Goals and Objectives

Vascular & Interventional Radiology Senior and Junior

Supervisor

Dr. Ashish Gupta - General Campus 

VIR Sr

Ideal Scheduling

PGY 4 or 5 as the 3^rd VIR block required by the RCPSC.

Introduction

This rotation aims to expose the resident to areas of VIR not covered in the introductory 2 blocks.  Specifically, reporting of CT angio (non-neuro), and carotid doppler will be emphasized.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Gain an understanding of the indications and protocols for non-neuro CT angio imaging.
• Gain knowledge of theoretical, practical and legal aspects of radiation protection including possible harmful effects as related to CT.
• Gain a working knowledge of vascular and pertinent nonvascular anatomy.
• Gain knowledge of all aspects of vascular and nonvascular interventional radiology including an understanding of vascular disease and appropriate application of vascular imaging to patients.
• Gain knowledge of the complications of contrast media administration.
• Become proficient in interpretation and reporting of arterial Doppler US cases—including carotid dopplers.

Communicator

• Understand the importance of communication with referring physicians, including an understanding of when results should be urgently communicated.
• Communicate effectively with patients and their families and
• have a compassionate interest in them. The resident is trusted to inform patients prior to the procedure and obtain informed consent. The resident must be able to explain complications that might occur to the patient as well as the clinical indications and contra-indications to the study.
• Recognize the physical and psychological needs of the patient and their families undergoing radiological investigations or treatment, including those related to culture, race and gender.

Collaborator

• Demonstrate the ability to function as a member of a multidisciplinary health care team, especially with the technologists, nurses and referring physicians.

Manager

• Learn to organize the workday to include a balanced approach to patient care, learning needs and other activities.
• Utilize information technology to optimize patient care, learning and other activities.

Health Advocate

• Identify important determinants of vascular disease.
• Understand and communicate the benefits and risks of vascular and non-vascular investigation and treatment.
• Recognize when investigation and/or treatment would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of vascular and non-vascular imaging and intervention.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Demonstrate an ability to be a teacher of vascular and non-vascular imaging and intervention to medical students, residents, technologists and clinical colleagues.

Professional

• Deliver the highest quality care with integrity, honesty and compassion.
• Be punctual and available for assigned duties
• Exhibit appropriate personal and interpersonal behaviours including accepting constructive criticism.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements of Vascular/Interventional Radiologists.

Schedule

Daily

• Monday: CT Angio**
• Tuesday: Ports
• Wednesday: Angio room
• Thursday:
  • AM: ports
  • PM: CT Angio**
• Friday: picc day or arterial Doppler day at MMI

**Residents should also review and report the Carotid Doppler studies with the designated neuro staff on CT angio days.

Attend Weekly Subspecialty Rounds

Mondays 16:30 – 17:30:  Dialysis work rounds – Civic and General campus Radiology classroom (videoconferenced).

Evaluation

• Mid-rotation written & face to face evaluation.
• Written & face to face end of rotation evaluation.

Recommended Reading

Must Read

Karim Valji. Vascular and Interventional Radiology.  Saunders. 2006.

Reference Texts

Funaki. Teaching Atlas of Vascular & Non-Vascular Interventional Radiology. Thieme Medical Publishers. 2007.

Stanley Baum. Abrams Angiography: Interventional Radiology. Lippincott Williams & Wilkins. 2005.

Revised: Feb 12 2013.

Vascular and Interventional Junior

Supervisor

Dr. A. Gupta General Campus

Dr. K. Smyth Civic Campus

Schedule Heading

VIR

Ideal Scheduling

Second half of PGY3 year as two consecutive blocks, one at the General Campus, the other at the Civic Campus.

Introduction

When on rotation, the resident is expected to gain as much technical and clinical experience as possible and either assist or perform the vast majority of angiograms and interventional procedures. The resident’s work is closely supervised by a staff radiologist and/or fellow and the resident will not be expected to perform any procedure without supervision.

Topics in Vascular and Interventional Radiology

The following is a non-exhaustive list of topics to aid the resident in organizing their self-directed learning while on rotation:

Vascular Interventions and Imaging

• Aortic aneurysm imaging (conventional and CT angiography), endovascular repair and post-procedure follow-up and complications
• Peripheral arterial disease imaging (conventional and CT angiography), endovascular treatment and complications
• Acute peripheral arterial thrombosis – diagnosis and intra-arterial thrombolysis.
• Renal artery stenosis – etiology (i.e. atherosclerosis, FMD), diagnosis (conventional, CT and MR angiography), treatment and complications
• Mesenteric ischemia – etiology (i.e. atherosclerosis, median arcuate ligament syndrome), diagnosis, treatment and complications
• Thoracic outlet syndrome
• Vasculitis – diagnosis and treatment of complications
• IVC filter insertion and removal – indications and complications
• Contrast allergy treatment and premedication

Central Venous Access

• PICCs
• Port-a-caths
• Single/Dual/Triple lumen central venous catheters
• Tunnelled central venous catheters (i.e. Hickman catheter)

Dialysis

• Temporary and permanent hemodialysis catheter insertion, exchange and acute and chronic complications
• Hemodialysis fistula creation, types, imaging and treatment of complications including stenosis, thrombosis and steal syndrome

Hepatobiliary Imaging and Interventions

• Portal vein embolization
• Transarterial hepatic chemoembolization.
• TIPS
• Percutaneous transhepatic cholangiogram
• Transhepatic common bile duct stenting
• Cholecystogram and cholecystostomy

Gastrointestinal Imaging and Interventions

• Upper and lower gastrointestinal hemorrhage diagnosis and treatment
• Percutaneous gastrostomy, jejunostomy and cecostomy tubes
• Percutaneous intraperitoneal abscess drainage

Thoracic Imaging and Interventions

• Chest tube placement in treatment of pleural effusions, empyemas, pneumothorax.
• Hemoptysis and bronchial artery embolization
• Pulmonary AVM/AVF diagnosis and embolization.

Urogenital Interventions

• Nephrostograms, cystograms, ileal conduits and neobladders
• Nephrostomy tube insertion, exchange and complications
• Ureteral stent insertion and exchange
• Uterine artery embolization

Trauma

• Diagnosis with conventional and CT angiography
• Embolization (i.e. splenic, hepatic, arterial laceration/hemorrhage)

Vascular and Interventional Equipment

• Vascular access needles
• Guidewires
• Catheters and vascular sheaths
• Angioplasty balloons
• Vascular and non-vascular stents
• Embolization material

Commonly Used Medications

• Conscious sedation (i.e. Versed, fentanyl, narcan)
• Pre-procedural (antibiotics, contrast nephropathy prevention)
• Anticoagulation and thrombolysis (i.e. heparin, tPA, protamine)
• Vasodilators (i.e.nitroglycerin)

Educational Objectives

Medical Expert-Clinical Decision Maker

• Gain an understanding of the formation of all types of angiography images including physical and technical aspects, patient positioning and contrast media.
• Gain knowledge of theoretical, practical and legal aspects of radiation protection including possible harmful effects as related to fluoroscopy.
• Gain a working knowledge of vascular and pertinent nonvascular anatomy.
• Gain knowledge of all aspects of vascular and nonvascular interventional radiology including an understanding of vascular disease and appropriate application of vascular imaging to patients.
• Gain knowledge of the complications of contrast media administration.
• Become proficient in arterial catheterization, perform a normal femoral angiogram and dialysis fistulogram and demonstrate ability in handling catheters and guidewires.
• Learn to recognize basic catheters and understand their mechanism of use.
• Demonstrate the ability to manage a patient during a procedure in close association with a supervisor.
• Recognize when the patient’s best interests are served by discontinuing a procedure or referring the patient to another physician.
• Understand acceptable and expected results of vascular imaging and interventional therapy as well as unacceptable and unexpected results, including knowledge of, and ability to manage complications.
• Understand appropriate follow-up of care of patients who have received investigations or interventional therapy, follow a patient’s course when admitted secondary to a complication.
• Learn to obtain informed consent.
• Understand and apply a sound and systematic style of reporting. Junior residents are not expected to dictate cases, while senior residents should dictate cases in which they participate. All cases will be discussed with the resident both during and following the procedure and the dictation represents only a portion of the workload in this particular subspecialty.
• Be actively involved in both vascular and nonvascular interventional work.
• The resident is expected to assist in more complicated procedures such as angioplasties and embolizations.
• Review the list of procedures scheduled for the next day and read around cases to be performed.

Communicator

• Understand the importance of communication with referring physicians, including an understanding of when results should be urgently communicated.
• Communicate effectively with patients and their families and have a compassionate interest in them. The resident is trusted to inform patients prior to the procedure and obtain informed consent. The resident must be able to explain complications that might occur to the patient as well as the clinical indications and contra-indications to the study.
• Recognize the physical and psychological needs of the patient and their families undergoing radiological investigations or treatment, including those related to culture, race and gender.

Collaborator

• Demonstrate the ability to function as a member of a multidisciplinary health care team, especially with the technologists, nurses and referring physicians.

Manager

• Learn to organize the workday to include a balanced approach to patient care, learning needs and other activities.
• Utilize information technology to optimize patient care, learning and other activities.
• Learn to appropriately allocare health care resources effectively 

Health Advocate

• Identify important determinants of vascular disease.
• Understand and communicate the benefits and risks of vascular and non-vascular investigation and treatment.
• Recognize when investigation and/or treatment would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of vascular and non-vascular imaging and intervention.
• Be an advocate for the patient, particularly following procedures by accompanying patients back to Surgical Day Care or Post Anaesthesia Care Unit

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Demonstrate an ability to be a teacher of vascular and non-vascular imaging and intervention to medical students, residents, technologists and clinical colleagues.

Professional

• Deliver the highest quality care with integrity, honesty and compassion.
• Be punctual and available for assigned duties.
• When appropriate, accompany patients back to Surgical Day Care or Post Anaesthesia Care Unit following their procedure.
• Exhibit appropriate personal and interpersonal behaviours including accepting constructive criticism.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements of Vascular/Interventional Radiologists.

Schedule

Daily

• 07:45 - 08:00: Obtain informed written consent for first scheduled procedure (when no morning rounds). 
• 08:00 - 12:00: Participate in procedures and post procedural care.
• 12:00 - 13:00: Noon rounds
• 13:00 - 16:00: Participate in procedures and post procedural care, daily case imaging review and dictations. If appropriate, see in-patients scheduled for the following day, obtain written informed consent and write pre-procedure orders.

**On Wednesdays the Junior residents should spend time in CT starting IVs with the nurses.

Attend Weekly Subspecialty Rounds

• Tuesdays 16:00 – 17:00: Vascular Surgery work rounds – Civic campus A2 classroom.

Presentation

The resident is to prepare a 15-20 minute presentation based on a topic of their choosing, an interesting case or recent journal article.  The presentation will be given during the last scheduled Angio-Interventional morning rounds during their second block rotation.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading

Must Read

Karim Valji. Vascular and Interventional Radiology.  Saunders. 2006.

Reference Texts

Funaki. Teaching Atlas of Vascular & Non-Vascular Interventional Radiology.  Thieme Medical Publishers. 2007.

Stanley Baum. Abrams Angiography: Interventional Radiology. Lippincott Williams & Wilkins. 2005.

Revised: Sept 22, 2021

Body MRI

Variable—as indicated on the rotation schedule.

Scheduling

Body MRI

Ideal Scheduling

PGY 3 & 4/5 both at Civic Campus (minimum 2 rotations)

Note—in addition to MRI, residents should report at least 5 x-rays/ day (preferably AXR).

Education Objectives

Medical Expert-Clinical Decision Maker

• Gain a basic understanding of the physics of magnetic resonance image production.
• Gain a basic understanding of the physics of inherent tissue contrast in magnetic resonance images and how to manipulate this contrast.
• Become familiar with coronal and sagittal anatomy.
• Learn the indications for 1.5T and 3T magnetic resonance imaging versus other imaging modalities and the particular strengths and limitations of MRI specific to abdominal and pelvic imaging.
• Formulate a reasonable differential diagnosis based on the signal characteristics of detected abnormalities.
• Gradually acquire knowledge of imaging protocols and the reasoning behind these protocols.
• Show an understanding of a sound, succinct and systematic style of reporting.

Communicator

• Produce reports which describe imaging findings, most likely differential diagnoses and recommend further testing or management.
• Understand the importance of communication with referring physicians, including an understanding of when the results of an investigation or procedure should be urgently communicated.
• Communicate effectively with patients and their families and have a compassionate interest in them.
• Recognize the physical and psychological needs of the patient and their families undergoing an MRI investigation including culture, race and gender issues.

Collaborator

• Demonstrate the ability to function as a member of a multidisciplinary health care team.
• Develop confidence in effective consultation, conduct of radiological conferences and ability to present material and lead case discussions.

Manager

• Manage time effectively to balance patient care and learning needs.
• Understand the use of available computer workstations and PACS including the three dimensional work station as it pertains to the practice of magnetic resonance imaging.

Health Advocate

• Understand and communicate the benefits and risks of MRI.
• Recognize when MRI would be detrimental to the health of the patient, for instance in the presence of metal implants or extreme claustrophobia.
• Educate and advise on the use and misuse of MRI.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise medical literature.
• Gain the ability to be an effective teacher of magnetic resonance imaging to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for assigned duties.
• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal behaviours including accepting constructive criticism.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements in the performance and interpretation of magnetic resonance imaging studies.

Schedule

Daily

Day begins at 8:00 am or 8:30 when there are morning rounds.

Determine if any studies require urgent interpretation.

Protocol 20 or more cases on CPEO under the supervision of the radiologist.

Review of all available examinations, with subsequent staff review throughout the day and report these cases on that day.

Be available throughout the day to deal with queries from technologists, including “scan & show” cases, Buscopan injections, rectal contrast.

Be available throughout the day for consultations from clinicians.

On the odd Tuesday morning and Friday, there might be 3 trainees on service at the Civic.  In order to optimize the workload for trainees and add exposure to scanning problem solving with technologists, we recommend the following:

• If 3 trainees are present on Tuesdays, the fellow spends the morning with the MR technologists
• If 3 trainees are present on Fridays one resident should spend the morning and the other the afternoon with the technologists

The technologists are excellent teachers and are happy to help trainees understand practical aspects of scanning.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading

Richard C. Semelka. Abdominal-Pelvic MRI. Wiley. 3rd ed. 2009.

Evan S. Siegelman. Body MRI. Saunders. 2004.

Revised: Jan 10, 2017

Breast Imaging and Interventional

Supervisor

Dr. Raman Verma

Scheduling

Breast

Ideal Scheduling

Second half of PGY2 year

Second half of PGY3 year

First half of PGY4 year

First half of PGY5 year

Introduction

This rotation aims to teach the resident in a graduated fashion the principles of breast cancer screening and to familiarise the resident with diagnostic breast interventional techniques. Modalities to be covered include mammography, ultrasound and MRI.

Educational Objectives

Medical Expert-Clinical Decision Maker

Objectives are divided into Junior (PGY2&3) and Senior (PGY4&5) objectives.

Junior Residents

• Become familiar with mammographic positioning.
• Understand the physics of mammography and the basics of quality control.
• Develop a basic approach to mammographic interpretation.
• Understand the mammographic and ultrasound characteristics of benign and malignant lesions.
• Become proficient in performing breast ultrasound.
• Become familiar with the different types of breast microcalcifications and their mammographic appearance.
• Work-up a palpable breast lump or a mammographic asymmetric opacity, microcalcification or nodular lesion.
• Perform a stereotactic core breast biopsy using a biopsy gun without assistance.
• Perform a cyst aspiration under ultrasound guidance without assistance and an ultrasound guided biopsy of lesions over 1 cm in size with staff assistance.
• Become familiar with the performing of needle localization.

Senior Resident

• Report all available mammograms on a daily basis.
• Review and report all breast ultrasound examinations performed daily with minor staff assistance.
• Perform all the stereotactic core biopsies without assistance and all the ultrasound guided core biopsies with only minor assistance.
• Perform mammotome biopsies with minor assistance.
• Perform all available pre-operative needle localizations with minor assistance.
• Protocol all Ontario Breast Screening Program work-ups, supervise work-ups and make appropriate management decisions with minor assistance.
• Review referrals for biopsies and decide on appropriate management with some assistance.
• Suggest appropriate patient management when faced with a surgical pathology report from a core biopsy that does not correlate with the mammographic or ultrasound appearance of a lesion.
• Function as a junior consultant within the breast imaging & intervention team including the surgeons & nurses at the centre.
• Understand the indications, basic protocol and basic interpretation of breast MRI.

Communicator

• Produce a breast imaging report which describes imaging findings, most likely differential diagnoses and recommend further testing and management.
• Understand the importance of communication with referring physicians, including an understanding of when results should be urgently communicated.
• Communicate effectively with patients and their families and have a compassionate interest in them.
• Recognize the physical and psychological needs of patients and their families undergoing breast imaging investigations and/or treatment including issues related to culture, race and gender.

Collaborator

• Demonstrate an ability to function as a member of a multidisciplinary health care team especially with technologists, nurses, surgeons and family physicians.

Manager

• Conducting or supervising quality assurance in mammography including an understanding of the safety issues and economic considerations.
• Understand computer science as it pertains to the practice of breast imaging and intervention.

Health Advocate

• Understand and communicate the benefits and risks of breast imaging and intervention, including population screening.
• Recognize when breast imaging or intervention would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of breast imaging.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise available and relevant medical literature.
• Effectively teach medical imaging and intervention to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for assigned duties.
• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal behaviours.
• Practice breast imaging and intervention ethically and consistent with the obligations of a physician respecting the needs of culture, race and gender.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements of breast imaging and intervention.

Schedule

Daily

The rotation takes place at the Women’s Breast Health Centre on the 5^th floor in the Grimes Lodge and at the Riverside Campus of The Ottawa Hospital.

The resident should be present from 08:00 to 17:00.

The resident will be relieved of his/her duties from 12:00 - 1:00 for daily teaching rounds, academic half-day and all other scheduled teaching activities.

The resident should attempt to be available for all scheduled procedures.

The resident should keep a log book of all procedures performed as well as the pathology results of these procedures.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading

Daniel B Kopans. Breast Imaging; Lippincott Williams & Wilkins. 3rd ed. 2006.

Gilda Cardenosa. Breast Imaging Companion; Lippincott Williams & Wilkins. 3rd ed. 2007.

Ellen Shaw de Paredes. Atlas of Mammography; Lippincott Williams & Wilkins. 3rd ed.

American College of Radiology. Breast Imaging Reporting and Data System® (BI-RADS®) Atlas. 2007.

Revised: May 5, 2010.

CARDIAC RADIOLOGY  

SUPERVISOR Dr. Anuj Dixit  

SCHEDULE HEADING Cardiac  

IDEAL SCHEDULING

- Junior rotation (4 weeks of cardiac) -PGY2/3

- Senior rotation of combined cardiothoracic radiology -PGY4/5

INTRODUCTION

Cardiovascular radiology involves imaging of the heart, pericardium, cardiac valves and thoracic systemic and pulmonary vessels.  It also involves imaging the effect of heart disease on the lungs.

The first rotation aims to provide basic knowledge and exposure to the field of cardiovascular radiology, thus providing a solid background for the second rotation.

During the second rotation the resident will have a more focused exposure to cross-sectional imaging. The junior rotation occurs during PGY-2/3 lasting 4 weeks and the senior rotation occurs during PGY-4/5 and lasts 4 weeks. A duration of 8 weeks is felt to be required to ensure the resident gains adequate exposure to the increasing number of cross-sectional modalities used to image the cardiovascular system and to familiarize the resident with the different post-processing software techniques used for study interpretation. Although, a 8-week period is insufficient to acquire the knowledge and skills expected of a cardiovascular radiologist, the goal of the rotation is to familiarize the resident with the main imaging modalities in cardiac radiology and their indications and contraindications, as well as to acquire interpretative skills to diagnose the most common cardiac and thoracic vascular diseases. It is felt that a minimum of 3 weeks in each of the rotations (cardiac and cardiothoracic) is necessary to meet the goals and objectives of the rotation.

EDUCATIONAL OBJECTIVES:

General Objectives

1. Acquire a basic knowledge of cardiovascular radiology, including the interpretive and consultative skills expected of a general radiologist.
2. Acquire a working knowledge of the various modalities used in cardiovascular imaging, including their scope and limitations.

Medical Expert-Clinical Decision Maker

1. Describe the anatomy of the heart, coronary arteries, valves and thoracic vasculature (aorta and pulmonary arteries) on x-ray, CT and MRI.
2. Demonstrate the ability to interpret chest radiographs in patients with cardiac disease in both the outpatient and acute settings.
3. Explain the most common cardiac and thoracic vascular disease processes.
4. State the indications and contraindications for cardiac CT and MRI.
5. Explain patient preparation including heart rate control required for cardiac CT.
6. Discuss the different types of imaging acquisition techniques used for cardiac CT and thoracic aortic CT angiography including retrospective and prospective gating
7. Interpret CT and MR of the thoracic aorta, heart and pericardium
8. Apply reconstruction techniques to reformat the coronary arteries and thoracic aorta using post-processing software.
9. Discuss the imaging planes and basic sequences used in cardiac MRI.

Communicator

1. Recognize a sound and systematic style of reporting.
2. Communicate effectively with patients.
3. Produce imaging reports, which describe major imaging findings, most likely differential diagnoses and recommended further testing and management.
4. Understand the importance of communication with referring physicians including an understanding of when the results of an investigation should be urgently communicated.

Collaborator

1. Consult effectively with other physicians, technologists, nurses and other health care professionals.
2. Demonstrate the ability to function as a member of a multidisciplinary health care team especially with referring cardiac surgeons and cardiologists.

Manager

1. Utilize resources effectively to balance patient care and learning needs.
2. Utilize information technology to optimize patient care.

Health Advocate

1. Identify the important determinants of health affecting cardiac patients and balance radiation dose with the clinical benefit of an imaging study.
2. Understand and communicate the benefits and risks of cardiovascular investigation and treatment including population screening.
3. Recognize when radiological investigation or treatment would be detrimental to the health of the patient.
4. Educate and advise on the use and misuse of cardiovascular imaging.

Scholar

1. Develop, implement and monitor a personal continuing education strategy.
2. Critically appraise sources of medical information.
3. Demonstrate the ability to teach the plain film and basic CT and MR findings of cardiac disease to medical students, residents, technologists and clinical colleagues.

Professional

1. Be punctual and available for assigned duties.
2. Deliver the highest quality care with integrity, honesty and compassion.
3. Exhibit appropriate personal and interpersonal behaviours.
4. Accurately assess one’s own performance, strengths and weaknesses.
5. Understand the ethical and legal requirements of cardiac radiology.

LOCATION:

Rotation is based in the S-level of the Heart Institute in the common reading room. This is one floor beneath the Heart Institute foyer/ cafeteria. The radiology staff will be in a smaller reading room next to the CT scanner. Your ID badge will not be programmed to access this room and you will have to contact the staff to let you in. The staff will be available at 613-696-7000 ext. 10927.

Please use the system templates/iPad for reports especially for cross sectional imaging (cardiac MR and cardiac CT, CT thoracic aorta as well as TAVI CTs). Borrow the templates from the fellows/staff.

EXPECTATIONS:

The staff, residents and fellows in cardiac radiology have the following expectations to complete each day as a team:

1. Report all inpatient chest radiographs reviewed before 3:00 PM at the Heart Institute
2. Report all high and stat chest/aorta CT’s reviewed before 5:00 PM at the Heart Institute
3. Cardiac CT days: Report all cardiac CTs performed that day as well as the MR aorta
4. Cardiac MR days: Report all cardiac MRs performed the prior day
5. On certain days there will be a second cardiac radiologist who will be covering structural cardiac CT and CT aortas. Please review this on qGenda in order to know who to review those cases with
6. Outpatient aorta CT and MR time permitting

PLAIN FILMS:

You should report at least 20-25 plain films every day. You will dictate and review chest radiographs with staff in the morning and afternoon. You are responsible for all inpatient chest radiographs reviewed before 3:00 PM at the Heart Institute

CARDIAC CT DAYS (JUNIORS):

There are 15-22 cardiac CT’s/day. The first 2 weeks of your rotation, you are expected to report at least 1 cardiac CT/day and progressively increase the number of cardiac CT’s to 2-3 /day by the end of the rotation.

At the beginning of the day, you should communicate with the fellows and agree on which case(s) you will be reporting.  Cases are reviewed as a group with the fellows and staff.  You are encouraged to participate in the review and be prepared to discuss the case(s) you are reporting.

You are encouraged to review as many cardiac CT’s as you can on a daily basis in order to familiarize yourself with post-processing techniques and to participate during the reviews.

Cardiac CT Report forms / iPad’s are available from the technologists so you can record your findings for each patient. If you discard the case report forms at the end of the day, put them in the confidential waste bin as you exit the CT/MR area before the double doors near the elevator rather than in the garbage in the reporting room.

You are also expected to report at least 2-4 CT chest/aorta/pulmonary angiograms per day.

******NOTE FIRST DAY OF CARDIAC CT************:

On your first day of the rotation you should watch at least 1 cardiac CT performed by the technologists. Focus on familiarizing yourself with the details of image acquisition.  It is important to watch the cardiac CT nurse go through the history with one of the patients prior to one cardiac CT to understand the heart rate control medication algorithm and the important questions that determine the pre-test probability of coronary artery disease in each patient.

CARDIAC MR DAYS (JUNIORS):

Read the prior days outpatient cardiac MR’s as well as any inpatient cardiac MRI done on the same day. You should review at least 1-2 cardiac MRI’s before the daily review with staff and fellows and you should be prepared to discuss these. At the beginning of the day, you should communicate with the fellow and agree on which case you will report. You are expected to report at least 1 cardiac MR/day. Focus on routine cases such as ischemic and non-ischemic cardiomyopathies. Congenital cases should be avoided until your senior rotation. You should review all the MR cases done even if you do not dictate them so that you are able to review the cases during the review.

**********NOTE FIRST DAY ON CARDIAC MR******:

On your first day in cardiac MR dedicate time to observe the technologists perform 1 cardiac MR and 1 MR angiogram of the aorta or pulmonary arteries. Focus on the different cardiac planes and sequences used in cardiovascular MR. Once you have done this, observe the fellow perform post-processing. Ask the staff or alternatively the fellow to teach you how to navigate through the multiple sequences sent to PACS for every cardiac MR so that you are able to look at these independently.

CARDIAC CT DAYS-SENIOR ROTATION:

You are expected to read at least 2-3 cardiac CT’s/day at the beginning of the rotation and progressively increase the number of cardiac CT’s up to 3-4 cardiac CTs/day by the end of the rotation.

Remember, you are able to interpret as many cardiac CT’s as you can (10-14 cases/day) but you are only expected to dictate 2-3 cardiac CT’s.

Please communicate with the fellows at the beginning of the day so you that you can agree on which cases you are reporting. The cardiac CT’s will be reviewed in the afternoon with staff and fellows and you are encouraged to participate in the review and discuss the cases you have read.

*You are encouraged to read 2-4 aorta/chest CTs (aortography, CT pulmonary angiography and inpatient CT’s).

CARDIAC MR DAYS-SENIOR ROTATION:

At the beginning of the day, you should communicate with the fellows and agree on the case(s) you will be reporting. You should review 1-2 cardiac MR’s before the review and be prepared to discuss your findings.

*You are encouraged to read at least 1-4 chest/aorta CT’s/day .

MULTIDISCIPLINARY ROUNDS:

TAVI Rounds: Every Thursday @ 7:40 AM

Congenital Heart Disease Rounds: Monthly on Monday @ 5:30 PM

Aorta Rounds: Infrequent, staff will inform you if they are occurring during your rotation

EVALUATION:

Mid-rotation written evaluation

Written and face-to-face/ virtual feedback at the end of rotation

RECOMMENDED – RESOURCES & READINGS

PHONE APPS:

CMR Explorer: https://apps.apple.com/ca/app/cmr-explorer/id1449044618

CMR CHD: https://apps.apple.com/ca/app/cmr-guide-chd/id1457448420

Cardiac Imaging Planes: https://apps.apple.com/ca/app/cardiac-imaging-planes-1-2-3/id595251859

eAnatomy: https://apps.apple.com/us/app/imaios-e-anatomy/id334876403

ON-LINE RESOURCES:

Journal of Thoracic Imaging- Residents’ Collection:

http://journals.lww.com/thoracicimaging/pages/collectiondetails.aspx?TopicalCollectionId=15

North American Society of Cardiac Imaging (NASCI)- Education- Curriculum

http://www.nasci.org/Education/Cardiovascular-Imaging-Curriculum/Table-of-Contents

NASCI Curious Cases Webinar (first Tuesday of every month at 4:00 pm EST with ability to watch prior webinars free of charge):

https://www.nasci.org/curious-cases-webinar/

CMR Pocket Guides

Cardiovascular and Congenital Heart Disease pocket guides-

https://www.escardio.org/Sub-specialty-communities/European-Association-of-Cardiovascular-Imaging-(EACVI)/Research-and-Publications/CMR-Pocket-Guides

Society of Thoracic Radiology-Online Lectures in Cardiac Imaging

http://thoracicrad.org/?portfolio=education

University of Virginia-Cardiac MR: The Basics

http://www.med-ed.virginia.edu/courses/rad/cardiacmr/index.html

READINGS:

ARTICLES:

Selected papers on cardiac CT and MR articles are available via Google Drive. Please ask the rotation supervisor to share the link with you. This will be regularly updated.

BOOKS:

Cardiac Imaging: Rad Cases.

Cardiac Radiology: The Requisites.

Cardiac Imaging (Rotations in Radiology) – email rotation supervisor if a copy is needed

Cardiovascular Magnetic Resonance: A Companion to Braunwald’s Heart Disease

Goals & Objectives Thoracic Radiology

Supervisor

Dr. C. Souza General Campus

Dr. R. Peterson Civic Campus

(updated July 2014)

Schedule Heading

Chest

Ideal Scheduling

PGY2 – 2 blocks at the General Campus approximately 6 months apart

PGY3 – 1 block at the Civic Campus

PGY4 – 1 block at the General Campus

PGY5 – 1 block at the General Campus in the first half of the year

Introduction

The thoracic imaging rotation is system oriented with training in all appropriate imaging modalities and interventional procedures. There is a close working relationship with respirology, thoracic surgery, oncology and pathology.

Educational Objectives

Medical Expert-Clinical Decision Maker

PGY2 and PGY3

• Understand the nature of formation of x-ray and CT images of the chest, including the physical and technical aspects, patient positioning and contrast media.
• Gain knowledge of chest anatomy on both x-ray and CT.

PGY4 & PGY5

• Perform interventional procedures including fine needle aspiration biopsies of focal thoracic lesions, core biopsies and insertion of pleural drainage catheters.
• Demonstrate the ability to manage the patient independently during procedures in close association with the technologists and nurses as well as the specialist or other physician who have referred the patient.
• Know when the patient’s best interests are served by discontinuing a procedure or referring the patient to another physician.
• Attain the knowledge and ability to manage radiological complications effectively.

All Residents

• Gain knowledge of the theoretical, practical and legal aspects of radiation protection and the possible harmful effects of radiation.
• Gain knowledge of clinical radiology including understanding of thoracic diseases, appropriate selection of imaging modality, importance of informed consent and complications such as contrast media reactions.
• Understand the fundamentals of quality assurance in thoracic radiology.
• Understand the acceptable and expected results of investigations and/or interventional therapy as well as unacceptable and unexpected results.
• Understand the appropriate follow-up care of patients who have received investigations and/or interventional therapy.
• Show understanding of a sound and systematic style of reporting.
• Develop effective consultation skills, conduct clinico-radiological conferences, present scholarly material and lead case discussions.

Communicator

• Demonstrate the ability to produce a report to describe the imaging findings, most likely differential diagnoses and recommend further testing and/or management.
• Understand the importance of communication with referring physicians, including an understanding of when the results of an investigation or procedure should be urgently communicated.
• Communicate effectively with patients and their families and have a compassionate interest in them.
• Recognize the physical and psychological needs of the patients and their families undergoing radiological investigations and/or treatment including the needs of culture, race and gender.

Collaborator

• Learn to function as a member of a multidisciplinary health care team including the thoracic surgeons, respirologists, oncologists and the pathologists.

Manager

• Gain competency in supervising quality assurance, including assessing the quality of all reported imaging studies.
• Become competent in computer science as it pertains to the practice of thoracic radiology.

Health Advocate

• Understand and communicate the benefits and risks of fine needle aspiration biopsy, core biopsy and insertion of a pleural drainage catheter.
• Learn to recognize when radiological investigation or treatment would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of radiological diagnostic tests and intervention.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Demonstrate the ability to be an effective teacher of radiology to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for film review.
• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and medical/legal requirements of radiologists.

Schedule

Plain films

The resident will review and report with a chest radiologist daily.

CT

The resident will assess CT scans, review these with staff and dictate them daily. The resident should protocol CT requisitions at least once weekly and review these protocols with staff.

Lung biopsies

The resident will learn to perform lung biopsies and insert pleural catheters. 

The resident should protocol biopsy requisitions at least once a week. 

At the General Campus the resident is responsible for the 9am biopsy and is welcome to be involved in other procedures any given day. 

At the Civic Campus the resident will assist with procedures all days.

Chest ultrasound and interventional techniques

The resident will learn to perform thoracentesis, catheter drainage of empyema or effusions.

ICU film interpretation

The resident will participate in the review and reporting of ICU radiographs.

Daily

Day begins: 8:00 am.

Day ends: 5:00 pm.

Clinical rounds: 12:00 to 1:00 pm

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading

Webb, Mueller. High Resolution CT of the Lung. 4th ed. 2008, Lippincott Williams & Wilkins.

Fraser, Colman. Synopsis of Diseases of the Chest. 3rd ed. 2005. Saunders. Muller, Silva.

Imaging of the Chest, 2-Volume Set: Expert Radiology Series. 1st ed. 2008. Saunders

ACR Learning File online.

Revised: September 2012.

Goals & Objectives Community Elective

Supervisor

Riverside Campus and Renfrew Victoria Hospital- Dr. Frank Lee

Other Sites (non-TOH) – As Per Individual Rotation arrangements.

Schedule Heading

Community Elective

Ideal Scheduling

PGY4 – 1 block

*** Option for residents to go to Renfrew for up to 3 days/ week to complement the time at the Riverside.A Radiologist is on-site on Tuesday-Wednesday and Friday. The resident should discuss which day(s) they want to spend there with Dr. Lee.

*** On Thursdays the Resident should go to the General Campus Prostate Biopsy Service (7^th floor CAC).

General Objectives

PGY4: To provide an introduction to the different scope and pace of practice in non-academic centers. This also allows residents to experience practice in more remote areas that may not have access to the myriad modalities offered at academic centers.

Objectives

Medical Expert/Clinical Decision Maker

1. To obtain an understanding of the varied modalities and body systems that a general community radiologist must be familiar with.
2. To gain an understanding of how to manage patients with more limited resources than typically available at an academic center.  This may include arranging urgent referral to the ED in the cases when unexpected or urgent findings arise.

Communicator

• To report studies in a sound and systematic style which accurately describes imaging findings and most likely differential diagnoses, and recommends further testing or other management when indicated.
• To understand the importance of communication with referring physicians, including an understanding of when results should be urgently communicated.
• To recognize the physical and psychological needs of the patient undergoing investigations and their families, including factors related to culture, race, and gender.
• To communicate effectively with patients and their families the indication and complications of examinations and or procedures.

Collaborator

• To function as a member of a multidisciplinary health care team by consulting effectively with other physicians and health care professionals, and by contributing effectively to team activities.

Manager

• To gain an understanding of quality assurance in a general radiology department including safety issues and economic considerations.
• To learn to take on a role as manager of a busy imaging department including communication with referring clinicians, technologists and clerical staff.

Health Advocate

• To understand and communicate the benefits and risks of imaging, including the theoretical, practical and legal aspects of radiation protection, possible harmful effects, complications of procedures and contrast administration.
• To recognize when examinations or procedures would be detrimental to the health of a patient and educate and advise on the use of alternate modalities or diagnostic strategies.

Scholar

• To learn the critical appraisal of medical information as it pertains to this rotation and develop, implement and monitor a personal continuing education strategy.
• To facilitate the learning of patients, staff, students and other health professionals.

Professional

• To learn to accurately assess one’s own performance, strengths, and weaknesses and obtain staff feedback in these regards.
• To gain an understanding of the ethical, medial, and legal requirements of a radiologists.
• To exhibit appropriate personal and interpersonal professional behaviors.
• To be available for assigned duties.
• To be punctual.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Last updated: May 5, 2010.

Daily Schedule (Riverside Campus—other sites will vary)

• The workday begins either after morning rounds at the General, or, if there are no rounds, at 8am.
• The resident will plan the schedule for the month prior to starting the rotation and will review with Dr. Lee.
• The resident and staff will decide beforehand what types of cases and procedures are to be reviewed and performed. Ideally, the resident will be exposed to a balanced mix of fluoroscopy, biopsy, CT, US and MR. This may involve performing a variety of duties every day, or focusing on one duty (eg. US) and rotating on a daily basis.
• Cases will be reviewed with the staff radiologist (and fellow as appropriate). A minimum of two review sessions should occur daily, one in the morning, and one in the mid-afternoon. (e.g. 10:30 and 15:30) A third review session in the late afternoon will often also be required.
• All cases will be dictated before the end of the day. Ideally, at least one of the daily review sessions with staff should include a review of some of the resident approved report.
• Sick Days - When a resident is obliged to take a sick day, the resident is obligated to inform one of the site specific administrative assistants of the absence. The appropriate people can then be notified.

Reading List

No specific texts. Reading based on the modality and or organ system of focus is recommended.

Updated: July 14^th, 2015

Goals & Objectives ENT Neuroradiology

Supervisor

Dr. Lancu

Schedule Heading ENT/Neuro

Ideal Scheduling

Second half of PGY3

Introduction

The ENT radiology allows exposure to a maximum of head and neck imaging. Residents on regular Neuroradiology rotations will preferably leave ENT studies for the resident on this rotation. On days where the volume of ENT studies is insufficient, the ENT radiology resident will supplement their workload with regular Neuroradiology studies.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Become familiar with the anatomy of the paranasal sinuses, nasopharynx, oropharynx, hypopharynx and larynx.
• Understand the different anatomical compartments of the neck.
• Become familiar with the different pathologic processes which occur in each compartment.
• Understand staging of head and neck cancer and how it relates to different treatment options.
• Become familiar with the differential diagnoses of lesions affecting the head & neck according to the compartment the lesion is placed in.
• Volume of imaging expected of 8-10 CTs, or 6-8 MRIs, per half day.

Communicator

• Produce a radiologic report which will describe the imaging findings, most likely differential diagnoses and when indicated recommend further testing and/or management.
• Understand the importance of communication with referring physicians including an understanding of when the results of an investigation or procedure should be urgently communicated.

Collaborator

• Demonstrate the ability to function as a member of a multidisciplinary health care team especially with the ENT surgeons and pathologists.

Manager

• Utilize resources effectively to balance patient care, life-long learning and other activities.
• Utilize information technology to optimize patient care.

Health Advocate

• Educate and advise on the use and misuse of ENT imaging.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Learn to critically appraise medical literature.
• Demonstrate the ability to be an effective teacher of ENT radiology to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for assigned duties.
• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal behaviours.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements of ENT radiology.

Schedule

Daily

Review each day’s ENT CT scans and MRIs.

Attend ENT rounds invariably every Thursday at 12:15PM, Conference rooms A&B, TOHCC, at the OGH. Residents should attend if presenting cases or there are no resident rounds.

Evaluation

Mid-rotation verbal evaluation.

Written end of rotation evaluation.

Recommended Reading

Shankhar, Khan, Cheung. Head & Neck Imaging.

Harnsberger. Handbook of Head & Neck Imaging.

Reference: Som, Curtin. Head & Neck Imaging

Revised: Sep 08, 2016.

Fluoroscopy

Variable (see schedule)

Schedule Heading

Fluoro-GI

Ideal Scheduling

Early PGY2

Introduction

During this 4-week rotation, the resident will learn fundamental fluoroscopy skills, including patient safety and quality supervision for a variety of inpatient and outpatient GI procedures. The resident will learn inpatient exam selection and protocolling as well as inpatient and outpatient exam performance, interpretation and reporting of the following procedures: pharyngogram, esophagogram, upper GI exam, small bowel follow-through, single contrast and double contrast enema, enteroclysis, sialogram, fistulogram and anogram as the availability of clinical material permits. Abdominal radiograph quality supervision and reporting will be taught.

Evaluation will be based on the resident’s performance in procedures, film interpretation, reporting and oral examination as well as satisfactory completion of the general objectives.

Residents will spend time at both the General and Civic Campuses (see daily schedule for details).

When there are no fluoro cases the resident should report AXR and body CT including CT enterographies.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Understand the formation of x-ray images and fluoroscopy, including the physical and technical aspects.
• Gain a knowledge of contrast media used in GI examinations.
• Gain an understanding of patient positioning used in GI examinations.
• Gain a knowledge of the anatomy related to GI radiology.
• Learn the importance of informed consent and the possible complications of contrast media administration.
• Understand the fundamentals of quality assurance.
• Demonstrate the ability to manage the patient independently during a procedure in close association with the technologists. The resident should know when the patient’s best interests are served by discontinuing a procedure or referring the patient to another physician.
• Understand the acceptable and expected results of GI examinations and interventional therapy as well as unacceptable and unexpected results. This must include knowledge of and ability to manage radiological complications effectively.
• Understand the appropriate follow-up care of patients who have received investigations and/or interventional therapy.
• Show an understanding of a sound and systematic style of reporting.
• Begin effective consultations and be introduced to clinical-radiological conferences.
• Begin to present scholarly material and lead case discussions. 

Communicator

• Communicate effectively with patients and their families and have a compassionate interest in them.
• Produce imaging reports which describe major plain film findings, most likely differential diagnoses and recommend further testing and management.
• Understand the importance of communication with referring physicians including an understanding of when the results of an investigation should be urgently communicated.
• Recognize the physical and psychological needs of the patient and their families undergoing GI examinations including the needs of culture, race and gender.

Collaborator

• Consult effectively with other physicians, technologists, nurses and other health care professionals.
• Demonstrate the ability to function as a member of a multidisciplinary health care team.

Manager

• Utilize resources effectively to balance patient care and learning needs.
• Utilize information technology to optimize patient care.
• Be competent in conducting or supervising quality assurance including understanding of safety issues and economic considerations.

Health Advocate

• Identify the important determinants of health affecting patients and balance radiation dose with the clinical benefit of an imaging study.
• Understand and communicate the benefits and risks of investigation and treatment including population screening.
• Recognize when radiological investigation or treatment would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of imaging.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Demonstrate the ability to teach the plain film findings of cardiac disease to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for assigned duties.
• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal behaviours.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and legal requirements of radiology.

Schedule

Daily

Day begins: 8:30 am (or 8am if there are no morning rounds)

Day ends: 5:00 pm or when the resident finishes dictations from the day.

Clinical rounds: as per rounds schedule

Civic Campus

• Tuesday** Note on the second Tuesday every month the resident should go to the General rather than the Civic Campus for the outpatient GI cases.
• Wednesday
• Friday

The radiology resident would then rotate to General Campus on Mon & Thurs.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Written end of rotation examination.

Recommended Reading

Textbook of Gastrointestinal Radiology. Richard M. Gore, Marc S. Levine. Saunders. 3 ed 2007.

Fundamentals of Gastrointestinal Radiology, Davis M, Houston JD, W.B. Saunders Co., 2002.

Gastrointestinal Radiology: The Requisites, 3rd Edition. Halpert RD, Feczko PJ, Mosby, 2006.

Barrett’s Esophagus: Diagnosis by Double-Contrast Esophagography: Gilchrist AM et al, AJR, Vol 150: pp. 97-102, Jan 1988.

Benign Gastric Ulcers: Diagnosis and Follow-up with Double-Contrast Radiography: Levine MS et al, Radiology, Vol 164: pp. 9-12, 1987.

Single-Contrast vs Double-Contrast Barium Enema in the Detection of Colonic Polyps: Ott DJ et al, AJR, Vol 146: pp. 993-996. 1986.

Double-Contrast Examination of the Colon without Decubitus Films: Gelfand DW, Ott DJ, AJR, Vol 169: pp. 1565-1567, Dec 1997.

Buscopan and Glaucoma: A Survey of Current Practice: Fink AM, Aylward GW, Clinical Radiology, Vol 50: pp. 160-164, 1995.

Patient Dose Reduction by Audit of Grid Usage in Barium Enemas: Seymour R.  British J. of Radiology, Vol 70: pp. 489-491, 1997.

Purpose of tbhe upper GI exam (UGI)

Despite the critical role historically played by UGI exam in the diagnosis of many disorders of the esophagus, stomach and duodenum, recent technologies have superseded fluoroscopy in many routine assessments of the upper GI tract.

Because of the successful treatment of most hyperacidity and H. pylori infections with modern therapy, peptic ulcer disease is a rarity and in general the UGI is not designed to uncover early evidence of such disease, or to investigate refractory dyspepsia.

Because endoscopic examination has become so widespread, UGI screening for malignancy is no longer indicated. The same is true for the search for occult bleeding or general assessment of esophageal or gastric mucosa.

The remaining indications for UGI include:

1. Dysphagia of any kind, motility assessment of the esophagus or stomach, upper GI obstructive symptoms,
2. Pre and post-surgical depiction of upper GI anatomy,
3. Respiratory presentations including pneumonia, asthma, aspiration, laryngitis,
4. Inability to tolerate endoscopy.

Since fluoroscopy involves ionizing radiation the radiologist has a duty to assess appropriateness of UGI requests and to direct the request to alternative tests if indicated.

Patient Safety

The radiologist must ensure that the exam is carried out with attention to patient safety, managing risks that include:

1. Contrast allergy
2. Table safety (falls, abrasions, blows from the overhead tube)
3. Aspiration
4. Ionizing radiation

Ask questions of technologists and radiologists in order to discover all the measures that can be taken to minimize risk. Upon entering the examination room the radiologist is the de facto radiation safety officer for the study. Your responsibility is to protect the patient, your coworkers and yourself from unnecessary exposure.

Ionizing Radiation

Measures to minimize radiation exposure to the patient include:

1. Keeping the collimation strictly limited to the area of interest. Magnify only when needed to depict small features.
2. Using the collimation light rather than active fluoroscopy to centre the beam.
3. Using continuous fluoro consciously to evaluate only dynamic processes. Do your thinking in front of still captured image.
4. Taking full exposure images only when the best spatial resolution is required.
5. Relying on fluoro image capture for the bulk of the exam. Learn how to maximize the quality of the fluoro image.
6. Avoiding patient positions or tube positions that produce excessive beam path length.

Because of the distribution of the anatomy and the requirement for frequent movement of the patient, the use of patient shielding (gonadal, breast) during much of the UGI is impractical. A reasonable goal for fluoroscopy time accumulated during outpatient UGI is 2 minutes. Report your fluoro times in order to become aware of your performance.

Performing the UGI

Interviewing the patient

Read the requisition. Introduce yourself to the patient, including your role as radiologist. Make sure the patient knows the basics of what is involved in the test. Ask the patient to give their version of the presenting symptoms. Ask relevant questions that may lead to modifications of your exam (evidence of aspiration, obstructed deglutition, limited mobility). Anticipate the major pathologies suggested by the patient’s account of symptoms and modify your exam accordingly.

The basic image record

Remember the radiologist’s dictum:” One view is no view”. In order to make a rational assessment of the anatomy, each element should be depicted in at least 2 views approaching orthogonality. Ideally this should include both a single contrast depiction using the Ba puddle and a double contrast depiction for each portion of the anatomy.

A good exam is a speedy exam. The conditions for optimal depiction of the stomach and duodenum deteriorate rapidly. Distending gas escapes; Ba suspension separates; contrast in small bowel shrouds the stomach.

Pharynx

If the patient has convincing pharyngeal symptoms, a dedicated depiction of pharyngeal swallowing is called for. This includes lateral, AP and prone right decubitus projections. Images should include elements of oral bolus delivery, condition of the soft palate, the larynx and upper trachea, the action of the cricopharyngeus. Record suitable images from a continuous fluoro capture.

Esophagus

Different approaches can be taken:

1. Starting with supine swallowing: This will put maximum load on muscular propulsion of the bolus and achieve maximal distension.
2. Starting with upright swallowing: This is more physiologic and is a better assessment of the practical severity of the problems.

Any anatomic or functional abnormality deserves both upright and supine or prone right decubitus depiction, in addition to orthogonal projections.

Depiction of the esophagus must include the actions of the cricopharyngeus and of the distal sphincter.

Stomach

Portions to be depicted specifically:

1. The cardia
2. The fundus
3. The body of the stomach
4. The antrum
5. The pylorus.

Learn the projections that provide optimal depiction of each of these portions.

Duodenum

Both single and double contrast depictions are required.

Learn the projections that optimize depiction of the duodenum. Learn how to encourage gastric emptying. Buscopan IV can be administered to obtain a hypotonic duodenogram if spasm is a problem.

GE reflux

If reflux occurs spontaneously during the exam, no provocative manoeuvre is required. The provocative manoeuver for GE reflux involves loading a Ba pool against the cardia, and having the patient swallow water to provoke return of Ba into the esophagus.

This may be done prone, supine, horizontal or with Trendelenburg, with or without abdominal

compression. Learn the advantages and disadvantages of each. Learn how to execute the manoeuvre promptly.

Jejunum

The last image is a quick single view of the proximal small bowel that excludes malrotation and displays normal early transit.

Revised: Jan 10, 2017

• Other topics and skills to be learned:
  • Advanced techniques of endometrial assessment, including endometrial saline infusion ultrasound.
  • Ectopic pregnancy including diagnosis, pitfalls, and differential diagnosis, pseudo-gestational sac, heterotopic pregnancy, sub-chorionic hemorrhage, ultrasound signs of early pregnancy failure, multiple gestations including determination chorionicity and amnionicity.
• To review cases with the gynecologist and report these where appropriate.

Communicator

• To demonstrate the ability to produce a report which describes the imaging findings, most likely differential diagnoses, and when indicated, to recommend further testing and/or management.
• To understand the importance of communication with referring physicians, including when the result of an investigation or procedure should be urgently communicated.
• To communicate effectively with patients and families and have a compassionate interest in them.  To possess a sensitivity to the propriety of the female patient undergoing a gynecologic scan and a sensitivity to the psychological reactions following pregnancy loss.
• To recognize the physical and psychological needs of the patient and their families undergoing radiological investigations and/or treatment including the needs of culture, race, and gender.

Collaborator

• To function as a member of a multidisciplinary health care team.

Manager

• To learn to utilize resources effectively to balance patient care, learning needs, and other activities.
• To learn to work effectively and efficiently in a health care organization.
• To utilize information technology to optimize patient care, learning and other activities.

Health Advocate

• To understand and communicate the benefits and risks of ultrasound.
• To educate and advise on the use and misuse of ultrasound imaging.

Scholar

• To develop, implement and monitor a personal continuing education strategy.
• To critically appraise medical information.
• To demonstrate the ability to be an effective teacher of ultrasound to medical students, residents, technologists and clinical colleagues.

Professional

• To be punctual and be available for assigned duties.
• To deliver the highest quality of care with integrity, honesty and compassion.
• To exhibit appropriate personal and interpersonal professional behaviors including accepting constructive criticism.
• To be able to accurately assess one’s own performance, strengths and weaknesses.
• To understand the ethical and medical/legal requirements of radiologists.

Daily Schedule

• 8am start if there are no morning rounds.
• If there are morning rounds, the resident will start at ~9am since travel from the OGH is necessary after rounds.
• It is optional for the resident to attend noon rounds since travelling from the Riverside may be disruptive to the day’s work.  Laura can make accommodations to try to V/C to the Riverside Board room when possible.
• The resident will stay until the day’s work is complete.
• Residents will be excused from the daily schedule for post-call days, academic half-days (Tuesday afternoon), visiting professors, and holidays.
• Optional involvement in endometriosis scanning program in DI with Drs. Fraser and Duigenan.  Resident can reach out to them to arrange.

Evaluation

Mid-rotation written evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading

Diagnostic Ultrasound. Rumack, Wilson, Charboneau.  Mosby, 3^rd Edition (2004).

Revised: December 8^th 2015

Communicator

• To demonstrate the ability to produce a report which describes the imaging findings, most likely differential diagnoses, and when indicated, to recommend further testing and/or management.
• To understand the importance of communication with referring physicians, including when the result of an investigation or procedure should be urgently communicated.
• To communicate effectively with patients and families and have a compassionate interest in them. To possess a sensitivity to the propriety of the female patient undergoing a gynecologic scan and a sensitivity to the psychological reactions following pregnancy loss.
• To recognize the physical and psychological needs of the patient and their families undergoing radiological investigations and/or treatment including the needs of culture, race, and gender.

Collaborator

• To function as a member of a multidisciplinary health care team.

Manager

• To learn to utilize resources effectively to balance patient care, learning needs, and other activities.
• To learn to work effectively and efficiently in a health care organization.
• To utilize information technology to optimize patient care, learning and other activities.

Health Advocate

• To understand and communicate the benefits and risks of ultrasound.
• To educate and advise on the use and misuse of ultrasound imaging.

Scholar

• To develop, implement and monitor a personal continuing education strategy.
• To critically appraise medical information.
• To demonstrate the ability to be an effective teacher of ultrasound to medical students, residents, technologists and clinical colleagues.

Professional

• To be punctual and be available for assigned duties.
• To deliver the highest quality of care with integrity, honesty and compassion.
• To exhibit appropriate personal and interpersonal professional behaviors including accepting constructive criticism.
• To be able to accurately assess one’s own performance, strengths and weaknesses.
• To understand the ethical and medical/legal requirements of radiologists.

Daily Schedule

Progressive hands-on scanning will take place with emphasis on certain skills each day.  Scanning will be supervised by a sonographer.

Residents will be excused from the daily schedule for post-call days, academic half-days (Tuesday afternoon), visiting professors, and holidays.

It is the expectation that the resident will be able to perform a pelvic and TVUS independently by the end of the rotation.

Noon rounds attendance is optional if residents feel they will benefit more from additional scanning time.

Evaluation

Mid-rotation written evaluation (optional).

Written & face to face end of rotation evaluation.

Recommended Reading

Diagnostic Ultrasound. Rumack, Wilson, Charboneau. Mosby, 3^rd Edition (2004).

Revised: February 22, 2017.

Medical Administration and Leadership Elective Goals & Objectives

Background

The term of the PARO Presidency is 1 year (June 2016-June 2017). This is a unique opportunity to lead a resident organization that represents almost 5000 members in the province of Ontario. Given my strong and enduring interest in Medical Administration and Leadership, I know that my experiences will be an asset both to my personal career goals and to the field of diagnostic radiology as a whole. In order to take the maximum advantage of this role, I would like to undertake longitudinally a Medical Administration and Leadership Elective.

Proposal

One block (20 days) will be set aside for this elective experience, to be used longitudinally as 20 days borrowed from each of the remaining 12 rotation blocks (as needed based on schedule requirements). The final block of the year will be used to make up missed rotation days in order to fulfill learning needs as identified mutually with the Program Director.

Evaluation

The rotation supervisor will be Dr. Robert Conn, PARO CEO. Dr. Conn has extensive leadership experience and has previously served as rotation supervisor for past Presidents fulfilling similar electives. Quarterly updates to the Program Director may be provided as requested on activities and outcomes. Evaluation will occur in the form of informal observation throughout the year.

Personal Goals

• Improved organizational and management skills.
• Increased skills in communication and conflict resolution.
• Increased skills in coaching and leadership.
• Increased team building skills.
• Improved ability to facilitate meetings and build consensus in a timely fashion.
• Expanded knowledge of health policy and health care system structure.
• Experience in leading a large, professional organization.
• Experience with large-scale budget management and skills in contract negotiation.
• Additional media training and public speaking opportunities.

Objectives

Medical Expert

• Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed.
• Develop an appreciation and understanding of health policy and its impact on medical practice.
• Effectively and appropriately prioritize professional duties.
• Enhanced appreciation for other specialties and the role of residents.

Communicator

• Establish positive relationships and listen effectively
• Address challenging communication issues
• Increase effectiveness of oral and written forms of communication
• Accurately elicit and synthesize relevant information
• Learn to find common ground on issues and problems
• Respect diversity and difference
• Be sensitive to issues of gender, religion and cultural beliefs
• Effectively present medical information to the public or media about medical or education issues
• Develop and enhance mentorship skills to mentor new resident and physician leaders
• Communicate effectively with a constituency

Collaborator

• Participate effectively in an inter-professional healthcare team
• Recognize and respect the diversity of roles, responsibilities and competencies of other professionals, including those outside medicine and/or healthcare
• Work with others to assess, plan, provide and review other tasks, such as educational work, program review or administrative responsibilities
• Describe the principles of team dynamics and respect team ethics, including: confidentiality, resource allocation and professionalism

Manager

• Work collaboratively with others both within PARO and other organizations
• Participate in systemic quality process evaluation and improvement, such as patient safety initiatives, accreditation processes and internal policy review
• Describe the structure and function of the healthcare system and the principles of healthcare financing
• Set priorities and manage time to balance clinical requirements, outside activities and personal life
• Recognize the importance of just allocation of healthcare resources, balancing effectiveness, efficiency and access with optimal patient care
• Serve in administration and leadership roles, as appropriate
• Chair or participate effectively in committees and meetings
• Lead or implement a change in health care
• Learn to effectively delegate and empower teams

Health Advocate

• Respond to the health needs of communities and identify opportunities for advocacy, health promotion and disease prevention
• Identify vulnerable or marginalized populations and respond appropriately
• Promote the health of individual patients, communities, and populations
• Describe how public policy impacts on the health of populations
• Identify points of influence in the healthcare system and its structure
• Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism
• Describe the role of the medical profession in advocating collectively for health and patient safety

Scholar

• Critically evaluate medical information and its sources
• Facilitate the learning of patients, families, students, residents, other health professionals, the public and others, as appropriate
• Select effective teaching strategies and content to facilitate learning and accurately disseminate knowledge to physician colleagues
• Demonstrate an effective lecture or presentation
• Provide effective feedback

Professional

• Exhibit appropriate professional behaviors, including honesty, integrity, commitment, compassion, respect and altruism
• Appropriately manage conflicts of interest
• Demonstrate a commitment to patients, the profession and society through participation in profession-led regulation
• Recognize and respond to others’ unprofessional behaviors
• Demonstrate a commitment to physician health and sustainable practice
• Strive to heighten personal and professional awareness and insight
• Recognize other professionals in need and respond appropriately

MUSCULOSKELETAL RADIOLOGY

Supervisor

Dr. Ryan Foster

Revised: Dec 2014, Sept 8, 2015, Sept 5, 2018

SCHEDULE HEADING MSK

IDEAL SCHEDULING

PGY2 – 2^nd half of year

PGY3 – Twice

PGY4 – 2nd half of year

PGY5 – 1^st half of year

Introduction

Overview of the rotations -MSK radiology includes plain films, ultrasound, CT, MRI, CT and MRI arthrograms and bone interventions (biopsy, drainage, therapeutic and diagnostic injections guided by the different imaging modalities).  The MSK radiology concerns pathologies involving joints, bones, and soft tissues of the appendicular skeleton and spine. In clinical practise, the scope includes trauma, rheumatology, metabolic and systemic bone diseases, tumors of bone, spine and soft tissues, congenital and developmental disorders, sports medicine, physical rehabilitation, internal derangement of joints and the management of pain.

Our residents have now 5 MSK rotations, three of them as PGY2 or PGY3, one as PGY4 and one as PGY5.

First rotation: the residents will get accustomed to learning the basics of bone and trauma radiology.  As the resident progresses through the rotation, more complicated studies and procedures will be naturally introduced, and MSK CTs will be also seen, stimulating the correlation of findings between different modalities and achieving a better understanding of cross sectional anatomy. The resident is also required to learn to perform the most frequent arthrograms and diagnostic injections (mostly shoulders and hips). They will supplement this experience with reading around trauma, orthopaedic procedures and the most common rheumatologic and metabolic disorders. Residents will be encouraged to review the ER/STAT cases done overnight for improved exposure to MSK CT while on their MSK rotation.

Second rotation: Equipped with the base knowledge from the first rotation, the junior resident will be progressively exposed to routine outpatient xrays and CTs of extremities and joints. Reading should then be progressively focused around arthritides, bone and soft tissue tumors and metabolic bone disorders.

Third rotation: In his last MSK rotation as junior resident, there will be now also some exposure to MRIs knees and possibly shoulder as a complement to this more CT focused rotation. Residents will be encouraged to evaluate arthropathic centered plain films given their complexity and required depth of knowledge. Ultrasound exposure will also be intensified in this rotation as the resident’s understanding of cross sectional anatomy improves.

Fourth rotation:  This rotation will now be more dedicated to cross section imaging, particularly MRIs, including the technique, protocoling and interpretation. They will also keep the plain films reading skills throughout the rotation, helping to further correlate the findings with other methods and with continued opportunity to practice main joints arthrograms. They should study cross-sectional imaging interpretation of MSK studies, particularly MRI. Initially the focus will be on knees and shoulders, and then progressively include the other joints, as well bone marrow diseases, and soft tissue tumors.  Residents will also be involved in reading both supervised and unsupervised MSK ultrasound cases as well as more complex procedures done throughout the day, depending on their availability. Residents will attend 2 days at the Riverside Campus where they will have the opportunity to scan routine MSK cases.

Fifth rotation:  The PGY5 rotation should be a consolidating block and by its end the resident functions as a junior consultant. The resident is expected to read plain films, perform the required procedures and supplement this with MRI and CT. In this final rotation, the resident may also improve MSK procedural techniques including bone biopsy, and hopefully see the introduction of protocoling routine CT/MRI. The MSK residents should rotate through the MSK hot seat and be responsible for taking the phone calls and managing the MSK requests. Again weekly US exposure through supervised and non-supervised cases will be had as well as an additional 2 days of scanning routine MSK cases at the Riverside Campus.

EDUCATIONAL OBJECTIVES

Medical Expert-Clinical Decision Maker

1. Understand the nature of formation of x-ray, ultrasound and CT images including the physical and technical aspects, patient positioning and contrast media.

2. Gain a working knowledge of normal plain film and cross sectional MSK anatomy.

3. Understand factors which contribute to the diagnostic quality of skeletal imaging, including an understanding of standard and special projections and tomography, as well as MRI studies protocoling.

4. Gain a basic knowledge of skeletal radiology including arthritides, osteomyelitis, bone ischemia, tumors and metabolic bone disease.

5. Obtain a good working knowledge of the techniques of arthrography and the ability to perform common arthrograms/injections and aspirations competently with supervision.

6. Acquire basic knowledge of the role of the various imaging modalities (plain film, ultrasound, CT, MRI, nuclear medicine and ultrasound) for the diagnosis of musculoskeletal pathology.

7. Report at least 150 cases each week with a minimum of 25 cases in the morning and 10 cases in the afternoon, even on arthrogram days.

8. Observe and/or perform at least 15-20 arthrograms/procedures during the 4 week rotation.

9. Attend applicable rounds: MSK resident rounds (Thursdays 7:30). If available, senior residents may opt to attend Sarcoma Rounds (Fridays, 12:00) where they will be expected to present at minimum a single case.

10. Review interesting cases with the rotation supervisors and bring interesting cases for discussion. Prepare cases and discussion for teaching files. (The number of cases will vary depending on the pathology seen during the rotation.)

11. Spend 1 half day session observing/aiding the technologists in doing orthopedic radiology cases (x-rays, CT, MRI and ultrasound).

12. For more senior residents, the rotation is organized on a resident-to-resident basis, to include an emphasis on CT and MRI. The resident will supplement their CT/MRI exposure with a minimum of 10 plain films daily to supplement their cross-sectional exposure. They should remain involved in procedures, taking on more responsibility and learning new procedures as experience allows.

Communicator

1. Demonstrate the ability to produce a report to describe the imaging findings, most likely differential diagnoses and recommend further testing and/or management.

2. Understand the importance of communication with referring physicians, including an understanding of when the results of an investigation or procedure should be urgently communicated.

3. Communicate effectively with patients and their families and have a compassionate interest in them.

4. Recognize the physical and psychological needs of the patients and their families undergoing radiological investigations and/or treatment including the needs of culture, race and gender.

5. Communicate adequately with the hospital staff, including technicians, nurses, clerks and other personal involved in the radiology through-put of patients.

Collaborator

1. Learn to function as a member of a multidisciplinary health care team.
2. Teach and discuss cases with the elective medical students, usually one day a week.

Manager

1. Gain competency in supervising quality assurance, including assessing the quality of all reported imaging studies.

2. Become competent in computer science as it pertains to the practice of emergency radiology.

3. Understand how the throughput of patients is done in radiology to allow proper healthcare service.

Health Advocate

1. Learn to recognize when radiological investigation or treatment would be detrimental to the health of the patient.

2. Educate and advise on the use and misuse of radiological diagnostic tests and intervention.

Scholar

1. Develop, implement and monitor a personal continuing education strategy.

2. Critically appraise sources of medical information.

3. Demonstrate the ability to be an effective teacher of radiology to medical students, residents, technologists and clinical colleagues.

Professional

1. Be punctual and available for consultations and film review.

2. Deliver the highest quality care with integrity, honesty and compassion.

3. Exhibit appropriate personal and interpersonal professional behaviours.

4. Accurately assess one’s own performance, strengths and weaknesses.

5. Understand the ethical and medical/legal requirements of radiologists.

Schedule

 - Typically the rotation will include 3 residents.

 - There are procedures on Mondays, Wednesdays and Fridays afternoons

First activities:

- You will be welcomed by the staff and receive initial orientations. You are officially part of the MSK team from now on.

 - Print your schedule and place it on the wall. Please annotate days post-call, vacation, conference, etc…

- Divide the procedure days with your colleagues (typically the Wednesday go to the senior residents). Write down your days on procedures on your schedule. - Set up proper PACS filters (staff will help with that): one for plain films (TRI-Camp, MSK and BONE, CR and RF) and one for cross-sectional studies (CT, MRI, Tri-Camp)

Specific activities

Junior residents

- Set up a filter in PACS: MSK plain films/CT = Modality- CR, RF, CT; Study type- MSK, BONE; if this is your third rotation, you may create a MSK cross-section filter to include MRIs= Modality- US, CT, MRI;  Study type- MSK, BONE;

- Please use the system templates for reports and procedures

- When there are two Junior residents simultaneously on rotation, one will give emphasis on emergency and in-patients studies and the other one will cover routine (non urgent) studies, including Rheumatology cases. If scheduled to do procedures in the afternoon, this resident should be the one reading routine studies.

- Our obligation as a section is to clear all CRs and RFs with STATs and HIGH priority done up to 5pm. The General Campus ER cases are read by the MSK section. We also have priority to read the Civic Campus ER cases, but the radiologist at that site will work as a backup. This is done by the combined action of the residents, fellows and staff, and it is everyone’s responsibility to manage this task.    - The typical number of cases seen per day is around 40, but this varies depending on their complexity and other activities. They should be dictated and sent for signature on the same day. If that is not possible, assign them to you and leave them as “needs over read” (light blue). Because of possible problems with the PACS, cases left in “green” status are sometimes accidentally read by someone else.

- After opening your x-rays, check the list for MSK CTs of the day and previous night/weekend. Actively divide the cases with your colleagues (you do not need to wait for the staff to ask you to pick up those cases).

- In your third rotation, after opening the x-rays and CTs you should also open one or two MRIs everyday (typically knees). On WEDNESDAY mornings, you will have the priority to open more MRI cases. Also, aim to be involved in 10 US per week. These will be in the form of non-supervised cases scanned at the Civic as well as supervised emergency or walking wounded patients at the General campus. Involvement would include reviewing the case or reporting it formally.

- There is a staff radiologist specifically assigned to review the plain films every day. Typically, there are going to be review sessions around 10:00 – 10:30 am and again at 3:00pm.

- Note – remember that you may request special attention of the staff to clear STATS/HIGH priority cases whenever you feel necessary. The MSK Plain film radiologist will be responsible for reviewing the junior residents reading plain films and performing procedures.

Senior residents

- Set up a filter in PACS: MSK cross-section= Modality- US, CT, MRI; Study type- MSK, BONE;

- Please use the system templates for reports and procedures

- Globally you have the priority to pick up the MRI cases, with some simple boundaries:

- Our obligation as a section is to clear all cases done up to 5pm. Keep an eye on the list. HIGH and STAT priority cases should be picked up as they appear and read ASAP. Keep the CT and MRI together in your list and don’t waste time changing filters. Although the junior residents will be in part responsible for CTs, you are their back-up. Do not wait for the staff to manage who will be reporting the studies and actively split them if necessary.

- An ideal typical day includes around 15 to 20 cross-section studies and 15 x-rays.

- If there is a junior resident on his third rotation, please share at least one knee MRI per day with him/her.

- On two Mondays of your rotation you will spend time at the Riverside Campus scanning MSK US cases. Typically, these day will be the on the 2nd and 4th weeks of rotation.

- The Tuesday’s morning is typically only dedicated to x-rays. However, the staff may request you to read cross sectional studies (more so when Monday is a holiday, but depending on the MSK worklist or other activities). Eventually another half day may the chosen to do plain films (preferentially the day you would be scheduled on arthro’s in the PM)

          - On Mondays, Wednesdays, Thursdays and Fridays you are responsible for both Campuses, but:

- On Thursdays there will be typically a fellow at the General taking care of supervised MRIs. Split the cases in the list with them, giving emphasis to your learning phase (knees and shoulders? Hips? Small joints?).

-In general, aim to be involved in 10 US per week. These will be in the form of non-supervised cases scanned at the Civic as well as supervised emergency or walking wounded patients at the General campus. Involvement would include reviewing the case or reporting it formally.

You are also invited to participate in the supervised cases discussions/protocoling. Be proactive and take the opportunity to see how the studies are done, from patient positioning to how the sequences are done and checked “live”. You should too officially spend a whole morning with the MRI technologists.

2- Wednesday mornings: if there is a junior resident on the third rotation he should be given 3 or 4 MRIs to read. Take that opportunity to see more plain films.

The MSK HOT SEAT

There is now a HOT SEAT tag above one of the workstations. The hospital staff has the phone number of that station to call when they need a consult or to request a study or procedure. Also, technologists will bring in doubts related to x-rays projections, CTs and MRIs protocoling. Typically a fellow or senior resident should sit at that workstation, but if there are only junior residents on schedule one of them should take it. After initial workup of the case it should be discussed with the fellow or staff. The management and communication skills used to handle the requests that may pop-up on that phone are a very important part of our practice, and should continuously be developed. A note- these skills are not in the books.

Some time with the technologists

It is imperative to properly understand how images are obtained in practice.

All residents should go once along the residency to watch and participate in the x-rays routine (one morning along residency). Please send an email to Melody Crawford, chief technologist of the General Campus (copy the rotation supervisor) to arrange the date to do this activity.

As a senior, the same will be done with the ultrasound (2 Mondays per rotation at the Riverside Campus) and MRI (one morning), as mentioned above.

TROUBLESHOOTING

- here are not enough MRIs in the list: If the list is empty (slow down, maintenance, etc..) go to the teaching files and open cases compatible with your level while continuing to take plain films. When reviewing with the staff you may go through these cases and take them as guided study. Another alternative is to open some cases of some months before and review then with the staff (you wont’ need to report them, so this is great way to gather experience with cases). Note- please do not forget to do your minimum number of x-rays.

- It is getting late and I need to review the cases: if there is a special situation (night shift, medical appointment, etc…), please request the priority for review. In the worst case you will review/report some of the cases on the next day. You will note the staff will only typically leave the hospital after all 5pm HIGH/STAT cases were reported.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

RECOMMENDED READING/TEACHING RESOURCES

Try reading around the cases that are seen in daily review sessions. The teaching files and the internet are also an excellent source of cases that were not seen throughout the rotation. Do not expect to read most books from cover to cover, but some of them are definitely worth the time invested. The following list is to serve as a reference guide. Also, ask the staff to bring some books for you to take a look at them.

V DRIVE- There are lectures saved in the V Drive, such as…

-ARTHROGRAPHY and JOINT INJECTIONS (Dr Rakhra), a valuable resource, particularly to learn or refresh injection skills.

BOOKS-

Fundamentals of Skeletal Radiology; Helms CA, W.B.Saunders.

Orthopedic Imaging: A practical Approach; Greenspan, Lippincott, Williams and Wilkins, 4^th ed. 2004 (must read)

Musculoskeletal MRI; Phoebe Kaplan , Robert Dussault, Clyde Helms

Musculoskeletal MRI; Clyde Helms, Nancy Major; A Saunders; 2^nd ed. 2008.

Bone and Joint Imaging; Donald Resnick; A Saunders; 3^rd ed. 2004.

Arthritis in Black and White; Brower A,  W.B.Saunders Co.

Musculoskeletal Imaging: The requisites; B.J Manaster, David May; 3^rded, 2006.

Arthrography; Freiberger RH, and Kaye JJ, Appleton-Century-Crofts, 1979 out of print, but the only arthrogram book that I know of, find it in the department. (must read)

Symposium on Arthrography; Anderson TM, RCNA Vol 19 No 2, June 1981

Imaging of Joints; Kaye JJ, RCNA Vol 28 No 5, Sept 1990

Normal Roentgen Variants That May Simulate Disease; Keats TE, A Mosby, 2006.

An Atlas of Normal Developmental Roentgen Anatomy; Keats TE, and

Smith TH, YBMP, 1977

Atlas of Roentgenographic Measurement; Keats TE., YBMP, 2001.

Radiologic Clinics of North America editions.

WEB-

- orthobullets.com

(more to be added – please also bring in your suggestions!)

Neuroradiology

Supervisors

Drs. D. Iancu

Schedule Heading

Neuro

Ideal Scheduling

PGY2 – 1 block at each campus 6 block apart.

FIRST BLOCK should be SPLIT b/w campuses (2 weeks @ each).

PGY3 – 1 block

PGY4 – 1 block

PGY5 – 1 block

Educational Objectives

Note: Residents are encouraged to take on the ‘hot seat’ duties. However, these should be distributed among all trainees on the rotation (fellows/ residents) to ensure a variety of clinical experience for all.

Medical Expert-Clinical Decision Maker

Please note that the volume expectations outlined below are mere guidelines and will vary depending on taking on other responsibilities such as ‘hot seat’ duties and procedures etc.

A. PGY 2

• Understand the nature of formation of CT images including the physical and technical aspects, patient positioning and contrast media.
• Understand the nature of function of fluoroscopic images and to develop the technical skills to and safely and effectively perform myelography or lumbar puncture.
• Become familiar with the basic anatomy of the brain, head, neck and spine. The resident should also develop an understanding of neuropathology with emphasis on neurovascular disease, trauma, congenital malformations and common neoplasms.
• Recognize the importance of an adequate clinical indication for a study in order to help expedite it, organize it and/or report it using the appropriate protocol, specially during on call.
• Understand a sound and systematic style of reporting.
• Become competent in performing myelograms and lumbar punctures.
• Volume of imaging expected of 7 CTs, or 5 MRIs, per half day.

B. PGYs 3&4

• Understand the nature of formation of MRI images including physical and technical aspects, patient positioning and contrast media.
• Develop a more complete understanding of complex neuroanatomy, including the cranial nerves and neurovascular anatomy (carotid and vertebrobasilar systems, vascular territories within the brain and the intracranial venous sinuses).
• Develop a more comprehensive knowledge of neuroradiology and pathology.
• Develop a more complete understanding of neuroradiologic differential diagnoses.
• Demonstrate the ability to manage patients independently during myelography and to know when the patient’s best interests are served by discontinuing a procedure or referring the patient to another physician.
• Understand the acceptable and expected results of investigations and/or interventional procedures as well as unacceptable and unexpected results, including knowledge of and ability to manage radiological complications effectively.
• Understand the appropriate follow-up care of patients who have received investigations and/or interventional therapy in the head, neck and spine.
• Demonstrate competence in effective consultation, and in the conduct of clinico-radiological conferences.
• Present scholarly material and lead case discussions in neuroradiology.
• Volume of imaging expected of 7-9 CTs, or  7 MRIs, per half day.

C. PGY-5

• Participate in neuroangiography.  At a minimum, be involved in interpretation of neuroangiography studies.
• Increase competence in all aspects of neuroimaging and differential diagnosis.
• Learn to protocol CT & MRI cases effectively. 
• Volume of imaging expected of 10 CTs, or 8 MRIs, per half day.

Communicator

• Demonstrate the ability to produce a radiologic report to describe the imaging findings, most likely differential diagnoses and when indicated, recommend further testing and/or management.
• Understand the importance of communication with referring physicians including an understanding of when the results should be urgently communicated.
• Learn to communicate effectively with patients and their families and have a compassionate interest in them.
• Learn to recognize the physical and psychological needs of patients and their families undergoing radiological investigations and/or treatment, including the needs of culture, race and gender.

Collaborator

• Learn to function as a member of a multidisciplinary health care team especially with neurosurgeons, neurologists and referring emergentologists.
• Identify cases in which there is a prompt need for further imaging workup or immediate feedback to the ordering physician.
• Help facilitate the access to the necessary imaging workup to promote a fast diagnosis and consequently enhance patient safety.

Manager

• Utilize resources effectively to balance patient care, learning needs and other activities.
• Become competent in computer science as it pertains to the practice of neuroradiology.

Health Advocate

• Develop an understanding and communicate the benefits and risks of radiological investigations and treatment.
• Learn to recognize when radiological investigation or treatment would be detrimental to the health of the patient.
• Educate and advise on the use and misuse of radiological imaging in neuroradiology.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise medical literature.
• Develop the ability to be an effective teacher of radiology to medical students, residents, technologists and clinical colleagues.

Professional

• Be punctual and available for assigned duties.
• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and medical/legal requirements of radiologists.

Schedule

Working Schedule

• Review each day’s CT Scans or MRIs.
  During the senior resident’s rotation, one week will be in CT functioning as the primary radiologist – “hot seat” - dealing with all consults and technical issues.
• Attend Neurosurgery rounds every Wednesday - 7:30 am in the C2 Clinic conference room, Civic Hospital. (ONLY IF NO RESIDENT ROUNDS ARE SCHEDULED THAT MORNING)
• Attend Neuroradiology Rounds every Wednesday - 4:00 pm in radiology C-118 (OCH) and OGH 1466 classroom.
• Do not attend Neurosciences Rounds unless there are no resident rounds that morning (every Friday 8:00 am in location that alternates between the Civic Hospital and the General Auditorium).
• Attend Neurovascular Rounds every Thursday at 4PM in the C2 Clinic conference room, Civic Hospital.

Evaluation

Mid-rotation verbal evaluation.

Written end of rotation evaluation.

Recommended Reading

Pearse Morris. Practical Neurangiography. Lippincott Williams & Wilkins, 2^nd ed. 2006. Ann

Grossman. Neuroradiology: The Requisites.

Osborn. Diagnostic Neuroradiology.

Scott W. Atlas. Magnetic Resonance Imaging of the Brain and Spine. Lippincott Williams & Wilkins, 4^th ed. 2008.

Revised: June 21, 2016.

GOALS and OBJECTIVES

NUCLEAR MEDICINE

SUPERVISORS Wanzhen Zeng (Civic)

E. Leung (General)

SCHEDULE HEADING

Nuclear Medicine

INTRODUCTION

Familiarity with scientific principles, technology, clinical applications and image interpretation necessary to supervise the performance of Nuclear Medicine studies. After three blocks of rotation trainees are expected to have sufficient knowledge to complete successfully the nuclear medicine component of the Royal College certification examination in Diagnostic Radiology and, after four blocks, the nuclear medicine section of the American Board of Radiology certifying exam in Diagnostic Radiology.

OBJECTIVES

Medical Expert/Clinical Decision Maker

Trainees shall familiarize themselves with routinely performed nuclear medicine procedures including patient preparations, radiotracers, image acquisition, normal biodistribution, interpretation, artifacts and limitations. Detailed system based procedures are listed below.

CNS

1. Cerebral perfusion study or Brain Scan with Tc_99m HMPAO or Tc_99m ECD (flow tracers Tc_99m DTPA, Tc_99m Pertechnetate and Tc_99m glucohepatonate used in the old days) for brain death, Alzheimer's disease and other cerebrovascular diseases
2. Shuntogram with In_111 DTPA for VP shunt patency
3. Cisternorgram with In_111 DTPA for normal pressure hydrocephalus and CSF leakage
4. FDG PET/CT for Alzheimer's disease and other cerebravascular diseases

Cardiovascular System

1. Myocardial perfusion with SestaMIBI, Myoview, Thallium, Rubidium, and Ammonia for cardiac perfusion defects and wall motion abnormality.
2. Hibernating myocardium with FDG, Thallium and other perfusion agents
3. Gated blood pool images with labeled RBCs with Tc_99m Pertechnetate for left and right ventricular ejection fraction and the cardiac size
4. Indications and side effects of treadmill exercise, and pharmacological stress with dipyridamole, adenosine, and dobutamine.

Pulmonary System

1. Perfusion scan with Tc_99m MAA and ventilation scan with Technegas, Tc_99m DTPA aerosol and Xenon 133 gas for pulmonary embolism and lung quantification prior to lung resection.
2. Perfusion scan with Tc_99m MAA to assess for right to left shunt

Musculoskeletal System

1. Bone scan with Tc-99m MDP to assess for trauma, tumors, metastases, osteomyelitis, metabolic bone disease, avascular necrosis, ... etc.
2. Bone scan with sodium F_18 fluoride PET/CT for back pain, trauma, osteomyelitis, child abuse, arthritis, avascular necrosis, metabolic bone disease, metastatic disease, abnormal radiographic or laboratory findings
3. SPECT and SPECT/CT for incremental sensitivity and lesion localization

Endocrine

1. Thyroid scan with I-123 or Tc-99m Pertechnetate for thyroid nodules. Thyroid scan and thyroid uptake for subacute thyroiditis, thyroiditis and thyrotoxicosis
2. Whole body thyroid scan with I-123 or I-131 for diagnostic study in patients with thyroid cancer status post total  thyroidectomy and radioiodine ablation therapy.
3. Dosage of I-131 sodium iodine for ablation therapy in thyroid cancer patients and patients with hyperthyroidism
4. Patient preparation, side effects,  radiation exposure precautions and management of contamination for radioiodine therapy in patients with hyperthyroidism and thyroid cancer.
5. Parathyroid scan with dual phase method with SestaMIBI and dual tracer with I-123 (or Tc_99m Pertechnetate), and SestaMIBI (or Myoview or Thallium) method, respectively. SPECT/CT for lesion localization and incremental sensitivity
6. MIBG scan for adrenal medullary tumors and I-131 NP59 for cortical tumors

Gastrointestinal System

1. Gastric emptying study with Tc-99m Pertechnetate labeled standardized meal for delayed gastric emptying
2. Hepatobiliary scan with Tc-99m DISIDA or Tc_99m BrIDA for acute cholecystitis, biliary atresia, and bile leak, and for gallbladder contraction with CCK
3. RBC scan or Sulfur Colloid scan for GI bleeding. RBC labeling methods and labeling efficiency. Damaged RBC scan for splenule
4. Meckel's scan with Tc_99m Pertechnetate for Meckel's diverticulum
5. Liver-Spleen scan with sulfur Colloid for focal nodular hyperplasia and accessory spleen
6. Salivary gland scan with Tc_99m Pertechnetate and lemon juice for Sjogren's syndrome, Warthin's tumor and radiation change.

Genitourinary System

1. Renal scan with Tc_99m MAG3, Tc_99m DTPA, Tc_99m glucohepatonate and I_131 Hippuran for differential renal function, obstruction with lasix, renal vascular hypertension with captopril, and GFR or effective renal plasma flow determination
2. Renal cortical scan with Tc_99m DMSA and Tc_99m glucohepatonate for renal infection and scar.
3. Testicular scan with Tc_99m Pertechnetate for acute testicular torsion and inflammation.

Infection/Inflammation

1. Gallium scan for infection and sarcoidosis
2. Tc_99m HMPAO labeled WBC  scan and In-111 Oxine labeled WBC scan for infection
3. Lymphoscintigraphy with Tc_99m labeled sulfur colloid for sentinel node

Oncology

1. Octreotide scan with In-111 and MIBG scan with I-131 or I-123 for neuroendocrine tumors
2. Performance of FDG PET/CT on NSCLC, lymphoma, melanoma, esophageal ca, colorectal ca, head and neck cancer, breast ca, cervical ca and ovarian cancer, compared to radiological images
3. SUV measurement and factors affect SUV value
4. Gallium scan for lymphoma

Miscellaneous

1. Lymphoscintigraphy with Tc_99m sulfur colloid for lymphedema

Basic Science

Basic science, including physics, instrumentation, radiopharmaceticals and radiobiology, is an important part of nuclear medicine. Part of the materials is covered in your physics lectures but residents shall do a lot of reading on their own. Trainees are encouraged to spend some time with technologists and at the radiopharmacy lab at the Civic Hospital.

Communicator

1. To report studies in a sound and systematic style which accurately describes imaging findings and most likely differential diagnoses, and recommends further testing or other management when indicated.
2. Understand the importance of communication with referring physicians, including an understanding of when the results of an investigation or procedure should be urgently communicated.
3. Communicate effectively with patients and their families and have a compassionate interest in them. Be able to communicate the radiation exposure of commonly performed Nuclear Medicine procedures to patients.
4. Recognize the physical and psychological needs of the patient and their families undergoing Nuclear Medicine investigations including culture, race and gender issues.

Collaborator

1. Demonstrate the ability to function as a member of a multidisciplinary health care team.
2. Develop confidence in effective consultation and ability to present material and lead case discussions.

Manager

1. Manage time effectively to balance patient care and learning needs.
2. Understand and effective use of HERMES Workstations and PACS.  
3. Residents are to help manage the Nuclear Medicine department at a level that is commensurate with their comfort and expertise.  Junior residents should be ‘reviewing’ cases with staff prior to allowing technologists to discharge cases.  Senior residents, under the guidance of staff, should be transitioning to more independent supervision of cases and technologists.

Health Advocate

1. Understand and communicate the benefits and risks of Nuclear Medicine studies.
2. Recognize when a Nuclear Medicine study would be detrimental to the health of the patient, for instance in the presence of pregnancy and radiation exposure to the fetus.
3. Educate and advise on the use of Nuclear Medicine studies.

Scholar

1. Develop, implement and monitor a personal continuing education strategy.
2. Critically appraise medical literature.
3. Gain the ability to be an effective teacher of Nuclear Medicine imaging to medical students, residents, technologists and clinical colleagues.

Professional

1. Be punctual and available for assigned duties.
2. Deliver highest quality care with integrity, honesty and compassion.
3. Exhibit appropriate personal and interpersonal behaviours including accepting constructive criticism.
4. Accurately assess one’s own performance, strengths and weaknesses.
5. Understand the ethical and legal requirements in the performance and interpretation of Nuclear Medicine studies.

Schedule

Daily

Day begins: 8:00 am (or 8:30 on days when rounds are on)

Day ends: 5:00 pm

Mornings: Residents will read PET scans for the Nuclear Medicine physician assigned to PET on that day. The Nuclear Medicine PET physician may or may not be physically present at the same site as the resident, therefore, review of PET scans could possibly take place in person or over the phone. Reviewing and submission of reports should be finished in order to allow for on time attendance at radiology lunch rounds.

Afternoon: Following radiology lunch rounds, resident will read general Nuclear Medicine scans for the site (Civic or General) to which they are assigned, and review with the onsite Nuclear Medicine physician.  

Exception: For residents assigned to the Civic Hospital, on Monday mornings, the resident(s) should report to the Nuclear Medicine physician in the Nuclear Cardiology reading at the Heart Institute to get exposure/assist in reading nuclear cardiology examinations.  After lunch, the trainee is expected return to the Civic Hospital reading room and read general nuclear medicine studies.

Ideal Scheduling

PGY3

PGY4

PGY5 (Possible Second Rotation in PGY 5 as elective if writing ABR)

Residents will spend ~ equal rotations at the General and Civic.

Evaluation

Informal evaluations/feedback are to be done on the daily basis.

Written end of rotation evaluation.

References

1. 1.Mettler F.A. and Guiberteau M. J. Essentials of Nuclear Medicine Imaging. W.B. Saunders Co.; Hardback; 2006.

2. 2.Ziessman H. A.,  O'Malley J. P. and Thrall J. H. Nuclear Medicine: The Requisites, third edition, Elsevier Mosby; 2006

3. Ziessman H. A. Nuclear Medicine: Case Review Series  Mosby, Paperback, 2010.

4. Nuclear Medicine Procedure Guidelines of SNM: http://interactive.snm.org/index.cfm?PageID=772

5. Nuclear Medicine Online Text Book: http://www.auntminnie.com/index.asp?sec=ref&sub=ncm

6. Online Nuclear Medicine Teaching File: http://interactive.snm.org/index.cfm?PageID=2208

Last Updated September 24^th, 2019

Obstetrical Ultrasound

Supervisor

Dr. Griff Jones

Schedule Heading

OB/Gyn

Ideal Scheduling

Once in PGY3 (scan) & again in PGY5 (report)

Introduction

These rotations aim to complement the 2 PGY2 ultrasound scanning rotations and 1 block gynaecological ultrasound rotation by focusing on obstetrical scanning. The PGY3 rotation will focus more on scanning technique with gradual transition to reporting & scanning. The PGY5 rotation will focus more on reporting.

** A male resident must not perform an endovaginal scan unless a qualified female chaperone is present.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Understand early embryonic and fetal development and be able to apply this to the diagnosis of failed early intrauterine pregnancy.
• Acquire knowledge of ectopic pregnancy diagnosis, pitfalls and differential diagnosis.
• Understand how ultrasound can be used to screen for aneuploidy
• Understand the standards for a second trimester fetal examination.
• Understand the principles of dating and fetal growth.
• Have a working knowledge of the major fetal anomalies that can be detected by ultrasound.
• Understand the role of Doppler in obstetrical ultrasound.
• Understand the common complications of pregnancy including bleeding, acute pain, premature rupture of the membranes, preterm labour and IUGR.
• Obtain the following measurements – CRL, BPD, head circumference, femur length and abdominal circumference.
• Scan to identify the following:
  • normal anatomy of the fetal head, spine, thorax and abdomen amniotic fluid volume, placental location and cervix.

Communicator

• Communicate effectively with pregnant patients and their families and have a compassionate interest in them.
• Recognize the physical and psychological needs of the pregnant patient and in patients with pregnancy loss, including culture, race and gender issues.
• Understand the importance of communication with referring physicians including an understanding of when the results of a procedure should be urgently communicated.

Collaborator

• Consult effectively with other physicians and work collegially with sonographers.
• Contribute effectively to interdisciplinary activities and rounds.

Manager

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely, and use information technology to optimize patient care, learning and other activities.

Health Advocate

• Identify the important determinants of health affecting pregnant patients.
• Contribute effectively to improved health of gravid patients and communities.
• Recognize and respond to those issues where advocacy of the mother and/or fetus is appropriate.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Be an effective teacher of obstetrical imaging to medical students and colleagues.
• Prepare and conduct multidisciplinary rounds.

Professional

• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practice medicine ethically, consistent with the obligations of a physician.
• Be punctual and available for assigned duties.
• 5. Accurately assess one’s own performance, strengths and weaknesses.

Important Questions

The following questions are also meant to help guide the resident through the rotation.

• Name each artefact and explain its physical basis
  • Visualization within the urinary bladder of an echogenic structure which is actually situated in the adnexa.
  • Repeating lines posterior to an IUCD.
  • Repeating lines posterior to gas bubbles in the bowel.
  • An area of sonic deadness posterior to the symphysis pubis.
  • A thin black line leading posteriorly from each side of a simple cyst.
  • Increased echogenicity posterior to an endometrioma.
• How do you calculate RI, PI, S/D ratio? How does the placental vascular resistance change with gestation in normal pregnancies? What happens in placental growth restriction?
• What is a reproducible anatomical landmark for locating the ovary by endovaginal scanning?
• Assuming a 28 day cycle, at what gestational age do we expect to see by endovaginal scan the gestational sac, yolk sac, and embryo?
• Define the terms discriminatory zone and threshold zone for b-hCG in the visualization of an early pregnancy by endovaginal ultrasound. How are these affected by multiple pregnancy?
• What are the clinical criteria which permit the use of methotrexate in the medical treatment of ectopic pregnancy?
• What is a pseudo-gestational sac? How does it differ from a true gestational sac?
• Define heterotopic pregnancy. What is the reported incidence?
• What ultrasound finding is the most helpful in excluding an ectopic pregnancy?
• What are the major ultrasound signs of early pregnancy failure?
• At what stage of pregnancy is genetic amniocentesis usually performed? What is the BPD at this stage?
• What is the risk of pregnancy loss from this procedure
• What is the advantage of CVS? Risk?
• Explain when the two major prenatal screening tests (IPS & MSS Quad) offered in Ontario for Trisomy 21 are performed and how they are different?
• Why is placenta previa often over-diagnosed in the second trimester?
• What is a sub-chorionic hemorrhage?  What is its clinical significance?  How does it differ from a retroplacental hemorrhage?
• How may one distinguish a myoma from a myometrial contraction?
• What is a succenturiate lobe? Significance?
• In twin pregnancies, what is the most common chorionicity-amnionicity? The least common?
• What are some of the conditions that may contribute uniquely to increased morbidity in twin pregnancy?
• What is the most accurate ultrasound parameter for dating a pregnancy?
• How is the BPD obtained? How can one correct for abnormal head shape.
• eg. dolichocephaly?
• How is the abdominal circumference obtained? Femur length?
• When do ultrasound measurements begin to reflect fetal growth more than fetal age?
• What are the accepted definitions of IUGR and macrosomia?
• What are two practical reasons for measuring the cerebellum?
• What are three major neural tube defects? What is the risk of recurrence in subsequent pregnancy?
• Name 5 major causes of elevated amniotic fluid AFP?
• Name five soft markers for aneuploidy seen at the time of a second trimester anatomy scan? If seen in isolation, estimate how much each one elevates the risk of fetal aneuploidy. What are choroid plexus cysts? Significance? Management?
• How does one diagnose enlargement of the cerebral ventricles?
• What are the two major abdominal wall defects? How are they distinguished by ultrasound? What is the clinical significance of each?
• For each of the following, describe the “classical” ultrasound findings and the clinical significance.
  • Renal agenesis
  • UPJ obstruction
  • Urethral obstruction
  • Multicystic dysplastic kidney
  • Infantile polycystic kidney disease
• What is hydrops fetalis? Describe some ultrasound features of this condition. What are the two major generic types? Which is more common? Of this type, what is the commonest cause in North America?
• How is fetal assessment carried out? How does it guide the perinatologist?
• What are the causes of a large-for-dates uterus?
• How is the 4-chamber view obtained? What structures are seen on a normal 4-chamber view? How do you distinguish the right from the left ventricle? Can the major congenital cardiac anomalies be excluded by a normal 4-chamber view?
• What are three causes of a mass in the fetal left hemithorax?

Schedule

Daily

• Day begins: 8:00 am
• Day ends: 5:00 pm

Evaluation

• Mid-rotation face to face evaluation.
• Written & face to face end of rotation evaluation.

Recommended Reading

ACR online lectures.

Ultrasonography in Obstetrics and Gynecology. Callen. A Saunders, 5^th ed. 2007

Diagnostic Ultrasound, Vol II. Rumack & Wilson.

Atlas of Ultrasound in Obstetrics and Gynecology. Doubilet, Benson. Lippincott Williams & Wilkins. 2^nd ed. 2003

Obstetric and Gynecologic Ultrasound: Case Review Series. Reuter, Babagbemi. A Mosby. 2^nd ed. 2006.

Revised: Sep 25, 2012.

PGY1 Year

Supervisors

Overall Supervisor: Dr. Matt McInnes

Individual Rotation

Supervisor Rotation dependant

Schedule Headings

Various

Ideal Scheduling

PGY1 Year

No specific rotation order other than Radiology in block 13.

Contents

1. Introduction
2. General Educational Objectives for the PGY 1 Year
3. Schedule
4. Specific Rotation Objectives
5. Emergency Radiology Reading list

Manager

Daily

Manager:

1. Introduction

   This first clinical postgraduate year aims to provide an opportunity to broaden the resident’s medical background and to gain a better understanding of the relevance of diagnostic imaging for a variety of medical disciplines.

   While the resident is a part of the Radiology training program and will be invited to all program activities such as academic half-days, visiting professors, research days and retreats, the duties and responsibilities of the PGY-1 rotations take precedence over the activities in the Radiology department.

2. General Educational Objectives For The PGY1 Year

   Medical Expert-Clinical Decision Maker

   1. Gain knowledge of anatomy, physiology, and pathology of the body systems relevant to each specific rotation.

   2. Learn to properly assess, treat and follow up patients for their acute or chronic illnesses.

   Communicator

   1. Communicate effectively with all members of the health care team.

   2. Learn to consult with physicians.

   3. Demonstrate effective communication skills when dealing with patients.

   4. Communicate effectively with patients and family.

   5. Maintain well organized patient notes and discharge summaries.

   Collaborator

   1. Use proper communication skills when interacting with members of the health team.

   2. Interact appropriately with others and demonstrate a team-based approach to managing patients.

   3. Contribute to multidisciplinary rounds and conferences

   Manager

   1. Consider advantages and disadvantages of various available diagnostic tests.

   2. Demonstrate awareness of the indications for interventions.

   3. Consider advantages and disadvantages of operative versus interventional techniques.

   4. Grasp of the limitations of the public health care system.

   5. Manage a reasonable clinical caseload during each rotation.

   Health Advocate

   1. Recognize consent issues, patient comfort and other patient-related issues.
   2. Recognize radiation dose issues when considering imaging.
   3. Understand the principles of Health Advocacy as it pertains to the individual patient as well as the population at large.
   4. Promote screening examinations and regular health care provider visits.

   Scholar

   1. Set personal learning goals & objectives.

   2. Take a leadership role in learning from others and teaching medical students.

   3. Create teaching cases for use by future trainees.

   4. Read journals regularly and attend journal clubs.

   5. Attend Radiology academic half-days when possible.

   Professional

   1. Demonstrate integrity, honesty and compassion.

   2. Show sensitivity and care to the patient and the patient’s family.

   3. Practice understanding of ethical and medical-legal requirements of all physicians.

   4. Demonstrate awareness of one’s own limitations.

3. Schedule

   The PGY1 year consists of 4-weeks of the following 10 core rotations:

   • Pediatrics
   • General Surgery
   • General Medicine
   • Emergency Medicine
   • Orthopedic Surgery
   • Neurosurgery
   • Respirology
   • Radiation Oncology
   • Intensive Care
   • Diagnostic Radiology

   4-week Medical Selective block where the resident chooses one of:

   • Cardiology
   • Pediatric Wards
   • General Medicine
   • ICU
   • NICU
   • Pediatric Respirology
   • Medical Oncology
   • Neurology

   4-week Surgical Selective block where the resident chooses one of:

   • ENT
   • General Surgery
   • Gynecology
   • Gyneoncology
   • Neurosurgery
   • Obstetrics
   • Thoracic surgery
   • Urology
   • Vascular Surgery

   4-week Non-clinical Selective block where the resident chooses one of:

   • Anatomy
   • Pathology
   • Research
   • Radiology

   The order of the blocks is selected by the Medical Education office and may differ for each resident, with the exception of the Radiology core rotation which is usually on Block 13.

   • The daily schedule and rounds attendance is at the discretion of the individual rotation.
   • Residents are expected to be punctual in all rotations.

   On-Call

   • Call duties and schedule are at the discretion of each individual rotation. 
   • PAIRO guidelines are to be followed at all time.

   Evaluation

   • Mid-rotation verbal evaluation as required.
   • Written end of rotation evaluation.
   • For most PGY1 rotations, the resident is responsible to select an evaluator and have him or her complete the on-line evaluation.
4. Specific Rotation Objectives

   ROTATION: Anatomical Pathology

   Overall Goal: This rotation in anatomical pathology is designed to introduce the resident to the components of a pathology laboratory with focus on surgical pathology and autopsy. The resident will learn to correlate clinical, radiological and pathological findings.

   Medical Expert:

   • Demonstrates knowledge of normal basic histology
   • Demonstrates basic knowledge of common pathological conditions, including infection, inflammatory conditions, neoplasia
   • Resident understands how specimens are handled and processed in a pathology laboratory, including frozen sections, cytological, surgical and autopsy material
   • Resident is able to demonstrate understanding of how correlation is made between pathology specimens, imaging studies and clinical information
   • Resident demonstrates a basic understanding of the principles of ancillary techniques in surgical pathology and how to organize and work up a case, with the assistance of a staff pathologist

   Communicator:

   • Able to communicate effectively with technical staff, support staff, supervisors and colleagues
   • Participates in departmental rounds

   Collaborator:

   • Demonstrates an ability to interact appropriately with pathology department staff
   • Demonstrates an understanding of the role of the anatomical pathologist in the health care team

   Manager:

   • Demonstrates a basic understanding of laboratory management structure and workload issues
   • Demonstrates an introductory understanding of safety and quality assurance issues, as well as laboratory information systems

   Health Advocate:

   • Demonstrates an understanding of the pathology laboratory role in providing accurate information pertaining to public health issues, including infectious diseases

   Scholar:

   • Demonstrates self directed study with study and review of material appropriate for rotation
   • Demonstrates ability to identify gaps in knowledge and expertise

   Professional:

   • Demonstrates a responsible work ethic, interest and enthusiasm for learning
   • Demonstrates professional work habits: punctual, organized, efficient
   • Recognizes their limitations and seeks assistance when necessary
   • Responsive to feedback

   ROTATION: Emergency Medicine

   Overall Goal: This rotation in Emergency Medicine is designed to expose the resident to common problems encountered in the emergency medicine patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

   Medical Expert:

   • Demonstrates an understanding of the pathophysiology of disease and injury and the natural history of disease and illness
   • Understands the requirements for follow up care
   • Develops increased competency in patient care and decision making for the emergency patient
   • Demonstrates the prompt recognition of acute illness and injury
   • Demonstrates an understanding of the principles of resuscitation, investigations, and diagnosis and management decisions
   • Perform a clinical assessment and collect all appropriate information, including interpretation of relevant imaging studies
   • Develop appropriate differential diagnosis and initiate management of:
     1. Acute illness/injury
     2. Traumatized patients
     3. Acute age related disorders
        1. Pediatrics
        2. Geriatrics
     4. Toxicological disorders
     5. Environmental disorders

   Communicator:

   • Completes the emergency chart in a comprehensive and legible manner
   • Communicates effectively and compassionately with the patient and family
   • Understands the importance of a multidisciplinary team and interacts in an appropriate and effective manner with consultant physicians, nurses, and other health professionals

   Collaborator:

   • Develop an understanding of the support services in the community, such as CCAC (Homecare), homeless shelters, detox services for patients being discharged from the ED
   • Functions as a member of the emergency team and understands the roles of other health professionals.
   • Demonstrates an understanding of the relationship of the emergency department with the EMS.
   • Demonstrates an ability to interact collegially and professionally with other physicians and all specialties Manager.
   • Understands the basics of department management with respect to the function of the patient board and the role of the charge nurse.
   • Understands the principles of quality assurance, risk management, and standards of care Health Care Advocate

   Scholar:

   • Attends the PGY 1 educational sessions, except when on booked vacation days
   • Demonstrates self directed learning, with study and review of material appropriate for rotation.
   • Demonstrates ability to identify gaps in knowledge and expertise.
   • Apply best practice to patient care decisions, based on critical appraisal of relevant literature

   Professional:

   • Demonstrates a responsible work ethic, interest and enthusiasm for learning
   • Demonstrates professional work
   • habits: punctual, dressed appropriately (greens acceptable), discharges duties in timely fashion
   • Recognizes their limitations and seeks assistance when necessary.
   • Responsive to feedback.

   Specific Techniques:

   • The resident during their Emergency Medicine rotation should demonstrate competency in the following procedures or techniques:
   • Arterial and venous access
   • Cardiopulmonary resuscitation (CPR)
   • Epistaxis management
   • Fractures- stabilization/reduction/immobilization
   • Use of slit lamp
   • Wound management- abscess/infection., animal/human bites, local anesthesia, and suturing.
   • The resident during their Emergency Medicine rotation may demonstrate competency in the following procedures or techniques:
   • Airway management
   • Analgesia- conscious sedation
   • Anesthesia- local and nerve blocks
   • Bladder catheterization/irrigation
   • Chest decompression
   • Dental trauma
   • Gastric lavage
   • Joint aspiration
   • Joint dislocation: reduction and immobilization
   • Removal of foreign bodies
   • Tonometry
   • Core problem assessment, work-up & emergency management should include:
   • Abdominal pain
   • Chest pain
   • Confusion
   • Dizziness
   • Weakness
   • Fever
   • GI bleeding
   • Hemoptysis
   • Nausea and Vomiting
   • Shortness of breath
   • Seizure
   • Sore throat & ear pain
   • Poisoning
   • Code management
   • Trauma management
   • Wound care/suturing
   • Fracture management

   ROTATION: Internal Medicine – CTU

   Overall Goal: This rotation in Internal Medicine is designed to expose the BCT resident to common problems encountered in the general medical patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

   Medical Expert:

   • Able to perform an organized, accurate and complete patient history and physical examination
   • Orders tests appropriately and utilizes/interprets results effectively in patient assessment and development of management plan
   • Interprets and integrates clinical information and test results, in order to develop and appropriately update patient care plans
   • Demonstrates good medical knowledge base
   • Demonstrates good judgment when setting management priorities
   • Able to assess and start initial management in an acute emergency.

   Communicator:

   • Establishes a therapeutic relationship and professional rapport with patients and families.
   • Clear, concise and legible problem-oriented medical records
   • Can obtain an informed consent
   • Provides clear instructions and checks whether the patient/family understands
   • Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting
   • Able to communicate effectively with health care team members, including technical staff, support staff, supervisors and colleagues

   Collaborator:

   • Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise
   • Able to request and provide consultations with clear understanding of question being asked
   • Takes on appropriate share of team assignments and assists others as required

   Manager:

   • Utilizes health care resources effectively to balance patient care, learning needs and outside activities.
   • Utilizes information technology to optimize patient care and life-long learning
   • Displays organizational skills with effective time-management
   • Identifies and addresses issues related to discharge planning

   Health Advocate:

   • Identifies the important determinants of health affecting patients.
   • Recognizes and responds to those patient care issues where patient advocacy is appropriate.
   • Identifies situations where patient advocacy is required.
   • Acts as a patient advocate.

   Scholar:

   • Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.
   • Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students
   • Attends and contributes to rounds and other learning events
   • Accepts and acts on constructive feedback

   Professional:

   • Practices medicine ethically, demonstrating integrity, honesty and compassion.
   • Recognizes limitations and seeks advice and consultation when needed
   • Discharges duties and assignments dependably and in a timely fashion
   • Maintains appropriate boundaries in work and learning situations
   • Respects diversity of race, gender, disability intelligence and socio-economic status

   Specific Skills & Techniques:

   Competently performs the following procedures:

   1. Interpretation of diagnostic tests (EKG, Labs, Chest X-ray, ABG) Performance of E
   2. NG tube insertion
   3. Blood gases
   4. Intubation

   Common Problems in the General Medical Patient:

   • Cardiovascular disorders such as acute coronary syndromes, arrythmias, stroke, syncope, hypertension
   • Thromboembolic disorders such as DVT, PE
   • Respiratory disease such as asthma, COPD, lung cancer
   • CNS disorders such as stroke, seizure, headache, coma
   • Metabolic disorders such as acid-base, electrolyte disturbances, renal failure
   • Endocrine disorders such as thyroid disease, diabetes and its complications
   • GI disorders such as diarrhea, bleeding, hepatobiliary disorders, acute abdomen
   • Infectious Diseases disorders such as post-op fever, pneumonia, urosepsis, septic shock, cellulites, meningitis, HIV
   • Psychiatric disorders such as anxiety, depression
   • Geriatrics: dementia, delirium in the elderly, falls and confusion

   ROTATION: General Surgery

   Overall Goal: This rotation in General Surgery is designed to expose the BCT resident to common problems encountered in the general surgical patient. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

   Medical Expert:

   Demonstrates knowledge of:

   • The principles of wound healing
   • The principles of resuscitation, stabilization, and disposition
   • The natural history and progress of surgically related disease in the pediatric, adult, pregnant, and geriatric population
   • The indications and limitations of investigative modalities
   • The indications and limitations, mechanisms of action, interactions, and complications of pharmacologic agents
   • The indications, techniques, and complications of manipulative procedural skills
   • Complete a clinical assessment of patient with respect to the history and physical examination
   • Assess, develop a differential diagnosis, and initiate management common surgical problems including the following:
   • Hypovolemic shock
   • Fluid and electrolyte requirements
   • Abdominal pain

   - acute and chronic abdominal pain

   • Vomiting/diarrhea/constipation
     • change in bowel habits
   • G. I. hemorrhage
     • Upper and lower
   • Abdominal distension
     • bowel obstruction
   • abdominal mass
   • disorders of the hollow viscus: perforation, volvulus, herniation, ulceration, intussusception, strangulation
   • dysphagia
   • difficult urination
   • scrotal masses and hernias
   • breast mass and pain
   • neck mass
   • wound infections
   • anorectal disorders

   Demonstrates skills of:

   Demonstrates procedural skills:

   • Surgically assist for common, uncomplicated procedures
   • Incise and drain localized abscesses
   • Wound closure and repair
   • Cyst removal
   • Sigmoidoscopy/protoscopy
   • +/-Skin biopsy, Toe nail excision

   Communicator:

   Resident is expected to demonstrate communication skills in both verbal and written manner with:

   • Can obtain an informed consent
   • Establishes a therapeutic relationship and professional rapport with patients and families
   • Able to explain surgical disease and management plan in clear understandable fashion
   • Presents the patient’s problems clearly, concisely and  clearly, correctly in the clinical setting both verbally and in patient’s medical record

   Collaborator:

   • Participates in interdisciplinary teams, considering and respecting the opinions of other team members and contributing expertise as a general surgeon
   • Identifies and understands the roles, expertise and limitations of all members of an interdisciplinary team
   • Works with the other members of the interdisciplinary team to develop a plan for the general surgery patient; this may include preoperative and postoperative investigations, treatments and continuing care both in hospital and in ambulatory settings.

   Manager:

   • Demonstrates knowledge and awareness of appropriate resource allocation
   • Organizes the workload appropriately and demonstrates effective time management
   • Demonstrates knowledge of the principles of Quality Assurance in clinical practice
   • Gives due attention to details

   Health Advocate:

   • Able to identify operative risk factors in individual patients
   • Identifies risk factors for Gastrointestinal tract disease, Breast disease, and factors that deleteriously affect operative risk factors and counsesl patients accordingly
   • Aware of guidelines of care for both prevention of disease, as well as treatment of established disease

   Scholar:

   • Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature
   • Reads around consults seen in the ER, clinics, ward setting
   • Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students
   • Attends and contributes to rounds and other learning events
   • Accepts and acts on constructive feedback

   Professional

   • Interacts with patients, families, nurses and other health care personnel in a professional, respectful and ethical manner
   • Demonstrates a good work ethic
   • Examines and resolves any interpersonal difficulties in a professional manner
   • Strives to balance personal and professional roles and responsibilities, and demonstrate ways to resolve conflicts in these areas
   • Constantly evaluates her/his knowledge, skills and abilities, and recognize the limits of her/his professional competence

   ROTATION: Obstetrics and Gynecology

   Overall Goal: This rotation in Obstetrics and Gynecology is designed to expose the BCT resident to common problems encountered in the prepartum, intrapartum and postpartum patient. The resident will further enhance their skills in the assessment, diagnosis and management of the fetus and female patient population.

   Medical Expert:

   Knowledge

   • Demonstrates basic interpretation skills in (FHR) fetal monitoring
   • Demonstrate working knowledge of normal female and fetal development
   • Understands the complications of pregnancy and their initial emergent management and need for referral/consultation, including the first, second and third trimester
   • Demonstrates basic knowledge of indications and utility of imaging in the assessment of normal pregnancy and high risk patients

   Skills

   • Assess and write appropriate orders for low risk antepartum, intrapartum and postpartum patients
   • Assess and manage common post-operative/post-delivery problems and initiate the workup/therapy in more complex situations with supervision
   • Assess and manage common gynecologic problems presenting to E.R. and out patient office

   Communicator:

   • Establishes a therapeutic relationship and professional rapport with patients and families.
   • Formulates and completes clear, concise, legible and timely problem-oriented written/dictated consultation notes and discharge summaries
   • Able to communicate effectively with patients, families and health care team members
   • Can obtain an informed consent
   • Provides clear instructions and checks whether the patient/family understands
   • Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting

   Collaborator

   • Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise
   • Able to request and provide consultations with clear understanding of question being asked
   • Takes on appropriate share of team assignments and assists others as required 

   Manager:

   • Utilizes health care resources effectively to balance patient care, learning needs and outside activities.
   • Utilizes information technology to optimize patient care and life-long learning
   • Displays organizational skills with effective time-management
   • Identifies and addresses issues related to discharge planning
   • Able to set urgency priorities with respect to referrals

   Health Advocate:

   • Identifies the important determinants of health affecting patients
   • Recognizes and responds to patient care issues where patient advocacy is appropriate, including within the treatment team and outside services/agencies
   • Recognizes impact of societal factors on patient health (housing etc)

   Scholar :

   • Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.
   • Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students
   • Attends and contributes to rounds and other learning events
   • Accepts and acts on constructive feedback, developing a plan to correct gaps in knowledge or skills

   Professional:

   • Practices medicine ethically, demonstrating integrity, honesty and compassion.
   • Recognizes limitations and seeks advice and consultation when needed
   • Discharges duties and assignments dependably and in a timely fashion
   • Maintains appropriate boundaries in work and learning situations
   • Respects diversity of race, gender, disability intelligence and socio-economic status

   Specific Techniques:

   Competently perform the following procedures:

   • Abdominal and vaginal assessment of a labouring patient
   • Uncomplicated vaginal delivery (supervised)
   • Assist a Cesarean Section
   • Speculum exam (with PAP smear) and bimanual exam

   ROTATION: Orthopedic Surgery

   Overall Goal: This rotation in Orthpedic Surgery is designed to expose the resident to common problems encountered in orthopedics, including emergency, inpatient and outpatient settings. The resident will further enhance their skills in the assessment, diagnosis and management of this patient population.

   Medical Expert:

   • Demonstrates anatomical and orthopedic knowledge base appropriate for level
   • Able to perform a focused, accurate and complete history and physical examination
   • Understands the indications and limitations of various investigative imaging modalities (X ray, US, CT, MRI)
   • Demonstrates an understanding of the basic principles of fracture management, joint replacement and musculoskeletal injury
   • Able to synthesize clinical information, imaging and tests results for development of appropriate differential diagnosis and management plan for a variety of common problems in the orthopedic patient

   Communicator:

   • Establishes a therapeutic relationship and professional rapport with patients and families
   • Able to explain surgical disease and management plan in clear understandable fashion
   • Can obtain an informed consent
   • Presents the patient’s problems clearly, concisely and correctly in the clinical setting both verbally and in patient’s medical record

   Collaborator:

   • Participates in interdisciplinary teams, considering and respecting the opinions of other team members
   • Identifies and understands the roles, expertise and limitations of all members of an interdisciplinary team
   • Works and consults with other interdisciplinary team members and clinical colleagues to develop a plan for the orthopedic surgery patient; this may include preoperative and postoperative investigations, treatments and continuing care both in hospital and in ambulatory settings.

   Manager:

   • Demonstrates knowledge and awareness of appropriate resource allocation
   • Organizes the workload appropriately and demonstrates effective time management
   • Utilizes information technology to optimize patient care and life-long learning

   Health Care Advocate:

   • Able to identify operative risk factors in individual patients
   • Recognizes and responds to those patient care issues where patient advocacy is appropriate.

   Scholar:

   • Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature
   • Reads around consults seen in the ER, clinics, ward setting
   • Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students
   • Attends and contributes to rounds and other learning events
   • Accepts and acts on constructive feedback

   Professional:

   • Practices medicine ethically, demonstrating integrity, honesty and compassion.
   • Recognizes limitations and seeks advice and consultation when needed
   • Discharges duties and assignments dependably and in a timely fashion
   • Respects diversity of race, gender, disability intelligence and socio-economic status

   Important topics for review:

   • Fracture/dislocation management
   • Splint/cast application
   • Irrigation and debridement
   • Indications for nonoperative versus operative fracture management
   • Arthoplasty indications, procedure, complications
   • Basic knowledge of arthropathy and common sports-related injuries
   • Assistance in orthopedic surgical procedures
   • Preop/periop and postoperative care issues of the orthopedic surgery patient
   • Inpatient and post procedure care: wound, cast care
   • Infection management – wound, osteomyelitis

   Medical Expert:

   • Able to demonstrate the unique communication skills necessary to obtain thorough, focused neonatal and pediatric histories from children, parents or other caregivers
   • Able to perform a physical examination on infants and children, despite potential poor compliance
   • Able to recognize the unique natural history of neonatal and pediatric diseases and use this information in reaching a diagnosis and management plan for care
   • Able to individualize therapy, including drug therapy, nutritional, fluid and electrolyte needs, recognizing potential altered physiological states (such as immature hepatic and renal function) that affect therapy
   • Able to recognize the normal range and wide variation with respect to diagnostic tests involving infants and children of different ages
   • Able to diagnose and manage medical conditions presenting in the pediatric patient.  Guidelines for study include:
     1. Newborn illnesses – including jaundice, sepsis, seizures, feeding problems, failure to thrive, hypoglycemia, prematurity and developmental concerns
     2. Respiratory illnesses – including asthma, croup, bronchiolitis, cystic fibrosis and pneumonia
     3. Cardiac disease – including innocent and pathologic murmurs, congenital heart disease, arrythmias, congestive heart failure and Kawasaki disease
     4. CNS disease – including seizures, headaches, acquired brain injury and specific diseases affecting development (e.g. cerebral palsy)
     5. Gastrointestinal diseases – including gastroenteritis and dehydration, malabsorption and constipation
     6. Infectious diseases – including all common viral and bacterial infections
     7. Dermatology – including eczema, urticaria and erythematous rashes
     8. Hematology – including anemia and thrombocytopenia
     9. Child neglect and maltreatment – including skeletal injuries, skin lesions, sexual abuse and shaken baby syndrome

   ROTATION: Pediatrics

   Overall Goal: This rotation in Pediatric Medicine is designed to expose the resident to common problems encountered in the pediatric populations. The resident will further enhance their skills in the assessment, diagnosis and management of this unique patient population.

   Communicator:

   • Establishes a therapeutic relationship and professional rapport with pediatric patients, parents and other family members
   • Clear, concise and legible problem-oriented medical records, discharge summaries and consultations
   • Able to communicate effectively with health care team members, including technical staff, support staff, supervisors and colleagues
   • Provides clear instructions and checks whether the patient/family understands
   • Verbally presents the patient’s problems clearly, concisely and correctly in the clinical setting

   Collaborator:

   • Interacts and collaborates effectively with other physicians, health professionals and team members, recognizing their roles, responsibilities and expertise
   • Able to request and provide consultations with clear understanding of question being asked
   • Takes on appropriate share of team assignments and assists others as required

   Manager:

   • Utilizes health care resources effectively to balance patient care, learning needs and outside activities.
   • Utilizes information technology to optimize patient care and life-long learning
   • Displays organizational skills with effective time-management
   • Recognizes issues surrounding informed consent and refusal of treatment in children and adolescents and the right of adolescents to confidentiality

   Health Advocate:

   • Identifies the important determinants of health, including injury prevention
   • Recognizes and responds to those patient care issues where patient advocacy is appropriate
   • Identifies situations where patient advocacy and preventative health awareness is required
   • Recognizes the importance of giving accurate information with respect to immunizations, promoting safety in the home and on the street, counseling re smoking and substance abuse

   Scholar:

   • Develops, implements and monitors a personal continuing education strategy that includes the ability to critically appraise the literature.
   • Develops teaching skills that facilitate the learning of his/her patients and peers; uses opportunities to teach and supervise medical students
   • Attends and contributes to rounds and other learning events
   • Accepts and acts on constructive feedback

   Professional:

   • Practices medicine ethically, demonstrating integrity, honesty and compassion
   • Recognizes limitations and seeks advice and consultation when needed
   • Discharges duties and assignments dependably and in a timely fashion
   • Demonstrates awareness of the life-long significance of serious or chronic illnesses in children and the impact on their quality of life
   • Respects diversity of race, gender, disability intelligence and socio-economic status

   Specific Techniques:

   • Aseptic technique in performing medical procedures
   • Lumbar puncture
   • Bladder catheterization
   • Arterial and venous blood sampling
   • Insertion of umbilical venous and arterial line
   • Insertion of nasogastric feeding tubes

   ROTATION: Radiation Oncology

   Overall Goal: This selective rotation in radiation oncology is designed to introduce the BCT resident to the specialty of radiation oncology.  The resident will learn to correlate clinical and radiological findings and their integral relationship in assessing, planning treatment and managing the oncologic patient.

   Medical Expert:

   • Demonstrates a good understanding of the basic scientific and clinical knowledge relevant to the specialty of radiation oncology
   • Able to perform an organized history and physical examination, relevant to the patients encountered in the elective setting
   • Integrates pertinent information to arrive at appropriate patient assessment
   • Participates in the referral and planning process for patients referred to JCC including:  new patient assessment, consultation, treatment planning
   • Participates in imaging review and planning examinations, in order to gain appreciation of the key role of diagnostic imaging in the specialty of radiation oncology
   • Demonstrates an understanding of the principles of radiation treatment for cancer patients,: including radiation toxicity/complications of treatment

   Communicator:

   • Establishes a therapeutic relationship with patients and communicates well with families.
   • Able to communicate effectively with technical staff, support staff, supervisors and colleagues.

   Collaborator:

   • Interacts and collaborates effectively with other health professionals and team members, recognizing their roles, responsibilities and expertise

   Manager:

   • Understands and makes effective use of information technology
   • Demonstrates an understanding of importance of cost effective use of health care resources

   Health Advocate:

   • Demonstrates an understanding of the specialist’s role to intervene and advocate on behalf of patients with respect to social, economic and biologic factors that may impact on their health

   Scholar:

   • Develops and implements an ongoing and effective personal learning strategy
   • Demonstrates ability to identify gaps in personal knowledge and expertise

   Professional:

   • Demonstrates a responsible work ethic, interest and enthusiasm for learning
   • Demonstrates professional work habits: punctual, organized, efficient
   • Recognizes their limitations and seeks assistance when necessary
   • Responsive to feedback
5. EMERGENCY RADIOLOGY INTRODUCTORY READING

   Adapted from the reading list compiled by McGill University

   By Khashayar Rafat Zand, M.D., Shagran Bin Khamis, MBBS

   Introduction:

   In the first few months of radiology training, mastery of emergency radiology topics remains the major focus of training for new residents. In order to competently handle their on-call duties, beginning residents are expected to excel in diagnosis of life-threatening conditions.

   The paucity of a well-organized study resource to address such selective preparation represents an additional challenge. The excellent emergency radiology book by Harris has become outdated, appropriate to be used as an introductory, rather than a comprehensive resource. The frequently-advised “fundamentals of radiology” book by Brant & Helms is more of a review book and a “round rescue” rather than an emergency radiology walkthrough.

   It was in the face of this void that we decided to prepare this document. The first step was to put in order a comprehensive list of emergency radiology topics, which was adopted from “Core Curriculum in Emergency Radiology” by Dr. R. A. Novelline. Topic-specific articles were then chosen through PubMed searches. Only articles with large numbers of representative pictures from major radiology journals were chosen, with preference given to educational exhibits. A few hospital-specific topics were added, specifically those related to transplant imaging and hyperbaric surgery for the Royal Victoria Hospital. Musculoskeletal trauma topics except for Spine were excluded, considering their adequate coverage in the Greenspan’s textbook and Dr. Assaf’s excellent teaching case collection. The last section, “Foreign Bodies, Lines and Devices”, is added to serve as an on-call reference.

   We have tried to make this document as comprehensive as possible. Some topics are explored to a greater extent in the literature, hence the multiplicity of suggested articles in those areas. Although it was tempting to devise some kind of importance rank-order, either among different topics or for articles on the same topic, this would have not been more than arbitrary. We will leave this to the taste and preferences of the users. Also, due to the large number of the articles and time restraints, not all articles have been reviewed in depth. A few articles might lack the expected strength or content, but included for comprehensiveness

   The Table of Contents in the second page has hyperlink functions. Each article is linked to its PubMed source; clicking the name of the authors (while holding the control key) will open the article’s abstract in PubMed. All articles are available in electronic format through TOH/UOttawa libraries.

   Table of Contents:

   1. General
   2. Central Nervous System
   3. Face and Neck
   4. Spine
   5. Chest
   6. Cardiovascular Emergencies
   7. Abdomen; Trauma
   8. Abdomen; Non-traumatic Emergencies
   9. Gynecological /Obstetrical Emergencies
   10. Male Genitourinary Emergencies
   11. Contrast-related complications
   12. Foreign Bodies, Lines and Devices

1. General
   • Goldman SM. New proposed responsibilities of a radiologist in the emergency room: what you need to know and must, shall, should do. Emerg Radiol. 2006 Mar;12(3):87.
2. Central Nervous System
   1. Extra-axial hemorrhages & parenchymal injuries
      • Young RJ, Destian S. Imaging of traumatic intracranial hemorrhage. Neuroimaging Clin N Am. 2002 May;12(2):189-204. Review.
      • Zee CS, Hovanessian A, Go JL, Kim PE. Imaging of sequelae of head trauma. Neuroimaging Clin N Am. 2002 May;12(2):325-38, ix. Review.
      • Gruen P. Surgical management of head trauma. Neuroimaging Clin N Am. 2002 May;12(2):339-43.
      • Hammoud DA, Wasserman BA. Diffuse axonal injuries: pathophysiology and imaging. Neuroimaging Clin N Am. 2002 May;12(2):205-16. Review.
   2. Herniation syndromes
      • Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am. 2002 May;12(2):217-28. Review
   3. Cerebral infarction
      • Grunwald I, Reith W. Non-traumatic neurological emergencies: imaging of cerebral ischemia. Eur Radiol. 2002 Jul;12(7):1632-47. Epub 2002 May 30.
      • Mullins ME. Modern emergent stroke imaging: pearls, protocols, and pitfalls. Radiol Clin North Am. 2006 Jan;44(1):41-62, vii-viii. Review.
      • Gonzalez RG. Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain". AJNR Am J Neuroradiol. 2006 Apr;27(4):728-35.
   4. Dural sinus thrombosis
      • Lee EJ. The empty delta sign. Radiology. 2002 Sep;224(3):788-9.
      • Wasay M, Azeemuddin M. Neuroimaging of cerebral venous thrombosis. J Neuroimaging. 2005 Apr;15(2):118-28. Review.
      • Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005 Apr 28;352(17):1791-8. Review.
   5. Vascular injuries
      • Larsen DW. Traumatic vascular injuries and their management. Neuroimaging Clin N Am. 2002 May;12(2):249-69. Review
      • Stallmeyer MJ, Morales RE, Flanders AE. Imaging of traumatic neurovascular injury.Radiol Clin North Am. 2006 Jan;44(1):13-39, vii. Review
   6. Penetrating injuries
      • Kim PE, Go JL, Zee CS. Radiographic assessment of cranial gunshot wounds. Neuroimaging Clin N Am. 2002 May;12(2):229-48. Review.
   7. Reversible posterior leukoencephalopathy syndrome
      • Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin MS, Lamy C, Mas JL, Caplan LR. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996 Feb 22;334(8):494-500.
      • Wartenberg KE, Parra A. CT and CT-perfusion findings of reversible leukoencephalopathy during triple-H therapy for symptomatic subarachnoid hemorrhage-related vasospasm. J Neuroimaging. 2006 Apr;16(2):170-5.
3. Face and Neck
   1. Facial fractures
      • Sun JK, LeMay DR. Imaging of facial trauma. Neuroimaging Clin N Am. 2002 May;12(2):295-309. Review.
   2. Injuries of the orbit
      • Go JL, Vu VN, Lee KJ, Becker TS.  Orbital trauma. Neuroimaging Clin N Am. 2002 May;12(2):311-24. Review.
4. Spine
   • Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am. 2006 Jan;44(1):1-12, vii. Review.
   • Goradia D, Blackmore CC, Talner LB, Bittles M, Meshberg E. Predicting radiology resident errors in diagnosis of cervical spine fractures. Acad Radiol. 2005 Jul;12(7):888-93.
   • Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology. 2005 Mar;234(3):733-9. Review.
   • Ehara S, Shimamura T. Cervical spine injury in the elderly: imaging features. Skeletal Radiol. 2001 Jan;30(1):1-7. Review.
   • Bono CM, Vaccaro AR, Fehlings M, Fisher C, Dvorak M, Ludwig S, Harrop J. Measurement techniques for lower cervical spine injuries: consensus statement of the Spine Trauma Study Group. Spine. 2006 Mar 1;31(5):603-9. Review.
   1. Cranio-cervical / C1-C2
      • Aulino JM, Tutt LK, Kaye JJ, Smith PW, Morris JA Jr. Occipital condyle fractures: clinical presentation and imaging findings in 76 patients. Emerg Radiol. 2005 Nov;11(6):342-7. Epub 2005 Jul 15.
      • Harris J Jr. The cervicocranium: its radiographic assessment. Radiology. 2001 Feb;218(2):337-51. Review.
      • Deliganis AV, Baxter AB, Hanson JA, Fisher DJ, Cohen WA, Wilson AJ, Mann FA. Radiologic spectrum of craniocervical distraction injuries. Radiographics. 2000 Oct;20 Spec No:S237-50. Erratum in: Radiographics 2001 Mar-Apr;21(2):520.
   2. C3-T1
      • Rao SK, Wasyliw C, Nunez DB Jr. Spectrum of imaging findings in hyperextension injuries of the neck. Radiographics. 2005 Sep-Oct;25(5):1239-54. Review
   3. Thoraco-lumbar spine trauma
      • Daffner RH, Daffner SD. Vertebral injuries: detection and implications. Eur J Radiol. 2002 May;42(2):100-16. Review.
5. Chest
   1. Chest trauma
      • Kuhlman JE, Pozniak MA, Collins J, Knisely BL. Radiographic and CT findings of blunt chest trauma: aortic injuries and looking beyond them. Radiographics. 1998 Sep-Oct;18(5):1085-106; discussion 1107-8; quiz 1. Review.
      • Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A. Imaging of blunt chest trauma. Eur Radiol. 2000;10(10):1524-38. Review.
      • Gavelli G, Canini R, Bertaccini P, Battista G, Bna C, Fattori R. Traumatic injuries: imaging of thoracic injuries. Eur Radiol. 2002 Jun;12(6):1273-94. Epub 2002 Apr 20. Review.
      • Lomoschitz FM, Eisenhuber E, Linnau KF, Peloschek P, Schoder M, Bankier AA. Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms. Eur J Radiol. 2003 Oct;48(1):61-70. Review.
      • Nunez DB Jr, Torres-Leon M, Munera F. Vascular injuries of the neck and thoracic inlet: helical CT-angiographic correlation. Radiographics. 2004 Jul-Aug;24(4):1087-98; discussion 1099-100. Review.
      • Alkadhi H, Wildermuth S, Desbiolles L, Schertler T, Crook D, Marincek B, Boehm T. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi-detector row CT and three-dimensional imaging. Radiographics. 2004 Sep-Oct;24(5):1239-55. Review.
      • Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. 2006 Mar;44(2):213-24, viii. Review
      • Shanmuganathan K, Matsumoto J. Imaging of penetrating chest trauma. Radiol Clin North Am. 2006 Mar;44(2):225-38, viii. Review
      • Euathrongchit J, Thoongsuwan N, Stern EJ. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi-detector row CT and three-dimensional imaging. Radiographics. 2004 Sep-Oct;24(5):1239-55. Review.
         
   2. Acute pulmonary infections
      • Waite S, Jeudy J, White CS. Acute lung infections in normal and immunocompromised hosts. Radiol Clin North Am. 2006 Mar;44(2):295-315, ix. Review.
6. Cardiovascular Emergencies
   1. Aorta
      • Castaner E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardo Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications. Radiographics. 2003 Oct;23 Spec No:S93-110. Review.
      • Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in acute aortic syndromes: aortic aneurysm leak and rupture and traumatic aortic transection. AJR Am J Roentgenol. 2003 Aug;181(2):303-7.
      • Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer.
        AJR Am J Roentgenol. 2003 Aug;181(2):309-16.
      • Batra P, Bigoni B, Manning J, Aberle DR, Brown K, Hart E, Goldin J. Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography. Radiographics. 2000 Mar-Apr;20(2):309-20.
      • Sebastia C, Pallisa E, Quiroga S, Alvarez-Castells A, Dominguez R, Evangelista A. Aortic dissection: diagnosis and follow-up with helical CT. Radiographics. 1999 Jan-Feb;19(1):45-60; quiz 149-50.
      • Hayashi H, Matsuoka Y, Sakamoto I, Sueyoshi E, Okimoto T, Hayashi K, Matsunaga N. Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics. 2000 Jul-Aug;20(4):995-1005.
      • Macedo TA, Stanson AW, Oderich GS, Johnson CM, Panneton JM, Tie ML. Infected aortic aneurysms: imaging findings. Radiology. 2004 Apr;231(1):250-7. Erratum in: Radiology. 2006 Mar;238(3):1078.
      • Wong H, Gotway MB, Sasson AD, Jeffrey RB.  Periaortic hematoma at diaphragmatic crura at helical CT: sign of blunt aortic injury in patients with mediastinal hematoma. Radiology. 2004 Apr;231(1):185-9.
      • Alkadhi H, Wildermuth S, Desbiolles L, Schertler T, Crook D, Marincek B, Boehm T. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi-detector row CT and three-dimensional imaging. Radiographics. 2004 Sep-Oct;24(5):1239-55. Review.
   2. Pulmonary Edema
      • Gluecker T, Capasso P, Schnyder P, Gudinchet F, Schaller MD, Revelly JP, Chiolero R, Vock P, Wicky S. Clinical and radiologic features of pulmonary edema. Radiographics. 1999 Nov-Dec;19(6):1507-31; discussion 1532-3. Review.
   3. Thrombo-embolic disease
      • Katz DS, Loud PA, Bruce D, Gittleman AM, Mueller R, Klippenstein DL, Grossman ZD. Combined CT venography and pulmonary angiography: a comprehensive review. Radiographics. 2002 Oct;22 Spec No:S3-19; discussion S20-4. Review.
      • Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JA, McLoud TC. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics. 2004
      • Sep-Oct;24(5):1219-38. Review.
      • Fraser JD, Anderson DR. Venous protocols, techniques, and interpretations of the upper and lower extremities. Radiol Clin North Am. 2004 Mar;42(2):279-96. Review.
      • Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiology. 1999 Apr;211(1):9-24. Review.
      • Kluetz PG, White CS. Acute pulmonary embolism: imaging in the emergency department. Radiol Clin North Am. 2006 Mar;44(2):259-71, ix. Review
      • Remy-Jardin M, Mastora I, Remy J. Pulmonary embolus imaging with multislice CT. Radiol Clin North Am. 2003 May;41(3):507-19. Review.
7. Abdomen: Trauma
   • Stanescu L, Talner LB, Mann FA. Diagnostic errors in polytrauma: a structured review of the recent literature. Emerg Radiol. 2006 Mar;12(3):119-23. Epub 2006 Jan 17.
   • Miller LA, Shanmuganathan K. Multidetector CT evaluation of abdominal trauma. Radiol Clin North Am. 2005 Nov;43(6):1079-95, viii. Review.
   • McGahan JP, Richards J, Fogata ML. Emergency ultrasound in trauma patients. Radiol Clin North Am. 2004 Mar;42(2):417-25. Review.
   1. Active arterial extravasation on CT
      • Willmann JK, Roos JE, Platz A, Pfammatter T, Hilfiker PR, Marincek B, Weishaupt D. Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol. 2002 Aug;179(2):437-44.
   2. Splenic injuries
      • Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology. 2000 Oct;217(1):75-82.
      • Miller LA, Mirvis SE, Shanmuganathan K, Ohson AS. CT diagnosis of splenic infarction in blunt trauma: imaging features, clinical significance and complications. Clin Radiol. 2004 Apr;59(4):342-8.
   3. Liver injuries
      • Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, Kim JC, Jeong SW, Park JG, Kang HK. CT in blunt liver trauma. Radiographics. 2005 Jan-Feb;25(1):87-104. Review.
   4. Bowel & mesenteric injuries
      • Hanks PW, Brody JM. Blunt injury to mesentery and small bowel: CT evaluation. Radiol Clin North Am. 2003 Nov;41(6):1171-82. Review.
      • Brody JM, Leighton DB, Murphy BL, Abbott GF, Vaccaro JP, Jagminas L, Cioffi WG. CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis. Radiographics. 2000 Nov-Dec;20(6):1525-36; discussion 1536-7.
      • Butela ST, Federle MP, Chang PJ, Thaete FL, Peterson MS, Dorvault CJ, Hari AK, Soni S, Branstetter BF, Paisley KJ, Huang LF. Performance of CT in detection of bowel injury. AJR Am J Roentgenol. 2001 Jan;176(1):129-35.
   5. Pancreatic, Gallbladder and biliary injuries
      • Gupta A, Stuhlfaut JW, Fleming KW, Lucey BC, Soto JA. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. 2004 Sep-Oct;24(5):1381-95. Review.
      • Fleming KW, Lucey BC, Soto JA, Oates ME. Posttraumatic bile leaks: role of diagnostic imaging and impact on patient outcome. Emerg Radiol. 2006 Mar;12(3):103-7. Epub 2005 Dec 21.
   6. Renal injuries
      • Harris AC, Zwirewich CV, Lyburn ID, Torreggiani WC, Marchinkow LO. CT findings in blunt renal trauma. Radiographics. 2001 Oct;21 Spec No:S201-14. Review.
      • Kawashima A, Sandler CM, Corl FM, West OC, Tamm EP, Fishman EK, Goldman SM. Imaging of renal trauma: a comprehensive review. Radiographics. 2001 May-Jun;21(3):557-74. Review.
      • Smith JK, Kenney PJ. Imaging of renal trauma. Radiol Clin North Am. 2003 Sep;41(5):1019-35. Review
   7. Adrenal injuries
      • Rana AI, Kenney PJ, Lockhart ME, McGwin G Jr, Morgan DE, Windham ST 3rd, Smith JK. Adrenal gland hematomas in trauma patients. Radiology. 2004 Mar;230(3):669-75.
   8. Bladder injuries: intraperitoneal and extraperitoneal
      • Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics. 2000 Sep-Oct;20(5):1373-81. Review.
   9. Abdominal wall injuries and diaphragmatic hernias
      • Bergin D, Ennis R, Keogh C, Fenlon HM, Murray JG. The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol. 2001 Nov;177(5):1137-40.
      • Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics. 2002 Oct;22 Spec No:S103-16; discussion S116-8. Review.
      • Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am. 2006 Mar;44(2):199-211, vii. Review
8. Abdomen; Non-traumatic Emergencies
   • Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics. 2002 May-Jun;22(3):543-61. Review.
   • Frauenfelder T, Wildermuth S, Marincek B, Boehm T. Nontraumatic emergent abdominal vascular conditions: advantages of multi-detector row CT and three-dimensional imaging. Radiographics. 2004 Mar-Apr;24(2):481-96. Review.
   • Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G. Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain. Radiographics. 2004 May-Jun;24(3):703-15. Review.
   • Wittenberg J, Harisinghani MG, Jhaveri K, Varghese J, Mueller PR. Algorithmic approach to CT diagnosis of the abnormal bowel wall. Radiographics. 2002 Sep-Oct;22(5):1093-107; discussion 1107-9. Review.
   • McNamara MM, Lockhart ME, Robbin ML.  Emergency Doppler evaluation of the liver and kidneys. Radiol Clin North Am. 2004 Mar;42(2):397-415. Review.
   1. Intraperitoneal hemorrhage
      • Mortele KJ, Cantisani V, Brown DL, Ros PR. Spontaneous intraperitoneal hemorrhage: imaging features. Radiol Clin North Am. 2003 Nov;41(6):1183-201. Review.
   2. Liver and biliary tract
      • Hanbidge AE, Buckler PM, O'Malley ME, Wilson SR. From the RSNA refresher courses: imaging evaluation for acute pain in the right upper quadrant. Radiographics. 2004 Jul-Aug;24(4):1117-35. Review.
      • Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am. 2003 Nov;41(6):1203-16. Review.
      • Rubens DJ. Hepatobiliary imaging and its pitfalls. Radiol Clin North Am. 2004 Mar;42(2):257-78. Review.
      • Federle MP, Kapoor V. Complications of liver transplantation: imaging and intervention. Radiol Clin North Am. 2003 Nov;41(6):1289-305. Review.
      • Crossin JD, Muradali D, Wilson SR. US of liver transplants: normal and abnormal. Radiographics. 2003 Sep-Oct;23(5):1093-114. Review.
   3. Pancreas
      • Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002 Jun;223(3):603-13. Review.
      • Balthazar EJ. Complications of acute pancreatitis: clinical and CT evaluation. Radiol Clin North Am. 2002 Dec;40(6):1211-27. Review.
      • Remer EM, Baker ME. Imaging of chronic pancreatitis. Radiol Clin North Am. 2002 Dec;40(6):1229-42, v. Review.
      • Nikolaidis P, Amin RS, Hwang CM, Mc Carthy RM, Clark JH, Gruber SA, Chen PC. Role of sonography in pancreatic transplantation. Radiographics. 2003 Jul-Aug;23(4):939-49. Review.
   4. Urinary tract
      • Rucker CM, Menias CO, Bhalla S. Mimics of renal colic: alternative diagnoses at unenhanced helical CT. Radiographics. 2004 Oct;24 Suppl 1:S11-28; discussion S28-33. Review.
      • Dalrymple NC, Casford B, Raiken DP, Elsass KD, Pagan RA. Pearls and pitfalls in the diagnosis of ureterolithiasis with unenhanced helical CT. Radiographics. 2000 Mar-Apr;20(2):439-47; quiz 527-8, 532
      • Kenney PJ. CT evaluation of urinary lithiasis. Radiol Clin North Am. 2003 Sep;41(5):979-99. Review
      • Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics. 2005 Sep-Oct;25(5):1335-56. Review.
      • Sebastia C, Quiroga S, Boye R, Cantarell C, Fernandez-Planas M, Alvarez A. Helical CT in renal transplantation: normal findings and early and late complications. Radiographics. 2001 Sep-Oct;21(5):1103-17. Review.
      • Brown ED, Chen MY, Wolfman NT, Ott DJ, Watson NE Jr. Complications of renal transplantation: evaluation with US and radionuclide imaging. Radiographics. 2000 May-Jun;20(3):607-22. Review.
   5. Gastrointestinal hemorrhage
      • Lemos AA, Sternberg JM, Tognini L, Lauro R, Biondetti PR. Nontraumatic abdominal hemorrhage: MDCTA. Abdom Imaging. 2006 Jan-Feb;31(1):17-24.
      • Yoon W, Jeong YY, Kim JK. Acute gastrointestinal bleeding: contrast-enhanced MDCT. Abdom Imaging. 2006 Jan-Feb;31(1):1-8.
      • Puylaert JB. Ultrasonography of the acute abdomen: gastrointestinal conditions.
        Radiol Clin North Am. 2003 Nov;41(6):1227-42, vii. Review.
   6. Bowel obstruction
      • Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, Mueller PR. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Radiographics. 2006 May-Jun;26(3):733-44.
      • Huang BY, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. Radiol Clin North Am. 2003 Nov;41(6):1137-51. Review.
      • Petrovic B, Nikolaidis P, Hammond NA, Grant TH, Miller FH. Identification of adhesions on CT in small-bowel obstruction. Emerg Radiol. 2006 Mar;12(3):88-93; discussion 94-5. Epub 2005 Dec 13.
      • Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM. Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management. Radiology. 2001 Jan;218(1):39-46. Review
      • Blachar A, Federle MP. Bowel obstruction following liver transplantation: clinical and ct findings in 48 cases with emphasis on internal hernia. Radiology. 2001 Feb;218(2):384-8.
      • Blachar A, Federle MP, Brancatelli G, Peterson MS, Oliver JH 3rd, Li W. Radiologist performance in the diagnosis of internal hernia by using specific CT findings with emphasis on transmesenteric hernia. Radiology. 2001 Nov;221(2):422-8.
      • Blachar A, Federle MP, Dodson SF. Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology. 2001 Jan;218(1):68-74.
      • Takeyama N, Gokan T, Ohgiya Y, Satoh S, Hashizume T, Hataya K, Kushiro H, Nakanishi M, Kusano M, Munechika H. CT of internal hernias. Radiographics. 2005 Jul-Aug;25(4):997-1015
      • Furukawa A, Yamasaki M, Furuichi K, Yokoyama K, Nagata T, Takahashi M, Murata K, Sakamoto T. Helical CT in the diagnosis of small bowel obstruction. Radiographics. 2001 Mar-Apr;21(2):341-55. Review.
      • Boudiaf M, Soyer P, Terem C, Pelage JP, Maissiat E, Rymer R. CT evaluation of small bowel obstruction. Radiographics. 2001 May-Jun;21(3):613-24. Review.
   7. Bowel infarction
      • Rha SE, Ha HK, Lee SH, Kim JH, Kim JK, Kim JH, Kim PN, Lee MG, Auh YH. CT and MR imaging findings of bowel ischemia from various primary causes. Radiographics. 2000 Jan-Feb;20(1):29-42. Review.
      • Macari M, Chandarana H, Balthazar E, Babb J. Intestinal ischemia versus intramural hemorrhage: CT evaluation. AJR Am J Roentgenol. 2003 Jan;180(1):177-84.
      • Bradbury MS, Kavanagh PV, Bechtold RE, Chen MY, Ott DJ, Regan JD, Weber TM. Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics. 2002 May-Jun;22(3):527-41. Review.
      • Sebastia C, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics. 2000 Sep-Oct;20(5):1213-24; discussion 1224-6. Review.
      • Balthazar EJ, Yen BC, Gordon RB. Ischemic colitis: CT evaluation of 54 cases. Radiology. 1999 May;211(2):381-8.
   8. Perforation
      • Rubesin SE, Levine MS. Radiologic diagnosis of gastrointestinal perforation. Radiol Clin North Am. 2003 Nov;41(6):1095-115, v. Review.
   9. Appendicitis
      • Giuliano V, Giuliano C, Pinto F, Scaglione M. Chronic appendicitis "syndrome" manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults. Emerg Radiol. 2006 Mar;12(3):96-8. Epub 2006 Jan 11
      • Jacobs JE, Birnbaum BA, Macari M, Megibow AJ, Israel G, Maki DD, Aguiar AM, Langlotz CP. Acute appendicitis: comparison of helical CT diagnosis focused technique with oral contrast material versus nonfocused technique with oral and intravenous contrast material. Radiology. 2001 Sep;220(3):683-90.
      • Mun S, Ernst RD, Chen K, Oto A, Shah S, Mileski WJ. Rapid CT diagnosis of acute appendicitis with IV contrast material. Emerg Radiol. 2006 Mar;12(3):99-102. Epub 2005 Dec 17
      • Lane MJ, Liu DM, Huynh MD, Jeffrey RB Jr, Mindelzun RE, Katz DS. Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive patients. Radiology. 1999 Nov;213(2):341-6. 
      • Pinto Leite N, Pereira JM, Cunha R, Pinto P, Sirlin C. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol. 2005 Aug;185(2):406-17. Review.
      • Tamburrini S, Brunetti A, Brown M, Sirlin CB, Casola G. CT appearance of the normal appendix in adults. Eur Radiol. 2005 Oct;15(10):2096-103. Epub 2005 May 24.
      • Macari M, Balthazar EJ.  The acute right lower quadrant: CT evaluation. Radiol Clin North Am. 2003 Nov;41(6):1117-36. Review.
      • Yu J, Fulcher AS, Turner MA, Halvorsen RA. Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis. AJR Am J Roentgenol. 2005 Apr;184(4):1136-42. Review.
      • Yu J, Fulcher AS, Turner MA, Halvorsen RA. Helical CT evaluation of acute right lower quadrant pain: part II, uncommon mimics of appendicitis. AJR Am J Roentgenol. 2005 Apr;184(4):1143-9. Review.
   10. Diverticulitis
       • Chintapalli KN, Chopra S, Ghiatas AA, Esola CC, Fields SF, Dodd GD 3rd. Diverticulitis versus colon cancer: differentiation with helical CT findings. Radiology. 1999 Feb;210(2):429-35.
       • Buckley O, Geoghegan T, O'Riordain DS, Lyburn ID, Torreggiani WC. Computed tomography in the imaging of colonic diverticulitis. Clin Radiol. 2004 Nov;59(11):977-83. Review.
   11. Colitis
       • Kirkpatrick ID, Greenberg HM. Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy? AJR Am J Roentgenol. 2001 Mar;176(3):635-9.
       • Kawamoto S, Horton KM, Fishman EK. Pseudomembranous colitis: spectrum of imaging findings with clinical and pathologic correlation. Radiographics. 1999 Jul-Aug;19(4):887-97. Review.
   12. Epiploic appendagitis
       • Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics. 2005 Nov-Dec;25(6):1521-34. Review.
   13. Inflammatory bowel disease
       • Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease.
         Radiographics. 2000 Mar-Apr;20(2):399-418.
   14. Post-Op Abdomen
       • Yu J, Turner MA, Cho SR, Fulcher AS, DeMaria EJ, Kellum JM, Sugerman HJ. Normal anatomy and complications after gastric bypass surgery: helical CT findings. Radiology. 2004 Jun;231(3):753-60.
       • Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology. 2002 Jun;223(3):625-32.
       • Merkle EM, Hallowell PT, Crouse C, Nakamoto DA, Stellato TA. Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging. Radiology. 2005 Mar;234(3):674-83. Epub 2005 Jan 13. Review. 
9. Gynecological /Obstetrical Emergencies
   1. Trauma
      • Goldman SM, Wagner LK. Radiologic ABCs of maternal and fetal survival after trauma: when minutes may count. Radiographics. 1999 Sep-Oct;19(5):1349-57.
      • Lowdermilk C, Gavant ML, Qaisi W, West OC, Goldman SM. Screening helical CT for evaluation of blunt traumatic injury in the pregnant patient. Radiographics. 1999 Oct;19 Spec No:S243-55 discussion S256-8.
   2. Non-traumatic Acute abdomen in women
      • Saksouk FA, Johnson SC. Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics. 2004 Oct;24 Suppl 1:S133-46. Review
      • Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics. 2002 Jul-Aug;22(4):785-801. Review.
      • Webb EM, Green GE, Scoutt LM. Adnexal mass with pelvic pain. Radiol Clin North Am. 2004 Mar;42(2):329-48. Review.
      • Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, Kim H, Lee JM. CT and MR imaging features of adnexal torsion. Radiographics. 2002 Mar-Apr;22(2):283-94.
   3. Pregnancy related emergencies
      • Paspulati RM, Bhatt S, Nour S. Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am. 2004 Mar;42(2):297-314. Review. 
      • Lazebnik N, Lazebnik RS. The role of ultrasound in pregnancy-related emergencies. Radiol Clin North Am. 2004 Mar;42(2):315-27. Review.
10. Male Genitourinary Emergencies
    1. Urethra and penis
       • Ali M, Safriel Y, Sclafani SJ, Schulze R. CT signs of urethral injury. Radiographics. 2003 Jul-Aug;23(4):951-63; discussion 963-6. Review.
       • Sadeghi-Nejad H, Dogra V, Seftel AD, Mohamed MA. Priapism. Radiol Clin North Am. 2004 Mar;42(2):427-43. Review.
    2. Scrotal and testicular
       • Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. 2004 Mar;42(2):349-63. Review
       • Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology. 2003 Apr;227(1):18-36. Epub 2003 Feb 28. Review.
11. Contrast-related complications
    • Bettmann MA. Frequently asked questions: iodinated contrast agents. Radiographics. 2004 Oct;24 Suppl 1:S3-10.
    • Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions to intravenous iodinated contrast media: a primer for radiologists. Emerg Radiol. 2006 May 11
    • Masui T, Katayama M, Kobayashi S, Sakahara H. Intravenous injection of high and medium concentrations of computed tomography contrast media and related heat sensation, local pain, and adverse reactions. J Comput Assist Tomogr. 2005 Sep-Oct;29(5):704-8.
    • Rizzo S, Kalra MK, Maher MM. Importance of an expedited review of images after an adverse reaction to CT contrast material. AJR Am J Roentgenol. 2004 Oct;183(4):1174-5.
    • Seymour CW, Pryor JP, Gupta R, Schwab CW. Anaphylactoid reaction to oral contrast for computed tomography. J Trauma. 2004 Nov;57(5):1105-7.
    • Thomsen HS, Morcos SK; Contrast Media Safety Committee of European Society of Urogenital Radiology.  Management of acute adverse reactions to contrast media.Eur Radiol. 2004 Mar;14(3):476-81. Epub 2004 Jan 23.
    • Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our current understanding. Br J Radiol. 2005 Aug;78(932):686-93. Review
12. Foreign Bodies, Lines and Devices
    • Summers JB, Kaminski J. Foreign bodies. Radiographics. 2003 Nov-Dec;23(6):1701.
    • Taljanovic MS, Jones MD, Ruth JT, Benjamin JB, Sheppard JE, Hunter TB. Fracture fixation. Radiographics. 2003 Nov-Dec;23(6):1569-90. Review.
    • Hunter TB, Taljanovic MS. Glossary of medical devices and procedures: abbreviations, acronyms, and definitions. Radiographics. 2003 Jan-Feb;23(1):195-213.
    • Taljanovic MS, Jones MD, Hunter TB, Benjamin JB, Ruth JT, Brown AW, Sheppard JE. Joint arthroplasties and prostheses. Radiographics. 2003 Sep-Oct;23(5):1295-314. Review.
    • Hunter TB. Special report: medical devices and foreign bodies: an introduction. Radiographics. 2003 Jan-Feb;23(1):193-4.
    • Hunter TB, Yoshino MT, Dzioba RB, Light RA, Berger WG. Medical devices of the head, neck, and spine. Radiographics. 2004 Jan-Feb;24(1):257-85. Review. Erratum in: Radiographics. 2004 Mar-Apr;24(2):418.
    • Hunter TB, Taljanovic MS, Tsau PH, Berger WG, Standen JR. Medical devices of the chest. Radiographics. 2004 Nov-Dec;24(6):1725-46.
    • Taljanovic MS, Hunter TB, Miller MD, Sheppard JE. Gallery of medical devices: part 1: orthopedic devices for the extremities and pelvis. Radiographics. 2005 May-Jun;25(3):859-70.
    • Taljanovic MS, Hunter TB, O'Brien MJ, Schwartz SA. Gallery of medical devices: part 2: devices of the head, neck, spine, chest, and abdomen. Radiographics. 2005 Jul-Aug;25(4):1119-32.
    • Hunter TB, Taljanovic MS. Medical devices of the abdomen and pelvis. Radiographics. 2005 Mar-Apr;25(2):503-23.

Revised: April 19^th 2012

Physics Rotation

Supervisor

Rebecca Thornhill

Schedule Heading

Physics

Ideal Scheduling

PGY 4 or 5 (Elective Rotation)

Introduction

Over the course of residency, it is important for residents to gain an understanding of how medical imaging is performed and how to troubleshoot common problems. Radiologists should be capable of optimizing an imaging study given their unique knowledge of disease, clinical context and image interpretation skills. The goal of this rotation is to provide residents with a hands-on experience to consolidate their knowledge of imaging physics, including image acquisition, patient preparation, modality preparation, image post-processing, and to understand common workflow issues as well as challenges faced by imaging technologists.

During this rotation, the resident will be assigned to an imaging modality and will collaborate with the technologist. A schedule for the block is provided (see APPENDIX A). This schedule ensures the resident has a broad exposure to radiography, CT and MRI. The breakdown by workday (these are all half days) is divided between: MRI, CT and x-ray (including special procedures) with elective opportunity in mammography and cardiac CT.  For each modality, the resident will familiarize themselves with study protocols and patient preparation requirements. The resident will observe and/or assist the technologist as they position the patient and prepare the modality. The resident is encouraged to ask the technologist questions during this time.

It is recommended that residents read about imaging physics during this rotation. A list of recommended reading materials is provided (APPENDIX B).

During the rotation, the residents will be required to prepare a presentation for resident noon rounds.  This can be on any physics topic as it applies to radiology and should have a 20 minute didactic component followed by a 25 minute ‘case-based’ OSCE component composed of physics related issues/ problems commonly encountered in practice (artefacts, protocol optimization, quality assurance etc).  Ideally, the case-based portion would complement the didactic portion.  The resident will be given sufficient time and guidance during the rotation to complete this exercise.  The presentation will be scheduled during the last week or 2 weeks following the rotation.

The resident will be required to meet with the rotation supervisor at the beginning of the rotation, and on a weekly basis to discuss questions arising from the weekly reading, and progress regarding the end of rotation rounds presentation.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Expand knowledge of imaging physics while gaining practical imaging experience.
• Learn imaging study protocols.
• Develop approaches to troubleshoot imaging artefacts.
• Understand common workflow challenges.

Communicator

• Learn to communicate effectively with technologists.
• Learn to communicate effectively with patients in the radiology department.
• Improve understanding of practical imaging challenges and limitations to better communicate these to referring clinicians.

Collaborator

• Further understand challenges faced by technologists. This should help residents to collaborate more effectively and efficiently with technologists to optimize imaging and workflow.

Manager

• Gain first-hand insights on how to optimize usage of limited resources.
• Further understand common workflow issues experienced at each modality. This should help residents understand how to optimize triaging and protocolling of patients to match an individual patient’s needs with an imaging modality best suited to answer the clinical question.

Health Advocate

• Expand knowledge of patient safety issues relevant to imaging.
• Gain insights on when imaging may be inappropriate or could potentially harm a patient.

Scholar

• Improve knowledge of imaging physics.
• Gain an understanding of study protocols, patient preparation, imaging artefacts and image post-processing.

Professional

• Opportunity to interact professionally with patients and technologists.

Schedule

Daily

• Residents will rotate primarily at the Civic Campus with opportunity to rotate through the General Campus if needed (see modality leads).
• Day begins at 7:30 am (if rounds are scheduled) or at 8am (to start with technologists)
• Residents must attend all scheduled rounds and other academic sessions.
• The resident should continue to wear their pager and promptly answer any work related pages they may receive.
• Residents will work with technologists until noon.
• Residents will have the afternoon to do the following:
  • Work through Rad-Primer Physics questions and cases
  • Perform the assigned reading
  • Meet with rotation supervisor (once/ week)
  • Prepare the end of rotation presentation

On-Call: The resident will continue to take resident call at TOH during this rotation. Normal post-call rules apply.

Evaluation: Mid-rotation written & face to face evaluation. Written & face to face end of rotation evaluation.

APPENDIX A

Block schedule

(Cardiac CT and Mammo elective days are available)

Modality technologist leads

Special Procedures

General- Melanie Martin

Civic- Kim Huywan

CT

General-Greg Latourell

Civic-Rob Chatelain

MRI

General-Francine Mccullagh

Civic-Alain Berthiaume

APPENDIX B

Mandatory Reading and Exercises

Rad Primer Physics Modules—both the 15 basic and 2 expert modules should be completed during the rotation.

Suggested Readings

1) The AAPM/RSNA Physics tutorials for residents:

http://www.rsna.org/AAPM-RSNA_physics_Tutorials_for_Residents.aspx

2) Huda W. Review of Radiologic Physics. 3^rd Ed. Lippincott Williams & Wilkins: 2010.

- available within the Radiology Department library

3) Mamourian AC. Practical MR Physics and Case File of MR Artifacts and Pitfalls. Oxford: 2010.

- available within the Radiology Department library

4) Mangrum WI et al. Duke Review of MRI Principles: Case Review Series. Elsevier: 2012.

Revised: Jan 26^th, 2016

Radiology Research

Supervisor

As selected by the resident

Schedule Heading

Research

Ideal Scheduling

Second half of PGY3

Introduction

The resident will complete one research project which will ideally be presented in May of the PGY-3 year at the annual research day. Original research is optimal but an audit is quite acceptable as well. The resident is reminded that one block is an insufficient amount of time to complete an audit or research project, and that the research block should be used to complete a project that was begun in the PGY1 or PGY2 year.

REB approval and other ‘preparatory work’ should be complete prior to starting the research block.

During the PGY1 or PGY-2 year, all residents should seek out projects from the staff. If residents have difficulty, the program director, department chair and research chair can assist. Residents with an original idea of their own should approach a staff person to determine if this is a feasible project and to find a supervisor.

The resident should be prepared to submit their proposed research to the Research Ethics Review Board. The project supervisor or Research Director may also recommend certain available resource to the resident, such as the Methods Centre.  Depending on the nature of the project, the Residency Training Program may have funds available to pay for some expenses. All research should be done on hospital/university premises unless otherwise specified. Residents must attend all scheduled rounds during this time.

Once the research project is initiated, the resident should prepare a timeline (SEE APPENDIX A) setting specific deadlines for completion of each phase of the project. By the time the actual research block begins, the resident should present an outline of their rotation plan including the completed time line.

RCPSC Research Manual is available as a resource for residents on the v drive.

Educational Objectives

Medical Expert-Clinical Decision Maker

• Develop a research proposal.
• Conduct and complete a research project in a timely manner.
• Present your research at the Annual Research Day.

Communicator

• Learn to communicate effectively with the study supervisor, collaborators, and resource personnel.

Collaborator

• Work effectively and efficiently with research colleagues and supervisors to maximize the research potential of each individual.

Manager

• Utilize time, budget and resources effectively.

Health Advocate

• Gain an understanding of fundament of epidemiology and biostatistics and decision analysis.
• Understand the principles of safe and confidential data storage and management.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Learn to develop an appropriate research question.
• Critically assess the existing body of literature on a certain topic/research question.
• Gain an understanding of the principles of evidence based research.
• Learn an appreciation of the important role that basic and clinical research plays in the critical analysis of scientific developments related to radiology.

Professional

• Gain an understanding of research ethics.

Schedule

Daily

• Day begins: 8:00 am Day ends: 5:00 pm
• All research should be done on hospital/university premises unless otherwise specified. Residents must attend all scheduled rounds during this time. The resident should continue to wear their pager and promptly answer any work related pages they may receive.
• On-Call: The resident will continue to take resident call at TOH during this rotation. Normal post-call rules apply.
• Evaluation: Mid-rotation written & face to face evaluation. Written & face to face end of rotation evaluation.

APPENDIX A

Timelines for Resident Research Project

This should be completed by the resident and research project supervisor in advance of commencing the research block.

Supervisor: __________________________

Resident:_____________________________

Project Title: ____________________________________________________________

________________________________________________________________________

Proposed Authors and order:_______________________________________________

Dates of Rotation: _____________________

* REB submission should ideally be done prior to the research block as even expedited approval can take up to 8 weeks

Goal Journal for manuscript submission:____________________________________

Goal Conference for presentation:__________________________________________

Goal Conference Submission deadline:______________________________________

Suggested Reading

‘Radiology’ Statistical Concepts Series. This excellent, readable series of articles published in Radiology from 2002-4 is an invaluable resource for application of statistical methods to radiology research.

They are available in the v-drive at: V:\Common\Department of Academic Radiology\Research Program\Radiology Statistical Concepts Series

And online at: Radiology Statistical Concepts Series

Revised: Jan 7^th, 2014.

Goals & Objectives Ultrasound & Biopsy

Supervisors

Rotating q3-6 months. Supervisor name is listed on Resident Rotation Calendar.

SCHEDULE HEADING

US & Bx

IDEAL SCHEDULING

First half of PGY3; at least once in PGY4/5.

EDUCATIONAL OBJECTIVES

Medical Expert-Clinical Decision Maker

1.   Expand knowledge of physics of ultrasound to include the physics of duplex and     

      colour Doppler, basic Doppler spectral analysis and methods of quality control.

2.   Further knowledge of anatomy.

3.   Expand knowledge of differential diagnoses as they pertain to ultrasound studies.

4.   Develop an ability to work with and supervise the sonographers and ensure quality

      control.

5.   Continue to practice scanning techniques, with a strong emphasis on the       sonography of various pathologies.

6.   Become familiar with the advantages and limitations of percutaneous fine needle    

      aspiration/core biopsy by attending and participating in ultrasound-guided biopsies.

7.   Become proficient in ultrasound guided procedures including (but not limited to) thyroid, liver, superficial (eg. nodal, parotid), omental, prostate and renal biopsies, paracentesis, and their indications.

8.   Supervise daily scheduled ultrasound examinations consulting the supervising         

      radiologist for all cases.

9.   Manage patients during procedures in close association with the radiologist.

10. Know when the patient’s best interests are served by discontinuing a procedure or  

      referring the patient to another physician.

11. Understand the appropriate follow-up care of patients who have had   interventional procedures.

12. Develop competence in effective consultation, conduct of clinical radiological

      conferences and the ability to present scholarly material and lead case discussions.

Communicator

1.   Demonstrate the ability to produce a radiologic report which will describe the imaging findings, most likely differential diagnoses, and when indicated, recommend further testing and/or management.
2.   Understand the importance of communication with referring physicians including when the result of an investigation or procedure should be urgently communicated.
3.   Communicate effectively with patients and families and have a compassionate interest in them.
4.   Recognize the physical and psychological needs of the patient and their families undergoing radiological investigations and/or treatment including the needs of culture, race and gender.
5. Be able to lead or initiate a pre-procedural pause.

Collaborator

1.   Function as a member of a multidisciplinary health care team.
2.   Work in close collaboration with sonographers.

Manager

1.   Utilize resources effectively to balance patient care, learning needs and other activities.
2.   Work effectively and efficiently in a health care organization.
3.   Utilize information technology to optimize patient care, learning and other activities.

Health Advocate

1.   Understand and communicate the benefits and risks of ultrasound-guided biopsies.
2.   Recognize when an ultrasound-guided intervention would be detrimental to the health of a patient.
3.   Educate and advise on the use and misuse of ultrasound imaging.

Scholar

1.   Develop, implement and monitor a personal continuing education strategy.
2.   Critically appraise medical information.
3.   Demonstrate the ability to be an effective teacher of ultrasound to medical students, residents, technologists and clinical colleagues.

Professional

1.   Be punctual and be available for assigned duties.
2.   Deliver the highest quality of care with integrity, honesty and compassion.
3.   Exhibit appropriate personal and interpersonal professional behaviors including accepting constructive criticism.
4.   Accurately assess one’s own performance, strengths and weaknesses.
5.   Understand the ethical and medical/legal requirements of radiologists.

SCHEDULE

Daily

Day begins:    8:00 am (or 8:30 when there are morning rounds)

If you are on biopsy and have no rounds please show up early (7:45am) to get consent for procedures scheduled to begin at 8 am.

Biopsy cases MUST be reviewed in advance. Consider looking at the cases the day before (listed in “scheduled studies” on PACS) or come in early the day of the procedures to familiarize yourself with the list.

Day ends:       5:00 pm

Schedule

Monday: Report to General Campus Ultrasound (Module T). You will participate in any scheduled inpatient ultrasound-guided procedures. Remainder of day is spent reporting diagnostic US studies and protocoling biopsies. (Staff code on Qgenda: USG)

Tuesday: Report to General Campus Ultrasound (Module T). Tuesdays are a biopsy day. In between procedures, report venous ultrasound dopplers and protocol biopsies. Report to academic-half day in the afternoon. (Staff code on Qgenda: UBXG)

Wednesday: Report to General Campus Ultrasound (Module T). Wednesdays are a full biopsy day. In between procedures, report venous ultrasound dopplers and protocol biopsies. (Staff code on Qgenda: UBXG)

Thursdays:

1^st Thursday of rotation: report to US at the Riverside for a day of thyroid biopsies. Report backlog outpatient ultrasound studies (Riverside, RVH, Nunavut) between cases. (Staff code on Qgenda: TBXR)

2^nd Thursday of rotation: report to the 7^th floor CAC at the General for a day of prostate biopsies. (Staff code on Qgenda: PBXG)

3^rd Thursday of rotation: report to General Campus ultrasound (Module T). You will participiate in any scheduled native kidney biopsy (or other inpatient biopsies). Remainder of day spent reporting diagnostic ultrasound studies and protocoling biopsies. (Staff code on Qgenda: USG)

4^th Thursday of rotation: Your choice of #1 (Riverside thyroid), #2 (General Prostates) or #3 (General Renal/Main US). On occasion, a resident misses a Thursday due to postcall status, vacation or other approved leave. Therefore, this can serve to fill in any missed days, or can provide additional experience in required areas. Please ensure to communicate your choice to the rotation supervisor and supervising staff.

Friday: Report to General Campus Ultrasound (Module T). Fridays are a full biopsy day. In between procedures, report venous ultrasound dopplers and protocol biopsies. (Staff code on Qgenda: UBXG)

On Tuesdays after long weekends, there is no biopsy service at the General, so the resident should report to the General Campus Main Ultrasound department for diagnostic ultrasound work (and any scheduled inpatient biopsies).

Additional expectations: Report 5 CRs per day.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

RECOMMENDED READING

Rumack & Levine. Diagnostic Ultrasound. 5^th Ed. 2017

Ultrasound-Guided Procedures. Dogra & Saad. 2011

Ultrasound: The Requisites. 3^rd Ed. Hertzberg & Middleton. 2015

Revised: May 2019

Ultrasound Scanning

Supervisor

Laura Lang to compile evaluation from Head Sonographer.

Schedule Heading

US Scan

Ideal Scheduling

Two blocks in PGY2 each 6 blocks apart

Educational Objectives

Medical Expert-Clinical Decision Maker

• Understand the basic physical principles of diagnostic ultrasound, including the basic physics of sound transmission, transducer design and applications, image formation and interpretation and potential artifacts.
• Independently perform a thorough ultrasound examination of the abdomen and pelvis including starting the machine and selecting appropriate transducer(s),setting the TGC controls, sending images to PACS, recognizing the need for appropriate equipment care and maintenance.
• Gain the knowledge of ultrasonographic anatomy of the abdomen and pelvis.
• Identify the common abdominal/pelvic abnormalities encountered in daily practice.
• Understand the advantages and disadvantages of ultrasound as compared to other imaging modalities, in both clinical and radiologic diagnosis.
• Observe small parts scanning (thyroid, breast, scrotum) and interventional procedures which will vary with patient referrals. This should only be done if the first objectives have been mastered.
• To gradually assume responsibility for each abdominal/pelvic patient examination, subsequently reviewing each case with the radiologist in charge prior to dictation.
• Become familiar with applications of abdominal and peripheral Doppler examinations particularly peripheral venous Doppler.
• Perform small parts scans of the thyroid and scrotum.
• Perform basic duplex Doppler studies such as those of the upper and lower extremities.
• Participate in scanning of neonatal heads.
• Acquire knowledge of the physics of duplex and colour Doppler, basic Doppler spectral analysis, methods of quality control.

Communicator

• Demonstrate the ability to present ultrasound cases to sonographers and reporting radiology residents, fellows or staff that describes the imaging findings and offers a differential diagnosis in an organized and logical manner.
• Communicate effectively with patients and families and have a compassionate interest in them.
• Recognize the physical and psychological needs of the patient and their families undergoing ultrasound including the needs of culture, race and gender.

Collaborator

• Have the ability to function as a member of a multidisciplinary health care team.

Manager

• Learn to utilize resources effectively to balance patient care, learning needs and other activities.
• Learn to work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, learning and other activities.

Health Advocate

• Educate and advise on the use and misuse of ultrasound imaging.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise medical information.
• Demonstrate the ability to be an effective teacher of ultrasound to medical students and clinical colleagues.

Professional

• Be punctual and be available for assigned duties.
• Deliver the highest quality of care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviors including accepting constructive criticism.
• Accurately assess one’s own performance, strengths and weaknesses.
• Understand the ethical and medical/legal requirements of radiologists.

Schedule

Daily

• Day begins: 8:00 am
• Day ends: 5:00 pm

Evaluation

• Mid-rotation written & face to face evaluation.
• Written & face to face end of rotation evaluation.
• Weekly sonographer evaluations.

Recommended Reading

Ultrasound: The Requisites. Middleton, William D. Middleton (Author). Amazon's William D. Middleton Page

Find all the books, read about the author, and more.

See search results for this author

Are you an author? Learn about Author Central

Kurtz.  2^nd ed. 2003. Alfred B. Kurtz (Author). Visit Amazon's Alfred B. Kurtz Page

Find all the books, read about the author, and more.

See search results for this author

Are you an author? Learn about Author Central

Revised: May 5, 2010

Body CT

Supervisors

Civic Campus – Rotating as per BIG supervisor schedule.

General Campus – Variable is Civic full. If a resident is scheduled at the General they should split the time with the Civic resident in 2 week blocks at each campus.

Schedule Heading

Body CT

Ideal Schedule

PGY2 - 2 blocks 6 months apart, one prior to starting call

General Objectives

PGY2: To provide an introduction to CT of the abdomen and pelvis. The rotation comprises two 4 week rotations. Residents will typically rotate at the Civic campus. Occasional scheduling at the General Campus may occur depending on resident numbers.

Residents on their first block should ensure that they review all high/stat cases done overnight (even if they have been reported) in order to ensure they get a sufficient volume of these cases. If they have questions about the cases they should review them with the staff, senior resident or fellow.

Residents on their second rotation should be involved with all GI cases done at the Civic campus if there is no fluoro or GI-CTC resident on service.

Objectives

Medical Expert/Clinical Decision Maker

•  To obtain an understanding of the formation of CT images including physical and technical aspects, patient positioning, contrast media, and contrast reactions.
• To gain a sound understanding of normal axial anatomy of the abdomen and pelvis and to detect pathology and provide a suitable differential diagnosis.
• To understand the importance of informed consent, and of factors that may affect interpretation of CT images and differential diagnosis.
• To understand the value and methods of CT interventional procedures such as biopsies and abscess drainages and understand how these compare to fluoroscopy and ultrasound guided procedures.
• To learn to correlate CT findings with other imaging modalities.

Communicator

• To report studies in a sound and systematic style which accurately describes imaging findings and most likely differential diagnoses, and recommends further testing or other management when indicated.
• To understand the importance of communication with referring physicians, including an understanding of when the results of the CT should be urgently communicated.
• To become an effective consultant and understand the basics of conducting a clinico-radiological conference.
• To learn to present scholarly material and lead case discussions.
• To recognize the physical and psychological needs of the patient undergoing CT investigations and their families, including factors related to culture, race, and gender.
• To communicate effectively with patients and their families the indication and complications of contrast administration and the utility of performing a CT study.

Collaborator

•  To function as a member of a multidisciplinary health care team by consulting effectively with other physicians and health care professionals, and by contributing effectively to team activities.

Manager

• To gain an understanding of quality assurance in CT including safety issues and economic considerations.
• To become competent in computer science as it pertains to multi-planar CT reconstructions, density measurements, and other applications of the CT workstation.

Health Advocate

• To understand and communicate the benefits and risks of CT, including the theoretical, practical and legal aspects of radiation protection, possible harmful effects, and the role of CT in population screening.
• To recognize when a CT examination would be detrimental to the health of a patient and educate and advise on the use and misuse of CT.

Scholar

• To learn the critical appraisal of medical information as it pertains to this rotation and develop, implement and monitor a personal continuing education strategy.
• To facilitate the learning of patients, staff, students and other health professionals.

Professional

• To learn to accurately assess one’s own performance, strengths, and weaknesses and obtain staff feedback in these regards.
• To gain an understanding of the ethical, medial, and legal requirements of a radiologists.
• To exhibit appropriate personal and interpersonal professional behaviors.
• To be available for assigned duties.
• To be punctual.

Daily Schedule

1. The workday begins at 8:00am or 8:30 am when there are resident rounds.
2. The resident will protocol a minimum of 20 cases on CPOE and will review these with the fellow or staff radiologist.
3. The resident will be seated at a PACS station in the Body Reading room. The resident should be integral and ‘first line’ in fielding requests from the technologists as well as consultations from clinicians.
4. The resident will review all inpatient and ICU cases at the Civic and HI. The outpatient cases should be reported on a tri-campus basis from oldest to newest.
5. Cases will be reviewed with the staff radiologist. A minimum of two review sessions should occur daily, one in the morning, and one in the mid-afternoon. (e.g. 10:30 and 15:30) A third review session in the late afternoon will often also be required. Review session times should keep in mind that the staff radiologist is responsible for all inpatient patient scans performed before 17:00.
6. All cases will be dictated before the end of the day.  Ideally, at least one of the daily review sessions with staff should include a review of some of the resident approved reports.
7. The number of cases to be read each day depends on the resident’s experience level, as well as the number of consultations and cases to be protocolled that day. What follows is a guideline as to the number or cases to be read by the resident in a regular workday.  It should not be used as a minimum or maximum in that the resident should not stop working if this number of cases has been reached before the day is done, and the staff radiologist should take into consideration these other factors if the number of cases appears low.

PGY2 (1^st rotation): 08 cases

PGY2 (2^nd rotation): 12 cases

Evaluations

The rotation supervisor have both a mid-term (optional) and end of rotation face-to-face meeting and complete an evaluation in one45.

Sick Days

When a resident is obliged to take a sick day, the resident is obligated to inform one of the site specific administrative assistants of the absence. The appropriate people can then be notified.

Reading List

Introductory Texts

Fundamentals of Body CT; Webb, Helms, Brant; 3^rd Edition (October 2005).

A copy of this text is available for loan from each of the Civic and General Campuses.

Fundamentals of Diagnostic Radiology; Brant, Helms; 3^rd Edition (2006).

Gastrointestinal Radiology: The Requisites; Halpert, Feczko; 2^nd Edition (May 1999).

Gastrointestinal Radiology: The Requisites; Zagoria; 2^nd Edition (April 2004).

Intermediate Texts

Computed Body Tomography with MRI Correlation; Lee, Sagel, Stanley, Heiken; 4^th Edition (2005)

CT and MR Imaging of the Whole Body; Haaga, Lanzieri, Gilkeson; 4^th Edition (December 2002).

Multimedia

ACR Gastrointestinal CD-ROM (2^nd Edition).

Last updated: Jan 10, 2017

GI/CT & CTC

Supervisors

Civic Campus – Rotating as per BIG supervisor schedule.

General Campus – no rotations at General Campus. FYI staff who report CTC: Fraser, O’Sullivan, Doherty, Fasih, Ryan, McInnes, Schieda, Shabana, Macdonald.

Schedule Heading

GI/CT & CTC 

Ideal Scheduling

PGY3 1 block

PGY4-5 at least one block during these 2 years

General Objectives

To build on the knowledge gained during the PGY2 body CT rotations. The resident should transition to reading higher volumes, protocoling more cases and eventually be able to run a CT service independently. By the end of the second rotation, the candidate should be capable of running a CTC service. This should include an understanding of patient preparation (bowel prep), insufflation, risks and interpretation of cases. Residents will rotate at the Civic campus. Residents will also perform fluoroscopic procedures pertaining to GI pathology when there is no resident on the GI-fluoro service.

The resident will participate in any scheduled CT guided biopsies while on rotation (note: these are scheduled infrequently but are an important part of resident training).

Specific Objectives Pertaining to CTC

1. To complete at least 50 cases under the supervision of a staff (documented and signed off by staff).
2. To complete the CTC resident teaching file (contains 50 cases).
3. To be competent at insufflating and supervision of insufflations (suggest personally being present for at least 20 cases).
4. To be familiar with an appropriate bowel preparation (including fecal and fluid tagging).
5. To expand/ re-enforce fluoro-GI skills.

Objectives

Medical Expert/Clinical Decision Maker

• To obtain an understanding of the formation of CT images including physical and technical aspects, patient positioning, contrast media, and contrast reactions.
• To gain a sound understanding of normal axial anatomy of the abdomen and pelvis and to detect pathology and provide a suitable differential diagnosis.
• To understand the importance of informed consent, and of factors that may affect interpretation of CT images and differential diagnosis.
• To understand the value and methods of CT interventional procedures such as biopsies and abscess drainages and understand how these compare to fluoroscopy and ultrasound guided procedures.
• To learn to correlate CT findings with other imaging modalities.

Communicator

• To report studies in a sound and systematic style which accurately describes imaging findings and most likely differential diagnoses, and recommends further testing or other management when indicated.
• To understand the importance of communication with referring physicians, including an understanding of when the results of the CT should be urgently communicated.
• To become an effective consultant and understand the basics of conducting a clinico-radiological conference.
• To learn to present scholarly material and lead case discussions.
• To recognize the physical and psychological needs of the patient undergoing CT investigations and their families, including factors related to culture, race, and gender.
• To communicate effectively with patients and their families the indication and complications of contrast administration and the utility of performing a CT study.
• To learn to use the accepted reporting parameters for screening CTC (C-Rads) in order to ensure accurate and standardized communication of findings.

Collaborator

• To function as a member of a multidisciplinary health care team by consulting effectively with other physicians and health care professionals, and by contributing effectively to team activities.

Manager

• To gain an understanding of quality assurance in CT including safety issues and economic considerations.
• To become competent in computer science as it pertains to multi-planar CT reconstructions, density measurements, and other applications of the CT workstation.
• To gain competence in running a CT service including supervising technologists during performance of CT and CTC (including insufflation).

Health Advocate

• To understand and communicate the benefits and risks of CT, including the theoretical, practical and legal aspects of radiation protection, possible harmful effects, and the role of CT in population screening.
• To recognize when a CT examination would be detrimental to the health of a patient and educate and advise on the use and misuse of CT.
• To understand the risks and benefits pertaining to screening for colon cancer, and the role that CTC plays in screening.

Scholar

• To learn the critical appraisal of medical information as it pertains to this rotation and develop, implement and monitor a personal continuing education strategy.
• To facilitate the learning of patients, staff, students and other health professionals.

Professional

• To learn to accurately assess one’s own performance, strengths, and weaknesses and obtain staff feedback in these regards.  Specific to CTC, the resident should understand the importance of correlation with colonoscopy and pathology as part of a self-assessment program.
• To gain an understanding of the ethical, medial, and legal requirements of a radiologists.
• To exhibit appropriate personal and interpersonal professional behaviors.
• To be available for assigned duties.
• To be punctual

Daily Schedule

1. The workday begins at 8:00am or 8:30 am on the days there are morning rounds. The resident will begin the day by speaking with the CT technologists re: the CTC cases scheduled to determine if any imminent issues that need to be resolved.
2. The resident will perform fluoro-GI procedures at the Civic campus on days when there is no Fluoro-GI resident.
3. The resident will protocol the GI, CT and CTC cases on CPOE with the staff radiologist.
4. The resident will be seated at the PACS station nearest to the CT control room. The resident should therefore expect to be the first person to be contacted for technologist questions, “will see” unenhanced examinations, imaging consultations, and imaging requests. The residents will personally supervise at least 20 CTC insufflations. Subsequent to the 20, the resident will supervise technologist insufflation. The staff radiologist will be available to assist the resident as required.
5. The resident will review the CTC cases done that day or unreported from previous days.
6. If no CTC cases are available, the resident will review (in the following order of priority): inpatient abdominal x-rays > outpatient abdominal x-rays > inpatient and ICU CTs > and outpatient CTs (tri-campus from oldest to newest). CTC volume should be supplemented with non CTC cases.
7. Cases will be reviewed with the staff radiologist. A minimum of two review sessions should occur daily, one in the morning, and one in the mid-afternoon. (e.g. 10:30 and 15:30) A third review session in the late afternoon will often also be required. Review session times should keep in mind that the staff radiologist is responsible for all inpatient patient scans performed before 17:00.
8. All cases will be dictated before the end of the day. Ideally, at least one of the daily review sessions with staff should include a review of some of the resident approved reports.
9. The number of cases to be read each day depends on the resident’s experience level, as well as the number of consultations and cases to be protocolled that day. What follows is a guideline as to the number or cases to be read by the resident in a regular workday.  It should not be used as a minimum or maximum in that the resident should not stop working if this number of cases has been reached before the day is done, and the staff radiologist should take into consideration these other factors is=f the number of cases appears low.

PGY3 (1^st rotation): 15 cases

PGY4-5 (2^nd rotation): 15-20 cases

* Note on CTC days a full day of work would typically be 5-6 CTCs plus AXR and or GIs.

Evaluations

The rotation supervisor will have both a mid-term and end of rotation face-to-face meeting.

Sick Days

When a resident is obliged to take a sick day, the resident is obligated to inform one of the site specific administrative assistants of the absence. The appropriate people can then be notified.

Reading List

Introductory Texts

Fundamentals of Body CT; Webb, Helms, Brant; 3^rd Edition (October 2005).

A copy of this text is available for loan from each of the Civic and General Campuses.

CTC Reference Judy Yee CTC textbook available in resident library.

Intermediate Texts

Computed Body Tomography with MRI Correlation; Lee, Sagel, Stanley, Heiken; 4^th Edition (2005)

CT and MR Imaging of the Whole Body; Haaga, Lanzieri, Gilkeson; 4^th Edition (December 2002).

Multimedia

ACR Gastrointestinal CD-ROM (2^nd Edition).

Last updated: Jan 10, 2017.

Communicator

• Communicate effectively with pediatric patients and their families and have a compassionate interest in them.
• Recognize the physical and psychological needs of the pediatric patient and their families undergoing radiological investigations and/or treatment including culture, race and gender issues.
• Understand the importance of communication with referring physicians including an understanding of when the results of a procedure should be urgently communicated.
• Listen effectively, and accept and provide constructive criticism.
• Gain an understanding of a sound and systematic style of reporting.

Collaborator

• Consult effectively with other physicians, technologists, nurses and other health care professionals.
• Contribute effectively to interdisciplinary activities and rounds.

Manager

• Utilize resources effectively to balance pediatric patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely, and use information technology to optimize patient care, learning and other activities.

Health Advocate

• Identify the important determinants of health affecting pediatric patients and balance radiation dose with the clinical benefit of an imaging study.
• Contribute effectively to improved health of pediatric patients and communities.
• Recognize and respond to those issues where advocacy is appropriate such as in suspected cases of child abuse.

Scholar

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Be an effective teacher of pediatric imaging to medical students, residents, technologists and clinical colleagues.
• Prepare and conduct multidisciplinary rounds.
• Contribute new cases to the weekly Interesting Case Rounds (Thursday, 12-1 pm).

Professional

• Deliver the highest quality care to the pediatric population with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours when dealing with children, parents, colleagues and consultants.
• Practice medicine ethically, consistent with the obligations of a physician.
• Be punctual and available for assigned duties. The resident should notify the rotation supervisors in a timely fashion, of any holidays, illnesses, postcall, or other absences.
• Accurately assess one’s own performance, strengths and weaknesses.

Schedule

Daily

Day begins: 8:00 am

Day ends: When the assigned daily duties are completed

Clinical rounds: 12:00 to 1:00 pm*

Interdisciplinary rounds: 4:00 to 5:00 pm *

*Please check weekly schedule for teaching & interdisciplinary rounds during rotation

Individual daily teaching sessions - to be arranged with Staff Radiologist

On-Call

The call schedule is arranged prior to commencing the rotation. The residents are given an option to do a full-weekend on call or split the weekend on call prior to commencing their rotation.

Residents do not take call at any other hospitals or sites when on rotation at CHEO, and ideally no call is taken on the day proceeding the first day at CHEO.

PAIRO Home call rules are followed for the CHEO pediatric rotation.

Evaluation

Midterm and final evaluations are filled out as per the One45 system.  Ideally, the pediatric radiology supervisor will try to meet with the trainee at these times as well to discuss their evaluation.

Recommended Reading.

Must Read

“Technical Book” provided by the CHEO Radiology Department.

“Interesting Articles for Resident Reading” binder located in CHEO Radiology Conference room.

Reference Texts

Donald R. Kirks. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3^rd ed. Lippincott Williams & Wilkins. 1997.

Leonard E. Swischuk. Imaging of the Newborn, Infant, and Young Child. Lippincott Williams & Wilkins. 2003.

Leonard E. Swischuk. Emergency Radiology of the Acutely Ill or Injured Child. Lippincott Williams & Wilkins. 2000.

Marilyn J. Seigal. Pediatric Sonography. 3^nd ed. Lippincott Williams & Wilkins. 2010.

Frederic N. Silverman.Caffey's Pediatric X-ray Diagnosis: An Integrated Imaging Approach. Mosby. 1992.

A. James Barkovich. Pediatric Neuroimaging. Lippincott Williams & Wilkins. 2005.

Revised: November 18, 2016

Ultrasound Reporting

Supervisor

Rotating q3-6 months. Supervisor name is listed on Resident Rotation Calendar.

Schedule Heading

US Rept

Ideal Scheduling

Second half of PGY2

Educational Objectives

Medical Expert-Clinical Decision Maker

1.   Expand knowledge of physics of ultrasound to include the physics of duplex and colour Doppler, basic Doppler spectral analysis and methods of quality control.

2.   Further knowledge of anatomy.

3.   Expand knowledge of differential diagnoses as they pertain to ultrasound studies.

4.   Develop an ability to work with and supervise the sonographers and ensure quality control.

5.   Continue to practice scanning techniques, with a strong emphasis on the      sonography of various pathologies.

6.   Supervise daily scheduled ultrasound examinations consulting the supervising radiologist for all cases.

7.   Develop competence in effective consultation, conduct of clinical radiological conferences and the ability to present scholarly material and lead case discussions.

Communicator

1.   Demonstrate the ability to produce a radiologic report which will describe the imaging findings, most likely differential diagnoses, and when indicated, recommend further testing and/or management.
2.   Understand the importance of communication with referring physicians including when the result of an investigation or procedure should be urgently communicated.
3.   Communicate effectively with patients and families and have a compassionate interest in them.
4.   Recognize the physical and psychological needs of the patient and their families undergoing radiological investigations and/or treatment including the needs of culture, race and gender.

Collaborator

1.   Function as a member of a multidisciplinary health care team.
2.   Work in close collaboration with sonographers.

Manager

1.   Utilize resources effectively to balance patient care, learning needs and other activities.
2.   Work effectively and efficiently in a health care organization.
3.   Utilize information technology to optimize patient care, learning and other activities.

Health Advocate

1.   Understand and communicate the benefits of ultrasound investigations.
2.   Recognize the limitations of ultrasound investigations and be able to communicate comparable or better alternatives for the clinical question posed.
3.   Educate and advise on the use and misuse of ultrasound imaging.

Scholar

1.   Develop, implement and monitor a personal continuing education strategy.
2.   Critically appraise medical information.
3.   Demonstrate the ability to be an effective teacher of ultrasound to medical students, residents, technologists and clinical colleagues.

Professional

1.   Be punctual and be available for assigned duties.
2.   Deliver the highest quality of care with integrity, honesty and compassion.
3.   Exhibit appropriate personal and interpersonal professional behaviors including accepting constructive criticism.
4.   Accurately assess one’s own performance, strengths and weaknesses.
5.   Understand the ethical and medical/legal requirements of radiologists.

SCHEDULE

Daily

Day begins:    8:00 am (or 8:30 when there are morning rounds)

Day ends:       5:00 pm

Academic Afternoons: every Tuesday pm.

Schedule

Monday to Friday: Report to Civic C1 Ultrasound. You will participate in reporting ultrasound studies performed at the Civic Campus. If caught up, you can read backlog outpatient ultrasound studies from Nunavut, RVH, or Riverside. Be available to supervise, check and troubleshoot cases presented by US technologists. You are also encouraged to participate in any ultrasound-guided procedures that are scheduled. Typically, a few paracenteses are performed on Mondays. Occasional inpatient biopsies are booked throughout the week. (Staff code on Qgenda: USC UBXC)

Additional expectations: Report 5 CRs per day.

Evaluation

Mid-rotation written & face to face evaluation.

Written & face to face end of rotation evaluation.

Recommended Reading.

Rumack & Levine. Diagnostic Ultrasound. 5^th Ed. 2017

Ultrasound: The Requisites. 3^rd Ed. Hertzberg & Middleton. 2015

Revised: May 2019