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Body CT RAH

GENERAL OBJECTIVES:

 This rotation is structured for both junior (PGY2-3) and senior (PGY4-5) residents. On completion of this rotation, the resident will have learned to function as a consultant radiologist to referring family physicians and specialists in all areas of body CT involving chest, abdominal and pelvic, and musculoskeletal disease processes commonly assessed with CT.  The resident will demonstrate the ability to triage and perform CT guided interventional procedures to the required level of competence for obtaining certification by the Royal College.
 

SPECIFIC OBJECTIVES

At the completion of this rotation, the resident will have acquired the following competencies and will function effectively as:
Medical expert/clinical decision-maker

Specific Requirements: 

Basic science knowledge:

o        Demonstrate knowledge of cross sectional anatomy of the chest, abdomen and pelvis, and musculoskeletal system. This includes conventional transverse imaging, and multiplanar reformations, as they pertain to CT.
o        Demonstrate knowledge of clinical radiology and pathology as it pertains to assessment of relevant disease processes imaged with CT. The emphasis will be placed on pathology of the chest, abdomen and pelvis. Musculoskeletal pathology will be a secondary focus, as this is covered primarily with the MSK rotation.
o        Understand the physics behind CT image acquisition.
o        Understand the technical parameters used to obtain CT images. Be able to adapt technical parameters to affect image quality. Understand the source of different CT artifacts.
o        Demonstrate knowledge of radiation dosing and protection.
  • Diagnostic CT:
o        This will be the primary emphasis for junior residents.
o        As an introductory rotation for beginning residents (PGY2), the emphasis will be on disease pathology commonly seen in an emergent and inpatient setting, in able to prepare residents for call responsibilities.
o        Understand the clinical and laboratory presentations of various pathology.
o        Be able to apply appropriate imaging protocols for evaluation of various disease processes of the chest, abdomen and pelvis. MSK imaging will be a secondary focus.
o        Understand the use, risks, complications and contraindications of iodinated contrast. Be able to obtain informed consent for the use of iodinated contrast.
o        Understand the principles of radiation dosing and protection.
o        Develop a systematic approach to CT interpretation.
o        Be able to detect abnormal findings, normal anatomy and variants for each case.
o        Be able to offer an appropriate differential for all abnormal findings.
o        Be able to summarize overall findings and differentials, and offer appropriate recommendations for each case.
o        Understand clinical and treatment implications of various findings and disease processes.
o        Be competent in basic post processing techniques.
  • CT guided intervention:
o        This will be offered for more senior residents and junior residents who demonstrate exceptional abilities and motivation. Note that this does not negate the need to develop good diagnostic CT skills.
o        Understand the indications for different CT guided procedures. The resident should also understand when such procedures are not indicated, and be able to offer appropriate alternatives to referring clinicians.
o        Describe the risks and benefits of CT procedures. The resident should understand the components of informed consent and be able to obtain informed consent for all procedures performed.
o        All residents, regardless of technical abilities, should be competent in basic interventional techniques. This includes patient positioning, sterile technique, application of local anesthetic and basic biopsies and drainages.
o        More advanced residents should demonstrate technical competence in more difficult procedures, including but not limited to lung, abdominal and bone biopsies and drainages of smaller deeper collections.
o        Understand the use, advantages and disadvantages of the different biopsy needles and drainage catheters.
o        Be able to give conscious sedation. This necessitates knowledge of use, dosage, contraindications of various sedative medications.
o        Identify the acceptable and expected results of CT interventional procedures as well as potential complications. The resident should be able to deal with potential iatrogenic complications.
o        Understand appropriate post procedure care and follow up

Communicator

 
Specific Requirements:
·         Apply a systematic style of reporting for all body CT cases.
·         Have the ability to assemble a report that succinctly describes the CT findings, give the most likely differential diagnoses, and recommend further testing and/or management when indicated.
·         Dictate and verify reports in a timely fashion.
·         Understand the importance of communication with referring clinicians, particularly in a situation when the results of an investigation or procedure should be urgently communicated.
 

Collaborator

 
Specific Requirements:
·         Consult effectively with other physicians and health care professionals.
·         Have the ability to function as a member of a multidisciplinary health care team. The resident should be able to supervise and work together with nursing and technical staff.
·         Be able to suggest alternative imaging modalities when CT may not be appropriate in a given clinical situation, for both diagnostic and interventional studies.
 

Manager

 
Specific Requirements:
·         Understand quality assurance issues related to body CT, including, but not limited to, misdiagnoses, radiation dosing, technical parameter optimization.
·         The resident should be able to manage the daily workflow through the CT department.
·         The resident should be interpreting or performing an adequate volume of cases, appropriate to their level of training.
 

Health Advocate

 
Specific Requirements:
·         Describe and explain the benefits and risk of CT investigations including population screening.
·         Educate and advise on the use and misuse of CT imaging.
 

Scholar

 
Specific Requirements:
·         Competence in evaluation of the medical literature.
·         Demonstrate ability to be an effective teacher to medical students, fellow residents, technologists, and clinical colleagues.
 

Professional

 
Specific Requirements:
·         Punctuality, attendance, reliability and respect in the workplace.
·         Be able to accurately assess one’s own performance, strengths, and weaknesses.
·         The resident should be aware of their own limitations, especially with interventional procedures, and recognize the need to call for help when appropriate.
 
CT ROTATION – DUTIES FOR RESIDENTS
 
1.      More experienced (PGY3-5) residents will be responsible for assigning protocols for all of the body CT cases for the day with guidance from the attending radiologist. The protocols will be applied individually to each case to best assess the clinical question. Ideally, all protocolling should be finished as early as possible (0815 or even the day before) to enable smooth workflow throughout the day. PGY2 level residents should review protocols with staff to become familiar with the different protocols used, especially for emergent on call type cases.
2.      The resident will be available to monitor cases as they are performed to ensure that a completely diagnostic study is obtained.
3.      The resident will field telephone calls and written requests for emergent add-on studies and will triage these according to the patient’s clinical status as assessed by the provided clinical information.
4.      The resident should either observe or be involved in all CT guided interventional procedures. The degree of involvement will depend upon the experience of the resident.
5.      The resident will continue to review the cases for the day, including other pertinent studies, and will develop a list of differential diagnoses for the CT findings. These cases will be checked with the attending radiologist and dictated by the resident.
 
RESIDENT EVALUATIONS
 
The Resident’s day-to-day performance will be evaluated.  The end of rotation evaluation will be done by a committee of radiologists involved with CT over the month.  It is the responsibility of the Resident to ensure that the end of rotation evaluation is both completed by the committee and reviewed with the Resident by the CT supervisor within one or two weeks of completing the rotation.  
 
SUGGESTED READING:
·         Webb WR, Brant WE & Major NM. Fundamentals of Body CT, 3rd ed. Saunders 2005.
·         Lee JKT, Sagel SS, Stanley RJ & Heiken JP. Computed Body Tomography with MRI Correlation, 4th ed. Lippincott Williams & Wilkens 2006.
·         Webb WR, Müller NL & Naidich DP. High-Resolution CT of the Lung, 3rd ed. Lippincott Williams & Wilkens 2001.