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Original Article

The value of medical student radiology education: A comparison of 1-week, 2-week, electives, and compulsories

Limchareon, Sornsupha*; Kongprompsuk, Sutasinee

Author Information
Journal of the Chinese Medical Association: June 2018 - Volume 81 - Issue 6 - p 548-551
doi: 10.1016/j.jcma.2017.09.010


    1. Introduction

    There are various types of radiology curricula offered among medical schools.1–5 Most of the American medical schools have no required radiology clerkship.1,2 This little amount of radiology education has resulted in only modest percentages of the interns reported high confidence in the interpretation of plain chest and abdominal radiographs.3 A survey of medical students' opinions demonstrated that most of them recognized the importance of radiology and 63%–77% of them planned to take a radiology rotation as an elective during their medical schools.2,6 Thus the need for medical imaging education is increasing. A survey by Straus et al.4 demonstrated that 63% of radiology department chairs required radiology as part of a formal medical school course and teaching by radiologists. In contrast, only one-third of radiology chairs' perceptions considered the importance of medical student teaching for department success to be critical.7 Most of deans and chairs' opinions reported a need for a standard imaging curriculum.8 Nowadays, there have been no written guidelines or consensus statement about how and when to teach radiology to medical students.

    The purpose of our study was four fold: 1) to determine whether clinical-year students demonstrated statistically significant improvement of the test after having taken the dedicated radiology rotation; 2) to determine whether students in different clinical years (fifth and sixth) had statistically significant difference in score improvement of the test; 3) to determine whether different periods of time in education (1-week and 2-week) had statistically significant difference in score improvement of the test, and; 4) to determine whether elective or compulsory had statistically significant difference in score improvement of the test.

    2. Methods

    2.1. Study design

    We retrospectively reviewed the pretest and posttest scores taken by fifth-year and sixth-year medical students who participated in a 1-week or 2-week radiology rotation. The ethic committee approval was received by the university review board, No 56/2560. Written consent was not obtained from participants because the test was in part of the course evaluation.

    2.2. Setting

    At our institution, radiology education is a standalone course for the fourth-year medical students in a space of two weeks. Didactic lectures of basic radiology knowledge are provided for 15 h, followed by interactive radiologic interpretation sessions for 25 h and the other 20 h in small group (eight students for each group) rotations. A small group session introduces students to routine works in the radiology department, at which students are asked to discuss the indication, contraindication and appropriate use of imaging. Following the radiology curriculum, students might have radiology exposure in informal training supervised by interns or ward staffs during their clinical rotations.

    At the academic year 2014, dedicated two-week radiology elective was offered to sixth-year medical students. On the following year, a dedicated two-week radiology rotation was compulsorily added to sixth-year medical students and a 1-week radiology rotation was compulsorily added to fifth-year medical students. During radiology rotation, the students exposed to real-life radiology works, interpreted and discussed plain radiographs, and special studies such as mammography and computed tomography in person with radiology staffs in a reading session and performed US in US room. However, the number of cases was by chance according to routine studies in the department. No didactic lecture was delivered.

    2.3. Testing

    The student was instructed to identify and interpret a 30-image quiz within a 90-min time period to evaluate medical students' pre-radiology knowledge on day 1 of the course. A 30-image quiz was chosen by a senior author (L.S) with 24 years of experience. The case mix for the study consisted of 15 plain radiographs, nine spotted views of CT studies, five spotted views of US studies, and a mammography. The plain radiographs consisted of a normal adult chest radiograph, four abnormal adult chest radiographs, two abnormal pediatric chest radiographs, two abnormal adult plain abdomen series, an abnormal pediatric abnormal plain abdominal radiograph, and four abnormal bone radiographs. The CT studies consisted of two abnormal CT brains, an abnormal CT chest, two abnormal CT abdomens, three abnormal CTAs, and an abnormal CT bone. The US studies consisted of a focal lesion in the liver, a dilated renal collecting system, a free intra-abdominal fluid, a thyroid cystic nodule, and a testicular torsion. No answer for each question was specifically discussed in between radiology rotation. The same test-set was delivered to the students on the last day of the course. The other author (K.S) examined and scored all the students' answer sheets, to limit inter-rater variability, blinded to students' identifications as well as the state of pre-test or post-test.

    2.4. Statistical analysis

    A paired t-test was used to compare the mean pre- and the post-test score of each group to determine whether the improvement was statistically significant. One-way analysis of variance (ANOVA) was used to compare the differences between pre- and post-test scores of three groups. An unpaired t-test was used to compare mean improvement score between two groups (between 1-week and 2-week course, between the fifth year and sixth-year students, and between elective and compulsory students). The relationship between students' background characteristics, in which measured in terms of GPA and the differences of scores was determined by Pearson's correlation. A p-value less than 0.05 were considered significant. The data were analyzed by SPSS version 17.

    3. Results

    A total of 76 students participated in this study. At the academic year 2014, there were 14 sixth-year medical students participated in 2-week radiology elective, divided into one to three students per rotation. The pre-test results or the post-test results were missed in three students. Thus eleven students have the completed pre-test and post-test results. Then 11 sixth-year medical students were enrolled. At the academic year 2015, there were the two groups of compulsory medical students. First, 20 fifth-year medical students participated in a 1-week radiology rotation but one of them had the incomplete pretest and posttest scores. Then 19 five-year medical students were enrolled. These students were divided into five students per rotation. Second, 42 sixth-year medical students participated in 2-week radiology rotation but three of them had incomplete pretest or posttest. Then 39 sixth-year medical students were enrolled. These students were divided into 2–3 students per rotation.

    Demographic data of all groups showed no statistical difference. In all groups, students scored significantly higher on the post-tests. The pre-test group mean (standard deviation [SD]) was 111.6 (31.9) compared with the post-test group mean of 156.2 (35.4) (p < .001). The changes in score between pre-test and post-test in all groups were not statistically different as illustrated in Table 1. We compared the changes in score between fifth-year and sixth-year medical students. The result revealed that the improved score for the fifth year (mean = 34.2, SD 26.7) and the sixth year (mean = 48.6, SD 41.5) did not differ significantly (p = .166). The results of comparison of the improved score between 1-week (mean = 34.2, SD 26.7) and 2-week (mean = 48.6, SD 41.5), (p = .166); between elective (mean = 46.8, SD 26.6) and compulsory (mean = 44.2, SD 40.4), (p = .838) were also no statistically different. We also compared the pre-test mean scores between fifth-year (112.0, SD 33.9) and sixth-year students (111.4, SD 31.4). The result showed that there was no statistically significant difference of pre-test mean scores between both groups (p = .947).

    Table 1:
    Comparison of the changes in scores.

    The students were classified into two groups, above and below mean GPA, as high and low-performance backgrounds to determine whether performance background had a significant effect on the improved score. Twenty-eight students were in the low-performance background group while 41 students were in the high-performance background group. There was no significant difference in the improved scores among students with a low-performance background (mean = 35.0, SD 39.0) compared with a high-performance background (mean = 51.2, SD 37.0) according to their GPA as demonstrated in Table 2. However, the mean post-test scores of students who had high-performance background were significantly higher than the low-performance background group (p = .001).

    Table 2:
    Mean scores between low and high performance background students.

    4. Discussion

    All students' scores improved significantly from pre-test to post-test. This result is not surprising as demonstrated in the previous literature that educational intervention improved students' knowledge.9–12 There was no significant effect of medical student year on the improved score. This is supported by a recent article by Gispen and colleague.13 They found no significant differences in post-test scores between second-year medical students, third-year medical students and fourth-year medical students after a 4-week radiology elective.13 Even in preclinical-year students also showed a significant higher post-test score in interpreting US images of the focused assessment with sonography for trauma (FAST) examination after training in a short session.9 These results suggested that students' years have no significant difference in ability to learn with the same materials and methods. This was similar to that observed by Salajegheh et al.14 but in a different way. They have demonstrated significant improved radiological interpretation skills in first year students compared to second year students when the first year medical students received more learning materials. Additionally, early exposure to radiology education to pre-clinical students had significantly improved students' knowledge and attitudes towards radiology.15,16 Our results also demonstrate that time spent in radiology rotation either 1-week or 2-week has no significant effect on the increased radiologic interpretive skill. These results revealed that clinical-year medical students can acquire interpretive skill in the only 1-week period. However, these results cannot be generalized to other subjects because clinical reasoning with the uses of images differs from without.17 The improved score between elective and compulsory students also showed no significant statistical difference. This result means that dedicated education improved students' knowledge regardless of interest level. Additionally, the current study demonstrates that the pre-test and post-test scores of the fifth-year and the sixth-year were not different statistically. This may be implied that knowledge retention about radiology after they finished radiology class in the fourth-year is not more than a year or in another way, students don't get any more radiology knowledge in their clinical rotations. Little has been written on the timing of radiology knowledge retention. An article that studied prospectively on the US knowledge retention after the training phase, revealed no decline in performance at 10 months.18 There was one significant finding in the present study, that is, the mean post-test scores of students who had high-performance background were significantly higher than the low-performance background group. It is reflected that high-performance students can acquire knowledge better than the low-performance student in a short learning period. Therefore time space for low-performance students to acquire similar knowledge content should be further investigated.

    There were several limitations in the current study. As a nature of tests set, they consisted of abnormal cases and the participants were aware of them. This tests set was a simulated interpreting circumstance and the readers realized that there would be no effect on the patient management. Furthermore, these image quizzes may not adequately represent all of the varying radiology abnormalities. Additionally, the test-set was developed by the senior author, not by the team. Standardized examination similar to those used in America should be developed in our country.19 We limited time to do the test that is not real in clinical practice. Our study focused on image interpretation only. The other aspects of radiology education, for example, the appropriate use of imaging modality and radiation safety were not evaluated. Future studies could include all aspects of radiology knowledge. Another important limitation of our study is the lack of a control group. It is possible that students would get score improvement by knowing only the tests set after they did the pretest. Therefore memorizing effect could not be avoided. In addition, the number of participants was small. The result needs validation by larger-scale studies.

    Preliminary data demonstrated that vertical education is an effective means of teaching.19–21 Our teaching model is a vertical curriculum that includes basic radiology knowledge in the fourth year and adding the other 1-week or 2-week dedicated radiology rotation in the fifth year or sixth year. Although this model of education is effective, it requires a substantial of time commitment from academic radiologists and space of time in the clinical curriculum. The use of this model may be limited where the clinical curriculum space is tightened, or where the academic radiologists are a shortage. The importance of radiology education should be promoted and supported by the faculty and administration.

    In conclusion, we present a valuable vertical radiology curriculum including basic radiology education in the fourth-year and the other 1-week or 2-week dedicated radiology rotation in the fifth- or sixth-year. After the clinical-year radiology rotation, students demonstrated significant improvement in interpretive skill, which can improve the patient care. We would like to share this type of radiology education and hope that radiology education will become a compulsory component of the curriculum in all institutions in the near future.


    Special thanks to Dr. Chuenrutai Yeekian for statistical analysis.


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    Medical students; Radiology; Undergraduate medical education

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