Analyse the data
- Write up a report, suggesting recommendations that can improve adherence to current guidelines or seeking to improve current guidelines
- Option of re-auditing with these new recommendations implemented
What’s the difference between audit and research?
An audit is generally focused on evaluating current practices or outcomes against predefined standards or guidelines. It is aimed at assessing existing practices.
Research is predominantly about generating new knowledge, answering a specific question, or testing a hypothesis. The goal is generally to develop new theories.
What is the value of doing research as an SPR?
Well, I think there are many reasons why it would be important to get involved in research as a registrar.
Firstly it would lead to an improvement in my clinical knowledge, in areas perhaps outside my daily clinical experience and I see this as an opportunity for additional learning.
I think contributing to a growing body of new research, would encourage me to keep updated with new and exciting changes in the field.
I know from by BSc, that it really helped enable me to think more critically about things, which I could carry into my everyday practice.
Overall, the fact that you are improving patient care and advancing the field of radiology would also lead to job satisfaction and would further develop my skills in leadership and collaborating with different people.
Who works in the radiology department?
It is a multidisciplinary team consisting of:
- Radiologists of all different interests
- Radiographers
- Radiology nursing staff
- Receptionists and administrative staff
- Porters
- Depending on where MDTs are held you may have other consultants from different specialties
- RPA - radiation protection advisor - a medical physics expert who advises on all aspects of radiation protection.
- RPS - radiation protection supervisor - a senior radiographer which is involved in upholding these standards.
Is clinical governance important in radiology?
Clinical governance is a systematic approach to maintaining and improving the quality of patient care.
It is very important in radiology in terms of:
- Patient safety and ensuring minimal radiation exposure to patients and staff
- Incident reporting
- Learning from discrepancy meetings
- Review of guidelines and protocols
- Ongoing education and developing opportunities for trainees
- Patient experience
- Auditing
- Reducing costs and increasing efficiencies
- Ensuring staff members are happy and satisfied with their work to reduce gaps
Explain the 10-day rule
Women of childbearing age should only undergo non-urgent abdominal or pelvic X-ray examinations within the first 10 days following the start of their LMP, to minimize potential radiation exposure to a developing fetus if they are unknowingly pregnant
Primarily used for high-dose imaging procedures like CT scans of the abdomen and pelvis, barium enemas, and certain interventional radiology procedures.
Whats the difference between the 10 day and 28 day rules?
10-day rule - high dose radiation eg CT scans can be performed in the first 10 days of a menstrual cycle
28 day rule - low dose eg XRAY can be performed at any point in the 28 days as long as a period has NOT been missed
28-day rule = Don’t do X-rays or imaging on women during the first 28 days after the start of their period if there’s a chance they could be pregnant (even if they don’t know it yet).
Do you know of any guidelines on how to deliver an effective radiology report?
Yes the British Society of Radiology (BSR) format
Patient Details
Technique
Findings - normal/abnormal
Organ/System-specific Findings
Compare with Previous Studies
Impression / Conclusion with summary of significant findings
Recommendations
Limitations (if applicable)
Signature/date
It’s very important to avoid the use of “hedging” -
What is your understanding of CT scanning
CT scanning (or Computed Tomography scanning) is a technique that uses X-rays and computer processing to create detailed cross-sectional images of the body.
Rotates an Xray tube around the patient whilst they lie on a motorised table. Images are reconstructed by the computer.
Contrast can be used to enhance tissues, and is especially useful in terms of visualising soft tissues and blood vessels.
Advantages - high resolution, fast, non-invasive, 3d, cheaper than MRI
Disadvantages - radiation exposure, contrast reactons, artifacts
What is your understanding of MRI?
MRI (Magnetic Resonance Imaging) is a non-invasive imaging technique that uses powerful magnetic fields, radio waves, and computer processing to create detailed images of the internal structures of the body, particularly soft tissues like the brain, muscles, joints, spinal cord, and organs.
The magnetic field causes hydrogen ions to align with the magnetic field. Then a radiofrequency pulse is applied which causes them to spin or flip out of alignment with the magnetic field. After turning this off, they return to their original alignment, which is detected by the receiver coils.
The computer generates detailed images.
PROS: no radiation, high resolution, superior soft tissue contrast. Key for neurology investigations, MSK,
CONS: metalwork, contrast reactions, noise, cost, time-consuming
TYPEs:
Functional MRIs - brain - measures brain activity for pre-surgical planning
MRA
MRS - spectroscopy - measures chemical composition of tissues
What is ultrasound?
Ultrasound is a non-invasive imaging technique that uses high-frequency sound waves to create real-time images of the internal structures of the body.
High frequency sound waves are produced by the probe and transmitted in pulses that reflect back when they meet boundaries in the tissue.
The speed of the sound depends on tissue density.
A computer processes this and creates a digital image.
Doppler, 2d, 3d, 4d (3d in time)
PROs: non invasive, no radiation, handheld, real time imaging, cost effective
CONs: operator dependent, reduced image quality eg with obesity, limitations in penetration (EG overlying bone), and depth
You see a patient and perform an Ultrasound. It shows liver metastasis and the patient is asking if the scan is normal. How do you handle this situation? Explain your reasons why.
- Remain Calm and Professional
- Provide an Honest and Clear Explanation
- Ensure the Patient Understands the Need for Further Investigation
- Offer Reassurance
- Direct the Patient to the Next Steps
- Avoid Speculation
- Offer Support and Resources
Empathy: Addressing the patient’s concerns with compassion and understanding is crucial in reducing anxiety and maintaining trust between the patient and their healthcare providers. A diagnosis of liver metastasis can be terrifying, and acknowledging the emotional burden of such a concern can help the patient feel supported.
Clarity: It’s important to explain that an ultrasound finding is not a definitive diagnosis. By providing the patient with a clear understanding of the next steps and possible further tests, you ensure they are not misled into thinking that the diagnosis is final.
Professional Boundaries: As a radiologist, your role is to interpret the imaging results, not to make final clinical decisions or discuss treatment options. By referring the patient to their primary care physician or specialist, you ensure that the care team takes a holistic approach to the patient’s situation.
Avoiding Miscommunication: Providing a balanced and honest explanation of the situation reduces the risk of miscommunication or giving false hope or ungrounded fear to the patient. The situation needs careful management, and providing a realistic understanding of the process is key.
Patient Empowerment: By giving the patient a clear understanding of the next steps, you empower them to actively engage in their healthcare process and ask the right questions during their follow-up appointments.
“The ultrasound does show some areas in your liver that could suggest the presence of metastatic disease. However, this is just part of the picture, and we cannot make a definitive diagnosis solely based on the ultrasound. There are several steps we need to take, including discussing these findings with your doctor, who will likely recommend further tests, such as a CT scan, MRI, or biopsy, to confirm the diagnosis and determine the most appropriate course of action.”
“The results of your ultrasound will be shared with your referring doctor, and they will arrange for any additional tests or consultations you may need. The doctor will also be available to answer any questions you might have regarding the next steps.”
Do you know why we use contrast?
- Improve Contrast Between Tissues
- Highlight Blood Vessels and Vascular Structures
- Enhance Tumours
- Improve Detection of Inflammation or Infection
- Assessing Organ Function and Perfusion
- Improve Imaging of the Central Nervous System
- Aid in Postoperative or Post-Trauma Evaluation
- Guide Procedures and Interventions
Types: iodine, gadolinium, barium
TNM staging
The TNM system stands for:
T(<4) = Tumor: Describes the size of the primary tumor and its extent (how deeply it has invaded the surrounding tissues).
N(<3) = Nodes: Describes the extent of regional lymph node involvement (how many nearby lymph nodes contain cancer).
M(<1) = Metastasis: Describes whether cancer has spread to other, distant parts of the body (distant metastasis).
How do you think ‘any willing provider’ has affected radiology?
- Increases competition - faster or slower diagnostic pathways, more options for patients
- Encourages growth of teleradiology
- Balance of competition with high quality care
- Financial pressures - downward trajectory of prices
- Impact quality - varying levels of expertise, different standards being upheld
Do you have evidence of a taster week?
I did a rotation in Radiology during university, which opened my eyes to aspects of the radiology department. Fundamentally, it showed us an overview of the department: we saw patient journey’s from wards the department and really experienced the patients perspective. We spent time with radiographers, understanding their critical roles in the working of the department. We were able to see different modalities in action for the first time, and were provided with teaching from radiologists.
Then, during my F2 I undertook a taster week in radiology. I spent time observing CT guided biopsies, paediatric ultrasound scans, the troubleshooting radiologist, Hot reporting and interventional radiology to name a few. This week really depicted how varied and exciting a career in radiology would be. It gave me a chance to speak directly with trainees to understand the difficulties they faced, especially in terms of FRCR exams! But also aspects they really enjoyed, many cited the fact they felt the programme was well run, with significant consultant contact and teaching.
Briefly describe sensitivity, specificity, PPV and NPV.
Sensitivity = True positives rate.
The ability of a test to correctly identify people who have a disease or condition.
Specificity = True negatives rate.
The ability of a test to correctly identify people who do not have a disease or condition.
Highly sensitive tests will lead to positive findings for patients with a disease, whereas highly specific tests will show patients without a finding having no disease.
PPV = Accuracy of positive test results.
NPV = Accuracy of negative test results.
Discuss contrast reactions?
Types of Contrast Reactions
Mild Reactions:
These are typically non-serious and go away quickly without any treatment. Examples include:
- Warm sensation or flushing (feeling of warmth)
- Metallic taste in the mouth
- Nausea or a slight headache
- Itching or a mild rash
Moderate Reactions:
These are more noticeable but usually not life-threatening. They may require medical attention and sometimes treatment:
- Urticaria
- Wheeze
- Dizziness
Severe or Life-Threatening Reactions:
These are rare but serious reactions that require immediate medical attention. Examples include:
- Anaphylaxis
- Severe hypotension (low blood pressure)
- Cardiac arrest or arrhythmias
- Severe bronchospasm (tightening of the airways)
These reactions require emergency care
Its also important to think about renal function: in that contrast-induced nephropathy is a concern and more likely in the presence of renal failure.
Renal failure also leads to reduced excretion of contrast and therefore increased likelihood of reactions
Who is present in a trauma call?
Trauma team leader - usually ED consultant
Primary survey doctor - usually EM trainee
Anaesthetist - manages vascular access
Orthopaedic surgeon
General surgeon
Radiographer
Practitioner - assists the anaesthetist
Scribe - trauma nurse coordinator
EM nurses - collects blood products
Runner - healthcare assistant
What is radiology?
Radiology is a medical specialty that uses imaging to diagnose and treat disease.
Why do you want to do radiology?
I am an academic individual and I really enjoy learning every day!
Radiology is an incredibly diverse specialty that is constantly evolving and I think it will continue to stimulate me throughout my career. Across my career, I’ve enjoyed many specialties and I feel that in learning radiology, I will continue to retain and use much of the knowledge I have gained. I think overall it’s a very exciting time to be getting into radiology, in that there are huge advancements in terms of interventional radiology and the application of new technologies such as AI.
Clinical History: 33 Male RTA - GCS 13, pulse 114 BP 80/40 O2Sat 90 % 5 l O2
Head: There is a left, extradural haematoma, measuring a maximal depth of 5cm. This overlies, the left frontal temporal, and parietal lobes. There is no midline shift. The cerebellar tonsils above the level of the foramen magnum. The skull vault and base are unremarkable.
Chest: There is no mediastinal haematoma. The great vessels, opacify normally. There are multiple left sided rib fractures with a left-sided tension pneumothorax with a maximal depth of 8cm and 3cm mediastinal shift to the right.
Abdomen and pelvis: There is active extravasation of contrast arising from the left, renal parenchyma. There is a surrounding perinephric haematoma, 10cm left retroperitoneal haematoma and layering of blood within the pelvis. The liver, spleen pancreas, gallbladder, right, kidney, adrenals, and visualised, unprepared, bowel are unremarkable.
Musculoskeletal: No evidence of further bony injury in the axial or appendicular skeleton.
Question
You are the requesting clinician; how do you proceed with the findings in the report?
I would hope that at this stage, a trauma call would have already been put out before the arrival of this patient to hospital.
The patient should have been resuscitated prior to CT scanning.
Most immediately after this scan, a focus on resuscitation is important lead by the trauma team leader and anaesthetist on call, alongside all relevant specialties of the trauma team.
The most important way to address these issues would ultimately be based on c-A-E management.
My first action would be to inform the trauma team leader, who would listen to advice from all of the relevant specialties for this report:
- General surgery - regarding the tension pneumothorax [B] which needs urgent chest drain, but also regarding assessment of the extravasation of blood around the kidney. This may require an interventional radiologist for endovascular embolisation. The kidneys receive 20% of cardiac output, and so this is a life-threatening bleed that needs urgent attention.
- Neurosurgery, regarding the extradural haematoma, which could be rapidly expanding and result in herniation, especially in a young patient with a young brain.
Ultimately the trauma team leader will decide on the order of management, and this patient will likely need urgent transfer to theatre.
What journals do you like reading?
European Radiology
BJR (british journal of radiology)
Radiology - RSNA
Published in european radiology:
Experimental psychologist
When AI provided incorrect results, false negative and false positive rates among the radiologists increased.
False positives decreased when AI results were deleted, versus kept, in the patient’s record.
False negatives and false positives decreased when AI visually outlined the region of suspicion.
Explain recent changes to the governments approach to cancer
28-day diagnosis target for all cancer patients.
Expansion of AI technology and imaging capacity to support quicker, more accurate diagnosis.
Improvements to national screening programs and the two-week wait pathway.
Investment in diagnostic centres, mobile imaging units, and equitable access to care, particularly for underserved communities.
What is consent?
The process by which a patient agrees to undergo a medical treatment, procedure, or intervention after being fully informed about the risks, benefits, alternatives, and potential outcomes.
Important to consider capacity. If the patient does not have capacity a consent form 4 will be completed and involves discussion with a NOK or LPA, acting in the patients best Interests and considering advanced directives.
Barium contrast reactions
Barium aspiration - pneumonia, pneumonitis
Bowel perforation can occur, particularly in patients with pre-existing GI conditions, which could lead to peritonitis if not treated promptly.
Constipation and delayed bowel evacuation can occur after barium enema or oral contrast procedures, and adequate hydration and post-procedure care are essential.
Hypersensitivity reactions are rare but may occur, particularly to additives in the barium preparation, and may require medication to manage.
Careful patient selection
Give me an example of a breakdown in communication
When I was in F1 I had a patient who needed to return to SDEC for a repeat blood test for a transaminitis which was presumed secondary to antibiotics they had received. The patient was desperate to leave, and had left the department before their discharge summary had been completed, which was due to be sent to their property. I gathered from the notes that this follow up plan may not have been communicated to the patient and so I proceeded to phone the patient to explain the instructions of what needed to happen and why. The patient thanked me for this information and eventually attended SDEC. I think this case is important for a few reasons: patient safety is a priority. It also depicted that when things are rushed or a department is busy, mistakes can be made.
I think this last point is particularly key in radiology: in that I have read that the number of scans is increasing year on year without a match in workforce provision. As a result it is important that radiologists do not increase their number of reports at the expense of missing key findings. It’s also important for radiologists to advocate for more consultant posts, training posts and seek to reduce reliance on outsourcing.
Are radiology trainees satisfied with their training?
My first hand experience from my taster week, is that many of the radiology trainees felt pleased with their training. Many cited the fact that there was lots of consultant contact: I feel that this suits my style of learning. I really enjoy seeing senior decision making in action, and being able to ask questions in real time. Many reported that there was regular teaching, and they felt supported by other radiologists, especially during reporting sessions.
That being said, I do understand from the GMCs national training survey that there are some issues that trainees have reported.
For example, 14% of trainees felt at high risk of burnout.
I understand from speaking to radiology trainees that there is a great deal to learn, and the FRCR exams are difficult. It is also important to recognise that the number of scans is increasing year on year, despite increases in the workforce of radiologists, and the numbers of radiologists per head is significantly lower in the UK than other economically developed countries. As a result, a greater pressure is put onto radiologists year on year.
How do you deal with this sort of pressure as a radiologist?
I think its very important to not increase the report volume, at the cost of the value or accuracy of the report, as this can lead to further problems in terms of negatively affecting patient care, or causing delays if things are missed.
In general if I am under pressure: I try to work as systematically as I can, to ensure things are not missed.
It’s important to employ risk management strategies:
Maintaining focus on one task at a time
Working systematically
Not rushing, but trying to work efficiently
Allowing time for unexpected delays or emergencies
Ensuring you have time to take a break, which can improve concentration
More general things:
Staying well hydrated and ensuring you eat a healthy meal at lunch
Ensuring you are well rested when coming into work
Have you done any research?
During my 4th year BSc I conducted a systematic review of literature, looking at phytoceutical use in respiratory disease. This was an excellent experience and gave me a broad understanding of how high-tier research is conducted. I was interested in this topic because many medicines, such as aspirin, are derived from plants, but also commonly used in a variety of OTC medicines. I chose 5 phytoceuticals to look at and then searched pubmed, medline and embase for suitable trials after setting inclusion and exclusion criteria. I then quality scored these studies twice to determine progression to the review stages, for example scoring based on double-blinding, appropriate placebos and drop outs. I uncovered many pitfalls in the ways that these studies were run: for example likely insignificant doses, a lack of verified quantification of symptoms, lack of excluding interactions and conflict concealing.
Ultimately there was not enough data to prove the hypothesis that phytoceuticals were useful in respiratory disease and further research would need to be done.
