Bridging Knowledge, Learning Style and Generational Gaps

Moving Towards Modern Medical Education and Training — Part 9


Let’s consider the plight of the first-year radiology resident.

This person faces a mountain of ever increasing and sophisticated knowledge, which has accumulated at a constantly accelerating rate since the 1970’s. We ask these very successful students and new physicians to become competent in the full range of diagnostic imaging’s role in medical care, and also the physics and science of imaging technology. What tools we do we provide to reach these extraordinary goals?

There is no defined curriculum, nor has there ever been:

  • Trainees are generally provided a list of books to read, perhaps with a critique of their content or some targeted reading assignments.
  • We provide a mandated series of 45–60 minute lectures, the content of which is largely discretionary. Most lecture content is forgotten soon after leaving the lecture hall and the same goes for the topical clinically oriented lectures that make up the rest of this discretionary “curriculum”.
  • Case conferences are held, with one resident taking a case and the remainder left to observe. Black pearls of disinformation abound and many go uncorrected.

This is not a system that can accomplish its intended goal.

Our trainees are very bright people who have grown up in the age of the internet, and have been using it all their lives on a daily basis. We, as educators in diagnostic imaging, have sorely under-leveraged the extraordinary IT tools currently available by way of the internet’s maturation.

Worse, we continue teaching in willful ignorance of the tenets of pedagogical and adult learning principles that our educational colleagues in primary, secondary and university settings have been applying and refining for generations.

As a result, we are well behind in delivering an important outgrowth of modern education, that being; effective distance delivery of an asynchronous education (in an adult learning model). How do we answer for this neglect to modernize and optimize our educational mission?

No, putting recorded lectures on the internet is not much of a solution. It is a bland, simplistic attempt to exploit this extraordinary communication resource for cost reductions. You can watch a video as often as you like, which is handy — especially if it’s hard to stay awake! But even an inspirational or quality video lecture cannot on its own be a means to transfer a useful comprehensive competency, or wisdom.

Amongst the modern adult learners in the practice of medicine there are more physicians in need of effective learning tools than our resident trainees. We now have multiple generations of practicing physicians interpreting diagnostic images who have been educated using largely archaic methodologies and without an identifiable curriculum.

All the generations have predictable knowledge gaps because none have matriculated from a competency based system with an endpoint of true proof of competency. Some non-radiologists who routinely interpret imaging studies are mostly self-taught. Many board-certified diagnostic radiologists are asked to practice the full range of diagnostic imaging at a competent or expert level — an impossible ask to fulfill.

These people, who should aspire to life-long learning principles, are dominantly visual, auditory and tactile adult learners. So, how can we bridge the knowledge and learning style gaps and provide this mixed group of generational learners that suite of appropriate and modern educational tools?

Simply put, as a profession, we should be providing learning platforms they can use to customize an individual learning experience, from a suite of tools that present a comprehensive and logical curriculum.

Such a platform could support the unique personal, as well as very common identifiable knowledge gaps that exist, regardless of any person’s knowledge, training and experience, or their learning style biases.

In part, knowledge gaps will vary depending on the generation queried. Considering CT and MRI as benchmarks for rate of progress the current population of practicing radiologists might be divided into 4 groups:

1 — Those that were trained beginning with the advent of ultrasound and CT in about 1974 and ending in the early 1980’s. At this “era’s” start there were plain films with their contrast iterations (e.g. BE, IV), multidirectional tomography and the early days of sophisticated angiography. At the outset, CT was done with a water bag and slice acquisition times ranging from 5 seconds to 60 seconds and would eventually move to 1–2 second single slice acquisitions; ultrasound was only bistable but soon to move to analog imaging with articulated arms and eventually digital acquisition and small parts techniques.

There was not really much to master intellectually compared to what is now required, although subspecialty training was already well underway. Neuroradiology in particular with highly specialized imaging techniques angiography, pneumoencephalograhy foreshadowing the need for subspecialized technological, and organ system expertise with the genesis of the American Society of Neuroradiology.

2 — Those that were trained beginning in the 1980’s with the advent of faster CT scanners and early MRI with imaging at 1.5 Tesla as a “proposal” at the start of this “generation”. This era ended in about the early to mid-1990’s with “high field, high resolution” MRI and ever improving CT image quality. An era of accelerated but still limited change that was predictive of the coming more challenging demand for the knowledge base acquisition growth to come.

3 — Those that were trained beginning in the early to mid-1990’s with the first multislice (two-slice detector system) CT scanners coming courtesy of Elscint. This grew to more sophisticated multislice detectors and gantry changes that provided faster CT acquisition times setting the stage for the explosion in CT applications to come.

In addition, more advanced MRI receiver coils as well as more sophisticated pulse sequences including DWI and early functional MRI emerged. That era ended around 2005 and represented the birth of a very substantial change in the knowledge base required to practice proficiently in more than one subspecialty.

4 — Those trained in this current era have experienced extraordinary advances in multislice CT, the birth of very sophisticated CT angiography with perfusion. MR advanced applications have included very sophisticated custom pulse sequences that can exploit flow dynamics, advanced DWI/DTI and functional MRI. This era is still in progress and continuously generates a formidable knowledge base required to practice at a proficient level in more than one or two subspecialty areas.

This extraordinary acceleration of knowledge begs the question of confining the definition of general radiology to something that can actually be achieved. It also requires a competency based educational model to confirm proficiency in chosen areas of subspecialty and/or the “new” and more limited concept of general radiology practice.

Throughout these artificial “eras/generations” there have been parallel landmark changes that have pushed diagnostic imaging into the forefront of medical decision-making in many patients. These have evolved to a deconstructed PACS model of practice where images can rapidly, along with very sophisticated post-processing tools, be widely distributed to ordering clinician’s, accompanied by real-time, finalized radiology reports.

These changes have influenced attitudes and behaviors of the “generations” of practicing radiologists somewhat differently. We have moved from behaviors causing us to be perceived as relatively unavailable 9 to 5 docs that “don’t take any call”, to physicians who must be actively involved in aggressively moving medical decision-making forward 24/7/365.

In this cultural shift, the notion that interpreting diagnostic images is simple “describing the findings” (an attitude that was clearly dominant in many practitioners of diagnostic imaging in generations past and unfortunately still exists in the minds of some) is not acceptable.

As we modernize our approach to training and life-long learning, those modern methods must teach how to integrate the imaging findings by way of critical thinking. Along with that fundamental task the educational system must establish firm lines of ethics and behavior with regard to communication with treating providers and interacting with them as timely consultants for the benefit of our patients.

Coming Next: Part 10 — Answers for “Gaps” — Within our grasp?


I am on a mission to modernize post graduate medical education. With my team at the University of Florida, we have spent the last eight years developing a competency based curriculum and evaluation for radiology, based on modern learning theory. In this essay series, Moving Towards Modern Medical Education and Training, I examine in detail the pathway to modern learning and educational theory, and the outcome of the application of modern learning principles in this sphere of medical education.

Part 1: Medical Education: How Did we Arrive at the Current State

Part 2: “See one do one teach one”

Part 3: Teaching to the Test

Part 4: Competency or Passing the Boards? Every patient wants an expert.

Part 5: Errors and “Experts”

Part 6: Real Experts and Tolerable Error

Part 7: An Invitation to Harm?

Part 8: Three Ways Medical Education Could Better serve the Modern Learner

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