MSK Resident Curriculum

MSK Radiology Resident Curriculum

INTRODUCTION

Welcome to the Musculoskeletal (MSK) Radiology Resident Rotation. Although there is much to know, we are confident that the time you spend with us and studying on your own will be sufficient to make you strong in this section. Our large volume of imaging and procedural cases will ensure a well rounded and fun experience with us over the next four years.

The ACGME has established six General Competencies that residents in all specialties must achieve, and has determined that each residency must be able to assess their residents’ progress in achieving these competencies through Practice Performance Measurements. The Competencies include patient care (PC), medical knowledge (MK), practice-based learning and improvement (PBL), interpersonal and communication skills (ICS), professionalism (P), and systems-based practice (SBP). We have put together a curriculum that will help ensure you meet these criteria.

The curriculum outlined below should guide your studies and direct you to what we feel are important topics in MSK imaging. We acknowledge that this curriculum is heavily borrowed from the Society of Musculoskeletal Radiology (SSR). Significant organizational elements and language have been directly adopted and adapted from the SSR document provided to our department via the SSR website (www.skeletalrad.org).

Each technical objective in this curriculum is followed by one or more abbreviations. These abbreviations denote the General Competencies that each objective addresses. The rotations in this curriculum are expected to be 4-week rotations. This curriculum is broken down into three rotations because that is the minimum number of months a resident should spend rotating in MSK.

This document contains an appendix. That appendix is an MSK radiology curriculum guide previously developed and published in 1999 by the SSR Residency and Fellowship Education Committee and the Education Committee of the American Society of MSK Radiology and then revised, though not published, by the 2003-05 SSR Education Committee. That document serves as a larger list of knowledge based objectives for radiology residents learning MSK radiology, and is the primary source of the knowledge objectives in the current document. Certainly, you should be able to master the vast majority of topics covered in the appendix, but the curriculum below includes the knowledge objectives deemed to be most important to the practice of musculoskeletal radiology and those expected to be discussed extensively during our MSK rotations.

Rotation 1

Goals

After completing the first four-week rotation in musculoskeletal radiology, the resident will be able to:

• Demonstrate learning of knowledge based objectives and mastery of technical objectives for the first rotation

• Generate accurate and concise radiographic reports

• Communicate effectively with patients, referring clinicians, technologists and supervisory staff

• Understand standard radiographic positioning and anatomy

• Obtain essential patient information pertinent to the radiologic examination

• Demonstrate knowledge of clinical indications for radiography and indications for urgent computed tomography (CT) and magnetic resonance (MR) examinations

• Demonstrate a responsible work ethic

• Participate in quality improvement/ quality assurance activities

• Participate in the education of students and interns

Objectives

Knowledge based

o Demonstrate learning of normal radiographic and CT anatomy of the axial and appendicular skeleton

o Demonstrate learning of normal MRI anatomy of the knee and shoulder

o Demonstrate learning of normal MRI anatomy of the cervical, thoracic,and lumbar spine

o Recognize and accurately describe common fractures and dislocations of the appendicular skeleton

o Recognize and describe fractures and dislocations of the cervical, thoracic and lumbar spine. Understand basic mechanisms of injury and distinguish stable from unstable injuries

o Demonstrate learning of pathophysiology and radiology of fracture healing and complications of healing such as delayed union, malunion and nonunion

o Demonstrate learning of radiographic presentation and evaluation of osteomyelitis and septic arthritis

o Recognize and describe complications of orthopedic devices including fracture fixation and spine and arthroplasty hardware

Technical

o Dictate clear, detailed, and accurate reports that include all pertinent information as established in the American College of Radiology (ACR) Guidelines for Communication4 (PBL, ICS)

o Use appropriate nomenclature when reporting radiographic, CT, MR or ultrasound (US) findings of musculoskeletal disease (ICS)

o Communicate all unexpected or significant findings to the ordering provider and document whom was called and the date and time of the discussion in the report (ICS, PC, P)

o Obtain relevant patient history from electronic records, dictated reports, the patient, or by communication with referring provider (PC)

o Recognize and describe positioning and anatomy of standard radiographic examinations of the musculoskeletal system (MK)

o Effectively provide feedback to radiology technologists regarding quality of exposure and patient positioning (ICS, SBP)

o Recognize when it is appropriate to obtain help from senior residents or faculty when assisting referring clinicians (PC, P)

o Demonstrate responsible, ethical behavior; positive work habits; and professional appearance; and adhere to principles of patient confidentiality (P)

o Participate in discussions with faculty and staff regarding operational challenges and potential system solutions regarding all aspects of radiologic services and patient care (SBP)

Rotation 2

Goals

After completing the second four-week rotation in musculoskeletal radiology, the resident will be able to:

• Demonstrate learning of knowledge based objectives and mastery of technical objectives for the second rotation

• Continue to build and improve on skills developed during the first rotation

• Develop skills in protocoling and monitoring CT and MR examinations

• Demonstrate an understanding of the ACR Appropriateness Criteria5 and ACR Practice Guidelines and Technical Standards for musculoskeletal imaging6

• Participate in the education of junior residents, interns, and medical students

• Perform image guided procedures

Objectives

Knowledge Based

o Recognize and describe the radiographic presentation of Paget disease

o Demonstrate learning of a systematic approach to arthritis. Be able to describe and differentiate salient radiologic (radiographic, CT and MR) features of common arthropathies including osteoarthritis, inflammatory arthropathy (rheumatoid, psoriatic, reactive, juvenile chronic, and septic), crystal deposition diseases (calcium pyrophosphate deposition, gout, hydroxyapatite deposition), neuropathic arthropathy, connective tissue disease (systemic lupus erythematosus, scleroderma, dermatomyositis), pigmented villonodular synovitis, and synovial chondromatosis

o Demonstrate a systematic assessment of a solitary lesion of bone and be able to categorize the lesion as aggressive or nonaggressive. Develop an appropriate differential diagnosis based on patient age, lesion location, and lesion characteristics (margin, matrix, periosteal reaction, soft tissue extension).

O Demonstrate knowledge of systematic, safe and cost effective radiologic work-up of bone lesions including biopsy approach and compartmental anatomy.

o Recognize and describe common locations of and radiologic manifestations of osteonecrosis.

o Demonstrate knowledge of MRI safety issues including contraindication to scanning and use of contrast.

o Demonstrate learning of the use of various pulse sequences and planes of imaging used in MRI of musculoskeletal disorders

o Demonstrate learning of common knee and shoulder pathology on MRI (meniscal tear, tendon and ligament injury, fracture, chondral disease, rotator cuff tear, and labral pathology)

o Demonstrate learning of common pathology of the cervical, thoracic, and lumbar spine on MRI

o Demonstrate learning of the normal MRI anatomy of the hip and ankle

Technical

o Build and improve on skills acquired during first rotation

o Demonstrate the ability to gather essential and accurate patient information (electronic, personal communication) to appropriately prescribe MRI protocols (PC, ICS)

o Provide effective and timely feedback and education to CT and MRI technologists regarding quality of examinations (ICS, SBP)

o Demonstrate ability to monitor CT and MRI examinations to ensure the patient is adequately evaluated (MK, PC)

o Demonstrate an understanding of indications, contraindications, needle path, risks and post procedural management of CT and US guided procedures including management of complications (MK, PC)

o Provide technical and educational guidance to junior residents and students (ICS)

o Safely perform fluroscopically guided joint injections and aspirations with faculty supervision (PC)

o Demonstrate an understanding of indications, contraindications, radiation risks, and post procedural management of fluroscopically guided procedures including management of complications (MK, PC)

o Demonstrate an ability to counsel a patient and obtain informed consent before performing a procedure, including a description of the procedure, risks, benefits, and alternatives; and solicit and respond to patient questions without discrimination based on religious, ethnic, sexual, economic, or educational differences (ICS, PC, P)

o Maintain a log of all procedures performed including complications (PBL)

Rotation 3

Goals

After completing the third four-week rotation in musculoskeletal radiology, the resident will be able to:

• Demonstrate learning of knowledge based objectives and mastery of technical objectives for the third rotation

• Continue to refine skills developed during the first two rotations

• Effectively use information technology to address clinical problems

• Participate in the education of junior residents and medical students

• Become a more independent provider of musculoskeletal radiologic interpretive services

• Manage clinical and technical questions from technical and support staff

Objectives

Knowledge based

o Recognize radiologic findings and describe pathophysiology of endocrine disease including hyperparathyroidism, renal osteodystrophy, osteomalacia/rickets, hypophosphatasia, hypophosphatemia

o Recognize radiologic findings of hematopoietic and storage diseases including sickle cell anemia, thalassemia, mastocytosis, and Gaucher’s disease.

o Demonstrate systematic approach to relatively common dysplasias and congenital conditions such as achondroplasia, osteogenesis imperfecta, osteopetrosis

o Demonstrate learning of common pathology of the hip and ankle on MRI

o Demonstrate learning of anatomy and common injuries/pathology of the elbow and wrist on MRI

Technical

o Improve and build on skills acquired during the first two rotations

o Demonstrate the ability to locate, appraise and assimilate evidence from scientific studies related to the performance and interpretation of musculoskeletal imaging (PBL)

o Demonstrate the ability to teach a junior colleague how to protocol examinations and plan procedures (PC, ICS)

o Demonstrate the ability to assess and prioritize requests for add-on procedures (PC)

o Demonstrate the ability to answer common procedural and policy questions from technologists and support staff (PC, ICS)

Rotation 4

Goals

After completing the fourth four-week rotation in musculoskeletal radiology, the resident will be able to:

• Demonstrate learning of knowledge based objectives and mastery of technical objectives for the fourth rotation

• Continue to refine skills developed during the first three rotations

• Effectively use information technology to address clinical problems

• Participate in the education of junior residents and medical student.

• Continue to become a more independent provider of musculoskeletal radiologic interpretive services

• Manage clinical and technical questions from technical and support staff

• Learn with the fellow

Objectives

Knowledge based

o Generalize review of all musculoskeletal radiology focusing in areas of individual weakness

o Demonstrate knowledge of musculoskeletal ultraasound

o Participate in advanced musculoskeletal procedures (small joints, ankle, elbow, and wrist).

Technical

o Improve and build on skills acquired during the first three rotations

o Continue to locate, appraise and assimilate evidence from scientific studies related to the performance and interpretation of musculoskeletal imaging (PBL)

o Teach junior colleague how to protocol examinations and plan procedures (PC, ICS)

o Assess and prioritize requests for add-on procedures (PC)

o Answer common procedural and policy questions from technologists and support staff (PC, ICS)

References

1. Accreditation Council for Graduate Medical Education. Competencies Definitions and Practice Performance Measurements for Diagnostic Radiology. Available online athttp://www.acgme.org/acWebsite/RRC_420/420_compDefsPerfMeas.pdf. Accessed 9/01/06.

2. Accreditation Council for Graduate Medical Education. Program Requirements for Graduate Medical Education in Diagnostic Radiology. Available online athttp://www.acgme.org/acWebsite/downloads/RRC_progReq/420pr701_u705.pdf. Accessed

9/05/06

3. Collins J, Abbott GF, Holbert JM, et al. Revised Curriculum on Cardiothoracic Radiology for Diagnostic Radiology Residency With Goals and Objectives Related to General Competencies. Acad Radiol 2005; 12:210-223.

4. American College of Radiology. ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Available online at http://www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDF. Accessed 9/06/06.

5. American College of Radiology. ACR Appropriateness Criteria: Expert Panel on Musculoskeletal Imaging. Available online at http://www.acr.org/s_acr/sec.asp?CID=1206&DID=15047. Accessed 9/06/06.

6. American College of Radiology. ACR Practice Guidelines and Technical Standards. Available online at http://www.acr.org/s_acr/bin.asp?CID=1848&DID=14800&DOC=FILE.PDF. Accessed 9/06/06.