RESIDENT GUIDELINES by pengxiuhui

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									RESIDENT

GUIDELINES




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ABSENCE POLICY (rev. 10/23/08)
The ABR Leave Guidelines are as follows: “Leaves of absence and vacation may be
granted to residents at the discretion of the program director in accordance with local
rules. Within the required period(s) of graduate medical education, the total such leave
and vacation time may not exceed SIX CALENDAR WEEKS (30 working days) for
residents in a program for one year, TWELVE CALENDAR WEEKS (60 working days) for
residents in a program for two years, EIGHTEEN CALENDAR WEEKS (90 working days)
for residents in a program for three years, or TWENTY FOUR CALENDAR WEEKS (120
working days) for residents in a program for four years. If a longer leave of absence is
granted, the required period of graduate medical education must be extended
accordingly.”

For our five-year integrated residency program, we have expanded the allotment to a
total of 150 working days over the five-year period. Residents cannot exceed thirty (30)
days per year of leave away from the program without the risk of incurring extra days at
the end of their residency; exceptions must be approved by the Program Director. The
GME office (through New Innovations) as well as the ABR tracks your absences, so
please monitor your totals carefully; the program will not be responsible if you come to
the end of your program and find that you are over the 150 days.

ALL absences away from the program will count toward the ABR total with the exception
of: official holidays, approved offsite rotations, educational conferences/meetings
approved by the program director, and “other excused leave” as listed below.

The program will grant residents time off in the following increments with appropriate
documentation and approvals:
VACATION

PGY 1-3: 15 days per year + 4 winter holiday at discretion of department
PGY 4-5: 20 days per year + 4 winter holiday at discretion of department

-- Will not be carried over from year to year unless pre-arranged with the PD
-- “Personal days” are included in the vacation time
-- Plan to take at least half of your vacation days prior to January 1; after January 1, the
chief residents have the authority to schedule unused vacation time at their
convenience, not yours
-- A maximum of four residents are allowed to be gone at one time for ANY reason; this
is governed by a “first come, first served” rule
-- Vacation will not be granted for the date of the in-service exam
-- Please do not plan vacation while on angio, fluoro (GI/GU), Ellis, neuro CT, night float
-- Do not make travel plans until you have received the approved request form; the
department is not responsible for any loss of monies you may incur if you make non-
refundable travel arrangements and then your request is not approved
-- Verbal approvals of vacation are not valid; it’s not official until we get the purple form
-- Vacation taken without prior written approval will be considered leave without pay




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EXTRA COMPENSATION: NO compensatory time will be given for covering long
weekends, holidays, in-service exam, etc. Any arrangements made for covering other
residents because of schedule conflicts, etc., should be worked out as an even trade-off
with the other resident involved and with the approval of the chief resident(s); no extra
compensation will be granted for this. If a trade is made and the expected resident fails
to show up, the resident originally on the schedule will be held responsible, unless the
trade was officially discussed with the chief residents and/or published. If this person is
not available, the Chief Resident will be called to arrange coverage. The resident who
did not show will then take two equivalent call days for the resident who covered.

SICK LEAVE/FAMILY MEDICAL LEAVE

10 days per year (50 days’ total over 5 years)

-- May be carried over from year to year
-- Can be used for family members as well as self
-- Unplanned – notify chief resident(s) and the program coordinator before 8 AM
-- Planned – complete purple form and give to Chiefs for approval
-- Will be counted as time away from the program for ABR purposes
-- Excessive sick leave will require documentation and may be pursued by the Program
Office in an effort to encourage good health practices. In general, if the resident has
been out sick for 3 or 4 consecutive days, the Program may require a certified doctor
note. Also, recurrent sick leaves of shorter durations, particularly if the resident needs to
dip into accrued sick leave, will need a verifiable physician’s note to prevent abuse.
-- Failure to give proper notice or adhere to policy will result in a deduction from your
annual vacation leave or leave without pay if vacation time is not available.
-- Up to 12 weeks of Family Medical Leave (including maternity/paternity leave) will be
granted in accordance with the Family and Medical Leave Act (FMLA) as complied with
by the University of Missouri. The complete text of the Family and Medical Leave Act is
included in the Institutional Policy. Time off for extended medical leave will be deducted
from available sick leave, then from available vacation time. If leave taken exceeds the
available sick days and vacation days, the resident will be placed on leave without pay.
Be aware that taking the full twelve weeks of family medical leave which is
allowed by FMLA could conflict with the standards set by the ABR on when
you can graduate and when you can take boards (see guidelines above).

BEREAVEMENT

The program will grant up to two days per year to attend a funeral of a family member
plus up to three days’ travel time if the funeral is at a distance. This must be approved
by the Program Director and does count as time away from the program.

FELLOWSHIP/JOB INTERVIEWS

A total of five days during PGY1-4 is available for interviews. Seniors completing their
residency program are allotted five additional days during the PGY5 year to be used for
either interviews or a radiology-related conference/review course. Additional funds are
at the discretion of the current department chair. Documentation is REQUIRED in order



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to use this leave: copy of invitation to interview or copy of conference brochure. This is
counted as time away from the program.

EDUCATIONAL CONFERENCES & MEETINGS

5 days per year (meeting dates plus 1 travel day, if not touching a weekend)
Chief residents – additional 5 days for AUR or ACR
Presenters members – additional 3 days
RSNA – the program will give time for the resident to attend one time per residency with
a maximum of five residents gone at a time. If a resident wishes to attend the
conference more than once, then they may use their own meeting time. This time will
be counted as educational and not as away from the program for ABR purposes.

--This time will be granted for radiology-related conferences only, including board
reviews, academic conferences, organized medicine meetings, etc.
-- May also be used for interview days with appropriate approvals
-- Please submit a signed meeting request form plus documentation of the conference to
the program coordinator for verification
-- Additional time/money is available to residents who are presenting or who hold an
elected/appointed national leadership position
-- Each resident is encouraged to attend the RSNA meeting one time during his/her
residency; the scheduling of this is up to the chief residents
-- Missour State Radiological Society meetings (spring or fall meeting): each resident
must attend once during residency. The MRS will provide mileage cost to and from
Columbia and up to one night hotel stay the night before. Spring meeting is held
between Kansas City and St. Louis each alternate year and fall meeting at Lake of the
Ozarks.
-- Educational fund monies may be used for travel and/or registration expenses for
approved conferences and meetings (see “Educational Fund” section); funding is up to
the discretion of the Department Chair and institutional policies

OFFSITE ROTATIONS/AFIP

Offsite rotations will only be considered to meet ACGME educational requirements which
the institution is unable to provide through any means. These are always at the
discretion of the program director and the chief residents after approval of the GME
requirements. Time spent at approved offsite rotations and/or AFIP are considered part
of the residency program and will not count toward the ABR total towards time away.
Appropriate forms and approvals must be submitted for inclusion in the resident’s folder.
A maximum of one resident per block will be allowed on an AFIP or offsite rotation,
unless there is a pressing and verifiable personal or departmental need.

HOLIDAYS

The University grants a total of 8 holidays as follows:

Independence Day (July 4 only)                Labor Day
Thanksgiving (2 days)                         Christmas Day (December 25)



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New Year’s Day (January 1)                   MLK Day
Memorial Day

If the holiday date falls on a weekend, either the previous Friday or the following
Monday will be granted as a holiday, consistent with institutional policy.       The
department also currently has a half-staff policy for the two weeks of Christmas and
New Year’s which is re-assessed yearly.

OTHER EXCUSED ABSENCES

ACLS/BLS re-certification
ABR exams (actual date + one day travel time if out of state)
Step 3 ; 2 days (for PGY1’s and PGY2’s ONLY)

NOTIFICATIONS

Following is the procedure for notifying the department of planned time off:

      Complete leave request at least one week prior to start of leave to allow for
       processing time;
      Let your attending know that you will be gone;
      Arrange coverage, if required, with the chief residents
      The chief residents will notify the program coordinator who will make the
       appropriate schedule changes online

Following is the procedure for notifying the department of unplanned time off:

      Call or page the chief resident (or the acting chief resident). Keep calling until
       you reach them.
      The chief resident will notify the attending in your assigned rotation and arrange
       coverage if necessary.
      The chiefs will also notify the program coordinator who will make the appropriate
       schedule changes online

Any changes in the rotation schedule or call schedule must be approved by the chief
residents. Major changes to the rotation schedule also require the PD’s approval.

LEAVE REQUEST FORMS

The “purple forms” are located in the rack in the residents’ room. They need to be
completed for ALL time taken away from work, including vacation, interviews, meetings,
planned sick leave (surgery, maternity leave, etc.), and “free” days, such as ACLS, BLS,
and Step 3 (for scheduling purposes). Leave Request Forms should be submitted and
approved at least two weeks before the start date of your requested leave time and prior
to beginning the rotation in which you wish to take leave. Any cancellations or changes
should be also be submitted on the purple form.

To request time off:




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      Make certain you have enough leave on the books to cover your request
      Check to see how many other residents are already off on those dates
      Complete the top portion of the form, including the rotation you will be on
      Fill in the dates and other information under the appropriate heading
      Use a separate form for each request
      Consecutive days may be put on the same form (don’t worry, you will not be
       charged for the weekends)
      Put the form in the Chief Residents' box in the residents’ room
      The Chief Resident will review it and give it to the PC for scheduling
      The Program Coordinator will put a copy of the form, marked either approved or
       disapproved in your mailbox
      It is not official until you get the signed copy back

To cancel scheduled time off:

      Complete the top portion of the form
      Fill out the “Cancel Leave” section
      Put in Chief Residents’ box
      The Program Coordinator will put a signed copy in your mailbox
      If you wish reschedule requested time off, you need to submit two separate
       forms: one to cancel the old dates and one to schedule the new dates

AFIP

As part of the resident educational experience, each radiology resident will have the
opportunity during the residency program to attend the six-week radiology AFIP course
in Washington, DC. The department covers the $1500 tuition plus provides up to $2500
living expense allocation which is available to the resident through reimbursement.
Registration for AFIP should be made at least 60 days in advance of the beginning date
of your course. This is done through the Program Coordinator. You also need to
arrange housing while you are there and this should be worked through the department
business office. Information on slide preparation and details of the course are available
on their website: www.afip.org.

CALL ROOMS

On-call accommodations are provided in the form of two individual call rooms, each
furnished with a bed, a computer, a television set, and a private bathroom with a shower.
Linen and towels are changed daily by hospital maintenance. These call rooms are for
the use of the resident on call ONLY. Please take care to lock up your belongings as the
Department is not responsible for loss of personal property from the call rooms.

CALL SCHEDULE

Call is scheduled in the following increments:

               week day evening shift        5 PM - 8 PM
               senior night float            8 PM - 8 AM
               junior night float            8 PM - 8 AM
               weekends                      12-hour shifts assigned



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               holidays                      12-hour shifts requested

On weekdays, the period between 5 PM and 8 PM is covered by the PGY1-2's and the
attending assigned to the evening shift. There are two residents on call for the evening
shift: buddy call for PGY1’s shadowing PGY2’s from July through December (5PM to 8
PM) and back-up coverage by the resident at the Imaging Center from January through
July (5 PM to 7PM). Angio is covered by the angio resident until 8 PM. The resident(s)
on evening call carries both pagers until the night float residents arrive at 8 PM.

Junior and senior night float are regular rotations and are included on the rotation
schedule. The night float hours are Sunday night through Thursday night, 8 PM to 8 AM.
The night float rotations are scheduled in two-week increments. During night float, the
junior resident carries the primary call pager (1707) and the senior resident carries the
specials pager (3717). There are on-call faculty members available by pager for both
general radiology and the cardiac/interventional area. The resident on night float will
have no duties during the daytime hours for the weeks that they are on call; however, all
their cases must be checked out and signed off prior to their going home each morning.

The weekend call schedule is published separately from the rotation schedule and is
arranged by the Chief Resident(s). Weekend night call is Friday and Saturday night, 8
PM to 8 AM. Weekend day call is Saturday and Sunday, 8 AM to 8 PM. Sunday night is
covered by the night float residents. The residents sign up for holiday call at the
beginning of each year, generally taking two 12-hour shifts each, with senior residents
given first preference.

Any changes to the call schedule shall be coordinated with the Chief Resident and the
Program Coordinator and should be made as far in advance as possible. If a trade is
made and the expected resident fails to show up, the resident originally on the schedule
will be held responsible. If this person is not available, the Chief Resident will be called
for coverage. The resident who did not show will then take two equivalent call days for
the resident who covered. Any questions regarding the call schedule should be directed
to the Chief Resident.

MIDAS call -- The resident on call is also responsible for the MIDAS teleradiology that
we provide to some of the surrounding rural hospitals. Any questions regarding MIDAS
should be directed to Tom McCord (pager 499-8706).

Nuclear medicine call -- The radiology resident on call takes primary call for nuclear
medicine. The nuclear medicine fellow is on 24-hour backup call with Dr. Singh and Dr.
Greenspan providing further backup if necessary. Due to the lack of faculty at the VA,
we have agreed to cover VA nuclear medicine as part of our regular call schedule.


Call Regulations

    Be available during the shift for emergency and in-house interpretations for UH,
     EFCC, and VAH. This includes CT, US, MR, angio, MIDAS, and plain films.
     Teleradiology cases will be read by the evening shift radiologist when they are
     there. At other times, they are drafted by the residents.




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    All in-patient and ER CT, US, and MR cases will be drafted by the resident and
     read with the evening shift radiologist when they are in the hospital. At other
     times, the reports are drafted for review in the morning.

    The PGY1 and 2 residents will read all plain-film interpretations during the
     evening shift.

    The PGY1's are exempt from night float for the first six months and will not be
     scheduled for night float until they have passed an image review exam at the
     Program Director’s discretion and can show a basic understanding of normal
     procedures

    PGY-5 residents who have passed the written board exam and are preparing for
     their orals will be relieved of call duties after January 1 (except Imaging Center)
     of their final year in order to prepare for the oral board exam. Any senior not
     preparing for the oral boards will be placed back in the call pool.

CASE LOGS

Radiology residents are required by various oversight organizations to keep logs of
specific cases in which they participate. Beyond these requirements, we also suggest
that you keep track of interesting cases for presentation at case conferences or for use
in your colloquia. We are currently furnishing case log notebooks for this purpose but
we may be moving to PDA’s in the future if needed. Your log book is reviewed on a
semi-annual basis during your performance evaluation with the Program Director.
Because of HIPAA concerns, no data that might identify a patient should be kept in the
log book.

ANGIO/INTERVENTIONAL

You are required by the ACGME to keep a log of all invasive procedures
(angio/interventional) in which you participate.

MAMMOGRAPHY

The RRC (Residency Review Committee) for Diagnostic Radiology requires that “each
resident should have documentation of the interpretation/multireading of at least 240
mammograms within a six-month period within the last two years of the residency
program.”

OB ULTRASOUND

As part of our mandate from the ACGME to establish a radiology resident rotation
specific to actual experience reading OB ultrasounds, we are requesting that you track
all ultrasounds in which you participate, during both your clinical rotations, your senior
OB ultrasound rotation, and regular radiology rotations.

NUCLEAR MEDICINE




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In compliance with recently issued NRC (Nuclear Regulatory Commission) regulations,
residents in radiology are now required to participate in at least three cases involving
oral administration of < 33mCi of I-131. The specific dates for each occurrence should
be kept in a log book and submitted to the nuclear medicine program director for
certification. SPECIFIC FORMS WILL BE PROVIDED FOR THIS.

RESIDENT CASE LOG SYSTEM

The Resident Case Log System for Operative Log Reporting is an internet-based case
log system utilizing CPT codes and ICD9 codes to track resident experiences
implemented by the ACGME and effective for radiology residencies as of July 1, 2006.
The areas to be tracked for radiology are: chest x-ray; CT abdomen/pelvis; CTA/MRA;
image-guided biopsies/drainage; mammography; MRI body; MRI brain; MRI knee; PET;
ultrasound abdomen/pelvis. MARS has been set up to track these numbers for each
resident. The application is set up to allow residents to enter data on a regular basis at
their convenience. Additional training and instructions on the use of this system will be
provided at the beginning of each academic year or as needed. Currently, we plan to
enter data every quarter and document this also in individual portfolios.

CHIEF RESIDENT

The Chief Resident(s) is elected on a yearly basis by the residents and faculty, usually
serving from January to January. In addition to a monthly stipend, the Chief Resident
receives an additional $1500 to attend the AUR/A3CR2 annual meeting and an
additional $400 book allowance.     The Chief Resident shall at all times present an
outstanding example by his/her conduct and professionalism as well as serving as the
primary liaison between residents and faculty in the following ways:

    As the first contact point in the resident grievance process (all grievances stated
     by residents should be carried up the chain of command and followed to
     resolution)
    As the resident representative at faculty and other committee meetings
    As the person responsible for making sure that all residents are aware of any
     departmental policy changes and how it affects them as well as insuring that the
     residents understand and exist by existing policy

The Chief Resident performs the following duties in addition to responding to specific
requests from the Program Director:

    Produce the call schedule to be approved by the Program Director
    Handle all questions and problems regarding the call schedule, including
     arranging coverage if the scheduled resident does not show up or if there is
     some confusion regarding who is on call because of trades
    Serve as the principal keeper and distributor of the Board recall questions
    Maintain the moonlighting logbook
    Arrange and schedule journal clubs, colloquia, and medical student lectures to be
     given by the residents
    Attend the monthly Medical Education Committee meeting
    Assist in faculty recruitment by taking the faculty candidate to lunch and on a tour
     of the facilities and other duties as requested by the department secretary



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    Coordinate departmental tours for residency candidates during interviews in
     December and January and participate in the Match ranking process

COMMUNICATIONS

PAGERS

You will be provided with a pager which you will keep throughout your training. This
pager is to be worn during working hours regardless of the location of your assignment.
Junior and senior call pagers are kept in the CT reading area and are to be used when
you are on call. Batteries are available from any of the secretaries or in the drawer in
the call room. Pagers needing repair should be taken to the Telecommunications
Department (located in the hallway on the way to the cafeteria). Please report loss or
theft of your pager to the Program Coordinator immediately.

E-MAIL

The department uses e-mail as its primary source of immediate communication. Each
resident is given a University e-mail address upon entering the program. These
addresses are available on the computers in the reading rooms via the internet
(www.health.missouri.edu) with your sign-on and password. All conference changes,
meeting notices, policy updates, changes in personnel, etc., will be communicated via e-
mail, so it becomes extremely important that you check your e-mail at least once a day.

FAX

The department's fax number is (573) 884-8876. The fax machine is located in the
copier room and is for use for both educational and hospital purposes. Long distance
faxes require a long-distance IAT code (this is assigned to each resident at the
beginning of the residency). Incoming faxes are picked up twice daily and put in the
individual mailboxes.

MAILBOXES

Each resident has an assigned mail box in the residents' room. Outgoing mail can be
left in the mail cart in the copier room. All outgoing mail must have postage on it, either
stamps for personal mail or a mail code for business mail. In order to go out that day,
mail must be placed in the basket no later than 9:00 AM. The departmental address is:


                      Radiology Department, DC069.10
                      University of Missouri Health Care
                      One Hospital Drive
                      Columbia, MO 65212

CONFERENCES
FORMAT

Resident conferences are held in the radiology conference room M253 at 7:15 a.m. and
12:00 noon daily (Monday through Friday), with additional conferences scheduled on


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occasion. The conferences consist of both didactic lectures and case conferences and
each of the sub-specialty topics are to be covered at least once a month. Introductory
lectures for the PGY1's will be offered as part of the July conference schedule. The
Advanced Radiological Life Support (ARLS) videos will also be shown as part of the
PGY1 preparation. The monthly schedule is available online on MARS and New
Innovations and is also posted on the door to the conference room.

ATTENDANCE

Attendance at conference is mandatory (with the exception of physics conferences for
those who have passed their exam) unless there is an acceptable reason for non-
attendance. Acceptable reasons include but are not limited to: approved leave
(vacation, sick leave, meetings), rotations at other facilities (AFIP, offsite rotations), call
schedules (night float, Friday call, clinical call), scheduled procedures, or family
emergency. It is the responsibility of the chief residents to make sure the residents
understand this requirement; the chiefs will also be responsible for enforcing it.

Residents are also expected to be PUNCTUAL for attendance at the conferences. Any
resident arriving more than ten minutes late for a conference will be considered tardy.
Three tardies = one unexcused absence. Four unexcused absences = the loss of ½
vacation day. The absence “clock” is reset every two months.

If there are continued attendance problems with a particular resident, a letter will be
written to that effect and placed in the resident’s folder. In addition, if a resident fails to
attend a minimum of 70% of conferences for each half of the academic year, he/she will
lose privileges, including educational fund monies, permission to moonlight, attendance
at national meetings, and priority on the vacation list.

PHYSICS

We instituted a new physics conference schedule for 2006 but will be reviewing it for
possible changes. Physics lectures begin in April and continue through June and run
concurrently with senior board reviews (shown in brackets on the monthly schedule).
The textbook is Bushberg, The Essential Physics of Medical Imaging (2nd ed.) and will
be purchased for you (on loan) by the department. In July and August, Dr. Boote will
conduct RAPHEX review sessions and Dr. Volkert will give his radiobiology series. All
physics conferences are required for residents who have not yet passed the physics
portion of the written board exam.

COLLOQUIA/JOURNAL CLUB

Each resident is required to present one 30-minute conference per year on a relevant
topic which has been pre-approved by a faculty member. Topics are not to be repeated
by the resident. The colloquia should be Power Point presentations, preferably with
handouts, and are attended by both residents and faculty.

Each resident is also required to present a minimum of two academic articles per year
from refereed journals at Journal Club. The articles may be selected by the resident
from those provided by faculty members or they may select an article from their own
reading. Each presentation should be a brief summary (do NOT read the article out loud
verbatim!) and should be no more than ten or fifteen minutes long. Copies of the articles


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should be made and distributed to all residents and faculty prior to the Journal Club
presentation.

All colloquia topics and journal club articles require pre-approval by a faculty mentor on
the appropriate approval form (“green sheet”). These forms along with a summary of the
presentation should be placed in the resident’s portfolio for review by the program
director.

Residents choose their own presentation dates from the list and are expected to note the
date and arrange their schedules around it. The faculty mentor signing your “green
sheet” is expected to attend your presentation so please confirm the date with him/her.
If the resident fails to give their scheduled presentation or if the presentation is sub-
optimal, he/she will be assigned a make-up date PLUS an additional one-hour
presentation on a topic assigned by the Program Director. A note to this effect will be
placed in the resident’s file.

COPIES

The copier is located in Room M210B and is made available for educational and hospital
purposes only. The code to use the copier is 1+ the last four digits of your social
security number. If the copier malfunctions, please notify the key operator. The use of
the copy center at the Health Sciences Library requires an account number which is
available from the Program Coordinator only if the copies have been requested by a
faculty member. All other library copies must be paid for by the individual; however, you
may check the book/journal out and bring it back to the department and use the
department copier. In making copies, please observe any copyright restrictions which
may be in place regarding the material being copied.

CERTIFICATES & LICENSES

It is the resident’s responsibility to make sure that the following are current and on file in
the Program Office:
         -- Missouri state medical license (either temporary or permanent)
         -- BNDD/DEA certificates
         -- ACLS/BLS certification
         -- Staff Health annual screening
         -- Code of Conduct annual completion certificates
         -- ECFMG documents

CORE COMPETENCIES (detailed outline in “Goals and Objectives” section)

The ACGME (Accreditation Council for Graduate Medical Education) is currently
requiring that all U.S. medical residency programs adhere to a set of minimum standards
in general competencies in the following areas:

       -- patient care
       -- medical knowledge
       -- practice-based learning and improvement
       -- interpersonal and communication skills
       -- professionalism



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       -- systems-based practice

These competencies are reflected on the form used to evaluate the resident after each
rotation and are also included in the goals and objectives set for each rotation. Each
resident is expected to take an active part in achieving these minimum standards. For
further information regarding the general competencies, please go to the ACGME
website (www.acgme.org) under “Outcome Project.” This site also contains information
for residents on duty hours and complaint procedures.

DOSIMETERS

Radiation film badges are required by Environmental Health and Safety and are supplied
by the department to all residents. The badges are collected to be read on a monthly
basis. On the first of each month, you should place your old badge in the holder in the
copier room and pick up your new one. Continued failure to do so will result in
disciplinary action.

DRESS CODE

All residents should plan to come to work dressed professionally and appropriately.
Neither lab coats nor ties are required.

EDUCATION COMMITTEE

The purpose of the Education Committee will be to bring to the attention of the Program
Director suggestions for improvement in residency education. They will also monitor
residents on probation and assist with dismissal of residents from the program to assure
that due process has been followed.

EDUCATIONAL FUND

Each resident is allotted a $1000 educational fund for each of the five years of their
participation in the program to be used for books, journals, and meeting expenses (this
money cannot be used for computer purchases). In addition to this, the department
provides the Brant and Helms radiology text to each PGY1 resident.

Additional money is granted to:

    Residents presenting papers at meetings -- up to $1500 bonus allocation with a
     maximum of $1500 per academic year (pre-approval by the Program Director is
     required to be eligible for this additional funding)
    The resident in charge of lab coat linen service -- $250 additional book allowance
    The resident chosen as Outstanding Resident of the Year -- $100 additional book
     allowance
    The Chief Resident(s) – monthly stipend, $400 additional book allowance, and
     $1500 to attend the AUR/A3Cr2 annual meeting

EMERGENCY CODES




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The following emergency codes will be called over the overhead announcement system.
Emergency code checklists are posted at every telephone with specific instructions
about what to do when reporting or responding to codes.

              CODE BLUE/ PEDS STAT -- Individual without pulse or respiration
              CODE RED -- Fire
              CODE CHEMICAL -- Chemical spill
              HEALTH PHYSICS ALERT -- Radiation emergency
              CODE GREEN -- Bomb threat
              CODE GRAY -- Hostage situation
              CODE BLACK -- Infant abduction
              CODE YELLOW -- Severe weather warning
              SEVERE WEATHER WATCH -- Conditions favorable

EVALUATIONS

ONLINE EVALUATIONS

As of 2006, we will begin implementing online evaluations using the New Innovations
internet-based software as mandated by the Graduate Medical Education (GME) office.
The target dates for this are: July 1, 2006, for online rotation evaluations of residents by
radiology faculty; September 30, 2006, for 360-degree evaluations by staff and rotation
evaluations by outside faculty; December 31, 2006, for semi-annual faculty evaluations
by the residents; June 30, 2007, for yearly program evaluations by the residents (and
seniors). The time frame for each of these evaluations will remain the same as for the
current system of written evaluations.

EVALUATIONS COMPLETED BY RESIDENTS

Residents are asked to evaluate the faculty members on a semi-annual basis (at the end
of December and the end of June). The faculty are rated on the following criteria:
willingness to teach, quality of teaching, availability, concern for patient care, fund of
knowledge, interpersonal skills, ability to communicate, and service as a role model.
The resident evaluations of the faculty will be figured into the faculty's end-of-the-year
performance rating.

The resident evaluations of the faculty are handled on a strictly confidential basis (the
resident’s name is not shown on the written evaluation). The completed evaluations are
turned in to the Program Director and are not made available to anyone except the
Department Chair. The Program Director is responsible for correlating all of the
evaluations received and preparing a summary report for the Chair of the Department.
The original evaluation forms are retained by the Program Director until one month after
the summary report has been submitted and then the forms are destroyed (shredded).

Residents also complete a program evaluation at the end of each academic year. The
information from the program evaluations is reviewed by the Medical Education
Committee and submitted to the Department Chair. The resulting recommendations are
used to implement appropriate changes within the department.

EVALUATIONS COMPLETED BY FACULTY



                                            14
Written evaluations of the residents are performed at the end of each rotation by the
faculty who worked with them on that rotation. The residents are rated per the ACGME
core competencies: patient care; medical knowledge; practice-based learning and
improvement; interpersonal and communication skills; professionalism; and systems-
based practice. The completed evaluations are given to the Program Director who
reviews them with the residents on a bi-annual basis during their performance review.
These evaluations will be used (along with other criteria) to determine if remediation is
needed for an individual resident.

The Program Director encourages ongoing verbal input between faculty and resident
during a particular rotation and specifically requires a “mid-rotation” verbal
communication from the faculty to the resident regarding his/her progress. If a negative
written evaluation is received for that particular resident and a mid-rotation evaluation
was not conducted by that faculty member, the written evaluation may not be fully
validated.

Evaluation forms are also sent to faculty who work with residents on their clinical
rotations. These are included in the review by the Program Director.

EVALUATIONS COMPLETED BY NON-FACULTY

As of May 2006, we began giving the techs and nurses the opportunity to evaluate
residents via a 360-degree evaluation. We also periodically provide patients with a
“Patient Care Survey” card to be filled out on specific residents on selected rotations.
These non-faculty evaluations certainly do not hold as much weight as faculty
evaluations but will be reviewed with the resident by the Program Director as part of their
professionalism and communication core competencies. Problem areas or trends will be
tracked and appropriately addressed or asked to be improved by the program.

EXAMS

ACR In-Service Exam

The ACR In-Service Exam is mandatory for all residents except those who have passed
the written boards and are preparing to take the oral boards. Do not make any plans for
vacation or conference leave at the time of this exam. If you are at the AFIP, you will
take the exam there.

Residents are expected to score in the 30th percentile or above on the in-service exam.
Any resident not achieving this minimum score will be counseled by the Program
Director and will arrive at a plan to correct this deficiency.

Board Exams

       USMLE Step 3

It is strongly recommended that residents take Step 3 during their PGY1 year. If the
resident takes Step 3 during his/her while a PGY1 or PGY2, the time will not count
againt them; after that, they must use their vacation time. Residents should contact the
Federation of State Medical Boards (817/571-2949) or the licensing authority in
Jefferson City (573/751-0098) to obtain application materials, information about Step 3


                                            15
eligibility requirements, fees, and other information. Step 3 became completely
computer-based in 1999. Sylvan Prometric, a division of Sylvan Learning Systems,
provides computer-based testing services for USMLE.

       Written/Oral Boards

Application for written boards must be filed and the fee paid by September 30 of the year
preceding your first examination. The applications and all information is available on the
ACR website: www.theabr.org . Residents may now take the physics portion of the
written examination in the fall of their second year of residency (PGY2 for the integrated
residents). The fees are as follows: $900 with the initial application (September); $900
when the confirmation is received from the board the (May); $900 when notification is
received of eligibility to take the oral boards. The resident and not the department is
responsible for all fees; educational fund monies may not be used to pay exam fees.

LAB COATS

The department furnishes two lab coats to each resident. Laundry services are provided
by the hospital. Lab coats for residents and faculty are taken to the linen room and
picked up again by a volunteer 2nd-year resident who receives additional book
allowance for providing the service. Soiled lab coats should be placed in the container in
the copier room. Fresh lab coats will be put in the closet in the residents' room. It is
your responsibility to make sure your lab coat is clean and in good repair at all times.

LEGAL ISSUES

Compliance: It is the responsibility of residents and faculty to assure that all resident
activity is adequately supervised by the attending faculty and that radiology reports are
dictated in accordance with ACR Documentation Standards in order to assure regulatory
compliance. Training is provided by the Compliance Department and within our
department. Billing staff will provide ongoing feedback to residents as needed.

Medical Liability/Risk Management: Incidents involving patients which have a possibility
for legal liability are to be reported immediately to the attending faculty who will assist
the resident in filing an incident report. The UMC legal counsel must be notified within
24 hours of any occurrence which may result in medical liability, such as deviation from
the standard of care. This is a condition of being insured by the University. Legal
counsel provides training on these risk management issues.

LIBRARIES

Radiology Library

The Radiology Library is located in Room M284 and is available to residents 24 hours a
day, seven days a week. To check out books, fill out the card inside the book with the
date of checkout and your signature and place it in the gray box which is located just
inside the library door.




                                            16
In addition to books and journals, the radiology library also contains various multimedia
resources which have limited availability to the residents. The policy for these is as
follows:

ACR/USCF Teaching File CD-Rom's: These are in the Program Office and can be
checked out for a maximum of two weeks, EXCEPT during the three months preceding
board exams, during which these CD's are available ONLY to the residents preparing for
oral boards. Other CD's (not teaching files) are located in the library and can be
checked out on the honor system in the usual fashion.

DVD's: These are also currently kept in Program Office and can be signed out for two
weeks at a time. Check out is limited to two DVD's at a time.

Videotapes: We have a set of board review videotapes from UCSF which are kept in the
Program Office. These are NOT generally made available to the residents. The faculty
have access to them to complement their lecture schedule. Starting in January each
year, we do make them available to the residents preparing for board exams on a limited
basis -- the tapes are checked out for one day (overnight or overweekend) and should
not leave the department. A TV/VCR can be set up in the library for viewing purposes or
you can view them using the VCR in the conference room. There is a sign-out sheet for
these. Check out is limited to a maximum of two videotapes at a time.

We limit access to certain resources during oral board preparation because they are
such a central part of the review process. If one of the videos or CD's gets lost or
damaged, we may not be able to replace it in time for the other residents to use it for
their board reviews. It is also important to return all of these resources in a timely
fashion so that they can be made available for everyone's use.

Use of Library Resources

In order to enable each and every resident to make the fullest use possible of the library
resources, please abide by the following regulations:

Always fill out the card before removing the book from the library, even if you are
only going to use it for “just a minute.” Minutes become hours and the book becomes
lost.
Return the books to the library in a timely fashion so that others may use them.
Four weeks (1 rotation) is the usual checkout period. Reminders are sent out quarterly.
After that, if the book is not returned, you could be charged the replacement cost.
Returned books should be given to the Program Coordinator (or other designed admin
staff) – do not leave them in the library or reshelve them yourself.
Take care of the books when you are using them. Do not mark in them, tear out
pages, or use the books for coffee cup coasters.
Keep the library tidy and have respect for the furniture and carpet.
You are responsible for the book if the card has your name on it, so if you pass the
book on to another resident, please make sure that the card has been changed. Also,
do not leave books lying in reading rooms, open areas, etc., as they will come up
missing.

Teaching Files


                                            17
There are general teaching files from cases presented by medical students who have
rotated through radiology available in the Radiology Library. The ACR teaching files are
kept in the Chief Resident's office and are for the use of radiology residents and faculty
ONLY. The ACR teaching files are also available on CD-ROM and can be checked out
from the Program Coordinator. Additional DVD or video courses are available for viewing
in the department. The program is considering making a back-up copy (if permitted by
vendor) and then these electronic courses can be made available for check-out. Various
radiology educational website links are available through internet access on almost all
computers in the department and library. A centralized electronic log book (without
patient identifiers) of teaching cases available on PACS is expected to be completed by
end June 2007 or sooner.

Health Sciences Library

The J. Otto Lottes Health Sciences Library is located in the atrium at the far north end of
the medical school on the 2nd floor. The resources in the library are available to all
personnel with an ID badge. Information on the library, including hours, interlibrary loan,
and access to the MERLIN catalog, OVID databases and on-line books and journals, is
available at their website (www.muhealth.org/~library/). If you need assistance in using
the library's resources, you may call them at 882-7033 or click "contact" on the website
for e-mail chat.

Any books or journals not available in the radiology library are generally available in the
Health Sciences Library located on the same floor of the medical school. Journal
articles and books can also be requested through ILL (inter-library loan) using the
Internet; see the Program Coordinator for information regarding this.

LICENSURE, DEA/BNDD NUMBERS

Application for and renewal of your Missouri medical license and your state and federal
drug numbers are your responsibility, whether you hold a temporary or permanent
license. A copy of your medical license and your current state and federal drug numbers
are kept on file in the program office and the GME office.

The fee for temporary licenses ($30) is covered by the department. If you choose to
apply for a permanent license, $30 of the permanent license fee is available for
reimbursement through the department by request of the resident.

The GMEOC has requested, when applying for or renewing a permanent license, that
you use the Hospital Administration address rather than the your home or department
address, as follows:
                     Clinical Information Services
                     One Hospital Drive, DC023.00
                     Columbia, MO 65121

Once copies of your permanent license are made for the GME file, the original will be
forwarded to the Program Coordinator, who will make a copy for the department file and
give you the original.

MEALS


                                            18
Food is provided 24 hours a day in the Residents’ Lounge in Room 1W-41. This room is
limited to residents, fellows and faculty and is keyed to your ID badge. During the
normal work day, a breakfast or sandwich buffet is provided (depending on the time of
day). After hours, frozen food is available to be microwaved. Snack foods such as
energy bars and fruits are also available. There is also a lounge area with a TV and
comfortable seating.

MISSION STATEMENT

The residency exists to provide service for the hospital and training for physicians in
radiology. Education is done through lectures, on-the-job training, self-study, and
service. As in all areas of health care, the welfare of the patient comes first.

MOONLIGHTING

[Please see “Professional Activities Outside the Educational Program”
under Institutional Polices.]

The ACGME has set forth the following regulations regarding moonlighting:
“First and foremost, the moonlighting workload must not interfere with the ability of the
resident to achieve the goals and objectives of their GME program. The program
director should monitor resident performance to assure that factors such as resident
fatigue are not contributing to diminished learning or performance, or detracting from
patient safety. The program director may also choose to monitor the number of hours
and the nature of the workload of residents engaging in moonlighting experiences.
Residents must not be required to engage in moonlighting. All residents engaged in
moonlighting must be licensed for unsupervised medical practice in the state where the
moonlighting occurs. It is the responsibility of the institution hiring the resident to
moonlight to determine whether such licensure is in place, adequate liability coverage is
provided, and whether the resident has the appropriate training and skills to carry out
assigned duties. The program director should acknowledge in writing that s/he is
aware that the resident is moonlighting, and this information should be part of the
resident's folder.”

As a departmental policy, we limit external moonlighting to PGY4 and PGY5 residents
who are in good standing in the program. You must get a letter of acknowledgement
(see above) from the Program Director prior to accepting any moonlighting
assignments. The chief residents will monitor and log all external moonlighting
performed by the resident. Your responsibilities to the residency program and to
University Health Care must always come first and you will be banned from moonlighting
if there is evidence that moonlighting activities are interfering with your performance as a
radiology resident.

Internal moonlighting -- We have an agreement with certain hospitals to compensate the
residents for teleradiology services. For every teleradiology case you read for these
hospitals while on call at night or on weekends, the department will compensate you for
the current negotiated amount. You need to keep your own records, which will be
confirmed by Tom McCord before payment. The forms for requesting payment are in
the holder in the copier room. There are also internal moonlighting opportunities at the



                                            19
Imaging Center which can be arranged through the department secretary.              Internal
moonlighting is always on a voluntary basis.


OFFSITE ROTATIONS

Offsite rotations (aside from AFIP) are occasionally granted for specific reasons. An
offsite request form must be completed and approved by the chief residents and the
program director. The policy is under re-assessment and currently being re-evaluated
as to how the quality of these rotations can be guaranteed and uniformly applied without
adversely affecting the curricula of the program or becoming a financial burden on the
hospital. If approved the following criteria should be adhered to (subject to modification):

-- The rotation must be to acquire education proven to be not available at UM-C.
-- The above must be confirmed by the division chief for that specialty.
-- The resident must be participating in a residency program with full responsibilities
-- Offsite rotations will be limited to one per resident over the course of the residency
-- The dates of the offsite rotation must be after written board exams (10/1).
-- Only one resident at a time will be allowed to be gone offsite (excepting AFIP).
-- The resident should be in his/her PGY4 or PGY5 year.
-- The request must be made before the yearly schedule is finalized.
-- The resident will present an extra colloquium based on their experience on the rotation
-- The offsite rotation will count as one of the planned elective rotations and will be
       deducted from the residents’ elective time.

RESEARCH

As part of the ACGME mandate, a minimum requirement for resident research has been
established. Each resident must complete at least ONE of the following during the
course of the residency:

       -- article or case review accepted for publication in a peer-reviewed journal
       -- poster or paper presented at a national, state, or chapter conference

The head of the radiology research committee will coordinate resident research activity.
The resident may either submit a proposal or request that he/she be assigned a topic or
project.

PAY CHECKS

All residents are paid by UMC on the last working day of each month through direct
deposit to your bank account. An earnings statement for each pay period will be sent to
your department address. Residents are signed up for direct deposit during their initial
orientation upon employment; changes to direct deposit after that can be made through
Judy Skouby or Human Resources.

SUBSTANCE ABUSE

The possession, use of, and/or distribution of alcohol or the manufacture, distribution,
dispensation, possession, or use of any controlled substance is prohibited on all


                                            20
University-owned or -controlled property and at University-sponsored or -supervised
activities. Violations of this policy may result in discharge or other discipline in
accordance with University policies and procedures covering the conduct of faculty, staff,
and students.      For the complete institutional policy, see "Substance Abuse and
Impaired Physician Policy" in the UMHC Policies and Procedures section.

TRAVEL

For any planned travel to meetings, conferences, review courses, etc., you must
complete a Travel Authorization form, obtain the program director's signature, and
submit it to the business office with a brochure or other information that provides
meeting dates, place of meeting, topic of conference, and price in print. “Failure to
process the appropriate forms and seek approval prior to the travel could compromise
the reimbursement of expenses.”

You may use your educational fund for travel expenses for meetings, review courses,
offsite rotations, and AFIP. All travel is done on a reimbursement basis. Before
planning any travel, please check with the business office regarding current
reimbursement policy.




                                           21
DEPARTMENTAL
& INSTITUTIONAL
    POLICIES




       22
ADVANCEMENT THROUGH RESIDENCY

MINIMUM STANDARDS

In order to continue to be offered yearly contracts for a continuation in the diagnostic radiology
program, residents are expected to meet the following minimum criteria:

       --attend at least 70% of all resident conferences for each half of the year
       --be in areas in which they are assigned at all times
       --be in the hospital at assigned times when they are on call.
       --keep a log of all of their interventional and angiographic procedures
       --follow new case log guidelines as per program and ACGME guidelines as
          previously mentioned in this manual under section of case logs
       --present at least one 30-minute colloquium per year
       --present at least two academic articles to the journal club per year
       --attend and participate in the interdepartmental conferences
       --behave in a professional manner under all circumstances

FAILURE TO PERFORM AT A SATISFACTORY LEVEL

In the event of excessive tardiness, failure to complete assigned daily work, lack of
professionalism/respect for patient care or failure to perform to the expectations of the attending
radiologist, the offending resident will be verbally counseled by that attending. If the resident fails to
accept the criticism and correct the problem, the Program Director will be notified and it will be noted
as “unsatisfactory” on the monthly rotation evaluation. If the resident receives a second unsatisfactory
evaluation within three months, he/she will be placed on probation.

PROBATION/DISMISSAL

After a resident has been disciplined as outlined above on two separate occasions within one year
(documented in writing by the Program Director), he/she will be placed on probation for six months. If
disciplinary action is taken against the resident in question while on probation, it is grounds for
dismissal per vote by the Education Committee. If no further disciplinary action is required, the
resident will be taken off of probation after six months.

GRIEVANCE PROCEDURE

Residents should approach the Chief Resident(s) first with any questions or problems they are having.
At the Chief Resident's discretion or the resident's request, the Program Director may be brought in.
After this point input/advice from the Department Chair may be requested by any involved. If a
solution is still not found to the satisfaction of all concerned, then the resident and/or faculty advisor
should proceed with filing a grievance at the University level. Please also see grievance policy in
subsequent sections.




CERTIFICATION

Certification from the University of Missouri-Columbia School of Medicine will be granted by meeting
the standards set by the American Board of Radiology and the standards set by the Department of
Radiology.
The American Board of Radiology states in its general qualifications for certification that the applicant
should be a specialist in diagnostic radiology and recognized by his/her peers to have high moral and
ethical standards in his/her profession. A certificate will be issued to each candidate who has finished
a prescribed and approved period of training and study and who has passed written and oral
examinations demonstrating an adequate level of knowledge and ability in diagnostic radiology in
accordance with the definitions stated in the “Bylaws and Rules and Regulations” of the American
Board of Radiology. A complete copy of the American Board of Radiology Guidelines is available in
the Radiology Department Office.

COMMITMENT TO GRADUATE MEDICAL EDUCATION

University of Missouri Health Care (UMHC) considers residents and fellows to be first and foremost
students rather than employees and all accreditation standards and activities should reflect this
distinction. As students, the residents need to be protected with respect to their educational
environment and the clinical settings in which they learn. Since residency settings vary substantially
throughout the country, solutions to the resident protection issues which have been articulated should
be implemented by UMHC rather than by a single national plan. UMHC must be accountable for
addressing resident concerns and issues at the local level.

UMHC has charged the Graduate Medical Education Oversight Committee (GMEOC) with responsibility
for maintaining quality and support of our graduate medical education programs and for
recommending standards to enhance the welfare of our residents and fellows to the Dean of the
School of Medicine. The GMEOC will oversee the resident programs with the help of elected residents
on the committee and partnering with the resident organization. The GMEOC will report to the Dean
of the School of Medicine. The Dean reports to the Provost and Chancellor of the University of
Missouri-Columbia and the President of the University of Missouri System. All increases in resident
position must be approved by the CEO.

The Associate Dean for Medical Education will serve as Chair of the GMEOC at the pleasure of the
Dean of the School of Medicine and be responsible for overseeing academic quality of programs. The
Senior Coordinator for Clinical Information Services will be the institutional official who has the
administrative responsibility for the authority and responsibility for the oversight and administration of
the graduate medical education programs and shall be a member of the GMEOC.

UMHC will provide financial and physical support needed to maintain the highest possible quality and
protection for our residents. UMHC looks to the GMEOC for recommendations about how to best use
the resources available and for right-sizing the programs to maintain optimal quality and protection.
INSTITUTIONAL POLICES

The following institutional policies are applicable to the residency program. Copies of these polices in
their entirety are included in this section.


       Resident Leave Restriction Policy
       Commitment to Graduate Medical Education
       Resident Eligibility and Selection Policy
       Non-renewal of a Resident/Fellow Contract
       Required ACLS/BLS/PALS Certification
       Institutional Vacation and Leave Policy
       Resident Work Hours Policy
       Professional Activities Outside the Educational Program (Moonlighting)
       Supervision of Residents and Fellows
       Policy for Processing Anonymous Evaluations
       Policy to Address Resident Concerns
       Grievance Policy for Residents/Fellows
       Disciplinary Action Policy for Residents/Fellows
       Policy to Monitor Residents and Fellows with Prior Issues of Concern
       Policy for Educational/Career Counseling
       Professional Assistance Policy
                Att. A: Substance Abuse & Impaired Physician Policy
                Att. B: Financial Advice/Counseling Resources
       Internal Review Policy
       Reduction in Size or Closure of a Residency/Fellowship Program
                               Resident Leave Restriction Policy

A program director (PD) may specify the rotations on which their residents may take leave (as
defined by your program).
Residents rotating outside their department may take up to one week (5 week days and one
weekend) of leave on rotations of 4 weeks (or one month) unless a restriction has been mutually
agreed upon by both PDs.
If a resident rotates to another department for longer than 4 weeks (one month), the proportion of
their leave allowed on those rotations should be proportional to the time on those rotations. (e.g. if a
neurosurgery resident rotates for 3 months on general surgery, they should be allowed to take ¼
(3/12) of their leave while on those rotations.
Leave should be scheduled and agreed upon between the two program directors. If no agreement is
reached, the GMEOC will arbitrate. The decision will be determined by a majority vote of the
members present.




Approved by the GMEOC 7/7/09
                             POLICY ON RESIDENT RECRUITMENT,
                                 ELIGIBILITY & SELECTION

Programs must select applicants on the basis of preparedness, ability, aptitude, academic
credentials, communication skills and personal qualities such as motivation and integrity.
Discrimination by gender, race, age, religion, color, national origin, disability or any other
applicable legally protected status is prohibited. Restrictive covenants are not permitted.

Each program director must be certain each resident/fellow candidate meets all ACGME, general
Missouri State Licensing Board criteria and immigration requirements before accepting the
individual into the program. The acceptance of unqualified candidates can lead to
withdrawal of certification by the ACGME. The primary verification process consists of the
following activities:

Programs will participate in an organized matching program, such as the National Resident
Matching Program (NRMP), if available.

A.     New US Graduates

1.            Application for residency/fellowship through the Electronic Residency Application
       Service (ERAS) serves as primary verification. (Minimum documents required: graduate of
       MD or DO medical school in the US or Canada which is accredited by LCME or AOA
       respectively; medical school transcript, Dean’s letter; United States Medical Licensing
       Examination (USMLE) Step 1 and 2 scores; reference letters) or:

2.            Completion of the Universal Residency Application with the above stated documents
       attached. Transcripts must be verified with the school.


B.     Foreign-Born and International Medical Graduates (IMG: a physician whose basic
       medical degree is conferred by a medical school located outside the US, Canada or Puerto
       Rico) must:

1.     Hold J-1 visa (exchange visitor) H-1B visa (temporary worker), immigrant visa or “green
       card” or an Immigration and Naturalization Service (INS) issued or approved work permit
       if not a US citizen.

2.     Have a full unrestricted license to practice medicine in the State of Missouri or hold an
       Educational Commission for Foreign Medical Graduates (ECFMG) Standard Certificate,
       which is a prerequisite to practice medicine in the US and is an eligibility requirement to
       take Step 3 of the USMLE. A Standard ECFMG Certificate is issued to an applicant who
       meets the examination requirements, fulfills the medical education credentialing
       requirement and clears their financial account with ECFMG. This Certificate is considered
       valid if the “valid through” dates of the English test and CSA is not later than the program
       start date. In order for an applicant to obtain permanent validation of the Certificate,
       ECFMG must receive documentation from an official of the program confirming the
       applicant’s entry to the program, at which time, ECFMG will provide a “valid indefinitely”
       sticker to the holder of the Certificate.

C.     Residents Entering a Program After Completing Preliminary Year at Another
       Institution - In addition to the requirements of A or B of this policy, requires a:

1.     Letter from the program director of the resident’s preliminary year program indicating
       he/she has successfully completed the preliminary year of training and must obtain written
       or electronic verification of previous educational experiences and a summative
       competency-based performance evaluation of the transferring resident.
D.     Graduates of medical schools outside the United States who have completed a
       Fifth Pathway program provided by an LCME-accredited medical school.

       A Fifth Pathway program is an academic year of supervised clinical education provided by
       an LCME-accredited medical school to students who meet the following conditions: (1)
       have completed, in an accredited college or university in the United States, undergraduate
       premedical education of the quality acceptable for matriculation in an accredited United
       States medical school; (2) have studied at a medical school outside the United States and
       Canada but listed in the World Health Organization Directory of Medical Schools; (3) have
       completed all of the formal requirements of the foreign medical school except internship
       and/or social service; (4) have attained a score satisfactory to the sponsoring medical
       school on a screening examination; and (5) have passed either the Foreign Medical
       Graduate Examination in the Medical Sciences, Parts I and II of the examination of the
       National
       Board of Medical Examiners, or Steps 1 and 2 of the United States Medical Licensing
       Examination (USMLE).

E.      Physicians Entering a Fellowship - In addition to the requirements of A or B of this
policy, requires a:

       Letter from the program director of the resident’s previous program indicating he/she
successfully completed the residency program.
1.

2.    Verification that the completed residency program is accredited and meets the
      ACGME requirements for entry into that particular fellowship.

3.    Reference letter from the Hospital where the physician previously practiced
      and a National Practitioners Data Bank (NPDB) query, if the fellowship start
      date is not immediately after residency completion.

F.    Restrictive Covenants

1.    ACGME accredited residencies must not require residents to sign a non-
      competition guarantee.




Revisions approved by the GMEOC: 12/4/07; 10/6/09
           NON-RENEWAL OF A RESIDENT/FELLOW CONTRACT



Purpose:     To provide a procedure in the event a resident or fellow’s contract will not
             be renewed for the following year.


1.    The Program Director must provide a written notice to the resident/fellow
      indicating that their contract for the following year will not be renewed.
      Justification for non-renewal of the contract must be adequately outlined. This
      written intent must be given to the resident/fellow no later than four months
      prior to the end of the current appointment.

2.    If the primary reason for non-renewal of the contract occurs within four months
      prior to the end of the current appointment, the Program Director must provide
      written notice as early as circumstances will allow, prior to the end of the
      appointment.

3.    The resident/fellow must be allowed to implement the institution’s grievance
      procedures, including those outlined in the Health Sciences Center’s “Policy to
      Address Resident Concerns”.
                  REQUIRED ACLS/BLS/PALS CERTIFICATION


All residents/fellows who have direct contact with patients must maintain active
certification in BLS and ACLS. This includes all training programs, with the exception of
Pathology.

Child Health, Family Practice and Med/Peds training physicians must maintain PALS
certification.
                INSTITUTIONAL VACATION AND LEAVE POLICY



Purpose: The ACGME requires an Institutional Leave Policy that is known to all
Residents.


Each program must have its own vacation and professional leave policy that it makes
available to its residents/fellows before they sign their contracts and that:

·      Follows ACGME program requirements.

·      Complies with MU’s Family Leave Policy.

The institution will fund up to one month each year of any combination of vacation and
leave for each resident.

To hold a GME position for their return, residents/fellows must obtain written approval
from their department for leave/vacation that exceeds one month per year. Adverse
decisions, as always, may be appealed through the Policy to Address Resident
Concerns, and then as a grievance.
                         RESIDENT WORK HOURS POLICY


The new resident duty hour standards (see figure 1), which become effective on July 1,
2003, are causing academic medical centers and schools of medicine to evaluate
various strategies to ensure all residency programs achieve and maintain compliance.
Many clinical services, especially surgical programs, have needed to reduce the average
hours worked per resident to comply with the new standards. Changes in resident hours
can impact staffing strategies of physician and non-physician staff and how clinical work
is assigned. Regardless of the changes made, organizations need to consider the affect
of the changes on the quality of care provided, resident educational experience, and
costs to the organization. UHC conducted a benchmarking project to better understand
the state of readiness among the membership and identify strategies planned or
implemented to comply with the resident work hour standards from a service delivery
perspective.


Figure 1. Summary of Resident Duty Hour Standards

   Limit of 80 duty hours per week, averaged over four weeks
   24-hour limit on continuous duty, with up to 6 additional hours for transfer, debriefing, and
    didactic activities
   Call scheduled no more than every third night, averaged over four weeks
   10-hour minimum rest between duty periods
   One full (24 hour) day in seven free of patient care, averaged over four weeks
   In-hospital hours during call from home counted
   Program director/institution approve moonlighting
   Education of residents and faculty about fatigue and its management
   Support to reduce time spent on routine tasks
                          PROFESSIONAL ACTIVITIES
                     OUTSIDE THE EDUCATIONAL PROGRAM
                              (MOONLIGHTING)


Policy:         The ACGME requires that the institution assure that each training
                program maintains a policy that specifies moonlighting conditions,
                whether moonlighting by Housestaff within that program is allowed or is
                not, and that this policy be referenced in each trainee contract.

Purpose:        To provide an institutional policy that guides and provides a basis upon
                which programs will add their specific policy. To inform and protect
                Housestaff who choose to moonlight while training at the University of
                Missouri-Columbia, Health Sciences Center.

Definitions:

Housestaff: Residents and fellows are physicians in training for Board certification.
Housestaff are required to have a temporary or permanent Missouri medical license and
are provided University Physician malpractice insurance during official training activities.
Billing, directly or indirectly, for services during such training hours is not permitted.

Internal Supervised Resident Activity (ISRA): Elective resident/fellow participation in
patient care within their residency/fellowship program and license that exceeds ACGME
requirements. ISRA includes an additional stipend but must be voluntary, on the
University Hospitals and Clinics campuses or at a UHC site where training normally
occurs and rendered under GME Oversight Committee approval with the same faculty
supervision, attending billing, and documentation rules, and at a level of clinical
responsibility as is appropriate for the training physician’s level of training. Activity falling
outside any of these requirements is moonlighting. A resident/fellow may voluntarily
choose to participate in this elective responsibility (if offered by their department) upon
successful completion of the PGY1 year. This activity is counted the same as their
regular duties toward the duty hour limitations.

Moonlighting: Voluntary medical practice/work done by residents/fellows outside of
his/her training program.

Information:

1.        Standards applicable to moonlighting:

      Any resident/fellow wishing to moonlight must receive written approval to do so
       from their Program Director. This must be in the resident/fellow file. Moon-
       lighting must be approved by the Department Chairman and Program Director of
       the training program and these individuals should assure that moonlighting is not
       detrimental to training in any significant way.      The Program Director must
       monitor the moonlighting activity to ensure that the resident/fellow does not
       become excessively fatigued. The Program Director may limit or suspend moon-
       lighting activity if excessive fatigue or interference with the required training
       activities is found.
    Moonlighters, since they are attending physicians, must, before they begin
     moonlighting, hold permanent licenses – Missouri medical, Federal narcotics
     (DEA) and State narcotics (BNDD). They must have medical staff privileges and
     malpractice coverage for the patient care they will provide.

    Moonlighting can be medical practice outside of the training program, but within a
     University of Missouri Health Sciences Center location or under a University of
     Missouri contract. In this situation, the University of Missouri Health Sciences
     Center provides for malpractice coverage and any related legal representation.
     A permanent State license and Medical Staff privileging and credentialing are still
     necessary. CMS also requires that, for in-house moonlighting, the training
     institution must have a contract with each resident/fellow that specifies the
     moonlighting is separate from ACGME training and done under a regular state
     license and for CMS-approved medical services.

       A resident/fellow moonlighting at any health care entity which is not a part of the
       University of Missouri Health Sciences Center requires that arrangements be
       made between the moonlighter and the health care entity for malpractice
       coverage and related legal representation. The moonlighter is operating
       independently of the University and must assume no such coverage exists
       unless these arrangements have been completed.

    Moonlighters are subject to all local, state, and federal laws that apply to
     attendings when and where they moonlight.

    Moonlighting must comply with visa guidelines. Certain visas do not allow work
     outside the training program.

Each program must create a policy that complies with this Health Sciences Center
Institutional Policy and place this and the institutional policy in their program manual.
Programs may choose to permit, not permit, or limit moonlighting.

Program policy should require that moonlighting will not interfere with Housestaff training
responsibilities/schedules or contribute to excessive fatigue, as well as stipulate
consequences for Housestaff who do not comply with the training program policy.




                                            35
                            MOONLIGHTING POLICY
                         FOR J-1 OR H-1B VISA HOLDERS


The June 30, 1999, Federal Register of the USIA (United States Information Agency)
outlined policies regarding moonlighting of non-resident aliens with visas. J-1 visa
holders are prohibited from obtaining employment that is not a part of their training
program. H-1B visa holders are also prohibited from moonlighting unless specifically
allowed, as specified, in their visa. Any resident or fellow in a training program at the
University of Missouri who fails to comply with this regulation is at risk of deportation.

To ensure compliance with this regulation, the following process will be followed:

   1) Any resident/fellow wishing to moonlight must receive approval to do so from
      their program director. Moonlighting must be approved by the Department
      Chairman and Program Director of the training program and these individuals
      should assure that moonlighting is not detrimental to training in any significant
      way. (Please refer to the “Professional Activities Outside the Educational
      Program” policy of the Health Sciences Center for moonlighting requirements.)

   2) The Department Chairman and/or Program Director must verify visa status. If it
      is determined that the resident/fellow wishing to moonlight is a J-1visa holder, the
      Chairman and/or Program Director will not allow the resident/fellow to moonlight.

   3) If it is determined that the resident/fellow wishing to moonlight is an H-1B visa
      holder, the Chairman and/or Program Director must request that the
      resident/fellow submit their H-1B visa documents for review by the University of
      Missouri Legal Counsel to determine whether the stipulation for outside
      employment is written in the visa. If moonlighting is not specifically allowed in the
      visa, the Chairman and/or Program Director will not allow the resident/fellow to
      moonlight.

   4) Each program must create a policy that complies with this Health Sciences
      Center Institutional Policy and place this and the institutional policy in their
      program manual.




                                            36
                  SUPERVISION OF RESIDENTS AND FELLOWS


Purpose:        To set institutional standards for faculty supervision of residents that
                assures their education and our compliance with ACGME institutional
                standards.

Assuring adequate supervision is the responsibility of the program director, department
and the institution.

The following are standards for all MU residents, irrespective of where they are training.
These are minimum rules. No program can fall below these standards, but they will be
expanded if:

      Documentation (HCFA or PATH) or Medical Staff rules at a given institution
       exceed these standards.

      An individual program has more stringent RRC requirements for supervision.

      The department elects to expand supervision requirements, using the following
       as a base.

      The clinical setting where the resident physician is training has additional rules.
       For example, the Harry S. Truman Memorial Veterans Hospital Policy is
       described in: Resident Supervision, VAH Handbook 1400.1, March 21, 00,
       available in the Resident Coordinators Office or at the VA.

Standards

1.      All patient care performed by residents during training will be under the
        supervision of a physician faculty member qualified to provide the appropriate
        level of care. The specifics of this supervision must be documented in the
        medical record by the supervising physician or resident.

2.      The supervising physician must be immediately available to the resident in
        person or by telephone 24 hours a day during clinical duty. Programs must
        assure this occurs: Residents must know which supervising physician is on call
        and how to reach this individual.

3.      Inpatient supervision: The supervising physician must obtain a comprehensive
        presentation for each admission. This must be done within a reasonable time,
        but always within 24 hours of admission. The supervising physician must also
        require the resident to present the progress of each inpatient daily, including
        discharge planning. All required supervision must be documented in the medical
        record by the resident and/or the supervising faculty member.
4.      Outpatient supervision: The supervising physician must require residents to
        present each outpatient’s history, physical exam and proposed decisions. All
        required supervision must be documented in the medical record by the resident

                                            37
     and/or the supervising faculty member.

5.   Supervision of consultations: The supervising attending must communicate with
     the resident and obtain a presentation of the history, physical exam and
     proposed decisions for each referral. This must be done within an appropriate
     time but no longer than 24 hours after notification of the consultation request. All
     required supervision must be documented in the medical record by the resident
     and/or the supervising faculty member.

6.   Supervision of procedures: The supervising faculty physician must be certain that
     procedures performed by the resident are warranted, that adequate informed
     consent has been obtained and that the resident has appropriate supervision
     during the procedure to include sedation. Whenever there is more than minor
     risk to the patient, the supervising physician must be present during the key
     part of the procedure. All required supervision must be documented in the
     medical record by the resident and/or the supervising faculty member.

7.   Supervision of emergencies: During emergencies, the resident should provide
     care for the patient and notify the supervising physician as soon as possible to
     present the history, physical exam and planned decisions.          All required
     supervision must be documented in the medical record by the resident and/or the
     supervising faculty member.

8.   Common questions:

     o   When does the supervising physician have to come in to see a patient? This
         would be typical of expected practice, or whenever the resident asks the
         supervising physician to be present or whenever HCFA or Medical Staff rules
         require this.

     o   To whom are faculty responsible for resident supervision? The program
         director, the chair of the department, the GME Oversight Committee and the
         Dean of the School of Medicine for educational supervision. The supervising
         physician is also responsible for HCFA documentation requirements and
         Medical Staff rules.




                                         38
          POLICY FOR PROCESSING ANONYMOUS EVALUATIONS


The ACGME requires that faculty members sign evaluations they complete of training
physicians. Programs may elect to have additional health care staff evaluate the training
physician, including peers or other co-workers (ie, nursing staff, techs). These
evaluations should be kept anonymous from the training physician being evaluated, to
the extent possible under the law. Anonymity may be maintained by having a summary
of these evaluations prepared by the program director or coordinator, which is then
placed in the training physician file. The evaluation instrument itself may be destroyed
or, if kept, assurance should be made that the anonymity of the evaluator will be
maintained.




                                           39
                 POLICY TO ADDRESS RESIDENT CONCERNS


Purpose: The ACGME requires that the Housestaff have assurance of an educational
         environment in which to raise and resolve issues without fear of intimidation
         or retaliation. This policy outlines a process by which residents can address
         concerns in a confidential and protected manner.

           The Housestaff representatives to the GME Oversight Committee will give a
           monthly report of resident issues identified during their monthly meetings, or
           through communication among resident(s). This report should include, but
           not be limited to concerns of residents about fairness of schedules, treatment,
           workloads, etc. Concerns will be addressed as needed in a way that
           excludes and prohibits retaliation toward any fellow or resident.

           Individual resident concerns should be addressed with the following process.

Process: Resolution should be attempted at the most local level. If resolution is not
         obtained at this level, the resident or fellow may proceed to the next level as
         appropriate to the nature of the concern.

       1. Contact the Chief Resident of the Program.

       2. Contact the Program Director.

       3. Contact the Department Chair.

       4. Contact the Housestaff Organization.

       5. Contact the Assistant Dean for Graduate Medical Education/Associate Dean
       for Medical Education.

If the issue is not able to be resolved by this informal mechanism, then a formal
grievance may be filed with the Program Director. See Grievance Policy.




                                            40
                                GRIEVANCE POLICY FOR
                                 RESIDENTS/FELLOWS


Purpose

To establish fair policies and procedures for the adjudication of resident grievances
related to the actions which could result in dismissal, non-renewal of agreement of
appointment, or any other action that could threaten a resident’s intended career
development.

A grievance procedure shall not be used to question a rule, procedure, or policy
established by an authorized faculty or administrative body. Rather, it shall be used as
due process by a resident who believes that a rule, procedure or policy has not been
followed or has been applied in an inequitable manner. An action may not form the
basis of a grievance if the resident merely challenges the judgment of the faculty as
medical educators in evaluating the performance of the resident.

For purposes of this policy, a grievance is defined as an allegation that:

1.     There has been a violation, a misinterpretation, an arbitrary or discriminatory
       application of University policy, regulation or procedure. This could be related
       personally to the resident physician -- to the privileges, responsibilities, or terms
       and conditions of the residency training program including academic or other
       disciplinary actions or the employment of the resident physician; or

2.     The resident physician has been discriminated against on the basis of race,
       color, religion, sex, national origin, age, disability, or status as a veteran.

Filing a Grievance

A resident physician who has a grievance shall initiate action by filing a signed, written
account of the grievance with the program director within thirty (30) calendar days of the
event out of which the grievance has arisen. The Program Director and Department
Chair have the discretion to discuss the grievance with the resident and other involved
parties in an effort to resolve the grievance. If the grievance is resolved in this manner,
the terms of the resolution will be put in writing and signed by the program director and
the resident. If the grievance is not resolved, the program director shall respond to the
grievance in writing within thirty (30) calendar days of receipt of the written grievance.

If the resident is uncomfortable in approaching his/her program director, the resident is
encouraged to discuss the issue with the GME Office.




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Grievance Appeals to the Dean

Should the resident physician be dissatisfied with the response of the program director,
he/she may, within ten (10) calendar days of receipt of such response, submit a written
appeal to the Dean of the School of Medicine, through the Associate/Assistant Dean
having responsibility over graduate medical education. Upon receipt of the written
appeal, a grievance panel will be formed by the Dean’s Office. The panel will consist of
one program director, one other faculty member and one resident member drawn at
random from the pool of participants in each group. The pool of participants in each
group will be solicited annually from all members of each group. The list of volunteers
will be maintained by the GME office. Names will be drawn randomly by the
Associate/Assistant Dean responsible for graduate medical education. No member of
the panel may be from the department of any of the involved parties. If a person whose
name is drawn is not able to participate because of prior commitments, another name
will be drawn. The panel may gather evidence, interview individuals and request further
information from the involved parties. Within 30 calendar days of the receipt of the
appeal, the grievance panel will give a written copy of their recommendation to the
Dean. If the decision of the panel is not unanimous, the dissenting party may submit a
written dissenting opinion at the same time. The Dean will respond in writing within 5
working days of receipt of the panel’s recommendation. The Dean may accept the
recommendation, amend it, reverse it or refer it back to the panel for reconsideration.
The decision of the Dean is final.

        (Also see the University of Missouri Employee Grievance Policy: 380.010)




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                           DISCIPLINARY ACTION POLICY


Resident physicians are subject to disciplinary actions including oral reprimands, written
reprimands, suspensions and discharge for misconduct or for performance which does
not meet acceptable standards.

Suspension Without Pay or Termination

Before a resident physician may be suspended without pay or terminated prior to the
specified ending date of his or her appointment, the resident physician should be
provided in writing with findings which the University believes support the proposed
suspension without pay, or the termination.

That written notice will be provided by the residency program director and will include
details concerning the findings of misconduct or the performance deficiencies. In
addition, the written notice will inform the resident physician that if he or she disagrees
with such findings and desires to contest the proposed disciplinary suspension or
termination, he or she must inform the residency program director in writing within ten
(10) days of receipt of the written notice.

After receiving notice that the resident physician disagrees with such allegations and
desires to contest the proposed disciplinary suspension or termination, the residency
program director will schedule a meeting with the resident physician so that he or she
will have an opportunity to present information in support of his or her position regarding
the findings.

After discussing the issues with the resident, the residency program director shall decide
whether (1) to impose the disciplinary suspension without pay or the termination which
had been contemplated, (2) to impose some lesser degree of discipline or (3) that the
resident physician should receive no discipline. That decision shall be communicated to
the resident physician in writing as soon as possible.

If the resident physician is dissatisfied with the decision of the residency program
director, he or she may, within ten (10) days of receipt of such written decision, file a
grievance in accordance procedures outlined in the Grievance Policy.




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           POLICY TO MONITOR RESIDENTS AND FELLOWS
                 WITH PRIOR ISSUES OF CONCERN



   Residents and fellows who have any issues of impairment identified by the
    various licensing agencies (Board of Healing Arts, DEA, BNDD) will have an
    appropriate monitoring and supervision plan developed by the program director.

   The plan may be proscribed by or in conjunction with the licensing agency. The
    plan will be approved by a subcommittee of the GMEOC authorized to act on the
    committee’s behalf in closed session.

   The medical executive committee or chief of staff at any hospital the
    resident/fellow is assigned will be notified of the issue and the monitoring plan.

   The chair of the GMEOC should be notified as soon as the issue is identified and
    preferably before a contract is offered.




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                      EDUCATIONAL/CAREER COUNSELING


Occasionally, a residency program director will request that a resident receive evaluation
and counseling for a problem they are having. This is usually done by members of the
UMC Psychiatry Department, although a program director may request evaluation by
someone outside the department or outside the University. The following guidelines
should be followed.

1.     The request for evaluation must be in writing from the program director with a
       general statement of the reason for the request.

2.     The evaluator will keep a record of the encounter(s) but not as part of the
       resident’s medical record. Appropriate confidentiality will be maintained.

3.     The evaluator will update the program director regarding the resident’s progress.
       At the outset, the resident will be informed that the program director will receive
       updates from the evaluator. The resident will discuss with the evaluator what
       information will be shared to maintain confidentiality.

4.     If a mental health disorder or substance abuse is found during the course of
       evaluation or counseling, appropriate referral to the health care system will be
       made. All University and State of Missouri requirements for reporting must be
       followed.

5.     The requesting department is responsible for the cost of the evaluation and
       counseling. If referral is made to the health care system, the resident’s insurance
       will be billed, and the resident will be responsible for any other expenses (just as
       with any other medical condition).




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                     PROFESSIONAL ASSISTANCE POLICY



Policy:        The policy of providing assistance to residents and fellows is delineated
               for the following conditions: 1) Mental Health; 2) Physical (Medical)
               Health; 3) Impaired Physicians; and 4) Financial. All requests for
               resource information will be treated confidentially.

               The Associate Dean for Medical Education will be the safety net to help
               trainees who feel they cannot get what they need through their Program
               Director. The Associate Dean will also be a resource to Program
               Directors in solving trainee issues. This individual or designee may be
               contacted at any time for emergencies.

Purpose:       Graduate Medical Education can be a stressful time for residents and
               fellows. It is our job to nurture and support our trainees so each is
               the best person and physician that he or she can be. The program
               directors are charged by their Residency Review Committees (RRCs) to
               monitor stress, depression, mental and/or physical illness of their
               trainees, and to assist in obtaining treatment and/or identifying methods
               of counseling. The institution is required by the ACGME to facilitate
               resident/fellow access to appropriate and confidential counseling,
               medical, and psychological support services. This includes the stipulation
               of written policies describing how physician impairment, including
               substance abuse, will be handled.

Definitions:   Substance Abuse: Use of alcohol or drugs with resulting diminution of
               ability to carry out responsibilities in the workplace.
               Resident Physicians: Resident or fellow trainees
               Impaired Physician: Physician is unable to perform trainee duties, in
               best judgment of the Health Sciences Center Physician Health
               Committee.

General Information: All trainees are enrolled in the University of Missouri group plans
for life insurance, long term disability, and medical benefits. This coverage includes
medical treatment as well as psychiatric counseling and treatment. In addition, the
Housestaff Organization has arranged for additional disability coverage at the individual
trainee’s expense.

Medical/Physical Health

Time off for treatment of medical or physical conditions will be granted in accordance
with the program’s specifics for medical leave of absence. The trainee may refer to their
training manual for this information or contact their program director.

Emotional/Psychological
Psychological illness such as short term psychological problems of situational distress,
anxiety, or stress, may result in impairing the ability to perform assigned job
responsibilities. Please refer to number 3 above and Attachment A, for information on
actions required by the Medical School. Treatment for such illness is generally covered
by existing health benefits.

Impaired Physicians

Residents or Fellows with substance abuse problems should be aware that the Health
Sciences Center’s policy is non-punitive if the treatment plan is adhered to, except as
identified in Attachment A, item B,5 of the “Substance Abuse Policy for Clinical Faculty
and Resident Physicians, ” which states that probable cause of impairment due to
substance abuse will result in a report to the Missouri Physician’s Health Committee
(MPHC) for further investigation and action. In accordance with laws regarding
reporting, the MPHC will be required to report substantiated substance abuse to the
National Practitioner Data Bank.

Also, please reference the University of Missouri policy on drug/alcohol abuse – HR508
“Drug/Alcohol Abuse in the Workplace,” University of Missouri, Human Resources
Benefits Manual.

Financial Consultation

Trainees in need of financial advice/counseling are encouraged to make early contact
with the University of Missouri - Columbia Medical School Financial Aid Coordinator.
Other private counseling organizations may be utilized and a list of local organizations is
provided in Attachment B.

Procedure:

Trainee:
                  2. Graduate Medical Education trainees should seek professional
                     help on their own when they feel this is necessary. If this is a
                     medical/physical or emotional/psychological condition, the
                     trainees primary physician should be contacted, or the campus
                     Employee Assistance Program may be contacted at 882-6701 to
                     provide free, confidential evaluation and referral for any problem -
                     financial, medical, psychological, etc.

                  3. Trainees are strongly encouraged, but not required, to inform their
                     Chief Resident and Program Director of medical illness, emotional
                     or psychiatric illness when any of these may interfere with
                     professional performance.        Confidentiality will be maintained
                     unless this is not consistent with good patient care.

Program
Director:         1.   The Program Director, upon becoming aware of a problem, either
                       through trainee performance, reports from others, or through
                       communication with the trainee, should be the first line to help the
                       resident physician resolve any issues. The Program Director
                     should discuss alternative sources of counseling and/or other care
                     with the resident physician and assist in initiating the process for
                     counseling.

                  2. Program Directors may, at their discretion, seek information about
                     alternatives      for      handling        medical/physical     or
                     emotional/psychological problems from other sources, such as
                     other Program Directors or the Graduate Medical Education
                     Office, while maintaining confidentiality.

                  3. If the determination has been made that the trainee is not able to
                     carry out assigned responsibilities due to substance abuse and,
                     after discussing the identified issues with the trainee, the trainee is
                     not willing or able to correct the problem, the Program Director
                     may temporarily remove the trainee from the rotation or change
                     the schedule pending expedient implementation of Attachment A:
                     “Substance Abuse Policy for Clinical Faculty and Resident
                     Physicians”. The trainee will continue to receive pay, fringe
                     benefits, and due process during the impaired physician process
                     of Attachment A.




Attachment A - Impaired Physician Policy, Clinical Faculty and Resident Physicians
Attachment B - List of Local Counseling Resources.
                                   Attachment A

              SUBSTANCE ABUSE AND IMPAIRED PHYSICIAN POLICY
            UNIVERSITY OF MISSOURI-COLUMBIA SCHOOL OF MEDICINE

                               HOUSESTAFF PROGRAM

The Dean, University of Missouri-Columbia School of Medicine, has established the
following program to address the issue of substance abuse and impairment by residents
/fellows operating under the auspices of the University of Missouri-Columbia Health
Sciences Center. This policy is similar to that in place for our clinical faculty.

Physicians hold a unique place in society. Professional standards require that persons
seeking care can be assured that their physicians are not impaired by reason of
substance abuse or mental illness. The purpose of this policy is:

       A.     To assure that patients receiving care from physicians, operating under
              the auspices of the University of Missouri-Columbia Health Sciences
              Center, receive the highest quality health care from individuals not only
              well trained and highly motivated, but unimpaired by reason of substance
              abuse or mental illness.

       B.     To assure that individual residents/fellows have access to appropriate
              health care and assurance of continued access to employment so long as
              they comply with institutional requirements and standards.

A.     HEALTH SCIENCES CENTER PHYSICIAN HEALTH COMMITTEE

       1.     The Health Sciences Center Physician Health Committee will, as needed,
              be appointed by the Dean, School of Medicine, to assume responsibility
              for oversight of the Health Sciences Center Physician Health Program to
              address issues of physician impairment or substance abuse.

       2.     Membership of the Health Sciences Center Physician Health Committee
              will consist of:

              a.     Two members of the clinical faculty appointed by the Dean,
                     School of Medicine. Individuals may be reappointed at the
                     discretion of the Dean.     One of these individuals will be
                     designated by the Dean to chair the committee.

              b.     One resident physician or clinical fellow appointed by THE DEAN
                     FROM RECOMMENDATIONS BY the House Staff Organization.

       3.     The Health Sciences Center Physician Health Committee will meet as
              often as necessary to fulfill its obligation.

       4.     All information presented at meetings of the Health Sciences Center
              Physician Health Committee, and all actions of the committee will be
            considered to be confidential except as provided herein and except that
            such information will be available to the Dean, School of Medicine and
            otherwise as required by law.

B.   RESPONSIBILITIES OF THE HEALTH SCIENCES CENTER PHYSICIAN
     HEALTH COMMITTEE.

     1.     The Health Sciences Center Physician Health Committee will initially
            establish a definition of impairment. This definition will be utilized by
            future committees. Following its establishment, it must be approved by
            the Dean, School of Medicine.

     2.     It is the responsibility of the Health Sciences Center Physician Health
            Committee to receive any admission of substance abuse or mental health
            problems by a physician, or allegations of impairment of physicians due to
            substance abuse or mental illness.

     3.     The Health Sciences Center Physicians Health Committee will be
            responsible for investigating those allegations. The Committee shall
            inform the individual in writing of the allegations and provide him/her an
            opportunity to respond to the allegations.

     4.     The Health Sciences Center Physician Health Committee shall inform the
            Dean if the Committee suspects the individual is impaired by substance
            abuse or mental illness, and presents potential risk to patients.

     5.     If probable cause to believe that impairment due to substance abuse is
            present, allegations related to possible substance abuse must be
            reported to the Missouri Physicians Health Committee for further
            investigation and action.

     6.     If there is probable cause to believe that impairment due to mental illness
            is present, the Health Sciences Center Physician Health Committee shall
            require psychiatric evaluation by a psychiatrist approved by the Health
            Sciences Center Physician Health Committee.

     7.     Upon determination that a resident/fellow is impaired due to substance
            abuse or mental illness, the Health Sciences Center Physician Health
            Committee will notify the Dean, School of Medicine.

C.   PERMISSION TO CONTINUE CLINICAL RESPONSIBILITIES

     If the resident/fellow has been removed from clinical responsibilities by the Dean,
     permission to resume clinical responsibilities will be granted only with the
     agreement of the Health Sciences Center Physician Health Committee and the
     Dean.
D.   CONTINUATION OF FACULTY APPOINTMENT

     1.   Residents/fellows found to be impaired by reason of substance abuse or
          mental illness may not be dismissed from employment prior to full
          evaluation of their impairment. They may, however, be removed from
          clinical responsibility. Full evaluation of impairment due to substance
          abuse will be made by the Missouri Physicians Health Committee. Full
          evaluation of mental illness will be made by a licensed psychiatrist
          approved by the Health Sciences Center Physicians Health Committee.
          The allegedly impaired physician may participate in determining the
          identity of that physician.

     2.   Residents/fellows found to be impaired by reason of substance abuse or
          mental illness may not be terminated based upon such substance abuse
          or mental illness during the term of their contract if they are compliant with
          the requirements of the Health Sciences Center Physician Health
          Committee, and the Missouri Physician Health Committee.

E.   TERMINATION OF APPOINTMENT

     1.   A resident/fellow who has been found to be non-compliant with the Health
          Sciences Center Physician Health Committee or the Missouri Physician
          Health Committee will be reported to the Dean, School of Medicine.
     2.   Noncompliance may be grounds for termination of appointment.
     3.   Any dismissal shall conform to applicable University procedures.
                                              Attachment B

                    FINANCIAL ADVICE/COUNSELING RESOURCES

Conway Jones
University of Missouri - Columbia
Medical School Financial Aid Coordinator
MA202 Medical Science Building ............................................................................. 882-2923


                  FINANCIAL/COUNSELING ORGANIZATIONS - LOCAL

A G Edwards & Sons Inc
      2100 Forum Blvd Columbia .......................................................................... 445-7088

American Express Financial
      1316 Old Highway 63 S Columbia ................................................................ 499-4945

American Express Financial Advisors
      601 Nifong Columbia................................................................................... 499-4880

American Express Financial Advisors Inc.
      2710 Forum Blvd Columbia .......................................................................... 446-2744

American Tax Service
      311A Bernadette Dr Columbia ...................................................................... 445-8364

David Banks, CFP
      2611 Luan Ct Columbia ............................................................................... 445-4308

Boone County National Bank
     Columbia ................................................................................................... 874-8490

Boone County National Bank Investor Services
     Columbia ................................................................................................... 874-8446

Alan Bunch, LUTCF
Principal Financial Group
       401 Vandiver Dr Columbia ........................................................................... 443-3535

Cambria Financial Management Inc
     Columbia ................................................................................................... 817-3180

Casey and Company LLC CPAs
      1 E Broadway Columbia .............................................................................. 442-8427
Consumer Credit Counseling Services of Mid-America
     (Staffed, in part, by MU Department of Consumer and Family Economics
     Students)
     205 E. Ash, Columbia .................................................................................. 443-0303

Dollar-Kuretich Doris Financial Advisor
       116 S Jefferson .......................................................................................... 581-5994

Finance World
      601 Business Loop 70 W Columbia ............................................................... 815-9700

Financial Architects Inc
      1000 W Nifong Blvd Columbia ...................................................................... 443-3183

Fundbuilder
     4818 Santana Cir Columbia ......................................................................... 815-1055

Kammerich Financial Services
    1951 Boone Village Plaza Suite D Boonville ............................................. 660-882-7620

Thomas Lightfoot
     1414 Rangeline Columbia ............................................................................ 874-3888

Lincoln Financial Advisors
      601 E Broadway Suite 304 Columbia ............................................................ 443-1654

Merrill Lynch                                                                                       800-
937-0948
       2804 Forum Blvd Suite 2 Columbia ............................................................... 446-7023

Mita Financial Services
       1961 Hirst Dr ....................................................................................... 660-263-8096

Money Concepts Financial Planning Center
     217 E Jackson Mexico ................................................................................. 581-4313

Northwestern Mutual Life
The Peter W. Graff District Agency
      1900 North Providence Rd Suite 307 ............................................................ 449-2488

Nova Financial
      811 Cherry St Columbia .............................................................................. 874-0434

Principal Financial Group
Betty Schuster, CFP
       401 Vandiver Dr., Columbia ......................................................................... 443-0389
Professional Planning Group
Christine Marks, CLU, ChFC
108 E. Green Meadows, Rd. Suite 7
Columbia, MO 65203 .............................................................................................. 443-8628

Sims & Associates Insurance & Financial Services
      4818 Santana Cir Suite B Columbia .............................................................. 874-4494

Waddell & Reed Inc
     1900 North Providence Rd Columbia ............................................................ 875-4494


                                 OTHER COUNSELING SERVICES

Employee Assistance Program ........................................................................... 882-6701

University Physicians Psychiatry Clinic ............................................................. 882-2511




                                                           54
                       INTERNAL REVIEW POLICY
           UNIVERSITY OF MISSOURI HEALTH SCIENCES CENTER


Purpose: The internal review assures: 1) continued quality of the program; and 2)
adherence to ACGME institutional and program specific requirements.

The University of Missouri-Columbia has delegated oversight of residency and fellowship
programs to the Graduate Medical Education Oversight Committee (GMEOC), under the
supervision of the Dean, School of Medicine.

An Internal Review Subcommittee will be appointed by the GMEOC for each residency
training program to conduct an internal review midway between the last and the next
scheduled RRC visit. This subcommittee will report to the GMEOC and be chaired by a
faculty member of the GMEOC, if possible.

The residency programs coordinator will maintain a log of anticipated RRC review dates,
establish a schedule for internal reviews, and assist the GMEOC chair in appointing
these subcommittees.

The Internal Review Subcommittee membership shall generally consist of 4 members:
1) the residency programs administrator; 2) as delegated by the GMEOC, she/he will
rotate faculty members of the GMEOC and notify the individual who will chair each
subcommittee; 3) & 4) a faculty member and resident/fellow from another department.
The program director from the reviewed department will report to the subcommittee.
The House Staff Organization President will be asked to recommend the resident/fellow
(if possible, a member of the House Staff Organization Executive Committee). When
necessary, the House Staff President will ask the resident/fellow’s program director to
assign coverage so this individual can attend.

The following process will be utilized:

Internal Review Purpose:

1) The internal review is to assess whether each program has defined, in accordance
with the relevant program requirements, the specific knowledge, skills and attitudes
required and provides educational experiences for the residents to demonstrate
competency in the following areas: patient care skills, medical knowledge, interpersonal
and communication skills, professionalism, practice-based learning and systems-based
practice.

2) The internal review is to provide evidence of the program’s use of evaluation tools to
ensure that the residents demonstrate competence in each of the six areas and other
competencies as outlined in the program requirements.

3) The internal review is to appraise the development and use of dependable outcome
measures by the program for required competencies, including the six general


                                               55
competencies.

4) The internal review is to appraise the effectiveness of each program in implementing
a process that links educational outcomes with program improvement.

The residency program’s coordinator, under the supervision of the residency programs
administrator, will select dates and times for the internal review meetings.

The residency program’s coordinator will create a questionnaire of ACGME institutional
and specific program requirements including the six general competencies as outlined in
the program requirements. This will be sent to all house staff in the program, the
coordinator and the director for the residency or fellowship program being surveyed.
House staff will be required to return the completed survey by the established deadline,
and the residency programs coordinator will compile survey results in a way that assures
anonymity. The questionnaire will explore whether ACGME Institutional and Program
policies are being implemented.

The house staff representative of the Internal Review Subcommittee and residency
programs administrator will meet with the program’s residents or fellows to discuss
questionnaire results and any further concerns. If any of the program’s
residents/fellows have not returned the questionnaire (excluding first year residents or
fellows), they will be asked to complete the survey during this meeting. The house staff
representative or programs administrator will present the results of the questionnaire and
any information obtained from the residents/fellows to the Internal Review
Subcommittee.

Information regarding ACGME institutional requirements and specific program
requirements, the accreditation letter from the last RRC review of that program, the
previous internal review and the completed resident survey results will be given to each
member of the Internal Review Subcommittee prior to the first internal review meeting.
They are to determine if prior concerns are corrected.

The program director will provide the subcommittee with an annual report. This should
be updated, if not current, and complete with all required elements.

1) The program director should provide adequate evidence of a curriculum complete
with goals and objectives that is used by the program for teaching program specific
competencies and the following six general competencies: patient care skills, medical
knowledge, interpersonal and communication skills, professionalism, practice-based
learning and systems-based practice.

2) The program director should provide evidence of adequate tools used to evaluate
resident competencies based on the goals and objectives.

3) The program director should provide a list of the evaluation tools he/she is using for
each of the competencies and should provide documented evidence of these tools to the
internal review committee.


                                               56
4) The program director should provide evidence of developing or using dependable
measures to access the residents’ competence in each area.

5) The program director should provide evidence of a process developed to link
educational outcomes with program improvement.

In addition, programs will make originals of all contracts, state licenses and affiliation
agreements available to the residency program coordinator.

The Internal Review Subcommittee will review compliance with all information described
in C through F above plus any additional data and share this with the program director
for input. Additional documents may be requested by the Subcommittee.

At the conclusion of the internal review meeting, the Internal Review Subcommittee
Chair will develop a preliminary report of findings, recommendations, strengths and
issues which need to be addressed. There should be noted in that report:

1) Verification of the existence of a curriculum with goals and objectives including those
for each of the general competencies.

2) A summary or list of the types of evaluation tools used by the program for evaluating
the competencies.

3) Comments on the program’s status in the development and use of dependable
measures to assess resident competency including the six general competencies.

4) Comments on the program’s status in developing a process that links educational
outcomes with program improvement.

5) Verification or confirmation from the residents as to the existence of a curriculum with
goals and objectives for teaching the competencies, their involvement in the curriculum
and the kinds of tools used by the program to evaluate them.

The preliminary internal review subcommittee report will be provided to the residency
programs coordinator and distributed to GMEOC members.

At the next regular GMEOC meeting, the chair of the Internal Review Subcommittee or
the residency programs administrator will present the preliminary findings to the GMEOC
with recommendations. The program director will be invited to this meeting.

After review, the GMEOC may choose any of the following actions:

1) Approve the internal review subcommittee findings as demonstrating satisfactory
compliance with no further action necessary;

2) Request further information from residents/program director and review compliance
at a subsequent meeting;


                                                57
3) Continue an ongoing internal review to determine progress towards meeting ACGME
and GMEOC requirements. There may be interim reports to the GMEOC for clarifying or
resolving issues prior to approval of the final report. Final approval will be awarded by
the GMEOC when all issues have been addressed. If the department is unable to satisfy
GMEOC concerns, a final report will reflect this.

The GMEOC Chair will provide the final internal review report to the program director,
the department chair, the Dean of the School of Medicine and a copy will be maintained
in a permanent file to provide to the ACGME Residency Review Committee reviewers.

The GMEOC may request an additional administrative review be conducted by the
program administrator at any time, or prior to any scheduled RRC visit, if it determines
this is necessary.




                                               58
Policy:                    Process for the:
                           1) Reduction in Size or Closure of a Program or
                           2) Closure of the Institution – Training Programs at
                           University of Missouri-Health Care



Effective:                 7-1-07; revised 3/7/00


Training Programs:

    1.   University of Missouri Health Care will inform the DIO, the GMEOC and residents/fellows as
         soon as possible when it intends to reduce the size of or close one or more programs.

    2.   Before any reductions or closures of programs occurs, the GMEOC will be asked for
         recommendations and input when there is a perceived need to reduce or close a program. The
         Dean will make final decisions.

    3.   For programs either reducing in size or closing, residents/fellows already in the program will
         either be allowed to complete their education or will be assisted in enrolling in an ACGME-
         accredited program in which they can continue their education.

    4.   Notification will be sent to the ACGME, by the DIO, indicating intent to voluntarily reduce or
         close a program.

    5.   Residents will be given final notification of the action by the DIO and the Program Director. This
         will include the effective date of the reduction or closure as soon as known.

Institution:

         University of Missouri Health Care will inform the DIO, GMEOC and residents/fellows as
         soon as possible if it intends to close.

In the event that all training programs under the sponsorship of the University of Missouri-
Columbia School of Medicine should be closed. All training physicians will receive notification of
this action and the effective date of closure by the DIO and their Program Director as soon as
possible. They will be assisted by their program director in finding new GME positions.

In the event that an affiliated institution closes, all efforts will be made to arrange for similar
educational experiences in another setting.




                                                         59
  GOALS
   AND
OBJECTIVES




     60
DEPARTMENT OF RADIOLOGY
UNIVERSITY OF MISSOURI HEALTH CARE
CURRICULUM/GOALS AND OBJECTIVES SUMMARY


The Department of Radiology, as part of the University of Missouri-Columbia School of
Medicine, works diligently to offer outstanding graduate training in all areas of
Radiology. Residents completing the program are expected to be well-trained in all
clinical and modality-based areas of Radiology and should be well-prepared to join a
private practice or continue with a fellowship in a subspecialty area of interest.
Residents are provided opportunity and training and then expected to demonstrate
competence in interpretation of exams and performance of radiologic procedures by the
time they have finished the program. They are expected to show independence and
exhibit a high level of clinical judgment as they are completing training.

Our department emphasizes patient care and education. The emphasis is on learning to
be an “Available, Affable, and Accurate” radiologist. Our goal is to train radiology
residents to think for themselves and we strive to provide leadership/mentorship by
example. Also, we provide the necessary tools and training to achieve and demonstrate
excellent clinical judgment, and act as an integral part of the overall health care team in
providing excellent patient management. This is achieved in part through having
residents become involved in a case by consultation prior to ordering and performing
procedures, especially invasive procedures. Since the University Medical Center
emphasizes provision of rural health care, the Department of Radiology, in support of
that, provides teleradiology services to a number of rural hospitals in central Missouri,
and our residents should feel comfortable in a rural setting. A number of our residents
choose a rural setting for practice after completion of training.

We think that it is important for our residents to be able to teach others. We provide
many opportunities for the residents to participate in teaching activities, and have the
residents present colloquia, journal club, case conferences, intra- and inter-departmental
conferences, and give presentations to medical students who are rotating through
Radiology. We also support research by residents and require them to complete a
project that can become a published paper and a presentation at a national, state or
chapter meeting.

The emphasis of our teaching services is the one-to-one, hands-on educational
experience “at the viewbox”. We strive to maintain a one to one ratio of faculty to
residents. In each area, either clinical or modality-based, the faculty member works
closely with the resident throughout the day. Residents are given graduated
responsibility throughout the program. In the first year, residents are very closely
supervised while they interpret studies, and the interpretation in the first few months is
generally a joint effort. As their training progresses, the residents will take on increasing
responsibility, and will often review a number of cases for review by the faculty member.
They are expected to be able to interface with residents and faculty of the clinical teams


                                                 61
in an increasingly competent and intelligent manner as training progresses. In the later
stages of training, residents are expected to be able to analyze and prepare even the
most difficult and complex cases for review by faculty.

Beginning in July, 2000, we incorporated the clinical rotations of the internship (PGY1)
year into an “integrated” residency program. Our integrated residents complete one to
two months of their nine-month clinical requirements in the PGY1 year, generally in
Emergency Medicine. In the next three years, they complete two to three clinical
rotations until their clinical requirement is fulfilled. In the PGY3 and PGY4 years, as the
residents hone their skills and interests, the rotations should be related to their areas of
interest. At this level, these residents would also serve as Radiology consultants for the
clinical services. During their clinical rotations, our residents continue to fulfill their on-
call responsibilities in Radiology.

The curriculum encompasses the 7 major clinical areas, 1) Neuroradiology, 2)
Musculoskeletal radiology, 3) Vascular and interventional radiology, 4) chest radiology,
5) breast radiology, 6) abdominal radiology, especially gastrointestinal and genitourinary
radiology, and 7) pediatric radiology, and the two modality based subjects, Ultrasound
and Nuclear radiology. The modalities of CT and MRI are incorporated into the clinical
areas. The curriculum therefore encompasses the entire scope of the practice of
Radiology, in terms of clinical areas and the modalities used for the evaluation of
patients. Goals and objectives are defined in each area. The goals and objectives for
each level of training in each area have nearly been developed.

For the academic year 2006-2007, the plan is to implement an improved and organized
teaching curricula and have a minimum of twenty to twenty-five core topics that will be
covered through lectures, cases, or other conferences and may be supplemented with
view box teaching. These core topics will be specific for each of the subspecialties of
radiology and will be repeated every 2 to 2 ½ years with review at regular intervals.

For each area, residents are expected to be able to accurately and concisely dictate a
report. They are expected to be able to communicate with referring clinicians, obtain
clinical history where appropriate, and relay findings and impressions from the radiologic
exam. They are expected to understand positioning in each area, if appropriate. They
are expected to understand the clinical indications for the exams in each area for a
multitude of clinical problems, and be able to advise clinicians on the best approach for
problem-solving. They are expected to demonstrate a proper work ethic. They are
expected to increase their fund of knowledge in each area. For procedures, they are
expected to develop and refine skills in planning and performing procedures.

Residents are expected to demonstrate competence not only in didactic information, but
also in providing sound clinical judgment. Additionally, the residents are now evaluated
according to the six core competencies, and are expected to perform satisfactorily in
each of those areas.



                                                  62
In addition to standard clinical work, residents are expected to present a colloquium on
a topic of their choosing, approved by faculty twice per year, and present a journal
article as part of journal club.

Evaluation of residents is performed after each rotation. In 2002, the evaluation form
was changed to include the six core competencies. These are: patient care, medical
knowledge, interpersonal/communication skills, professionalism, practice-based learning
and improvement, and systems-based practice.




                                              63
                   CORE COMPETENCIES FOR RADIOLOGY


Definition and Scope
Tools and Educational Activities
Evaluations


   1. Patient Care:

a). Definition and Scope – In promoting the health and well-being of patients, residents
are expected to provide appropriate, compassionate, and effective patient care.
Residents should develop a management plan based on radiological imaging findings
and available clinical information. They are expected to demonstrate proper technique
and competence in planning and performing image-guided procedures. They should
obtain information about the patient related to the requested test or procedure, select
the appropriate procedure and therapy, and discuss it with the supervising faculty. This
discussion should include a review of images as well as image quality and correlation
with various imaging studies, including x-rays, CT, MR, and ultrasound. These
observations should be communicated to supervising faculty in a clear and succinct
fashion and also reflected in the generated report.

b). Tools and educational activities – The main tool in achieving optimal patient care is
good communication between clinical and radiology services. This is supported by
electronic medical records systems for patient data including Power Chart, MARS,
RadNet, and the PACS system. Necessary hospital support staff (nursing, technologists
etc.) is provided at all times as well as direct supervision by faculty. Instruction is
offered at daily departmental and inter-departmental conferences, as view box teaching,
as part of the curriculum, and in courses offered by the department and hospital (BCLS,
ACLS, Code of Conduct training, etc.).

c). Evaluation – Monthly resident evaluations are performed by faculty based on patient-
care activities and these evaluations reflect areas of core competency as defined. The
following are metrics used in the evaluations: resident’s performance at the view box;
performance at case conferences; patient safety network reports (PSN); quality
assurance conferences; the number of significant missed abnormalities; and board
review conferences. Residents are required to maintain a log book which will become
electronic-based per ACMGE requirements beginning July 2006. Under this new
requirement, beyond interventional and other therapeutic log books, the required CPT
codes will be documented electronically per resident per PGY level. This data will be
used to analyze the adequacy of clinical exposure and performance at specific PGY
levels and will be compared between peers in the program and, in the future, with
national standards. This will help identify strengths and weaknesses of the program and
also its individual residents.




                                              64
   2. Medical knowledge:

a) Definition and Scope – Residents are encouraged and mentored to be
knowledgeable, scholarly, and committed to lifelong learning. They are expected to
recognize and describe relevant radiological findings; to synthesize radiological
observations into a drafted report; to form an impression; and to suggest possible
management and follow-up plans. The residents are encouraged and expected to utilize
information and technology provided to investigate clinical questions and for continued
self-learning. The residents should closely follow scientific progress in radiology by
becoming familiar with major journals and electronic resources and through participation
in Journal Club, colloquia, and conferences. Residents should know how to use
essential written literature, computer technology (including internet websites), and
educational CD and DVD courses available to them. Residents are required to
participate in the annual in-service exam conducted by the American College of
Radiology. They should be aware of and comply with radiation safety rules and
regulations, including the ALARA (“as little as reasonably achievable”) principle for
personal radiation protection and the NRC guidelines for nuclear medicine. Residents
should understand the concepts of quality control and quality assurance for imaging
devices, tests, as well as the safe use of contrast media.

b). Tools and educational activities – The tools available to residents include: direct
mentorship with faculty; direct view box and case teaching; feedback through the
radiology information system (MARS) of any significant changes to findings; case
conferences; and participation in health care in a large tertiary care center. Journal
Club, colloquia, computer technology (including internet websites), and CD and DVD
courses are used and remain available. Radiation biology and safety lectures are
provided on the principle of radiation safety and radiology life support video training
provides basic concepts of radiology safety, including possible contrast reactions. the
residents egularly attend the monthly quality assurance conferences run by the
department and ctively participate in daily departmental case conferences and didactic
lectures.

c). Evaluation – Residents’ medical knowledge is evaluated monthly by the faculty as
part of the written rotation evaluation. Evaluation of Journal Club and colloquia
presentations is being instituted. Evaluation of resident performance of medical
knowledge is also based on view box teaching, board review conferences, and
interdepartmental conferences which are mentored and supervised by the faculty. More
objective evaluation is based on the in-service examination conducted by the ACR,
written examinations of radiological physics and clinical diagnostic radiology, and the
oral examination in radiology conducted by the American Board of Radiology. The
written exam tests knowledge of facts and their use in clinical diagnosis. The oral
examination tests the ability to detect, recognize, and describe radiological findings,
synthesize them into a coherent clinical process, and develop an appropriate diagnosis
with a management or follow-up plan as appropriate.




                                              65
   3. Interpersonal/Communication Skills:

a). Definition and Scope – Residents are expected to be able to communicate clearly
and effectively and to work well others, including the patients, their families, physicians
within radiology, referring physicians from outside radiology, departmental technologists,
nursing staff, and support staff. Residents are required to obtain informed consent for
procedures when appropriate. They are also expected to be able to recognize urgent or
unexpected radiological findings and communicate and document these findings in the
patient record. They are required to produce radiology reports that are accurate,
concise, and grammatically correct. They are encouraged to be able to effectively teach
residents (cross-training), medical students, and other health care professionals,
including technologists.

b). Tools and educational activities – Supervising faculty serve as role models by
promoting a feeling of well-being and maintaining the minimum standard of
communication expected within the department and institution. Residents should be
learning good communication from a healthy working environment that exists and
depends on all staff, including attending physicians, technologists and other staff
members of the institution. Leadership, good communication, and feedback from the
residents is always encouraged, appreciated, and recognized. The institution also has
policies regarding communication standards for health care workers and provides
mandatory Code of Conduct and ethical behavior training online.

c). Evaluation - Formal evaluation is based on direct observation by supervising faculty.
The drafted radiological reports generated by the resident document style of
communication as well as their contact with the referring physician.           Resident
evaluations have been updated to include this core competency. 360-degree evaluations
and patient care surveys have been instituted within the department and will be used to
provide insight into interpersonal skills and communication by the resident. Informal
means of evaluation include verbal feedback from faculty, technologists, support
services, and nursing staff.

   4. Professionalism:

a). Definition and Scope – Residents should be altruistic and accountable and
demonstrate the highest level of medical ethics, in part by protecting and respecting the
best interests of the patient. Residents are expected to demonstrate a responsible work
ethic, be available on time, respect work assignments and attend conferences. They are
expected to demonstrate an acceptable personal demeanor and hygiene. They should
behave in a professional manner with respect to the dignity of patients and of all
members of the medical team. There should be no discrimination based on age,
ethnicity, gender, disability, or sexual orientation. Residents are required to be
responsive to patients’ needs by demonstrating integrity, honesty, compassion, and
commitment and are to respect the patients’ privacy and autonomy at all times.




                                                66
b). Tools and educational activities – Residents are taught to be professional and to
exhibit ethical behavior under all circumstances. They should show respect for everyone
with whom they come into contact, regardless of age, ethnicity, gender, disability, or
sexual orientation. Instruction in this is mostly done during day-to-day clinical care
practices under direct supervision and mentorship by the faculty. The hospital requires
each resident to comply with the patient’s privacy and autonomy requirement. Residents
attend orientation lectures before joining the program. Code of Conduct training is
required on an annual basis by the institution. The university also encourages
participation in additional lectures and CME activities available to medical professionals.
ACR videotapes are shown at least once a year as part of the residents conference
series and cover topics such as business aspects of radiology, job search, contracting
issues, ethics, medical organizational politics, and service orientation.

c). Evaluation – The formal means of evaluation include: the written rotation evaluation
which includes professionalism as part of the essential core competencies; 360-degree
evaluations which reflect performance in the absence of supervising faculty; and patient
care surveys which are used to provide insight into the professionalism of each resident.
Informal means of assessment and evaluation include: timeliness at work; availability for
conferences; and behavior and attitude towards self, colleagues, and other health care
workers.

   5. Practice-based Learning and Improvement:

a). Definition and Scope – Residents are expected to investigate and evaluate patient
care practices and be able to evaluate and assimilate scientific evidence in order to
improve their practices. They should participate in quality improvement and quality
assurance activities and are required to recognize and correct personal error by direct
feedback and supervision. Residents must develop and continuously improve skills in
obtaining medical knowledge using newer techniques and information technology
(including use of the internet and computer-based data) for accessing patient information
and researching disease and radiological information. Residents should be familiar with
viewing and manipulating images on the PACS (both remote and local). They should
improve their understanding of disease and patient care by attending inter-specialty,
correlative, mortality and morbidity (where applicable); and utilization conferences.
When applicable, follow-up on patient’s outcome based on clinical information is
encouraged. Such discussion should be pursued in case conferences as well as with
mentoring faculty.

b). Tools and educational activities – Tools available for practice-based learning and
improvement include: intradepartmental and interdepartmental conferences, combined
multi-disciplinary conferences, journal club, colloquia, quality assurance conferences
and view box teaching in the reading rooms. Computers with access to the internet and
web-based teaching tools are available in all rooms of the radiology department
including reading rooms, on-call rooms, radiology library, and the residents’ room. An
upgraded PACS system is provided by the department and a PACS support team as
well as a computer support team is available at all hours on an as-needed basis. The
institution also provides electronic medical records through MARS (local radiology
network), RadNet, and Power Chart.

                                                67
c). Evaluation - Evaluation of resident performance occurs in resident-run case
conferences; journal club and colloquia evaluations; 360-degree evaluations; patient
surveys; patient safety network (PSN); and presentation of reading material in rotations.

       6. Systems-based Practice:

a). Definition and Scope – Residents should understand all aspects of health care
practice. The program understands and emphasizes the importance of esidents learning
to work in a variety of health care settings and understanding the inter-relationship with
other health care professionals. Specifically, residents should be aware of and work with
patients in the hospital, in clinic settings, at diagnostic centers, and in private practice
settings. They should demonstrate knowledge of appropriateness and be able to apply
cost-effective health care principles such as resource allocation, diagnostic-related
groups (DRGs), and pre-certification by medical insurance. They should be aware of he
concept of providing optimal patient care and select the most cost-effective tests and
procedures, using and recommending other diagnostic tests that might complement
patient well-being. They should understand basic financial and business skills necessary
to function effectively in the current health care environment. They should understand
and obtain knowledge of coding, procedures, charges, billing practices, and
reimbursement mechanisms. Also, residents should know the importance of when to
recruit or call for additional subspecialty support, and recommend appropriate follow-up
and management plan within the resources available in the health care system.

b). Tools and educational activities – Residents learn about work conditions in hospitals,
diagnostic centers, and private practice settings through participation in day-to-day
clinical work in the health care institution. Resource allocation, methods directed towards
controlling health care costs such as diagnostic related groups (DRGs) and pre-
certification by medical insurance can be discussed in reading rooms, view box teaching,
and in case conferences. Didactic lectures and interactive courses are to be
implemented soon. The concept of providing optimal patient care with the most cost-
effective procedures by recommending other diagnostic tests is reflected in the
reporting, directly mentored by faculty. This often involves awareness of relevant
risk/benefit consideration, including financial and business skills to function effectively in
the health care delivery system available. The department plans to implement
knowledge of coding, procedural charges, and billing practices with the help of the billing
team available within the department. Currently, the residents learn during everyday
practice and discussion on a daily basis throughout the department in the various
reading rooms under direct supervision of the faculty.

c). Evaluation - Monthly resident evaluation forms completed by the faculty assess
resident competence in systems-based practice. The drafted/generated patient reports,
which include further plan and recommendations, reflects residents’ ability to understand
systems-based practice is directly evaluated by the supervising faculty on a daily basis,
at which point, needed guidance and recommendations are provided.




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GOALS AND OBJECTIVES
Chest Radiology

Minimum of three (3) four-week rotations over the course of the residency.

1st Rotation

Goals

After completion of the first chest rotation, the resident should be able to:

   1) Demonstrate a basic comprehension of at least 1/3 of the knowledge-based
      objectives as specified
   2) Accurately and concisely dictate a chest radiograph report
   3) Communicate effectively with referring clinicians and supervisory staff
   4) Demonstrate an understanding of standard patient positioning in chest radiology
   5) Obtain pertinent patient information relative to radiologic examinations
   6) Demonstrate knowledge of the clinical indications for obtaining chest
      radiographs, including when and if a CT and/or MRI may be necessary
   7) Demonstrate a responsible work ethic

Objectives

During the first rotation, the resident will be expected to:

   1) Demonstrate a working comprehension of at least one-third of the knowledge-
      based objectives established for chest radiology, as well as the following basic
      anatomy:
           o airway zones, secondary pulmonary lobule, acinus units, and bronchi
               segments, fissures, and airways
           o heart chambers and vascular structures
           o bones
           o mediastinal boundaries, junctional lines, and other structural lines on both
               a PA chest and a lateral chest
   2) Dictate clear, understandable chest radiograph reports, which should include the
      patient’s name, date, medical record number, comparison exam date, type of
      exam, indication for exam, and a brief and concise description of the findings
      and a short impression
   3) Contact the ordering physicians about all significant or unexpected radiologic
      findings and document the contact
   4) Obtain relevant patient history from available resources, including the referring
      clinicians
   5) Communicate patient positioning and indications for these positions
   6) Decide when it is appropriate to obtain help from supervisory faculty
   7) Arrive for the rotation on time and demonstrate a good work ethic


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2nd Rotation

Goals

By the end of the second chest rotation, in addition to the skills acquired as part of the
first rotation, the resident should be able to:

   1) Demonstrate further comprehension of the knowledge-based objectives;
   2) Identify the following structures on chest CT and MRI:
         o segments and lobes of the lung
         o pleura and extrapleural fat
         o airways
         o heart structure, including chambers, valves, arteries, veins, and sinuses
         o pericardium and recesses
         o pulmonary arteries and their branches and segments
         o aorta and great arteries
         o veins
         o bones
         o esophagus, thymus, thyroid
         o muscles of the chest
         o windows, recesses, fissures, and ligaments
   3) Continue to build on chest radiograph interpretive skills;
   4) Develop skills in protocoling, monitoring, and interpreting chest CT;
   5) Demonstrate an understanding of the ACR Appropriateness Criteria.

Objectives

During the second rotation, the resident will be expected to:

   1) Demonstrate a working comprehension of at least two-thirds of the knowledge-
      based objectives as specified;
   2) Appropriately protocol all requests for chest CT;
   3) Monitor all chest CT and instruct in additional images to complete the exam;
   4) Effectively present chest radiology cases in a conference setting;
   5) Demonstrate the ability to manage an intravenous contrast reaction;
   6) Demonstrate the ability to use chest fluoroscopy, including assessment of the
      diaphragm;
   7) Demonstrate effective communication skills and exhibit a high-level of
      professionalism.




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3rd Rotation

Goals

By the end of the third chest rotation, in addition to the skills acquired in the previous
two rotations, the resident should be able to:

   1) Demonstrate a high level of comprehension of the knowledge-based objectives
      for chest radiology;
   2) Exhibit refined skill in interpretation of films;
   3) Demonstrate skills in protocoling, monitoring and interpreting HRCT;
   4) Demonstrate skills in protocoling, monitoring & interpreting MR, including
      cardiovascular MR;
   5) Correlate pathologic and clinical data;
   6) Become more autonomous as a consultant and to begin teaching other residents
      and medical students.

Objectives

During the third rotation, in addition to the skills acquired in the first two rotations, the
resident will be expected to:

   1) Demonstrate comprehension of the knowledge-based objectives as specified
   2) Dictate accurate, concise chest radiographs, CT, and MRI with a 75% accuracy
   3) State the clinical indications for performing a HRCT examination
   4) Correctly protocol all HRCT exams, obtaining respiratory phase and positioning
      changes as indicated
   5) Correctly protocol and understand the technical principles of all chest MR exams
   6) Describe the CT protocol for the following:
          o thoracic aorta and great vessels
          o suspected pulmonary embolism
          o tracheobronchial tree
          o suspected bronchiectasis
          o lung cancer staging
          o esophageal cancer staging
          o suspected pulmonary metastases
          o suspected pulmonary nodule on a radiograph
          o shortness of breath
          o hemoptysis



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   7) Correctly understand and protocol MR exam of the chest including:
           o thoracic aorta
           o pulmonary arteries
           o thoracic veins
           o pericardium
           o cardiomyopathy and cardiac tumors
           o ischemic heart disease
           o valvular heart disease
           o right ventricular dysplasia
           o congenital heart disease of the adult
           o superior sulcus tumor
   8) Present an interesting cardiopulmonary case in collaboration with a pathologist,
       including radiologic and pathologic findings
   9) Perform lung biopsies with faculty supervision
   10) Work in the reading room independently, assisting clinicians with interpretation
       and teaching other residents and medical students

Conferences

Residents are expected to attend the following conferences as part of their education
during their chest rotations. By the third rotation, the residents are expected to be
preparing and presenting radiologic cases for multidisciplinary conferences.

    chest conferences at the University
        o pulmonary/radiology conferences at the University
        o tumor conferences
        o colloquia and Journal Club
    ACR teaching file conferences


Study Materials

       ACR Learning File CD-Rom
       Fundamentals of Diagnostic Radiology - Brant & Helms
       Chest Radiology: The Essentials - Collins & Stern
       Chest Radiology - Reed
       Felson’s Principles of Chest Roentgenology – Goodman
       Chest Radiology Companion – Stern & White
       Thoracic Radiology – Newell & Tarver
       Thoracic Radiology: The Requisites – McLeod
       Radiology of Chest Diseases – Lange & Walsh
       Radiology of Thoracic Diseases: A Teaching File – Swenson
       High-Resolution CT of the Lung – Webb, Muller & Naidich
       Imaging of Diffuse Lung Disease – Lynch, Newell & White
       Synopsis of Diseases of the Chest – Fraser & Pare


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        High Resolution of the Chest: Comprehensive Atlas – Stern, Swenson, et al
GOALS AND OBJECTIVES
Gastrointestinal Radiology

Minimum of three (3) four-week rotations over the course of the residency.

Goals

1st Rotation

The initial four-week rotation consists of an initial fluoroscopic guidance with a senior
resident/chief resident and attending supervision. First-month residents should become
acquainted with basic fluoroscopic techniques (i.e., limit use of radiation, learn use of all
fluoroscopic equipment). After completion of the first rotation, the resident should be
able to:

   1) Obtain pertinent patient information relevant to radiological examination
   2) Demonstrate an understanding of clinical indications and appropriateness for
       obtaining the examination and be able to determine if and when further
       investigation is needed
   3) Effectively communicate with the referring clinician and radiology supervisory
       staff
   4) Demonstrate fluoroscopic basic skills and techniques
   5) Understand patient positioning in fluoroscopy and any related techniques
   6) Demonstrate responsible work ethics
   7) Demonstrate a working knowledge of one-third to one-half of GI radiology and
       radiological pathology of GI diseases
   8) Know and understand the terminology for fluoroscopy GI radiology
   9) Be able to dictate clear, understandable GI/CT reports, which should include
       patient’s name, ID/MR#, exam type, indications, technique, limitations, findings,
       impression
   10) Contact referring physician with any significant or unexpected findings and
       document the same
   11) Prepare and understand the clinical scenarios of needs and demands of taking
       radiology after-hour call
   12) Develop one-third of the knowledge base and become familiar with the following
       procedures and their indications:
           o esophagram/barium swallow
           o upper GI single and double contrast examinations
           o hypotonic duodenography
           o small bowel series
           o enteroclysis
           o barium enema single and double contrast
           o per oral pneumocolon
           o feeding tube placement & positioning


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           o   check positions of G tube, J tubes , enteric tubes
           o   cystogram
           o   voiding cystourethrogram
           o   retrograde urethrogram
           o   hysterosalpingography
           o   fistulogram
           o   abscessogram
           o   antegrade nephrostogram
           o   loopogram/sinogram
           o   modified barium swallow
           o   T-tube cholangiogram

CT Scanning of the Abdomen and Pelvis

In addition to the general GI goals, the residents should also be familiar with the
following in relation to CT procedures:

   1) Indications and contraindications with use of oral and IV contrast
   2) Basic understanding of the principles of CT scanning, patient preparation
   3) Identify the appropriateness – indications and contraindications of CT scan
      exams
   4) Identify normal CT scan and GI anatomy related to liver, spleen, pancreas,
      peritoneal cavity retroperitoneum, adrenals, kidneys, GI tract, abdominal wall,
      soft tissues and bones of the abdomen and pelvis
   5) Identify basic pathologic processes related to these organs and viscera –
      including but not limited to – radiological, medical and surgical emergencies,
      trauma, neoplasms (benign and malignant), inflammatory conditions, congenital,
      metabolic, iatrogenic

2nd & 3rd Rotations

   1) Over the remainder of the rotations, the resident will consolidate the skills
      acquired previously and increase his/her fluoroscopic and CT scan protocol,
      performance and interpretive skills.
   2) Demonstrate further comprehension of the knowledge based objectives, GI
      related pathology by fluoroscopy and CT scan use.
   3) Improve on communication skills with attending physician, referring physicians,
      demonstrate more advanced radiological skills.
   4) Learn to more independently protocol, monitor and interpret Abdomen and
      Pelvis related CT scan and GI fluoroscopy exams,
   5) Understand the ACR appropriateness criteria for GI and CT exams and Contrast
      use guidelines.
   6) Be able to teach and guide the rotating medical students, junior radiology
      residents and other rotating interns and residents.



                                                74
   7) Learn to be able to effectively discuss the radiological anatomy and pathology
      related to GI disease and modalities discussed above with referring physicians
      and in conferences.

By the end of the third rotation , in addition to the skills acquired in the previous two
rotations, the resident should:

   1) Demonstrate high level of comprehension of knowledge-based objectives for GI
      radiology
   2) Exhibit refined skills for the performance and interpretations of GI related
      procedures and CT scans
   3) Demonstrate skills to protocol, monitor, and interpret CT scans
   4) Learn basic skills of body MRI and learn to protocol, monitor, and interpret GI,
      abdomen and pelvis related MRI scans
   5) Be able to correlate pathologic and clinical data
   6) Start to become more autonomous as a consultant radiologist to the radiological
      technologists, rotating clinical residents and referring physicians
   7) Be able to effectively teach other residents and medical students

Objectives

Professionalism:

While on the rotation, the residents are expected to be available in the fluoroscopic and
CT scan reading room area at all times during normal working hours or easily available
by pager. Normal working hours are from 8 AM to 5 PM or until all assignments are
completed.

Patient care:

Residents should read all exam requests, talk to the fluoroscopy patients (and if needed
to CT scan patients) and determine indications or contra-indications to the tests and the
appropriateness of the examination. After the indications have been determined, the
exam must be done under direct supervision and communication with the supervising
attending.

Communication skills:

The resident is expected to call the referring providers / physicians about any significant
or unexpected radiological findings and document the call. The resident should obtain
pertinent and relevant data prior to the procedure, such as prior radiological studies,
past medical/surgical history, history of contrast allergy or difficulty prior to examination.
The films should reviewed as soon as possible and a draft of the report made with the
supervising attending. The case may be reviewed again by the attending, if deemed



                                                 75
necessary. Direct feedback from supervising attending is expected and may            be
requested by the resident.




Conferences

Residents are expected to attend the following conferences as part of their education
during their GI rotations. By the third rotation, the residents are expected to be
preparing and presenting radiological cases for multidisciplinary conferences.

      Basic orientation lecture conferences at the beginning of the academic year
      Monthly GI and CT departmental case conferences and didactic lectures
      Radiology/pathology interdepartmental conferences
      Journal Clubs
      Colloquia
      Monthly interesting /difficult case conferences

Study Materials

       Departmental GI Fluoroscopy Protocol handout
       Manual of GI Fluoroscopy – Bruce Javors
       Fundamentals of Diagnostic Radiology – Brant & Helms
       Gastrointestinal Radiology: A Pattern Approach – Eisenberg
       Elementary Tract Radiology – Margulis
       Double Contrast Gastrointestinal Radiology – Levine, Rubesin, Laufer
       Textbook of Gastrointestinal Radiology – Gore & Levine
       Dynamic Radiology of the Abdomen: Normal & Patholigic Anatomy – Meyers
       Elementary Tract Imaging Teaching File – Johnson
       ACR GI Teaching Files on CD-Rom

Study Material for CT Scan Related to GI Tract

       Fundamentals of Body CT – Brant, Webb and Helms
       Body CT: A Practical Approach – Slone, Fisher, Pickhardt
       The GI Requisites – Halpert, Feczko
       CT and MRI Imaging of the Whole Body – Haaga, Lanzieri, Gilkeson
       Computed Body Tomography with MRI Correlation – Lee and Sagel
       Body MRI – ACR Test and Syllabus #46
       Abdominal-Pelvic MRI – Semelka




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77
GOALS AND OBJECTIVES
Pediatric Radiology

Junior rotation

The first rotation will be an introduction to pediatric radiology and the imaging exams
and disease processes unique to the pediatric population, including neonates, infants,
children and adolescents. At the end of the first rotation, the resident should be able to:

          1) Demonstrate basic comprehension of pediatric plain films including chest,
             abdomen, and bone radiographs
          2) Demonstrate basic comprehension of basic pediatric ultrasound including
             cranial ultrasound, abdominal ultrasound, and basic musculoskeletal
             ultrasound
          3) Demonstrate basic comprehension of pediatric CT and MRI exams to
             include neuro and body imaging
          4) Be able to perform and interpret pediatric fluoroscopic exams including, but
             not limited to, upper GI / esophogram, barium enema, VCUG, swallow
             study, nephrostogram, and intusussception reduction
          5) Dictate organized, understandable reports comprehensive but concise
             findings and a clear impression
          6) Understand common congenital abnormalities
          7) Appreciate the difference between pediatric and adult anatomy, physiology
             and disease processes and how these relate to imaging findings and
             diagnoses
          8) Protocol exams specific to each patient and his/her disease process
          9) Understand radiation safety and work with ordering physicians and
             technologists to practice low dose exams
          10) Act as a consulting physician to ordering physicians and services.

During the first rotation, the resident will:

        1) Participate in interpretation of plain films, ultrasound, CT and MRI of the
           pediatric patients including the neonatal intensive care unit, pediatric
           inpatient, and outpatient exams.
        2) Participate in daily viewbox teaching
        3) Prepare a “case of the day” to be presented to the pediatric radiology team
           each day
        4) Attend all pediatric radiology conferences and (when available)
           multidisciplinary conferences including pediatric uroradiology, genetics,
           inpatient rounds, pediatric problem conference, and NICU rounds
        5) Participate in and perform fluoroscopic examinations and ultrasound




                                                78
By the end of the first rotation, the resident will have:

       1) Read Fundamentals of Pediatric Radiology, Donnelly
       2) Completed the “junior radiology resident” modules from the Cleveland Clinic
          Pediatric Radiology website
       3) Completed the “Top 20 ER cases”
       4) Participated in the MU pediatric radiology case of the month
       5) Completed Disc I and passed the final exam


Senior Rotations

The second and third rotations will focus on more advanced pediatric imaging
techniques. At the end of these rotations, the resident should be able to:

         1)    Demonstrate comprehension of pediatric plain films including chest,
               abdomen and bone radiographs with a knowledge of the disease entities
               specific to the age of the patient
         2)    Demonstrate comprehension of pediatric ultrasound including cranial
               ultrasound, abdominal ultrasound, and basic musculoskeletal ultrasound
           3) Be able to perform basic pediatric ultrasound exams including, but not
               limited to: pylorus, hips for dysplasia, hips for effusion, renal, spine, and
               basic musculoskeletal.
           4) Demonstrate comprehension of pediatric CT and MRI exams to include
               neuro and body imaging
           5) Be able to perform and interpret pediatric fluoroscopic exams including,
               but not limited to: upper GI / esophogram, barium enema, VCUG,
               swallow study, nephrostogram, and intusussception reduction
           6) Dictate organized, understandable reports comprehensive but concise
               findings and a clear impression
           7) Understand common congenital abnormalities
           8) Appreciate the difference between pediatric and adult anatomy,
               physiology and disease processes and how these relate to imaging
               findings and diagnoses
           9) Protocol exams specific to each patient and his/her disease process
           10) Understand radiation safety and work with ordering physicians and
               technologists to practice low dose exams
           11) Act as a consulting physician to ordering physicians and services.

During the second and third rotations, the resident will:

       1) Participate in interpretation of plain films, ultrasound, CT and MRI of the
          pediatric patients including the neonatal intensive care unit, pediatric
          inpatient, and outpatient exams.


                                                 79
       2) Participate in daily viewbox teaching
       3) Prepare a “case of the day” to be presented to the pediatric radiology team
          each day
       4) Attend all pediatric radiology conferences and (when available)
          multidisciplinary conferences including pediatric uroradiology, genetics,
          inpatient rounds, pediatric problem conference, and NICU rounds
       5) Participate in and perform fluoroscopic examinations and ultrasound


By the end of the second and third rotation, the resident will have:

       1) Read Fundamentals of Pediatric Radiology, Donnelly
       2) Read relevant topics from Diagnostic Imaging: Pediatrics, Donnelly
       3) Read Pocket Radiologist: Pediatrics, Top 100 diagnoses and become familiar
          with these cases
       4) Read Pocket Radiologist: PedsNeuro, Top 100 diagnoses and become familiar
          with these cases
       5) Completed the “senior radiology resident” modules from the Cleveland Clinic
          Pediatric Radiology website
       6) Completed the “Top 20 ER cases”
       7) Participated in the MU pediatric radiology case of the month
       8) Completed Disc II and passed the final exam

Additional Reading Material

Caffey’s Diagnostic Pediatric Imaging, Kuhn and Slovis
Imaging the Acutely Ill and Injured Child, Swischuck
Pediatric Imaging, The Core Curriculum, Siegel and Coley
Pediatric Sonography, Rumack
Fundamentals of Pediatric Radiology, CD




                                               80
GOALS AND OBJECTIVES
Uroradiology

Minimum of three (3) four-week rotations over the course of the residency.

1st Rotation

The resident must have a basic knowledge of urinary system anatomy before the start
of the first rotation. As part of the first rotation, the resident will be expected to
become familiar with:
    1) contrast agent reactions and their treatments; pretreatment and hydration
        protocols (emphasis on ACR guidelines)
    2) methodology of urographic examinations and CT scan related to the GU system
    3) location of the “emergency drug box” and how to request emergency assistance
        (code CPR)
    4) sterile technique for venipuncture
    5) medical indications and contraindications for urographic and GU-CT examinations
    6) handling cancellation and/or postponement of examinations
    7) notation of any drugs administered in the patients’ hospital charts and
        departmental records
    8) common urologic problems, including acute stone obstruction, bladder outlet
        obstruction, pyelonephritis and trauma to the urinary tract.

1st-3rd Rotations

Over the course of the uroradiology rotations, the resident is expected to progressively:
   1) become familiar with the indications, contraindications, and limitations of
       excretory urography and CT scans related to the GU system
   2) understand and demonstrate the advantages and disadvantages of the
       urography, cystograms, urethrograms – excretory, retrograde, and voiding,
       suprapubic, nephrostograms, US, CT scan and MRI scans
   3) be familiar with the properties and types of urographic and intravenous contrast
       agents (ACR Guidelines)
   4) be able to recognize and treat allergic reactions to urographic contrast agents
   5) be familiar with contraindications to the administration of urographic contrast
       agents and the role of pre-medication (caution with Glucophage, Metformin)
   6) be able to modify and “tailor” the individual examination if necessary during the
       progress of the examination
   7) be able to analyze and give an accurate interpretation of urograms;
   8) participate more independently in consultations with medical students, house
       staff, and attending physicians
   9) dictate acceptable radiological reports
   10) understand the role of ultrasound, body CT, and MRI in GU imaging;
   11) review the uroradiological ACR teaching file



                                               81
   12) be actively involved with the teaching of medical students on the radiology
       rotations

Advanced Rotation (Years III, IV):

The resident will refine skills in the direction and interpretation of genitourinary imaging
procedures and being an effective consultant to the clinician. The resident will be
expected to demonstrate organization skills and educational knowledge consistent with
his/her level of training.

Objectives:

Professionalism:

   o   The resident is expected to be in the department and ready for patient exams by
       8:00 AM on normally-scheduled work days.
   o   While an examination is in progress, the resident should be in the urographic unit
       or in very close proximity for the purpose of observation, recognition, and
       treatment of any allergic reactions. (If absence from the unit becomes
       necessary, the resident must inform the appropriate faculty and arrange
       coverage.)

Patient care:

   o   Any previous uroradiological examination and/or previous pertinent radiological
       reports should be reviewed prior to commencement of the examination.
   o   It is the responsibility of the resident to report to the attending physician and to
       assure that the patient is free of any or has improved from any allergic
       manifestations prior to discharge from the department.

Communication skills:

   o   The resident is expected to perform a thorough questioning of the patient and a
       review of the hospital patient chart for any contraindications prior to the
       performance of the urogram and CT scans, If there are medical
       contraindications, the examination should not be performed. In questionable
       cases, the resident should consult with the appropriate faculty.
   o   After completion of the examination, the resident is expected to review the case
       with the attending and then dictate the same. Comparison with any previous
       examinations is mandatory.




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Conferences

Residents are expected to attend the following conferences as part of their education
during their uroradiology rotations. By the third rotation, the residents are expected to
prepare and present radiologic cases for multidisciplinary conferences.

      didactic lectures
      case conferences
      daily case discussion
      journal club
      colloquia

Study Materials

       ACR Contrast Media Handbook
       Radiology of the Kidney and Urinary Tract – Davidson & Hartman
       GU section, Fundamentals of Diagnostic Radiology – Brant & Helms
       Principles of GU Radiology – Barbaric
       Clinical Uroradiology – Emmett & Witten
       Clinical Urography: An Atlas and Textbook of Urological Imaging – Pollack
       Radiographic Atlas of the Genitourinary System
       GU Syllabi – American College of Radiology
       ACR GU Teaching CD ROM
       Essential Radiology – Amis & Newhouse
       Clinical Uroradiology – Pollack

Study Materials for CT and MRI Scans Related to GU Tract

       Fundamentals of Body CT – Brant, Webb and Helms
       Body CT: A Practical Approach – Slone, Fisher, Pickhardt
       The GU Requisites
       CT and MRI Imaging of the Whole Body – Haaga, Lanzieri, Gilkeson
       Computed Body Tomography with MRI Correlation – Lee and Sagel
       Body MRI – ACR test and Syllabus #46
       Abdominal-Pelvic MRI – Semelka, Wiley-Liss




                                               83
GOALS AND OBJECTIVES
Neuroradiology


Neuroradiology encompasses neuro MRI, neuro CT, and neuro angio/interventional.
Over the course of the residency, the resident should complete at least two (2) in each
of these areas.

In general, the residents on this rotation are expected to:

   1) be able to recommend the appropriate examination and related protocols for
      various indications, including trauma, hemorrhage, headache, cancer, infection,
      mass, stroke, diplopia, back pain, radiculopathy, myelopathy, hearing loss,
      endocrine dysfunction, and congenital abnormality
   2) be able to screen patients for absolute and relative contraindications to CT, MRI,
      and angio examination, including drug allergies, pregnancy, contrast reactions,
      weight limitations, capacity to control motion, and patient cardiopulmonary
      stability
   3) know the pathophysiology, imaging characteristics, and natural histories of the
      major conditions listed in the knowledge-based objectives
   4) know the MR and CT signal properties of blood as a function of age
   5) know MR and CT signal properties of cysts
   6) know MR and CT signal properties of fat, calcium, melanin, and metals
   7) know properties of MR sequences including SE, FSE, GRE, STIR, FLAIR, DWI,
      EPI-T2, ADC, TOF-MRA, and CE-MRA

Neuro MRI

Goals

Over the course of this rotation, the resident is expected to:

   1) develop skill and judgment in the perception and interpretation of MRI images of
      the brain, head and neck, orbits, and spine
   2) develop a knowledge base about relevant disease processes
   3) develop skill in the communication of radiologic information in report dictation,
      direct verbal interaction with referring physicians, other radiologists, and
      patients, and in conference presentation
   4) develop skill in the selection of MRI protocols based on clinical information

Objectives

On this rotation, the resident is expected to:

   1) perform daily image interpretation, dictation, and consultation


                                                 84
   2)   observe daily protocols
   3)   submit one teaching file case per week;
   4)   attend neuro conferences;
   5)   organize and present cases at the Thursday neuroradiology conferences;
   6)   organize and present cases at the once-a-month neuropathology conference;
   7)   read:
               Diagnostic Neuroradiology – Osborn
               Neuroradiology – Grossman & Yousem
               Diagnostic Radiology – Brant & Helms

Neuro CT and Neuro Angio/Interventional

Goals – CT

On this rotation, the resident is expected to:

   1) develop skill and judgment in the perception and interpretation of CT and
      conventional radiographic images of the brain, head and neck (including face,
      neck, orbits, sinuses, skull base, and temporal bones), and spine
   2) develop a knowledge base about relevant disease processes
   3) develop skill in the communication of radiologic information in report dictation,
      direct verbal interaction with referring physicians, other radiologists, and
      patients, and in conference presentation
   4) develop skill in the selection of CT protocols based on clinical information

Goals – Neuro angio/interventional

On this rotation, the resident is expected to:

   1) develop safe techniques in the performance of a carotid/cerebral angiogram,
      including:
   2) develop safe techniques in the performance of lumbar puncture, myelography,
      spine biopsy, and spine pain control (specific requirements are similar to section
      1 above)
   3) develop skill and judgment in the perception and interpretation of angio images
      of the carotid and cerebral vasculature
   4) develop a knowledge base about CNS vascular disease processes

Objectives

As part of this rotation, the resident is expected to:

1) perform daily CT and conventional radiograph image interpretation, dictation, and
consultation:
   o taking the patient history and establishing the indication for the exam


                                                 85
     o   evaluating the appropriateness of the examination
     o   explaining the procedure to the patient and advising the patient of complications
         and post-procedure care
     o prescribing conscious sedatives
     o monitoring the patient for adverse events
     o preparing for patient complications
     o instructing patients in appropriate breathing technique
     o cannulation of the femoral artery
     o sheath placement (with continuous flush)
     o achieving hemostasis following sheath removal
     o developing skill in the selection of appropriate catheters
     o catheter intermittent flush technique
     o catheter insertion and removal
     o catheter manipulation and placement in the ascending thoracic aorta and
         bilateral common carotid arteries
     o selecting contrast injection rates and quantities
2)   participate daily in angio and other interventional neuro cases
3)   exercise daily protocols
4)   submit one teaching file case per week
5)   attend neuro conferences
6)   organize and present cases at the Tuesday morning ENT conferences
7)   read:
         Cerebral Angiography – Osborn
         Practical Neuroangiography – Morris
         Diagnostic Radiology – Brant & Helms
         Neuroradiology – Grossman & Yousem
         Head and Neck Radiology – Harnsberger

Tips for preparing conference presentations:

        Please prepare PowerPoint slides; check with other residents for particulars.
        Describe and point to anatomy.
        Remember that some of the faculty are hard of hearing.
        Check MIDAS for old studies, particularly nuclear medicine, which is stored
        separately.
        Outside studies are storied in a separate area in the file room; sometimes it is
        necessary to request retrieval of a study (i.e., from the VA).




                                                 86
GOALS AND OBJECTIVES
Interventional Radiology

A minimum of two (2) rotations over the course of the residency. While on the rotation,
all residents are expected to:

    Arrive in the morning on time to evaluate in-patients from the previous day who
     need follow-up.
    Perform a pre-procedure work-up and obtain consent of patients.
    Keep a log of the procedures they have performed. This includes patient
     identification number, primary and secondary physicians involved in the
     procedure, complications and outcome. The log book will be reviewed
     periodically and is a requirement for completing the residency program.
    Compile a list of interesting cases.
    Follow-up on the patients who had procedures performed that day before the
     resident leaves for the day.

1st Rotation

The expectations for the resident by the end of the first rotation are as follows:

Angiography:

1) Understand the fundamentals of performing an angiogram:
   a) how to prep and drape for the examination
   b) what kind of needle to use for a femoral puncture, its name and description
   c) what kinds of landmarks are used to locate the femoral artery
   d) two ways to manually feel the femoral artery while puncturing with the needle
   e) the names and types of wires to use to pass through the needle into the femoral
      artery and to select vessels
   f) the size and kind of introducer that is most commonly placed
   g) the kinds of catheters that can be used for abdominal/pelvic/lower extremity
      angiography
   h) where to place catheters for each of the injections
   i) the volume and rate of contrast to inject for each artery
   j) what kind of contrast medium to use and why
   k) how to know when the exam is finished
   l) how to manually compress a femoral puncture site
   m) how to examine peripheral pulses before and after the angiogram
2) Know the possible complications of angiography:
   a) from the angiogram itself
   b) from the contrast medium
   c) what type of patient is at higher risk for complications
   d) how to minimize the complication risk


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3) Know the indications for different angiographic studies.
4) Know which kinds of lower extremity bypass grafts there are.
5) Know how to read an abdominal/bilateral lower extremity angiogram.
6) Know some of the collateral pathways for occluded aortas below the renal arteries.
7) Know some of the collateral pathways for occluded common and external iliac
   arteries.
8) Know the collateral pathways for occluded superficial femoral arteries.

Venous access:

1) Know how to use the Sonosite ultrasound unit to localize the internal jugular vein,
   common femoral vein, subclavian, basilic, brachial, and cephalic veins.
2) Know what equipment to use to make the puncture and how to puncture the vein
   using ultrasound guidance.
3) Know what size wire goes through the puncture needle.
4) Know how to measure for the length of catheter needed.
5) Know how to thread the catheter into the central venous system.
6) Know where the final tip position of the catheter should be.
7) Know the indications for dialysis, Hickman and PICC lines.
8) Know when to place single lumen and when to place double lumen lines.
9) Know the short- and long-term complications of central lines.

Abscess drain placements:

1)   Know the indications for placement.
2)   Know the contraindications for placement.
3)   Understand pre-op orders.
4)   Know the basic techniques for placement.
5)   Know which organs to avoid puncturing and how to avoid them.
6)   Begin to learn the equipment involved in the procedure.
7)   Understand short- and long-term complications.

Biopsy:

1)   Know the indications.
2)   Know the contraindications.
3)   Understand pre-op and post-op orders.
4)   Know the basic techniques for CT, ultrasound, and fluoro guidance.
5)   Know which organs to avoid puncturing and how to avoid them.
6)   Begin to learn the equipment involved in the procedure.
7)   Be familiar with short- and long-term complications.




                                               88
2nd Rotation

The expectations for the resident at the end of the second rotation are as follows:

1) Assume responsibility for patient management as part of an interventional radiology
   service.
2) Expand knowledge of the diverse pathology found in angiographic studies.
3) Know all of the above plus the following:

Arterial embolization:

   1)   What kind of patient comes to angiography?
   2)   What types of pre-angio assessments (studies) should be done?
   3)   Why do we do angiography?
   4)   What are the therapeutic interventions available?
   a)   What are the potential complications?
   b)   When would you not intervene?
   5)   How would you manage a patient with a GI bleed, trauma, malignancy?

Percutaneous nephrostomies:

   1) What are the indications for percutaneous nephrostomy tube placement?
   2) What are the imaging modalities that can be used to demonstrate obstruction?
   3) How do you perform the initial puncture using ultrasound guidance; using
      fluoroscopic guidance?
   4) What are the important anatomic landmarks?
   5) What part of the kidney do you want to puncture?
   6) What are the potential complications and how do we avoid them?
   7) When are catheters internalized?
   8) When can a catheter be removed?

Percutaneous transhepatic cholangiograpy and biliary drainage:

   1)   What are the indications and contraindications?
   2)   What are the available techniques?
   3)   Know the general anatomy.
   4)   Understand complications and management.
   5)   When is the drain internalized?
   6)   When can the drain be removed?
   7)   When do you exchange the drain and how?




                                               89
Peripheral vascular disease interventions:

    1) What are the indications for iliac (common iliac or external iliac)artery
       angioplasty? Stent placement?
       a) clinical
       b) angiographic
       c) hemodynamic
    2) Understand plaque morphology.
    3) Understand procedure details:
       a) access
       b) wires, catheters, balloons, stents
       c) anticoagulation
       d) complications
          i)       what are they?
          ii)      how to handle them
    4) Be able to perform effective follow-up:
       a) what examination, how frequent
       b) criteria used for restenosis/occlusion

Inferior vena caval filters:

1) What are the indications for IVC filter placement?
2) What are the contraindications for IVC filter placement?
3) How do you place one?
       a) approach
       b) venography
       c) sizing
       d) where to place in the IVC
4) What types of filters are available and what are the advantages of one over the
other?
5) What are the complications of filter placement?

Study Materials

        Vascular and Interventional Radiology – Valji & Bralow
        Interventional Radiology Essentials – Laberge
        Teaching Atlas of Interventional Radiology – Kadir
        Handbook of Interventional Radiologic Procedures – Kandarpa & Aruny

Reference:
        Abrams’ Angiography: Vascular and Interventional Radiology – Baum &
        Pentecost
        Venous Interventional Radiology with Clinical Perspectives – Savader, Trerotola
        SCVIR Syllabus
        Atlas of Vascular Anatomy – Uflacker


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Interventional Radiology – Castaneda-Zuniga




                                     91
GOALS AND OBJECTIVES
Musculoskeletal Radiology

Minimum of three (3) four-week rotations during the course of the residency.

1st Rotation

Goals

By the end of the first rotation, the resident is expected to be able to:

   1) Concisely dictate bone radiograph reports, including patient’s name, date,
      medical record number, comparison exam date, type of exam, and indication for
      exam;
   2) Discuss with referring clinicians about significant unexpected radiologic findings
      in an effective manner and document the call;
   3) Determine the appropriate type of radiology exam, CT, or MRI exam for different
      types of bone disorders or injuries;
   4) Recognize when to ask for help from radiology attendings on difficult cases;
   5) Behave in a professional manner, indicated by punctuality, a positive attitude,
      and a strong work ethic.

Objectives

1) Name all of the bones in the extremities.
2) Understand the meaning of the following terms:
      osteopenia
      osteoporosis
      angulation
      displacement
      comminuted
      distraction
      sclerosis
      periosteal reaction
      sunburst spiculation
      Codman’s triangle
      lytic
      blastic
      wide zone of transition
      narrow zone of transition
      matrix
      hemiarthroplasty
      total arthroplasty
3) Recognize the difference between inflammatory arthritis and degenerative arthritis.
4) Recognize cortical destruction and aggressive periosteal reaction.


                                                 92
5)   Learn eponyms for certain types of fractures.
6)   Recognize septic joints.
7)   Identify fractures and know the significance of the fracture.
8)   Accurately describe the different types of fractures.

2nd and 3rd Rotations

Goals

Same as first rotation with improved skills in the following areas: communication,
professionalism, patient care, medical knowledge and decision-making.

Objectives

     1) Improve descriptions of bone disorders or injuries and improve speed and
        diagnostic accuracy.
     2) Learn how to protocol CT examinations for different types of fractures.
     3) Learn basic principles of MRI, such as T1 and T2 and PD, and understand the
        differences between STIR sequences and chemical fat saturation sequences.
     4) Know the basic protocol for knee and shoulder MRIs.
     5) Know the indications and risks of arthrograms.
     6) Know how to perform a shoulder and a hip arthrogram.
     7) Know how to make a contrast solution mix for MR arthrograms.

Conferences

Residents are expected to attend the following conferences as part of their education
during their musculoskeletal rotations:

      two radiology bone lectures a month by musculoskeletal fellowship-trained
       attending
      one bone lecture by radiology bone fellow a month
      interdisciplinary spine conference once a month (with neurosurgery and
       orthopedics) -- 4th Tuesday at 5 pm, Radiology Conf Room
      interdisciplinary bone tumor conference twice a month (with orthopedics) -- 1st
       and 3rd Tuesday at 5 pm, Orthopedics Conf Room

Study Materials

        Fundamentals of Skeletal Radiology – Brant & Helms
        ACR Bone CD
        Bone and Joint Imaging – Resnick (reference)
        Orthopedic Radiology – Greenspan
        MR Imaging in Orthopedics and Sports Medicine, 2nd ed. – Stoller



                                                 93
GOALS AND OBJECTIVES
Ultrasound

Minimum of two (2) rotations over the course of the residency.

Introduction/Orientation

The ultrasound section of the Department of Radiology at UMHC is composed of several
locations: University Hospital, Ellis-Fischel Cancer Center, and outreach facilities. The
main department has five ultrasound rooms and five ultrasound machines: three
Acuson Sequoia, 2 ATL HDI 5000, and 1 portable Sonosite machine used primarily for
procedures. One additional Acuson Sequoia is installed at the Ellis-Fischel Cancer
Center. There are currently eight sonographers who staff the Department in several
overlapping shifts. Interaction with the sonographers is a valuable part of the rotation.
They are a very important source of teaching for the residents, particularly in their junior
years. Their input contributes to the final performance assessment.

An average of 15,000 studies is performed each year with an average of thirty to forty
studies performed per day. Once a week, studies are performed at the outreach center
in Boonville and these are generally brought to the University for interpretation at the
end of the day. Most breast ultrasound is performed at Ellis-Fischel. Additional studies
are performed by the OB/gyn group at Columbia Regional Hospital. The residents
participate in the performance and interpretation of these as part of their senior
rotations. Some vascular studies are read by the division of vascular surgery; these
include physiologic arterial studies and other vascular ultrasound. Interpretation
sessions are organized to include them.

Goals and Objectives of the Rotations

Residents on the ultrasound rotation will be expected to:

   1) Acquire a knowledge of multiplanar cross-sectional anatomy as displayed by
      ultrasound.
   2) Understand basic ultrasound physics and image generation as well as artifact
      formation.
   3) Develop the ability to recognize pathology as demonstrated by ultrasound and
      understand the advantages and limitation of ultrasound as an imaging modality;
   4) Understand the basic components of the ultrasound machines and their
      operation including image optimization;
   5) Demonstrate the ability to perform various ultrasound examinations based on the
      resident’s level of training (this is outlined in detail below);
   6) Demonstrate the ability to perform basic ultrasound-guided interventional
      procedures (training in this is in conjunction with the Division of Vascular and
      Interventional Radiology and mammography.)



                                                94
   7) be able to generate an appropriately descriptive report and a reasonable
      differential diagnosis and recommendations;
   8) demonstrate other skills related to ultrasound as defined under “Pediatric
      Radiology” and “Interventional Radiology.”

In addition to the above, residents at the junior levels will be expected to:

   1) Demonstrate the ability to perform a complete abdominal ultrasound examination
      by the end of the first rotation;
   2) Be able to do a basic evaluation of superficial structures such as scrotal
      ultrasound and thyroid.

In addition to the above, residents at the senior level will be expected to:

   1) Demonstrate knowledge of the indications for ultrasound examinations of the
      fetus at various gestational ages;
   2) be able to recognize the basic fetal anatomy and various pathologic conditions;
   3) Demonstrate knowledge of the various pathologic conditions that occur in
      pregnancy;
   4) Perform a detailed obstetric ultrasound examination;
   5) Perform a detailed pelvic ultrasound, including an endovaginal examination;
   6) Perform a basic carotid ultrasound examination.

Duties and Responsibilities

The resident is expected to:

   1) Be in the ultrasound reading room no later than 8:00 AM on normal working
       days and to be either in the area or within reach by pager until at least 5:00 PM.
       It may be necessary to stay later or arrive earlier as circumstances dictate.
   2) Check the schedule for special cases and procedures and prepare for them.
   3) Check all cases that are performed by the technologists and evaluate them for
       quality and presence of pathology within the limits of their experience.
   4) In follow-up examinations, ensure that the area in question is identified and has
       been adequately evaluated.
   5) Perform a personal ultrasound evaluation for practice and, if necessary, confirm
       abnormality or obtain additional images.
   6) Determine if there are prior ultrasound examinations or other relevant imaging
       studies and retrieve them, obtaining additional clinical information as necessary.
   7) Present the case to the attending radiologist (all cases should be seen by a
       physician before the patient leaves the area).
   8) Dictate a reasonably descriptive report with an appropriate differential diagnosis
       and recommendations.
   9) Call reports to the referring physician as necessary.
   10) Contribute cases to the teaching file.


                                                95
   11) Prepare case conferences.
   12) Participate in the instruction of medical students and other non-radiology
       residents during their senior rotations.
   13) Obtain consent and prepare patients for interventional procedures.
   14) Evaluate on-call cases, draft a preliminary report, and report the findings to the
       referring physician. Limitations and problems should be discussed with the
       attending radiologist the following morning.

Conferences

The following basic topics on ultrasound will be presented at resident conferences over
the course of a year:

      Liver, Gallbladder, and Biliary Tract
      Pancreas and Spleen
      Urinary Tract: Kidneys, including Transplant Ultrasound and Doppler
      Small Parts: Scrotal Ultrasound, Thyroid and Parathyroid
      Musculoskeletal Ultrasound
      Uterus and Adnexa
      Vascular Ultrasound Principles, Carotid Ultrasound
      Vascular Ultrasound Peripheral Arterial and Venous Evaluations
      Obstetric Ultrasound I: The Basic Examination, First-trimester Bleeding
      Obstetric Ultrasound II: Common Congenital Abnormalities
      Obstetric Ultrasound III: Third-trimester Bleeding, the Placenta
      Obstetric Ultrasound IV: The High-risk Examination/Cases
      Hands-on Biopsy Demonstrations
      “Knobology” with Sonographers: Knobs, Switches, Toggles, and Buttons

Study Materials

       Clinical Sonography: A Practical Guide – Sanders
       Ultrasound: the Requisites – Kurtz & Middleton
       Diagnostic Ultrasound, 2nd ed. – Rumack, Wilson, Charboneau
       Diagnostic Ultrasound: A Logical Approach – McGahan, Goldberg
       ACR Syllabi on Ultrasound
       Ultrasonography in Obstetrics and Gynecology, 4th ed. – Callen
       Introduction to Vascular Sonography – Zweibel
       Pediatric Sonography – Siegel
       ACR Teaching Files
       Ultrasound PACS teaching files
       Thomas Jefferson University ultrasound video series
       On-line resources:
              AuntMinnie.com
              PeterCallen.com
              journal sites


                                               96
97
GOALS AND OBJECTIVES
Mammography

Breast imaging will consist of a three-month rotation for both junior and senior
residents. The regular workday is 8:00 AM to 5:00 PM. The resident should arrive
promptly after the morning conference or inform the attending of any delays.

Residents will actively participate in the understanding and interpretation of screening
and diagnostic mammograms. They will also learn breast ultrasound and additional
imaging including, but not limited to, spot compression views and magnification views.
Residents will be able to participate and have hands-on experience with breast
ultrasound-guided biopsies, stereotactic biopsies, and needle localization procedures.

1st Rotation

Objectives

   1) Understand the epidemiology of breast cancer and ACS guidelines for
      mammography.
   2) Learn the difference between screening and diagnostic mammograms.
   3) Understand the importance of additional imaging (spot compression views,
      magnifications views, and breast ultrasound).
   4) Understand the BI-RADS (Breast Imaging and Reporting and Data System).
   5) Understand the assessment categories for BI-RADS (0 through 5).
   6) Evaluate palpable and non-palpable breast masses with appropriate imaging and
      decide when to recommend biopsy.
   7) Evaluate breast cancer screening in patients with prostheses.
   8) Understand the MQSA guidelines and quality control; participate in positioning
      and quality control issues with the lead technologist or assignee.

2nd Rotation

Objectives

   1) Advance skills to interpret and give preliminary reads on diagnostic
      mammograms.
   2) Evaluate the post-surgical breast in breast cancer patients.
   3) Participate in and understand stereotactic and ultrasound-guided procedures.
   4) Participate in needle localization procedures.
   5) Evaluate the male breast and understand diseases that affect the male breast.
   6) Understand the role of both MRI and PET with breast cancer patients.
   7) Discuss with patients relevant findings on mammograms, particularly the
      necessity of biopsies or other medical/surgical options.




                                              98
3rd Rotation

Objectives

   1)   Interpret and give preliminary reads on diagnostic mammograms.
   2)   Participate in and understand stereotactic and ultrasound-guided procedures.
   3)   Participate in oral board reviews for mammography.
   4)   Fulfill MQSA requirements for an interpreting physician: state license to practice
        medicine, be ABR certified with two months of training in mammography OR
        have at least three months of documented training, interpreted 240
        mammograms in last six months (or within last two years, if board certification
        obtained at first allowable time). Read a thousand mammograms during the
        course of the residency. Attend all conferences and lectures in the related
        topics.

Conferences

In addition to the above coursework, through the three rotations, residents will be given
conferences consisting of both didactic and case conferences on mammography, breast
ultrasound, procedures, and PET and MRI of the breast. This will also include, besides
mammography: radiation protection, radiation effects, and radiation physics. Residents
are strongly encouraged to participate in the ACR Mammography Conference in
Washington, D.C., during their AFIP course.

Study Materials

  BI-RADS – American College of Radiology Breast Imaging
  Breast Imaging – Kopans
  Breast Imaging Companion – Cardenosa
  ACR Teaching File on Ultrasound




                                               99
COMPUTED TOMOGRAPHY: BODY IMAGING SECTION
Goals and Objectives


The University Hospital computed tomography (CT) service begins its weekday schedule
at 8:00 AM unless there is morning conference. Residents assigned to the service
should arrive by this time, Monday through Friday. The CT schedule ends at 5:00 PM at
which time the on-call resident takes over. If the on-call resident is occupied elsewhere,
the CT resident will stay after 5:00 PM if necessary.

The staff radiologist will be assigned to the CT area each day. After becoming familiar
with CT operations, the CT resident will assume responsibility for daily supervision of the
CT area. This will be coordinated with the CT technologists and CT staff. Specifically,
the CT resident will have the following tasks:

   1) Computer printout of scheduled patients should be reviewed at the beginning of
      the day. Many of the exams are routine, but others require special planning.
      The CT staff should be consulted for planning special CT exams and procedures.
      If there is inadequate information on a patient, call the referring physician.

   2) The CT resident should be available in the CT area throughout the day (except
      for noon conferences) for consultation and to monitor exams for completeness.
      As exams are completed, the CT resident will draft reports.

   3) Emergency CT scans will be requested frequently and should be given priority. A
      phone report should be made to the requesting physician in the ER when these
      exams are completed.

A CT procedures manual will outline the parameters needed for routine exams and some
of the special features of various procedures. The CT nurse will be available during
many of the daytime hours to assist with CT patients and procedures.

Study Materials

       Computer Body Tomography with MRI Correlation – Lee, et al
       Computer Tomography of the Body – Moss, Gamsu
       Whole Body Computer Tomography & MRI – Haaga
       Computer Tomography – Brant, Helms




                                               100
ELLIS FISCHEL CANCER CENTER ROTATION
Goals and Objectives

Residents will rotate through the Ellis Fischel Cancer Center during their second, third,
and fourth years. Occasionally, first-year residents will also be assigned but not without
a more senior resident also on the rotation. One radiologist will be assigned to this
rotation with the resident. The rotation consists primarily of management of cancer
patients, cancer screening, and cancer diagnosis.

The workday typically begins at 8:00 AM, though interventional procedures may be
scheduled at 7:00 AM. After 5:00 PM, cases are managed by the on-call resident.
Imaging modalities include plain film, fluoroscopy, and CT. The resident is required to
correlate imaging studies, provide consultation to referring physicians, with attending
supervision, and draft all reports.

Conferences

   1) Residents are excused to attend 7:00 AM and 12:00 noon radiology conferences.

   2) Med/surgery oncology conference, Wednesday, 8:00 AM, Room 1054. Most
      cases presented require radiology review. The attending and resident will
      participate in the review and presentation of imaging studies.




                                              101
OUTPATIENT DEPARTMENT X-RAY AND ER READING ROOM
Rotation Requirements


Schedule

Residents should be in these areas at 8:00 AM each morning unless there is an early
morning conference. Residents are required to attend the noon conference but are
requested to return to the area as soon as possible after the conference. The workday
ends at 5:00 PM unless the resident is on call.

Service

The resident assigned to the ER and outpatient reading room is responsible for reading
any films that come through the MIDAS machine.

Study Materials

       The Language of Fracture – Schultz
       The Radiology of Acute Cervical Spine Trauma – Harris, Edeiken-Monroe
       Emergency Radiology – Harris, Ha
       The Radiology of Skeletal Trauma – Rogers




                                            102
GOALS AND OBJECTIVES
Nuclear Medicine

Residents are required by the NRC to complete a minimum of four months in nuclear
medicine over the course of their residency.

Goals and Objectives

The purpose of the nuclear radiology rotation and training is to acquire competence in
the various facets of nuclear radiology for the eventual practice of nuclear radiology and
for meeting the eligibility requirements for certification by the American Board of
Radiology and licensure by the Nuclear Regulatory Commission to use radionuclides
(unsealed sources). After initial training and orientation, residents are given increasing
direct responsibility for patients referred for nuclear medicine studies. Supervision of
residents by staff is maintained at all times.

The resident will be expected to learn the following:
    various in vivo nuclear medicine procedures
    radiopharmaceutical chemistry
    radiotracer preparation, calibration and dosing
    nuclear medicine physics and instrumentation
    indications for using nuclear medicine procedures
    radiation dosimetry and radiobiology
    radiation protection
    quality control

Duties and Responsibilities

While on the nuclear medicine rotation, the resident is expected to:

   1) Arrive no later than 8:00 AM. The workday is usually over by 5:00 or 5:30 p.m.,
      after which the on-call resident takes over.
   2) Attend radiology noon conferences.
   3) Coordinate nuclear medicine coverage with the nuclear medicine fellow.
   4) Participate in the monthly Journal Club, monthly correlative conference, and daily
      afternoon case review conference.
   5) Become familiar with the procedure manual or protocol book and the Nuclear
      Medicine Policy Manual. The resident is required to function in accordance with
      these policies and the radiation safety program at the University of Missouri-
      Columbia. For details, refer to the Nuclear Medicine Resident’s Manual.

Daily Case Reviews

Cases are read by the resident and reviewed by the attending physician throughout the
day. All clinical cases completed that day or during the previous overnight period are
presented to the staff by the resident. This provides a major learning experience for
house staff. Findings and differential diagnoses are discussed with the staff


                                               103
physician(s). Correlation with clinical and other radiographic data is made.
Recommendations regarding the probable diagnoses are made and further evaluation, if
any, is recommended. It is the resident’s responsibility to gather the radiographic
studies for correlation. This may be done with the assistance of the secretarial staff.
Following conference, the resident drafts or dictates the interpretations for each case for
review by the attending staff. After any corrections are made, the reports are transmitted
to the patient’s chart or referring physician. Preliminary reports are generated upon
completion of examination by the residents and finalized only after nuclear medicine staff
review. The format for the conference is informal.

Preliminary Report

During normal working hours, the resident will make a preliminary interpretation on all
cases as soon as the study is completed. Emergency and difficult cases should be
discussed with the attending physician in charge when the resident feels unsure about
the interpretation.

Consultation with Referring Physician

Frequently throughout the day, the house staff, medical students, and attending
physicians will come to the laboratory to discuss cases with the resident. The resident
should handle only those cases which he/she feels confident in interpreting. All others
should be interpreted with the assistance of the nuclear medicine staff physician.

Checking Films with QA/QC

Upon completion of the studies, the technologist will bring the images to the resident
who will check the image quality and determine if additional views are required. It is the
resident’s responsibility to check the patient and/or chart before the patient is discharged
to collect all relevant data so that he/she will be able to present the patient to the clinical
conference.

Procedure for Clinical Studies

The resident should observe the performance of nuclear procedures for technique,
instrumentation characteristics, radiopharmaceutical doses, and route of administration.
An updated procedure manual is maintained in the laboratory at all times.

Computer Analysis of Studies

The resident should learn to perform all computer-acquired studies such as gated heart,
radio-thallium, renal, lung, quantitative gastroesophageal studies, and gallbladder
ejection fractions. An updated protocol for computer analysis is maintained at all times.
New residents are given hands-on training at the beginning of their rotation or duties.

Correlative and QA Conference

A correlative conference is held every month. Each resident in nuclear medicine is

                                                 104
expected to work up and present two to three cases in this conference. Pertinent
radiology and other ancillary tests and pathology results are presented. All nuclear
medicine and radiology residents attend the conference with Dr. Singh moderating the
conference. The conference provides teaching experience as well as quality assurance
and data for QA conference.

Participation in Interdepartmental Conferences

The radiology resident will be expected to attend other conferences relevant to studies.
This includes the nephrology, endocrinology, pulmonary, neurology, GI, cardiac, and
child health conferences.

Journal Club

The resident will be expected to review a recent nuclear medicine article for presentation
to the nuclear medicine staff at the Journal Club held monthly or bi-monthly.

Study Materials

        Essentials of Nuclear Medicine Imaging – Mettler & Guiberteau
        Nuclear Medicine: The Requisites – Thrall & Ziessman
        Nuclear Medicine Physics: The Basics – Chandra
        Physics in Nuclear Medicine – Sorenson & Phelps

        Journals:
        Journal of Nuclear Medicine
        Clinical Nuclear Medicine
        Seminars in Nuclear Medicine
        Radiology and American Journal of Roentgenology
        Circulation and American Journal of Cardiology

Conferences

See list in section following.




                                               105
CORE COMPETENCIES FOR THE RESIDENT
Nuclear Medicine

In addition to developing competence in the specific nuclear medicine-related areas
described above, residents are expected to attain competence in the following general
areas:

1) Patient care
        a) Obtain information about the patient related to the requested test or therapy
using patient interview, chart, and computer database review, physical examination, and
contact with the referring physician.
        b) Select appropriate procedure or therapy based on the referring physician’s
request and the patient’s history. This involves selection of the appropriate
radiopharmaceutical, dose, imaging technique, data analysis, and image presentation. It
also includes review of image quality, defining the need for additional images and
correlation with other imaging studies such as x-rays, CT, MRI, or ultrasound.
        c) Communicate results promptly and clearly to the referring physician or other
appropriate health care workers. This communication should include clear and succinct
dictation of the results.
        d) Conduct therapeutic procedures. Therapeutic procedures must be done in
consultation with an attending physician who is a licensed user of radioactive material.
These procedures should include dose calculation, patient identify verification,
explanation of informed consent, documentation of pregnancy status, counseling of
patients and their families on radiation safety issues, and scheduling follow-up after
therapy.
        e) Maintain records (logs) of participation in nuclear cardiology pharmacologic
and exercise studies and in all types of therapy procedures.

2) Medical knowledge
Residents should closely follow scientific progress in nuclear medicine and learn to
incorporate it effectively for modifying and improving diagnostic and therapeutic
procedures.
       a) Become familiar with and regularly read the major journals in nuclear
medicine. During the residency, this will involve regular participation in Journal Club.
       b) Use computer technology including internet web sites and CD-Rom teaching
discs.
       c) Participate in the annual in-service examination.
       d) Know and comply with radiation safety rules and regulations, including NRC
and/or agreement state rules, local regulations, and the ALARA (“as low as reasonably
achievable”) principles for personal radiation protection.
       e) Understand and use QC (quality control) procedures for imaging devices,
laboratory instrumentation, and radiopharmaceuticals.




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3) Interpersonal skills and communication
Residents must communicate clearly and effectively and work well with each of the
following groups:
        a) patients and their families
        b) physicians in nuclear medicine and radiology
        c) referring physicians from other specialties
        d) nuclear medicine technologists
        e) other health care workers throughout the institution

4) Practice-based learning and improvement
Residents must develop and continuously improve skills in obtaining medical knowledge
using new techniques as they develop in information technology. This includes:
        a) Using the internet and computer databases to search for patient information,
disease, and technique information. Residents should also be familiar with viewing and
manipulating images with the computer, both locally and remotely.
        b) Residents should improve their understanding of diseases and patient care by
attending interspecialty conferences, correlative conferences, mortality and morbidity
conferences, and utilization conferences.
        c) Patient follow-up is essential for determining the accuracy of study
interpretation. Residents should regularly obtain such follow-up information and
correlate the clinical findings with their study interpretation.

5) Professionalism
Residents are expected to always behave in a professional manner. This includes:
       a) Consistent demonstration of completely ethical behavior.
       b) Respect for the dignity of patients and all members of the medical team.
       c) There should be no discrimination based on age, ethnicity, gender, disability,
or sexual orientation.
       d) Residents should be responsive to patients’ needs by demonstrating integrity,
honesty, compassion, and commitment.
       e) Residents should always respect the patient’s privacy and autonomy.

6) Systems-Based Practice
Residents should understand the principles of systems-based practice. This involves
learning to work in a variety of health care settings and understanding the
interrelationship with other health care professionals. Specifically, residents should be
aware of:
        a) Work conditions in hospitals, outpatient clinics, diagnostic centers, and private
practice settings.
        b) Resource allocation and methods directed towards controlling health care
costs such as diagnostic related groups (DRGs), APC, and pre-certification by medical
insurers.
        c) The concept of providing optimal patient care by selecting the most cost-
effective procedures and using or recommending other diagnostic tests that might
complement the nuclear medicine procedures. This also involves awareness of the
relevant risk-benefit considerations.
        d) Basic financial and business skills to function effectively in current health care
delivery systems. This includes an understanding and knowledge of coding, procedure

                                                107
charges, billing practices, and reimbursement mechanisms.

Resident Policies

1) Supervision

Appropriately qualified faculty must supervise all patient care services provided by
residents. The program director must ensure, direct, and document proper supervision
of residents at all times. Residents must be provided with rapid, reliable systems for
communicating with supervising residents and attendings. Attending physicians or
supervising residents with appropriate experience for the severity and complexity of the
procedure and the patient’s condition must be present at all times for the procedure.
The resident must review with a nuclear medicine faculty member all patient studies that
the resident has dictated.

2) Duty hours and work conditions

The practice of nuclear medicine requires 24-hour physician availability. Duty hours and
night and weekend call for residents must reflect the concept of responsibility for patients
and must provide for adequate patient care. Residents must not be required to regularly
perform unduly prolonged duties. However, in no case should the resident go off duty
until the proper care and welfare of the patient has been ensured. All residents should
have the opportunity to spend an average of at least one full day out of seven free of
hospital duties and should be assigned on-call duty in the hospital no more frequently
than, on average, every third night. It is the responsibility of the program director to
ensure assignment of reasonable in-hospital and on-call duty hours.

Resident stress, including mental or emotional conditions inhibiting performance or
learning and drug- or alcohol-related dysfunction, should be monitored. Program
directors and teaching faculty should be sensitive to the need for timely provision of
confidential counseling and psychological support services to residents. Training
situations that consistently produce undesirable stress on residents must be evaluated
and modified.

3) Other

The residents are required to maintain current certification for both basic life support and
advanced cardiac life support as per hospital policy for all staff.




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Nuclear Medicine Conferences

Brain and CSF Studies:

1. Physical, Chemical, Pharmacologic Basis of Brain SPECT & PET Agents                          Volkert
  (Tc-99m HMPAO, ECD, DTPA, GHA, Tc99 O4, F-18 FDG)
2. Clinical Indications of Brain SPECT and PET in Adults                                        Singh
  (CVA, Dementia, Brain Injury, Functional Disorder, Epilepsy)
3. Diamox-Interventional Brain Studies, Radionuclide Cisternography                             Singh
  (TIA, Hydrocephalus-NPH, CSF Leak, Shunt Patency, CSF Collections)
4. Clinical Indications of Brain SPECT and CSF Studies for Children                             Singh
  (CSF Leak, CSF-Shunt Patency, Epilepsy, Congenital Abnormalities etc.)

Endocrine:

1. Clinical & Biochemical Thyroid Function Tests (Part 1)                                       Dresser
  (Causes of Hyperthyroidism, Thyroid Function Tests: T3, T4, FT4, RU, TSH, TRH Stimulation)
2. Diagnosis of Thyroid Disorders in Adults & Children (Part 2)                                Dresser
  (Uptake & Imaging for Hyperthyroidism, MNG, AFTN. Merits & limitations of Tc-99m, I-123, I-131)
3. Diagnosis of Hyperparathyroidism & Parathyroid Imaging                                       Singh
  (Causes & Types of Hyperparathyroidism, Tl-201-Tc99m O4, Tc-99m MIBI + I-123 Protocols)
4. RadionuclideTherapy of Hyperthyroidism&Thyroid Cancer in Adults & Children Singh
  (I-131 for Graves, AFTN, MNG, Thyroid Ca Remnant, Local & Distant Mets)

Oncologic Procedures:

1. Tumor Imaging with Gamma Camera in Adults and Children                                       Singh
  (Octreotide, MIBG, In-111Oncoscint, Tc-99m CEA)
2. Tumor Imaging with PET in Adults and Children                                                Singh
   (Lung Ca, Melanoma, Lymphoma, GIT, Head & Neck, Neuroendocrine, Thyroid Ca)
3. Radionuclide Therapy of Bone Pain due to Cancer                                              Singh
  (P32, Sm-153 EDTMP, Re-186 HEDP, Sn-111 DTPA)
4.Radionuclide Therapy of NHL (I-131 & Y-90 labeled Mabs)                                     Singh
5. Breast Tumor Localization                                                               Greenspan
   (Miraluma, Tl-201, Tetrofosmin, Compare with Mammography, Ultrasound, Biopsy, FDG)

Pulmonary:

1. Pulmonary Embolism (V/Q Lung Scanning)                                                  Greenspan
  (PE, V/Q Methods, MAA+DTPA/Xe-133), Pioped & Other Criteria, vs. Spiral CT)
2. Split Lung Function, DVT (AcuTect, Mab, Venography etc.)                                    Dresser
  (Lung Ca, Bullous Emphysema, DVT Studies with Tc-99 RBC, MAA, AcuTect, Mab etc.)




                                                      109
Cardiac Nuclear Medicine:

1. Radiopharmaceuticals for Myocardial Perfusion & Metabolism                                      Volkert
   (Tl-201, Tc99m MIBI, Tetrofosmin, F-18 FDG, Fatty Acids etc.)
2. Myocardial Perfusion & Viability Assessment                                                     Singh
  (Tl-201, Single vs. Dual Tracer Protocol, Re-injection Tl-201, F-18 FDG, Palmitic Acid)
3. Planar & SPECT Imaging: Value, Limitations, Recognition of artifacts                         Singh
4. Provocative Drugs for Myocardial Stress                                                     Dresser
  (Dipyridamole, Adenosine, Dobutamine)
5. MUGA, PYP for Acute MI & Amyloidosis                                                        Dresser
  (First Pass vs. MUGA, Indications, MUGA vs. Echo, PYP in AMI, Amyloidosis etc.)

Osseous System:

1. Bone Scintigraphy for Malignant and Benign Neoplastic Conditions                         Greenspan
  (Primary & Sec Neoplastic Conditions, Osteoblastic-Osteolytic Lesions, Super Scan)
2. Bone Scintigraphy for Non-Neoplastic Bone Conditions (Adults & Children)                     Singh
  (Paget’s, Fibrous Dysplasia, Traumatic Fractures, Stress Fractures, RSD, Prosthesis,
  Avascular Necrosis, Sickle Cell Disease, Child Abuse trauma etc.)
3. Osteomyelitis, Prosthetic Infection, Abscess Localization in Adults & Children Singh
   (Ga-67, In-111 WBC, Tc-99m HMPAO, Mab)
4. Diagnosis of Osteoporosis (in Adults & Children)                                              Singh
  (Types of Osteoporosis, Techniques, Single PA, DPA, DEXA, CT, PIXI)

Genito-Urinary:

1. Indications for Radionuclide Renal Imaging in Adults & Children                               Singh
    (Urinary Obstruction, Hydronephrosis, Pyelonephritis, UV Reflux,
    Perfusion, Function-Qualitative-Quantitative, GFR & ERPF)
2. Indications for Renal Transplant, Testicular Imaging                                          Singh
   (ATN, Rejection, Urinary Leak, Obstruction, Torsion, Epididymitis etc.)
3. Diuretic Renography and ACE Inhibitor Renography                                              Singh
    (Hydronephrosis vs. Urinary Obstruction, Hypertension, RAS etc.)

Gastro-Intestinal Procedures:

1. Tc-99m Liver Agents for Clinical Nuclear Medicine Studies                                  Volkert
  (Tc-99m SC, Mini-Colloid, Albumin)
2. Liver, Spleen, Hepatobiliary Imaging                                                     Greenspan
  (Primary, Sec Neoplasm, Cirrhosis, Budd-Chiari, FNH, Acute & Chronic Cholecystitis, Bile Leaks etc.)
3. Functional Studies of Upper GI (GE Emptying/Reflux)                                          Singh
  (Gastric-Esophageal Emptying, GE Reflux, GBEF, Bile Reflux etc.)
4. Infusaid Pump, GI Bleed Localization, LeVeen Shunt Patency                                  Singh
  (Liver Mets, Pump Function, GI Bleed with SC, RBC, Peritoneo-venous Shunts)
5. Pediatric G.I.T. Procedures                                                              Greenspan
  (Meckel Diverticulum, Neonatal Jaundice, Biliary Atresia, Cholestasis etc.)




                                                        110
Follow-up or Correlative Conferences:

Follow-up conferences (aka correlative conferences, interesting case conferences,
difficult case conferences) are held every month. Both adult and pediatric cases are
presented. The radiology and nuclear medicine residents present the conferences with
Dr. Singh moderating. In addition, Dr. Greenspan presents several additional interesting
case conferences. The total number of case conferences is about 24 in a one-year
period.

Clinical Radiation Biology:

1. LET Concepts                                                                         Volkert
2. Neuron Interaction, Reactor                                                          Volkert
3. Direct versus Indirect Effects                                                       Volkert
4. Cell Survival Concepts                                                               Volkert
5. Cell Survival Workshop                                                               Volkert
6. Split Dose Concepts                                                                  Volkert
7. Cellular Sensitivity                                                                 Volkert
8. Organ System Radiation Sensitivity                                                    Volkert
9. Long Tern Effects                                                                    Volkert
10. Low Dose Latent Effects-Risk Factors                                                Volkert
11. Fetal Effects of Radiation                                                          Volkert

Miscellaneous:

Physics & Instrumentation of Positron Emission Tomography                                 Boote
  (Principles of Positron-Coincidence Detection, Dedicated & Dual Head PET Scanners)
Pharmacologic Basis of Radionuclides for Clinical Imaging                                Volkert
  (Physical, Chemical, and Pharmacological Basis, Pharmacokinetics)
Tc-99m-Chelates for Clinical Nuclear Medicine Studies                                    Volkert
  (Physical, Chemical, and Pharmacological Basis, Pharmacokinetics)
Preparation of Clinical Radiopharmaceuticals with Mo-99/Tc-99m Generator Volkert
  (Physical, Chemical Properties of Tc-99m, Generator Elution, Mo-99 and Aluminum Breakthrough)
In 111-Labeled Radiopharmaceuticals for Clinical Nuclear Medicine Studies                Volkert
  (Physical, Chemical, and Pharmacological Basis, Pharmacokinetics)




The schedule for the year begins July 1 and ends June 30th of the next year.

Note: nuclear medicine and radiology residents attend these conferences. The nuclear
medicine residents in the two-year program (for ABNM) attend additional courses (not
listed here) in basic sciences during the fall and winter semesters. These include
lectures on radiopharmaceuticals, radiation biology, generators, physics &
instrumentation, mathematics, computer applications, statistical methods, and
radioimmunoassay.


                                                      111
HARRY S. TRUMAN VETERAN’S HOSPITAL
Rotation Guidelines


Schedule

Residents are required to be in the VA reading room at 8:00 AM each morning or
within fifteen minutes after the morning conference/lecture. The workday is over at
4:30 PM but residents are responsible for emergency coverage from 4:30 until 5:00
PM. After 5:00 PM, the on-call resident will take over the needed responsibility.

Conferences

Residents are required to attend all 7:15 AM and 12:00 noon conferences. Residents
may leave 15 minutes before the start of the conference and should return to the VA
reading room within 15 minutes after the conference.

Responsibilities

Per the current affiliation agreement, the University furnishes two daytime residents
and one on-call resident to the VA.

The resident on CT rotation is expected to protocol, monitor, review, and draft all CT
exams occurring during regular working hours. The primary responsibility of the
resident on angio/fluoro is to participate on all interventional (vascular and non-
vascular) and fluoroscopy procedures. Both residents should be available in the
reading room when not performing procedures or at conference. Teamwork is not
only encouraged but expected, e.g., if one resident is very busy, the other resident
assigned is expected to help with the work. Residents will be evaluated on this
teamwork.

The on-call resident is assigned to both the University and the VA and should be
available by pager from 5:00 PM to 8:00 AM. This resident is expected to:

   1) Be available to approve after-hours medically emergent/urgent
      US/CT/MR/nuclear scans and interventional procedures, with occasional plain
      film or fluoroscopy interpretations.
   2) Contact the appropriate on-call technologist and, if needed, the attending for
      the procedure/scan.
   3) Be available to perform and render preliminary interpretations of the scan.
      The interpretation should include:
          a. the regular drafted report with the resident’s name
          b. the required first statement – “on-call, after-hours emergent exam;
              Dr. John Doe contacted about these preliminary results at
              pager/phone #       at --:-- hrs”
          c. for all after-hours exams, press the priority switch (left bottom on the
              dictaphone base) before completing/ending the dictation




                                              112
            d. if using the PACS for case interpretation, at the end of every dictation
               leave the case on the PACS as uninterpreted, i.e., convert (Y) to (N)
               for “interpreted before closing”

The VA intent is to be similar to a group practice. Direct communication is strongly
encouraged. VA attendings are required to review all work done by residents. All
exams are reviewed by staff physicians. Resident supervision is to be available at all
daytime hours.

Vacation/Sick Day Policy

Refer to the VA Residents’ Manual. A timekeeper will be assigned as per VA policy.
Cross-coverage for unexcused absences (such as moonlighting, etc.) has to be pre-
approved by the medical director or assignee.

Requirements

     Attend VA orientation
     Meet VA computer and privacy requirements
     Read VA Residents’ Manual

Radiology Staff

Fulltime staff:

        Jimmie D. Coy, DO (Director of Radiology)
        Mary Murphy, MD

Part-time staff:

        Michael Ranti Aro, MD
        Miguel Gelman, MD
        Terry Hoyt, MD
        Yash Sethi, MD

Service line and Nuclear Medicine Director:

        Thomas Dresser, MD




                                               113
CURRICULA




     114
KNOWLEDGE-BASED OBJECTIVES
Chest Radiology

Signs in chest radiology
   Plain film radiologic signs (see Chest Radiology: The Essentials – Collins & Stern):
                air bronchogram
                air crescent sign
                deep sulcus sign
                continuous diaphragm sign
                ring-around-the-artery sign
                fallen lung sign
                flat waist sign
                gloved finger sign
                golden S sign
                Luftsichel sign
                Hampton’s hump
                silhouette sign
                cervicothoracic sign
                tapered margins sign
                figure 3 sign
                fat pad sign and sandwich sign
                scimitar sign
                double density sign
                hilum overlay sign and hilum convergence sign
        Chest CT signs:
                CT angiogram sign
                halo sign
                split pleura sign

Interstitial lung disease
      List the types of interstitial lung disease (ILD).
      Associate other radiologic findings with ILD.
      Define Kerley A and B lines.
      Discuss asbestos-related pleural disease.
      Discuss the findings and staging of sarcoidosis.
      List etiologies of ILD with reference to predominant locations in distribution.
      Discuss anatomy and ILD findings with the use of HRCT of the chest.

Alveolar lung disease
      List the broad categories of both acute and chronic alveolar lung disease.
      Give specific diagnosis of ALD based on history and clinical findings.
      Discuss the predisposing factors and development in Adult Respiratory
          Disease Syndrome.
      Name three pulmonary-renal syndromes and be able to discuss them.
      Discuss the predisposing causes and plain film and CT findings of
          bronchiolitis obliterans organizing pneumonia (BOOP).




                                               115
Atelectasis, airways and obstructive lung disease
      Recognize partial and complete atelectasis of the different lobes of the lung.
      List the direct and indirect sings of atelectasis.
      List the different types or etiologies of atelectasis.
      Name four types of bronchiectasis.
      List five causes of bronchiectasis.
      Describe the finding of tracheal and bronchial stenosis on CT and give
          common causes.
      Discuss the three types of pulmonary emphysema and describe the CT
          finding.
      Define the term “giant bulla” and discuss imaging findings used to identify
          surgical candidates for bullectomy.

Mediastinal masses and mediastinal/hilar lymph node enlargement
     Give the anatomical borders of the anterior, middle, posterior, and superior
         mediastinum.
     Name the common causes of an anterior mediastinal mass.
     Name the common causes of a middle mediastinal mass.
     Name the common causes of a posterior mediastinal mass.
     Discuss the normal and abnormal vascular changes that can mimic a mass.
     Name two causes of masses in the thoracic inlet.
     Name the five etiologies of bilateral hilar lymphadenopathy.
     Name the three locations for lymph node involvement with sarcoidosis
         (Garland’s Triad).
     Identify the etiologies of “eggshell” calcifications.
     Discuss cystic masses in the mediastinal regions, including bronchogenic,
         pericardial, esophagus duplication, or thymic cysts.

Solitary and multiple pulmonary nodules
       Define solitary pulmonary nodule and pulmonary mass.
       Identify the three most common causes of pulmonary nodules.
       Discuss the important considerations for evaluation of nodules.
       Name the causes of multiple pulmonary nodules.
       Name the causes of cavitary pulmonary nodules.
       List the indications for percutaneous biopsy and complications of the
           procedure.
       State the indications for the placement of a chest tube.
       State the role of positron emission tomography (PET) in the evaluation of
           solitary nodules.

Benign and malignant neoplasms of the lung and esophagus
      Name the four major histologic types of bronchogenic carcinoma and explain
          the differences between small cell and non-small cell cancer.
      Discuss which lung cancer is most likely to cavitate and why.
      List the types of bronchogenic carcinoma that are usually central in location.
      Discuss staging of both non-small cell and small cell lung cancer.
      List the four most common extrathoracic sites for non-small cell lung cancer
          to metastasize.



                                              116
       Describe the radiation changes that can occur with therapy of lung carcinoma
          on both plain film and CT.
       Discuss the role of MRI and PET scanning in the staging of lung cancer.
       State the classification and imaging staging of esophageal carcinoma.
       State the classification and imaging staging of lymphoma.
       Discuss typical findings on chest radiography and chest CT of Kaposi
          sarcoma.

Chest trauma
      Identify a widened mediastinum and give the differential diagnosis.
      Describe the direct and indirect signs of aortic injury on contrast-enhanced
          CT.
      Name the five common causes of abnormal lung opacity on a trauma
          radiograph or CT.
      Identify and discuss a pneumothorax and pneumomediastinum on a trauma
          chest or CT.
      Name the three most common causes of pneumomediastinum in the trauma
          setting.
      Identify fallen lung sign and its significance.
      Distinguish between pulmonary contusion, laceration, and aspiration.
      Discuss the differential diagnosis of a cavitary lesion in the post-traumatic
          chest.

Chest wall, pleura, and diaphragm
      Name the four causes of a large unilateral pleural effusion on CT and chest
         radiography.
      Name four causes of pleural-based mass associated with bone destruction or
         infiltration of the chest wall.
      Give the differential diagnosis of pleural calcifications.
      Describe the typical chest radiographic appearances of pleural effusion and
         changes in body positions; give volumes of minimally-recognized
         effusions by location.
      Discuss the unilateral elevation of the diaphragm and etiologies.
      Discuss mesotheliomas and focal and diffuse pleural thickening.
      Explain changes in a tension pneumothorax and the acute implications
         involved.

Infection (immunocompetent, immunocompromised, and post-transplant
patients)
       Name the radiographic manifestations of primary pulmonary tuberculosis.
       Name the three most common segmental sites of involvement for
          reactivation of TB.
       Name and describe the four types of pulmonary Aspergillus disease and
          describe an intercavitary fungus ball on chest radiography and CT.
       State the radiographic appearance of Cytomegalovirus pneumonia.
       Give the major categories of disease-causing chest abnormalities in the
          immuno-compromised patient.




                                             117
       Identify two important infections and two neoplasms to consider in the AIDS
          patient, other than bacterial infections.
       Describe the appearances of Pneumocystis carinii pneumonia.
       Name four etiologies of hilar and mediastinal adenopathy in AIDS.
       Describe the radiographic appearance of blood transfusion reaction and its
          time course.
       Describe the appearance and course of mycoplasma pneumonia.
       Discuss the differential diagnosis of miliary pattern of the lung.
       Name the common endemic mycoses and their specific geographic location.
       State the most common pulmonary infections seen after solid-organ
          transplantation (i.e., heart, liver, kidney).

Unilateral hyperlucent lung (hemithorax)
      Identify the common causes for unilateral hyperlucent lung on chest
          radiograph (correlate with isotopic lung scan).

Congenital lung disease
     Name the components of the pulmonary venolobar syndrome.
     Recognize venolobar syndrome on chest radiographs, CT, and MRI.
     Discuss the diagnosis of pulmonary sequestration and explain the difference
         between intralobar and extralobar sequestration.
     Recognize bronchial atresia and state the most common lobes involved.

Pulmonary vascular
     Name five of the most common causes of pulmonary artery hypertension.
     Recognize enlarged pulmonary arteries on a chest radiograph and distinguish
        them from enlarged hilar lymph nodes.
     Recognize lobar and segmental pulmonary emboli on chest CT, chest
        MRI/MRA, and lower-extremity venous studies in the evaluation of
        suspected venous thromboembolic disease.

Thoracic aorta and great vessel
      State the normal dimensions of the thoracic aorta.
      Describe and classify aortic dissection and implication of medical vs. surgical
         management.
      Recognize the findings & distinguish each of the following on chest CT & MR:
              aortic aneurysm with and without rupture
              aortic dissection
              aortic intramural hematoma
              penetrating atherosclerotic ulcer
              ulcerated plaque
              sinus of valsalva aneurysm
              subclavian and brachiocephalic artery aneurysm
              aortic coarctation and aortic pseudocoarctation
      Recognize congenital variations of the aorta and great vessels.
      State the advantages and disadvantages of CT, MRI/MRA, and
         transesophageal echocardiography in the evaluation of the thoracic aorta.




                                              118
Ischemic heart disease
      Describe the anatomy of the coronary arteries.
      Recognize coronary arterial calcification of a chest radiograph and CT and
         state the current role of coronary artery calcium scoring.
      State which coronary artery is usually diseased when there is papillary muscle
          dysfunction.
      Describe the common acute complications of myocardial infarction.
      Describe the common late complications of myocardial infarction.
      Identify left heart failure on a radiograph and CT; correlate stages of
         pulmonary edema with wedge pressure measurements.
      Recognize an acute myocardial infarction on MR imaging.
      Discuss ejection fraction of the left ventricle and give normal values.
      Identify the presence of calcification of the myocardium on CT and give the
         etiology and significance.
      Define the role of angiography, echocardiography, stress perfusion
         scintigraphy, chest CT, and chest MRI in evaluation of a patient with
         suspected ischemic heart disease.

Myocardial disease
     Define the types of cardiomyopathy and list the common causes of each.
     Define right ventricular dysplasia and identify on MRI.
     State the most common benign primary cardiac tumors.
     State the most common malignant primary cardiac tumors.
     State the most common malignancies to metastasize to the heart.
     Distinguish cardiac tumor from thrombus on CT and MRI.
     Discuss the advantages and disadvantages of echocardiography, CT, and MRI
         for the evaluation of cardiomyopathy and cardiac tumors.

Cardiac valvular disease
      State the findings, the indications, and the relationship of each individual
         chamber enlargement and the presence of valvular disease.
      Recognize the findings of mitral valve stenosis and aortic valve stenosis.
      State the most common etiologies of the following:
              aortic stenosis
              aortic regurgitation
              mitral stenosis
              mitral regurgitation
              tricuspid regurgitation
              pulmonary stenosis
      Identify endocarditis and/or complications of endocarditis on radiographs, CT,
         and MRI.
      State the advantages and disadvantages of echocardiography and MRI for
         evaluation of patients with valvular heart disease.

Pericardial disease
      Recognize pericardial calcification on a radiograph and chest CT and list the
          most common causes.
      Describe and identify two chest radiographic signs of pericardial effusion.



                                              119
       State five causes of pericardial effusion.
       Recognize the following on chest radiography, CT, and MRI:
               pericardial cyst
               constrictive pericarditis
               pericardial hematoma
               pericardial metastases
               partial absence of the pericardium
               pneumopericardium

Congenital heart disease in the adult
     Recognize increased, decreased, and shunt vascularity on a chest radiograph
         and state the common causes of each.
     Recognize the following on imaging examinations:
             heart disease presenting during adulthood
                    left to right shunt
                    atrial septal and ventricular septal defects
                    partial anomalous pulmonary venous connection
                    patent ductus arteriosus
                    coarctation of the aorta
                    tetralogy of Fallot and pulmonary atresia with ventricular
                         septal defect
                    congenitally-corrected transposition of the great arteries
                    persistent left superior vena cava
                    truncus arteriosus
                    Ebstein anomaly
                    cardiac malposition, including abnormal situs
             heart disease originally treated in childhood
                    coarctation of the aorta
                    tetralogy of Fallot and pulmonary atresia with ventricular
                         septal defect
                    congenitally-corrected transposition of the great arteries
                    complete transposition of the great arteries
                    truncus arteriosus
                    commonly performed surgical corrections for congenital heart
                         disease
     Define the role or angiography, MRI, CT, and echocardiography in the
         evaluation of congenital heart disease.

Monitoring and support devices (“tubes and lines”)
      Be able to identify and state the preferred placement of the following as well
        as complications of malpositioning:
                     endotracheal tube
                     central venous catheter
                     Swan-Ganz catheter
                     feeding tube
                     nasogastric tube
                     chest tube
                     intra-aortic balloon pump



                                              120
                     pacemaker and pacemaker leads
                     automatic implantable cardiac defibrillator
                     left ventricular assist device
                     atrial septal defect closure device (“clamshell device”)
                     pericardial drain
                     extracorporeal life support cannulae
                     intraesophageal manometer, temperature probe, or pH probe
                     tracheal or bronchial stent
       Explain how an intra-aortic balloon pump works.

Post-operative chest
      Identify normal post-operative findings and complications of the following
      procedures:
              wedge resection, lobectomy, pneumonectomy
              coronary artery bypass graft surgery
              cardiac valve replacement
              aortic graft
              aortic stent
              transhiatal esophagectomy
              lung transplant
              heart transplant
              lung volume reduction surgery




                                             121
KNOWLEDGE-BASED OBJECTIVES
Pediatric Radiology

Cardiovascular System

Imaging modalities:
      chest radiographs – limitations
      angiocardiography – indications, projections
      echocardiography – standard views
      CT (including ultrafast and helical)
      MR – indications, anatomy
      nuclear cardiology

Congenital heart disease:
      congenital heart disease with decreased pulmonary blood flow
      (right-to-left shunt)
               tetralogy of Fallot
               Ebstein anomaly
               tricuspid atresia
      cyanotic congenital heart disease with increased pulmonary blood flow
      (left-to-right shunt)
               truncus arteriosis
               transposition of the great arteries
               single ventricle
               total anomalous pulmonary venous return
               endocardial cushion defect
      acyanotic congenital heart disease with increased pulmonary blood flow
      (left-to-right shunt)
               ASD
               VSD
               PDA

Gastrointestinal System

Imaging modalities:
      plain radiographs
      UGI/SBFT
      enteroclysis
      BE/air enema
      US
      CT
      MR
      ERCP
      nuclear medicine

Normal variants




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Biliary system:
         congenital
                biliary atresia
                neonatal hepatitis
                choledocal cyst
         acquired miscellaneous
                cholelithiasis
                hydrops of the gallbladder

Liver:
         infection
                 pyogenic abscess (including chronic granulomatosis disease of
                     childhood)
                 ascending cholangitis
         tumors and tumor-like conditions
                 benign
                         mesenchymal hamartoma
                         hemangioendothelioma
                 malignant
                         hepatoblastoma
                         metastases
         trauma
                 lacerations
                 subcapsular hematoma
                 contusion
         portal hypertension
                 cavernous transformation of the portal vein
         miscellaneous
                 portal venous gas
                 glycogen storage disease
                 transplant

Spleen:
       congenital
               abnormal visceroatrial situs
               wandering spleen
       neoplasms
               benign
                       lymphangioma
               malignant
                       lymphoma/leukemia
       trauma
               laceration
               contusion
               shattered spleen
               subcapsular hematoma
       splenic infarction
               sickle cell disease



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Pancreas:
       congenital
               pancreas divisum
               cystic fibrosis
       pancreatitis (and pseudocyst)
               trauma
               congenital anatomic abnormalities
                        pancreas divisum
                        choledocal cyst
       familial pancreatitis

Pharynx and esophagus:
      congenital and developmental anomalies
              esophageal atresia and TE fistula
      inflammatory lesions
              retropharyngeal abscess/cellulitis
      trauma
              foreign body
              iatrogenic pharyngeal perforation (due to NG or ET tube)
      miscellaneous
              GE reflux

Stomach:
      congenital
              duplications
              antral webs
      gastric outlet obstruction – acquired
              HPS
      inflammatory
              corrosive ingestion
              chronic granulomatous disease
      miscellaneous
              bezoars
              spontaneous rupture of the stomach (neonates)
              volvulus

Small bowel:
       congenital
             malrotation (including preduodenal portal vein)
             duodenal, jejunal, and ileal stenosis and/or atresia
             annular pancreas
             meconium ileus
             meconium peritonitis
             mesenteric and omental cysts
             duplication cysts
             Meckel diverticular (including jomphalo-mesenteric band)
             omphalocele, gastroschisis



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                 hernias
         neoplasms
                 benign
                 malignant
                         lymphoma
         malabsorption
                 CF
                 cow’s milk allergy
                 intestinal lymphangiectasis
         miscellaneous
                 necrotizing enterocolitis
                 ischemic bowel
                 intussusception
                 Ilenoch-Schonlein purpura

Colon:
         congenital
                 imperforate anus
                 duplications
                 colonic atresia
         functional disorders
                 Hirschprung disease
                 meconium plug/neonatal small left colon syndrome
         infection/inflammatory
                 appendicitis
         neoplasms
                 benign
                 malignant
                         lymphoma

Miscellaneous:
        lines and catheters
                umbilical arterial catheter
                umbilical venous catheter
        pneumoperitoneum (signs on plain radiographs)

Genitourinary System

Imaging modalities:
      plain radiographs
      IVU
      VCUG
      retrograde urethrogram
      nephrostogram
      retrograde ureterogram
      US
      Ct
      MR



                                               125
       nuclear medicine
       interventional techniques
       genitography

Normal variants

Kidneys:
       congenital anomalies
               UPJ
               duplication
               multicystic dysplasia
               agenesis
               hypoplastic kidney
               ectopia
                        ptosis
                        pelvic
                        crossed ectopia
               relationship of congenital renal anomalies with other congenital
anomalies
                  (i.e., VATER association, spinal dysraphysm, etc.)
               cystic renal disease
                        autosomal recessive
                        autosomal dominant
                        cysts associated with malformation syndromes
       inflammatory
               acute pyelonephritis
               reflux nephropathy
       neoplasms
               Wilms and Wilms variant
               nephrogenic rests
               mesoblastic nephroma
               multilocular cystic nephroma
               leukemia/lymphoma
       trauma
               subcapsular hematoma
               laceration (including those communicating with the collecting system)
               contusion
               avulsion of the renal pedicle
               UPJ avulsion or laceration
       miscellaneous
               renal vein thrombosis
               urolithiasis/nephrocalcinosis
               renal transplantation
               renovascular hypertension

Adrenal gland:
       neoplasms
               neuroblastoma



                                              126
       trauma
                hemorrhage and adrenal calcification

Bladders, ureters, and urethra:
       congenital
               posterior urethral valves
               ureterovesical junction obstruction
               primary megaureter
               bladder diverticuli
               ureteral duplication
               ureterocele
               urachal abnormalities
               hypospadias
               epispadias/exstrophy
               prune belly syndrome
               urologic sequelae of ano-rectal anomalies
       inflammatory/infectious
               urinary tract infection
               viral cystitis
       neoplasms
               rhabdomyosarcoma
       miscellaneous
               vesicoureteral reflux
               neurogenic bladder
               dysfunctional voiding

Male genital tracts:
       testicular torsion
       inflammatory/infectious
               epididymitis/orchitis
       neoplasms
               germ cell tumors
               germ cell plus stroma cell tumors
               gonadal stromal tumors

Female genital tracts:
      congenital
              congenital vaginal occlusion (hydrometrocolpos, etc.)
              fusion anomalies of the mullerian ducts (uterus didelphys, etc.)
              cloacal anomalies
      neoplasms
              ovaries
                       ovarian cysts (including torsion)
                       germ cell tumors
              uterus and vagina
                       rhabdomyosarcoma
                       clear cell adenocarcinoma




                                              127
         miscellaneous
                 differential diagnosis of intralabial masses
                         prolapsing ectopic ureterocele
                         obstructed paraurethral gland
                         imperforate hymen with hydrometrocolpos
                         urethral prolapse
                         sarcoma botryoides
                 intersex states
                         differential diagnosis
                         work-up

Neuroradiology

Imaging modalities:
      plain radiographs
      CT
      MR
      sonography
      myelography
      angiography

Normal variants

Skull:
         congenital
                craniofacial syndromes
                congenital dermal sinus
                premature craniosynostosis
         inflammatory
                osteomyelitis
         trauma
                caput succedaneum
                subgaleal hemorrhage
                cephalohematoma
                fractures

Spine:
         congenital
               absence or hypoplasia of the odontoid
               os odontoideum
               segmentation anomalies
               Kippel-Feil anomaly
               Sprengel deformity
               VATER association
               butterfly vertebrae
               spinal dysraphism
               diastematomyelia
               sacral agenesis (including caudal regression syndrome)



                                              128
                 partial absence (including Currarino triad)
         inflammatory
                 discitis
                 tuberculosis spondylitis
         neoplasms
                 Ewing sarcoma
                 aneurysmal bone cyst
                 osteoblastoma
                 osteoid osteoma
                 Langerhans cell histiocytosis of bone
                 metastases (including leukemia and lymphoma)
         trauma
                 fractures/dislocations
                 atlanto-dens and atlanto-occipital injuries
                 spondylolysis/spondylolisthesis
         miscellaneous
                 Scheurmann disease
                 scoliosis
                 intervertebral disc calcification

Brain:
         congenital
                migrational disorders
                         lissencephaly
                         pachygyria
                         schizencephaly
                         heterotopic gray matter
                         polymicrogyria
                holoprosencephaly
                anomalies of the corpus callosum
                hydra-encephaly
                Dandy-Walker malformations
                Chiari malformations
                cephaloceles
                neurocutaneous syndromes
                vein of Galen malformation
                aqueductal stenosis
         inflammatory
                bacterial infections (including meningitis, cerebritis, and abscess)
                tuberculosis infections
                viral infections (encephalitis)
                         TORCH infections
                         AIDS
         neoplasms
                posterior fossa
                         medulloblastoma
                         ependymoma
                         brainstem glioma



                                                 129
              supratentorial
                       pineal region tumors
                       cranipharyngioma
                       astrocytoma
                       oligodendroglioma
                       PNET
                       choroid plexus tumors
       cerebral infarction/ischemia
              arteritis
              sickle cell
              carotid occlusion
              venous sinus thrombosis
              hypoxic/ischemic injury in the newborn
                       intracranial hemorrhage
                       periventricular leukomalacia
       trauma (including shaken baby syndrome)
              cerebral injury (including shearing injuries and concussion)
              subdural hematoma
              epidural hematoma
              subarachnoid hemorrhage
       metabolic brain disorders
              leukodystrophies

Spinal Cord:
        congenital
               myelomeningocele/meningocele
               lipomyelomeningocele
               diastematomyelia
               tethered cord
               dermal sinus
               intradural lipoma
               hydrosyringomyelia
        tumors
               neurofibroma
               astrocytoma
               ependymoma
               metastases
               neuroblastoma, ganglioneuroblastoma, ganglioglioma
               sacrococcygeal teratoma

Chest and Airway

Imaging modalities:
      plain radiographs
      CT (including high resolution)
      bronchography
      sonography
      fluoroscopy



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         esophagography
         MR

Normal variants

Upper airway:
       congenital
              cystic hygroma
              branchial cleft cyst
              thyroglossal duct cyst
              tracheomalacia/bronchomalacia
              laryngeal stenosis, atresia, web
              laryngomalacia
              choanal atresia
       inflammatory
              tonsillar enlargement/adenoidal hypertrophy
              croup
              epiglottitis
       neoplasm
              juvenile angiofibroma
              subglottis hemangioma
              laryngeal papilloma
       trauma
              foreign body
              acquired subglottic stenosis

Chest:
         congenital
                agenesis/hypoplasia
                        venolobar syndrome
                bronchial atresia
                bronchopulmonary foregut malformation
                        sequestration
                        bronchogenic cyst
                        cystic adenomatoid malformation
                        congenital lobar emphysema
                tracheal bronchus
                lymphangiectasia
         inflammatory
                infections
                        bacterial pneumonia (including streptococcus, staphylococcus,
                           pertussis, chlamydia, mycoplasma, H. influenza) including
                           pneumonia, abscess, and post-infectious pneumatocele
                           viral pneumonia (including RSV, varicella, measles)
                        tuberculosis
                        pneumocystis infection
                        fungal infections
                AIDS



                                               131
        reactive airways disease
        bronchiectasis
        cystic fibrosis (including immotile cilia syndrome)
neoplasms
        mediastinal neoplasms
                 lymphoma/leukemia
                 teratoma
                 thymoma
                 neurogenic tumors
        primary lung tumors
                 adenoma
                 hamartoma
                 hemangioma
                 mesenchymal sarcoma
                    (and their association with developmental cystic lesions of
                     the lung)
                 metastatic lung neoplasms
                 chest wall neoplasms (including Askin tumor)
trauma
        contusion
        airleak
                 pneumothorax
                 pneumomediastinum
                 pulmonary interstitial emphysema
                 bronchopleural fistula
                 fracture of the tracheobronchial tree
                 airway foreign body
                 post-traumatic bronchial stenosis
                 post-traumatic diaphragmatic hernia
                 complications of tubes and lines
unique problems in the neonate
        hyaline membrane disease
        transient tachypnea of the newborn
        neonatal pneumonia
        congenital diaphragmatic hernia
        bronchopulmonary dysplasia
        meconium aspiration syndrome
        persistent fetal circulation
        ECMO therapy and its complications
        chylothorax
        airleak in the neonate
miscellaneous
        idiopathic pulmonary hemosiderosis
        collagen vascular diseases
        spontaneous pneumothorax
        cardiogenic and noncardiogenic pulmonary edema (including ARDS)
        histiocytosis




                                        132
Musculoskeletal System

Imaging modalities:
      plain radiographs
      CT
      MR
      ultrasonography
      nuclear medicine
      arthrography
      angiography

Normal variants

Congenital
      bone dysplasias
              osteochondrodysplasias affecting growth of tubular bones and spine
                  (identifiable at birth)
                       thanatophoric dysplasia
                       chondrodysplasia punctata
                       achondroplasia
                       asphyxiating thoracic dystrophy
              osteochondrodysplasias affecting growth of tubular bones and spines
                  (identifiable in later life)
                       metaphyseal chondrodysplasias
                       multiple epiphyseal dysplasia
              osteochondrodysplasias with disorganized development of cartilage
                  and fibrous components of the skeleton
                       multiple cartilagenous exostoses
                       enchondromatosis
                       polyostotis fibrous dysplasia
                       neurofibromatosis
              abnormalities of density of cortical diaphyseal structure &
                   metaphyseal modeling
                       osteogenesis imperfecta
                       osteopetrosis
                       pyncodysostosis
                       diaphyseal dysplasia
                       metaphyseal dysplasia
      limb reduction anomalies
         (including proximal focal femoral deficiency & radial ray anomalies)
      amniotic band syndrome
      congenital bowing deformities and pseudoarthroses
      congenital foot deformities
              pes planus
              talipes equinovarus
              pes cavus
              metatarsus adductus
      skeletal abnormalities associated with Down syndrome



                                            133
       skeletal abnormalities associated with mucopolysaccharidoses and
mucolipidoses
       developmental dysplasia of the hip
       skeletal abnormalities associated with neuromuscular diseases
               meningomyelocele
               cerebral palsy
               musculodystrophy

Infection/inflammatory:
        pyogenic osteomyelitis
        septic arthritis
        toxic synovitis of the hip
        tuberculosis
        syphilis
        juvenile rheumatoid arthritis
        hemophilic arthropathy

Neoplasm:
       benign
              osteochondroma
              unicameral bone cyst
              aneurysmal bone cyst
              nonossifying fibroma/fibrous cortical defect
              fibrous dysplasia
              Langerhans cell histiocytosis of bone
              osteoid osteoma
              osteoblastoma
              chondroblastoma
              chondromyxoid fibroma
       malignant
              Ewing sarcoma
              osteogenic sarcoma
              metastases (including leukemia/lymphoma)

Trauma:
      fractures
              accidental trauma (including Salter-Harris, greenstick, bowing, and
                  buckle fractures)
              non-accidental trauma (battered child syndrome)
              slipped capital femoral epiphysis
              thermal injury

Metabolic/endocrine:
      rickets
      renal osteodystrophy
      hyperparathryoidism
      hypoparathyroidism
      hypophosphatasia



                                              134
      scurvey
      bone age determination

Osteochondroses
      Legg-Perthes disease
      Kohler disease
      Freiberg disease
      osteochondritis dissecans
      Blount disease and physiologic bowing




                                              135
KNOWLEDGE-BASED OBJECTIVES
Gastrointestinal Radiology


LIVER

        Imaging Methods
        Anatomy
        Diffuse Liver
        Disease
        Liver Masses
        Liver Trauma

BILIARY TREE

        Imaging Methods
        Anatomy
        Biliary Dilatation
        Gas in the Biliary Tract

GALLBLADDER

        Imaging Method
        Anatomy
        Gallstones
        Acute Cholecystitis
        Chronic Cholecystitis
        Thickening of the Gallbladder Wall
        Gallbladder Carcinoma

PANCREAS

        Imaging Methods
        Anatomy
        Acute Pancreas
        Chronic Pancreas
        Pancreatic Carcinoma
        Islet Cell Tumors
        Cystic Lesions
        Pancreatic Trauma

SPLEEN

        Imaging Methods
        Anatomy
        Splenomegaly
        Cystic Lesions
        Solid Lesions



                                             136
     AIDS
     Splenic Trauma


PHARYNX AND ESOPHAGUS

     Imaging Methods
     Anatomy
     Normal Swallowing and Motility
     Motility Disorders
     Outpouchings
     Esophagitis
     Esophageal stricture
     Enlarged Esophageal folds
     Mass Lesions/Filling Defects
     Esophageal perforation and Trauma


STOMACH
     Imaging Methods
     Anatomy
     Helicobacter pylori infection
     Gastric filling defects/mass lesions
     Thickening gastric folds/thickened wall
     Gastric Ulcers

DUODENUM

     Imaging Methods
     Anatomy
     Duodenal filling defects/mass lesions
     Thickened duodenal folds
     Duodenal ulcers and diverticuli
     Duodenal narrowing
     Upper Gastrointestinal hemorrhage

MESENTERIC SMALL BOWEL

     Imaging Methods
     Anatomy
     Small Bowel filling defects/mass lesions
     Mesenteric Masses
     Diffuse small bowel disease
     Small bowel erosions and ulcerations
     Small bowel diverticuli




                                               137
COLON

        Imaging Methods
        Anatomy
        Colon filling defects/mass lesions
        Colon inflammatory disease
        Diverticular disease
        Lower gastrointestinal hemorrhage

APPENDIX

        Imaging Methods
        Anatomy
        Acute Appendicitis
        Mucocele of the appendix
        Appendiceal tumors




                                             138
KNOWLEDGE-BASED OBJECTIVES
Uroradiology

Adrenal glands:
       imaging methods
       anatomy
       adrenal hyperplasia
       adrenal adenoma
       adrenal metastases
       adrenal carcinoma
       cystic adrenal masses
       adrenal myelolipoma
       adrenal hemorrhage
       adrenal calcification
       endocrine syndromes

Kidneys:
       imaging methods
       anatomy
       congenital renal anomalies
       solid renal masses
       cystic renal masses
       renal cystic disease
       renal infections
       renal parenchymal disease
       ephrocalcinosis
       renal trauma

Pelvicalyceal system and ureter:
        imaging methods
        anatomy
        calculous disease
        hydronophrosis
        filling defect/mass in pelvicalyceal system or ureter
        stricture of pelvicalyceal system or ureter
        papillary cavities

Bladder:
       imaging methods
       thickened bladder wall/small bladder capacity
       calcified bladder wall
       bladder wall mass/filling defect
       pear-shaped bladder/extrinsic mass
       bladder outpouchings/fistula
       bladder trauma




                                                139
Urethra
       imaging methods
       anatomy
       urethral stricture
       urethral diverticulum
       urethral trauma

Female genital tract:
      anatomy
      congenital anomalies
      gynecologic malignancy
      benign conditions

Male genital tract:
       testes and scrotum
       prostate and seminal vesicles




                                       140
KNOWLEDGE-BASED OBJECTIVES
Neuroradiology

Brain:
         congenital brain malformations and phakomatoses
         hemorrhage
         infection
         ischemia/infarction
         neurodegenerative, toxic, and metabolic disorders
         sellar and parasellar lesions
         trauma
         tumor (extra-axial)
         tumor (intra-axial)
         vascular malformations and aneurysms
         white matter disease

Head and neck:
      glands (salivary, thyroid, and lacrimal)
      neck
      paranasal sinuses
      skull base
      temporal bone

Orbit:
         globe
         orbital

Spine:
         congenital
         degenerative and disc disease
         infection
         neoplastic
         vascular
         trauma




                                                 141
KNOWLEDGE-BASED OBJECTIVES
Musculoskeletal Radiology


Bone residents will have seen the following cases from teaching conferences prior to
the end of their residency. The following needs to be supplemented with the study
materials listed earlier. Furthermore, the resident should know the anatomy of the
knee, shoulder, elbow, hip, foot and ankle, and hand and wrist thoroughly on MRI.

Pediatric bone disorders:
        fibrous dysplasia
        unicameral bone cyst
        aneurysmal bone cyst
        non-ossifying fibroma
        fibrous cortical defect
        eosinophilic granuloma
        Brodie’s abscess
        Ewing’s sarcoma
        osteosarcoma
        enchondroma
        osteochondroma
        hereditary osteochondromas
        flat foot
        congenital vertical talus
        club foot
        neurofibromatosis
        diastometamyelia
        osteomyelitis and diskitis in spine
        Chance fracture
        sickle cell disease
        osteogenesis imperfecta
        Maffucci’s
        Ollier’s
        macromystrophic lipomatosa
        juvenile rheumatoid arthritis
        hemophilia changes and pseudotumor
        osteopoikilosis
        osteopetrosis
        achondroplasia
        septic hip in a child
        developmental hip dysplasia
        Legg-Perthe’s
        Gaucher’s disease
        scurvy
        rickets
        child abuse
        lead poisoning
        Panner’s disease



                                              142
       avulsion fracture of medial epicondyle
       rhabdomyosarcoma
       Madelung deformity of radius
       soft tissue hemangioma
       slipped capital femoral epiphysis

Tumors and tumor-like conditions:
      multiple myeloma
      metastatic disease
      prostate cancer
      chordoma of sacrum
      primary lymphoma of bone
      chondrosarcoma
      ivory vertebrae in lymphoma
      radiation-induced sarcoma
      liposarcoma
      malignant fibrous histiocytoma
      osteosarcoma
      Ewing’s sarcoma
      fibrosarcoma
      non-ossifying fibroma
      fibrous cortical defect
      eosinophilis granuloma
      chondroblastoma
      osteoid osteoma
      aneurysmal bone cyst
      adamantinoma in proximal tibia
      fibrous dysplasia
      giant cell tumor
      osteoma in sinuses
      osteochondroma
      osteoblastoma
      enchondroma
      polyostotic fibrous dysplasia
      multiple osteochondromas
      intrasosseous lipoma
      osteomyelitis

Trauma:
      skull fracture
      Jefferson fracture
      hangman’s fracture
      flexion teardrop fracture in c-spine
      unilateral locked facet in c-pine
      bilateral facet fracture in c-spine
      chance fracture
      burst fracture
      compression fracture



                                                143
spondylolysis at L5
coracoid fracture
anterior shoulder dislocation
posterior shoulder dislocation
Hill-Sach’s
bony Bankart
chronic shoulder impingement
full thickness rotator cuff tear on MRI or arthrogram
slap glenoid labral tear on MRI
subscapularis tear on MRI
elbow dislocation
loose body in elbow joint
radial head fracture
joint effusion
tennis elbow
Little Leaguer’s elbow
Panner’s disease
triceps tendon rupture on MRI
biceps tendon rupture on MRI
Monteggia fracture
Galeazzi fracture
night stick fracture
gamekeeper’s thumb
scaphoid fracture with AVN
AVN of lunate
negative ulnar variance
positive ulnar variance
stress fracture of sacrum and pubic rami on plain films and MRI
hip labral tear
avulsion of ischial tuberosity
avulsion of anterior superior iliac spine
greater trochanteric bursitis
Malgaigne fracture
Duverne fracture
dislocated total hip prosthesis, best seen on lateral view
patellar fracture
bipartite patella
Segond fracture
tibial plateau fracture
stress fracture of proximal tibia
quadriceps tendon rupture
ACL tear on MRI
PCL tear on MRI
bucket handle meniscal tear on MRI
medial collateral ligament tear on MRI
lateral patellar dislocation on MRI
Lisfranc fracture dislocation
calcaneal stress fracture



                                      144
       navicular AVN
       metatarsal stress fracture
       osteochondral injury of the talar dome
       tibialis posterior tendon rupture on MRI
       MRI of sinus tarsai syndrome
       plain film and MRI of AVN of talus
       MRI of Achilles’ rupture
       MRI of longitudinal split tear of peroneus brevis tendon
       peroneus brevis avulsion fracture
       Weber classification of fibula fractures
       perilunate dislocation
       lunate dislocation

Infection:
        sacroileitis
        osteomyelitis and diskitis in spine
        septic joints
        tuberculosis of the knee
        plain film and MRI of osteomyelitis in the foot

Arthritis and related conditions:
         atlanto-axial subluxation in rheumatoid
         ankylosing spondylitis
         hydroxyapatite deposition disease around shoulders or hips
         rheumatoid involvement in hands, feet, and large joints
         osteoarthritis in hands, feet, and large joints
         CPPD in hands or knee
         psoriasis in hands, feet, or SI joints
         Reiter’s in hands, feet, or SI joints
         gout in hands and feet
         pigmented villonodular synovitis in large joints
         ankylosing spondylitis
         Jaccoud’s arthropathy in hands
         hemophilic arthritis
         neuropathic joint
         synovial osteochondromatosis of large joints
         multicentric reticulohistiocytosis of the hands
         reflex sympathetic dystrophy
         manifestations of rheumatoid arthritis

Metabolic and endocrine:
      hyperparathyroidism
      hypertrophic pulmonary osteoarthropathy
      dermatomyositis
      rickets
      scurvy
      osteopetrosis
      mastocytosis



                                                145
       Paget’s disease
       acromegaly

Miscellaneous:
        lung cancer on shoulder film
        abdominal aortic aneurysm on lumbar spine film
        avascular necrosis of humeral head and femoral head
        plain film findings of scleroderma in the hands
        plain film findings of sarcoid in the hands
        Pitt’s pit in the hip
        melorheostosis




                                            146
KNOWLEDGE-BASED OBJECTIVES
Ultrasound

     Liver:
              anatomy
                      Couinaud segments
              diffuse liver disease
                      infectious
                      neoplastic
                      metabolic
              focal hepatic lesions
                      benign and malignant neoplasms
              vascular disorders
                      arterial and venous abnormalities
              post-surgical changes
                      transplantation
                      TIPS shunt evaluation

     Gallbladder and biliary tree:
             normal gallbladder
             acute and chronic cholecystitis
             benign and malignant conditions of the gallbladder wall
             cholelithiasis and choledocholithiasis
             inflammatory conditions of the biliary tree

     Spleen

     Pancreas

     Superficial structures:
            thyroid and parathryoid
            breast

     Scrotum

     Pelvis
              uterus and adnexa

     Vascular
            venous anatomy
            deep venous thrombosis
            physiologic venous procedures
            arterial evaluations: renal, mesenteric, aorta, extremities
            physiologic evaluations

     Obstetrics
            early pregnancy
            indications for examinations



                                             147
normal patterns of growth
use of common growth charts
interpretation of patterns of growth disturbances
components of various types of ultrasound evaluation,
    e.g., high-risk, etc.
various abnormalities detectable in each stage of gestation
components of an obstetric ultrasound report
indications, risks, and basic knowledge of procedures, such as
    amniocentesis




                               148
KNOWLEDGE-BASED OBJECTIVES
Interventional Radiology

SECTION I: PATIENT CARE
This section includes general aspects of patient care; its topics are in turn included,
as appropriate, as they relate to more specific sections of the outline which follows.

SECTION II: VASCULAR DIAGNOSIS
This section starts with a list of “common” topics--radiological and nonradiological
aspects of vascular diagnosis--which, in turn, are included as they relate to more
specific sections. The specific sections are divided primarily by anatomic regions.,
and then by organs or organ systems.

SECTION III: VASCULAR INTERVENTION
This section starts with a broad overview of major categories of vascular intervention
which, in turn, are included as they relate to more specific sections. The specific
sections are then divided primarily by anatomic regions and then by organs or organ
systems.

SECTION IV: NONVASCULAR INTERVENTION
This section starts with a list of “common” topics--radiological and nonradiological
aspects of nonvascular intervention--which, in turn, are included as they relate to
more specific sections. The specific sections are divided into traditional subsections
which relate primarily to organs or organ systems.

-----------------------------------------

SECTION I: PATIENT CARE IN VASCULAR AND INTERVENTIONAL RADIOLOGY

•   Pre-procedural assessment and care
•   Intraprocedural monitoring
•   Post-procedural followup and care
•   General pharmacologic considerations
•   Analgesia/anesthesia
•   Conscious sedation
•   Antibiotic therapy
•   Anticoagulation
•   Other

-------------------------------------------

SECTION II: VASCULAR DIAGNOSIS

PART I: Common topics

• Clinical and laboratory considerations
• Symptomatology and staging of vascular disease




                                                149
• Laboratory data (including non-imaging aspects of noninvasive vascular testing; for
example, ankle-brachial indices for lower extremity arterial disease)
• Epidemiology of vascular disease
• Natural history of vascular disorders
• Vascular anatomy: arterial and venous
• Normal anatomy
• Variant anatomy
• Anatomy of collateral pathways
• Vascular physiology, pathology and pathophysiology: arterial system
• Normal histology/physiology/morphology
• Hemodynamics: normal and abnormal flow
• Vasoactive extrinsic/pharmacologic agents
• Normal response
• Disorders related to pharmacologic/extrinsic agent exposure
• Atherosclerosis
• Medial sclerosis
• Pathophysiology of arterial ischemia
• Aneurysms
• Thromboembolic disorders
• Dissection
• Congenital vascular disorders
• Vascular malformations
• Other congenital disorders (for example, popliteal artery entrapment in the case of
lower extremity vascular disorders)
• Arterial effects of adjacent tissues/disorders
• Arterial infection
• Vascular alterations in neoplasia: vascular supply of neoplasms, primary vascular
neoplasms, vascular invasion by neoplasms
• Vascular alterations in inflammatory diseases
• Systemic vascular disorders
• Primary systemic vascular disorders: vasculitides and others (polyarteritis nodosa,
Takayasu’s arteritis, giant cell arteritis, Buerger’s disease)
• Altered vascular pathology in systemic disease states (for example, in diabetes
mellitus, collagen vascular disease, Behçet’s disease, etc.)
• Vascular trauma: injuries and vascular response to injury
• Mechanical injury: acute and chronic
• Thermal injury
• Alterations in coagulation status
• Hypercoagulable states
• Impaired coagulation
• Post-operative or post-interventional disorders
• Synthetic and endogenous grafts
• Myointimal hyperplasia
• Other/unclassified
• Vascular physiology, pathology and pathophysiology: venous/pulmonary arterial
system
• Normal histology/physiology/morphology
• Hemodynamics: normal and abnormal flow



                                              150
• Vasoactive extrinsic/pharmacologic agents
• Normal response
• Disorders related to pharmacologic/extrinsic agent exposure
• Thromboembolic disorders: acute and chronic
• Venous aneurysms
• Venous effects of adjacent tissues/disorders
• Congenital vascular disorders
• Vascular malformations
• Other congenital disorders
• Venous infection
• Vascular alterations in neoplasia: vascular drainage of neoplasms, primary vascular
neoplasms, vascular invasion by neoplasms
• Vascular alterations in inflammatory diseases
• Systemic vascular disorders
• Primary systemic vascular disorders
• Altered vascular pathology in systemic disease states
• Vascular trauma: injuries and vascular response to injury
• Mechanical injury--acute and chronic
• Thermal injury
• Alterations in coagulation status
• Hypercoagulable states
• Impaired coagulation
• Post-operative or post-interventional disorders
• Synthetic and endogenous grafts
• Intimal hyperplasia
• Other/unclassified
• Imaging of the vascular system: general principles
• Plain film
• Angiography: arteriography and venography
• Standard angiography
• Digital subtraction angiography
• Contrast agents
• Iodinated agents
• Carbon dioxide
• Vascular catheterization
• Equipment: needles, guidewires, catheters, etc.
• Vascular access
• Selective and subselective catheterization
• Risks and complications
• Contrast reactions, iodinated agents
• Anaphylactoid reactions
• Classification
• Prevention
• Ionic vs. nonionic agents
• Premedication
• Treatment
• Dose dependent reactions
• Classification



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•   Acute and chronic renal effects
•   Other
•   Prevention
•   Treatment
•   Procedural complications
•   Puncture site complications
•   Catheterization-related complications (apart from puncture site)
•   Systemic/generalized complications
•   Pharmacoangiography: agents and uses
•   Vasodilatation
•   Vasoconstriction
•   Other

PART II: Specific Topics

• Lower extremity vascular disease
• Arterial
• Peripheral atherosclerotic arterial disease
• Lower extremity aneurysms (iliac, femoral, popliteal, other)
• Nonatherosclerotic peripheral vascular disease (popliteal entrapment, adventitial
cystic disease
• Iatrogenic disorders: puncture site complications
• Trauma
• Venous
• Acute deep venous thrombosis
• Chronic deep venous thrombosis/venous insufficiency
• Combined: vascular malformations
• Upper extremity vascular disease
• Arterial
• Thoracic outlet syndrome
• Atherosclerosis
• Vasculitis, Raynaud’s disease and phenomenon
• Trauma
• Venous
• Acute upper extremity venous thrombosis
• Chronic upper extremity venous thrombosis
• Combined: vascular malformations
• Thoracic vascular disease
• Hemoptysis and its evaluation
• Pulmonary arteries and veins
• Pulmonary artery hemodynamics (as related to pulmonary angiography)
• Pulmonary thromboembolic disease
• Pulmonary arteriovenous malformations
• Pulmonary venous disorders
• Aortic disorders
• Aortic aneurysm
• Aortic dissection
• Aortic trauma



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• Congenital disorders
• Vasculitides affecting the aorta
• Post-operative aorta
• Central venous disorders (SVC, IVC)
• Central venous occlusive disorders
• Vascular diagnosis, abdominal and pelvic viscera
• Genitourinary system
• Kidney
• Renovascular hypertension: causes, workup, including noninvasive imaging, renin-
angiotensin system and renin sampling, arteriography
• Renal trauma
• Renal neoplasms
• Ureters/bladder
• Uterus
• Gastrointestinal Tract
• Gastrointestinal hemorrhage
• Workup considerations: angiography vs. endoscopy vs. nuclear medicine
• Specific causes
• Gastritis
• Peptic ulcer disease
• Mallory-Weiss tear
• Hepatobiliary: hemobilia
• Neoplasms
• Angiodysplasia
• Diverticulitis
• Vascular malformations
• Venous bleeding (see also section on portal hypertension)
• Other
• Angiographic evaluation
• Mesenteric ischemia
• Acute mesenteric ischemia
• Embolic
• Thrombotic
• Nonocclusive
• Mesenteric venous ischemia
• Other
• Chronic mesenteric ischemia/mesenteric atherosclerosis
• Mesenteric aneurysms
• Portal/hepatic vascular disorders
• Portal hypertension
• General imaging evaluation
• Angiographic evaluation: arterial portography, splenoportography, direct
portography, hepatic venography, wedge (or balloon occlusion) hepatic venography
and pressure measurements
• Classification
• Budd-Chiari syndrome and other forms of hepatic venous outflow obstruction
• Hepatic neoplasms: primary and secondary
• Pancreas



                                             153
• Vascular manifestations of pancreatic inflammatory disease
• Spleen
• Splenic trauma
• Adrenal glands
• Arteriographic and venographic evaluation of neoplasms (including risks in setting
of pheochromocytoma)
• Cardiac/coronary vasculature
• Congenital heart and great vessel disease
• Coronary artery disease
• Acquired non coronary heart disease
• Valvular
• Endocardial
• Myocardial
• Pericardial
• Vascular aspects of endocrine disorders
• Clinical aspects
• Venous sampling
• Indications
• Techniques
• Specific sites
• Thyroid/parathyroid
• Adrenal
• Pancreas
• Ovarian
• Postsurgical conditions
• Arterial and venous bypass procedures
• Grafts for aneurysms
• Grafts for dissection
• Dialysis access procedures and disorders
• Vascular aspects of organ transplantation
• Liver
• Kidney
• Pancreas
• Small bowel
• Heart
• Lung

----------------------------------------------

SECTION III: VASCULAR INTERVENTION

PART I: Common Topics and Major Categories, Vascular Intervention

•   Common Topics: vascular interventional procedures
•   Anatomic considerations
•   Indications and contraindications
•   Techniques, devices, materials
•   Results, efficacy



                                                 154
•   Risks and complications
•   Alternate techniques (surgical and medical therapeutic options)
•   Vascular canalization/recanalization: re-establishment of flow
•   Thrombolytic therapy
•   Pharmacologic thrombolysis
•   General principles
•   Specific agents: streptokinase, tissue plasminogen activator, others
•   Mechanical techniques
•   Fogarty balloon
•   Suction thromboembolectomy
•   Mechanical thrombolysis
•   Balloon angioplasty
•   Atherectomy
•   Mechanical recanalization
•   Vascular stents
•   Endovascular grafts
•   Other

•   Vascular blockade: obliteration of flow
•   Embolization:
•   Techniques
•   Transcatheter
•   Direct injection
•   Agents
•   Other methods
•   Ultrasound guided compression repair
•   Fibrin injection of pseudoaneurysms
•   Infusional therapy
•   Flow diminution
•   Flow enhancement
•   Re-routing of flow
•   Endovascular repair of aneurysms
•   Creation of new vascular channels (e.g. TIPS, fenestration of aortic dissection)
•   Vascular filters
•   Vascular foreign body removal
•   Intravascular/transvascular biopsy
•   Transvenous liver biopsy
•   Other

PART II: Specific Topics

•   Lower extremity vascular disease
•   Arterial
•   Occlusive atherosclerotic disease: recanalization
•   Aortoiliac
•   Femoropopliteal
•   Tibioperoneal
•   Intervention for peripheral arterial trauma



                                                 155
•   Thromboembolic disorders: recanalization
•   Peripheral arterial graft failure: recanalization
•   Iatrogenic disorders: therapy for puncture site complications
•   Venous
•   Combined: vascular malformations: obliteration
•   Upper extremity vascular disease
•   Arterial
•   Thromboembolic disorders: recanalization
•   Trauma
•   Venous
•   Acute upper extremity venous thrombosis: recanalization
•   Chronic upper extremity venous thrombosis: recanalization
•   Combined: vascular malformations: obliteration
•   Thoracic vascular disease
•   Hemoptysis
•   Bronchial embolization
•   Other techniques
•   Pulmonary arteries and veins
•   Pulmonary thromboembolic disease: thrombolytic therapy, thromboembolectomy
•   Pulmonary arteriovenous malformations: embolization
•   Aortic disorders
•   Aortic aneurysm: embolization, endovascular grafting
•   Aortic dissection: endovascular grafting, fenestration
•   Aortic trauma
•   Central venous intervention (SVC, IVC)
•   Central venous occlusive disorders
•   Thromboembolic disorders
•   Congenital webs
•   Indwelling central venous access
•   Caval filtration and related techniques for thromboembolic disease
•   Vascular diagnosis, abdominal and pelvic viscera
•   Genitourinary system
•   Kidney
•   Renovascular hypertension: recanalization techniques
•   Renal trauma
•   Renal neoplasms
•   Renal ablation
•   Gastrointestinal Tract
•   Gastrointestinal hemorrhage
•   Embolization vs. infusional therapy (vasopressin)
•   Specific sites
•   Upper GI (esophago-gastro-duodenal)
•   Small bowel
•   Colonic
•   Mesenteric ischemia
•   Acute mesenteric ischemia
•   Infusional therapy: vasodilators
•   Thromboembolic disease: thrombolytic therapy



                                            156
• Chronic mesenteric ischemia/mesenteric atherosclerosis
• Recanalization techniques: angioplasty, stents, etc.
• Mesenteric aneurysms/pseudoaneurysms
• Portal/hepatic vascular disorders
• Portal hypertension
• Variceal bleeding: embolization and infusional therapy
• Transjugular intrahepatic portosystemic shunt-stent (TIPS)
• Budd-Chiari syndrome and other forms of hepatic venous outflow obstruction
• Hepatic neoplasms: infusional therapy and chemoembolization
• Pancreas
• Therapy for vascular manifestations of pancreatic inflammatory disease
• Spleen
• Vascular intervention for splenic trauma
• Treatment of hypersplenism
• Cardiac/coronary vasculature
• Congenital heart disease
• Coronary artery disease
• Valvular disease
• Intravascular tumor therapy
• Infusional therapy
• Chemoembolization
• Vascular intervention in organ transplantation
• Liver
• Kidney
• Pancreas
• Small bowel
• Heart
• Lung
• Dialysis access intervention: recanalization techniques
• Congenital disorders: Principles and practice of interventional management of
arteriovenous malformations
 Uterine Artery Embolization

----------------------------------------------

SECTION IV: NONVASCULAR INTERVENTION

PART I: Common topics

•   Clinical and Laboratory Considerations
•   Symptomatology and staging of nonvascular disorders
•   Laboratory data
•   Epidemiology
•   Procedural aspects
•   Imaging modalities relevant to the performance of non vascular interventions
•   Indications and contraindications
•   Techniques, devices, materials
•   Results, efficacy



                                                 157
• Risks and complications
• Alternate techniques (surgical and medical therapeutic options)

PART II: Specific Topics

•   Biopsy and diagnostic fluid aspiration
•   Specific sites
•   Thoracic (see also thoracic nonvascular intervention, below)
•   Lung
•   Mediastinum
•   Pleura
•   Cervical
•   Thyroid/parathyroid
•   Salivary
•   Other neck
•   Superficial tissues
•   Abdominal
•   Liver
•   Pancreas
•   Biliary system
•   Spleen
•   Adrenals
•   Genitourinary
•   Kidneys
•   Ureters/bladder
•   Uterus/ovaries
•   Gastrointestinal tract
•   Retroperitoneum
•   Peritoneum
•   Paracentesis
•   Peritoneal masses
•   Bone
•   Tissue sampling considerations
•   Fluid/abscess drainage
•   Sites
•   Chest: see chest intervention, below
•   Abdomen/Pelvis
•   Peritoneal
•   Retroperitoneal
•   Genitourinary
•   Renal abscess
•   Renal cyst
•   Liver
•   Hepatic abscess
•   Bilomas
•   Hepatic cysts
•   Pancreas
•   Types of collections, pancreatic inflammatory disease (abscess, pseudocyst, etc.)



                                                158
•   Drainage in pancreatic inflammatory disease
•   Spleen
•   Gastrointestinal tract: see gastrointestinal intervention, below
•   Musculoskeletal
•   Categories
•   Cysts
•   Cyst sclerosis
•   Hematomas
•   Use of thrombolytic therapy
•   Lymphoceles
•   Lymphocele sclerosis
•   Abscesses
•   Biliary intervention
•   Percutaneous transhepatic cholangiography
•   Biliary obstruction: percutaneous biliary drainage and stenting
•   Malignant obstruction and strictures
•   Primary biliary tumors: cholangiocellular carcinoma, etc.
•   Ampullary and periampullary tumors
•   Metastatic disease (intraductal, extrinsic)
•   Benign obstruction and strictures
•   Primary disorders
•   Inflammatory (including sclerosing cholangitis)
•   Neoplastic
•   Post-surgical
•   Percutaneous cholecystostomy
•   Acalculous cholecystitis
•   Calculous cholecystitis
•   As an adjunct to cholangiography and biliary drainage
•   Treatment of biliary calculi
•   In the gallbladder
•   In the biliary ducts
•   Gastrointestinal intervention
•   Gastrointestinal intubation
•   Percutaneous gastrostomy and gastrojejunostomy
•   Percutaneous jejunostomy
•   Percutaneous cecostomy
•   Abscesses resulting from enteric leaks
•   Gastrointestinal fistulas: interventional management
•   Gastrointestinal strictures
•   Gastrointestinal obstruction
•   Gastrointestinal foreign body retrieval
•   Interventional radiology in specific disorders
•   Appendicitis
•   Diverticulitis
•   Genitourinary intervention
•   Renal obstruction
•   Antegrade pyelography and percutaneous nephrostomy
•   Whitaker test



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•   Nephroureteral stenting
•   Upper urinary tract strictures
•   Upper urinary tract calculi
•   Urinary leaks/fistulas
•   Urinary diversions
•   Bladder
•   Urethra
•   Strictures
•   Female specific
•   Fallopian tube recanalization
•   Thoracic nonvascular intervention
•   Chest tube placement and management
•   Pleural collections
•   Pneumothorax
•   Empyema
•   Natural history
•   Principles of therapy
•   Use of fibrinolytic agents
•   Malignant pleural effusions
•   Sclerotherapy
•   Hemothorax
•   Principles of therapy
•   Use of fibrinolytic agents
•   Infected parenchymal collections
•   Tracheobronchial tree
•   Stricture dilatation and stenting
•   Transthoracic needle biopsy
•   Mediastinal disorders
•   Foreign body retrieval: nonvascular
•   Nonvascular interventional aspects of organ transplantation
•   Liver
•   Kidney
•   Pancreas
•   Small bowel
•   Nonvascular interventional methods of tumor therapy
•   Direct injection techniques: ethanol, chemotherapeutic agents, cryotherapy
•   Nonvascular interventional methods of organ ablation
•   Other nonvascular intervention




[Adopted from the Education Committee of the Society of Cardiovascular and
Interventional Radiology, 1994 Curriculum Outline]




                                               160
KNOWLEDGE-BASED OBJECTIVES
Mammography

Breast Cancer – Overview
       breast cancer facts
       risk marker lesions
       prognostic factors
       genetics
       chemoprevention
       treatment options: an overview
       breast cancer staging (TNM classification)
       breast cancer staging (stages)

Regulatory Issues
       Mammography Quality Standards Acts (MQSA) of 1992: background
       MQSA requirements
       MQSA inspections
       MQSA personnel qualifications
          interpreting physicians
          radiologic technologists
          medical physicists
       MQSA reporting results
       MQSA equipment standards
       quality assurance under MQSA
       ACR’s mammography accreditation program

Quality Control
        general comments
        film labeling
        quality control tests (technologists)
        darkroom cleanliness
        processor quality control (operating levels)
        processor quality control (daily)
        processor quality control (control film crossover)
        screen cleanliness
        phantom images
        viewboxes and viewing conditions
        visual checklist
        repeat analysis
        analysis of fixer retention in film
        darkroom fog
        screen-film contact
        compression
        quality control tests (physicist)

Technical Considerations
       equipment
       contrast



                                                161
       technical factors
       automatic exposure control
       grids
       compression
       image blur
       cassettes, screens, and film
       processing artifacts
       processor artifacts

Screening Mammography
       general comments
       screening trials
       screening recommendations
       approach to screening mammography
       looking for . . . .
       screening views: general comments
       craniocaudal views
       mediolateral oblique views
       exaggerated craniocaudal views
       imaging women with implants
       breast compression and anterior compression views

Diagnostic Mammography and Problem-Solving
      general comments
      spot compression views
      microfocal magnification views
      tangential views
      rolled views (change-of-angle views)
      90-degree mediolateral views
      90-degree lateromedial views
      cleavage views
      caudocranial views
      lateromedial oblique views
      superolateral to inferomedial oblique views
      probably benign lesions
      malignant characteristics
      triangulation

Breast Ultrasound
       general comments
       technical considerations
       ultrasound artifacts
       scanning
       normal anatomy
       benign characteristics (solid masses)
       intermediate characteristics (solid masses)
       malignant characteristics (solid masses)




                                              162
Skin
       general comments
       skin manifestations of breast or systemic disease
       epidermal and sebaceous cysts
       neurofibromatosis
       Mondor’s disease
       steatocystoma multiplex
       inflammatory carcinoma
       miscellaneous

Nipple-Areolar Complex
       normal anatomy
       nipple changes associated with breast cancer
       dermatitis
       Paget’s disease
       nipple adenoma
       leiomyoma

Major Subareolar Ducts
       normal anatomy
       duct ectasia
       solitary papillomas
       papillary carcinoma

Terminal Duct
       normal anatomy
       multiple (peripheral) papillomas
       radial scars – complex sclerosing lesions
       ductal hyperplasia
       duct carcinoma in situ
               low nuclear grade DCIS
               intermediate nuclear grade DCIS
               high nuclear grade DCIS
       invasive ductal carcinoma (not otherwise specified)
       tubular carcinoma
       mucinous carcinoma
       medullary carcinoma
       invasive cribriform carcinoma
       adenoid cystic carcinoma
       miscellaneous
               squamous cell carcinoma
               metaplastic carcinoma
               secretory carcinoma (juvenile carcinoma)
Lobules
       normal anatomy
       cysts
       galatocele
       fibroadenomas



                                              163
         complex fibroadenomas
         juvenile fibroadenomas
         phyllodes tumor
         tubular adenoma
         lactating adenoma
         sclerosing adenosis
         lobular neoplasia
         invasive lobular carcinoma

Stroma
         general comments
         normal anatomy
                  vasculature
                  lymph nodes
         fat necrosis
         lipoma
         hamartoma (fibroadenolipoma)
         fibrosis
         mastitis/breast abscess
         pseudoangiomatous stromal hyperplasia
         hemangioma
         diabetic fibrous breast disease
         extra-abdominal desmoid
         lymphoma
         angiosarcoma
         metastatic disease
         miscellaneous
                  suture calcification
                  parasites
                  dermatomyositis

The Altered Breast
       breast biopsies
       lumpectomy and radiation therapy
               general comments
               mammographic findings after lumpectomy and XRT
       breast reconstruction
       mastectomy side views
       augmentation
       implant complications
       reduction mammoplasty
       hormone replacement
               Tamoxifen
       miscellaneous
               weight change
               chemotherapy
               pacemakers
               Dacron central line cuff



                                            164
               subcutaneous emphysema
               lactation
               premenstrual edema
               trauma

The Male Breast
      imaging the male breast
      gynecomastia
      male breast cancer

Interventional Procedure
       preoperative localizations
       parallel to the chest wall wire localization approach
               general comments
               procedure
       specimen radiography
               paraffin block radiography
       cyst aspiration
               pneumocystography
       ductography
               general comments
               procedure
               findings
       fine needle aspiration
       imaging guided needle biopsy
               general comments
               sampling methods
               procedure – stereotactic guidance
               procedure – ultrasound guidance
       radiology/pathology correlation sessions

Documentation and the Mammographic Report
     general concepts
     for masses
     for calcifications
     special cases
     associated findings
     documentation
     patient notification letters

The Mammography Audit
      general concepts
      definitions
      goals
      benefits of auditing




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