Medical students within the Radiology Departments: Drawback or opportunity?

Abstract

University Radiology training has been carried out for years out of the Radiology Departments, where radiologists play their professional role. However, the educational needs and the leadership of the Scientific Societies make the Radiology Departments to be involved more and more in that training, though it has to be done in overloaded professional environments where medical students can be seen as a drawback. Nevertheless, radiologists must play an important role in the Radiology training of the future doctors for optimising the use of diagnostic imaging techniques and enhance the future of the specialty by bringing to our Departments those medical students who had demonstrated the most adequate personal profiles. The Radiology Department is that place to succeed by increasing the healthcare outcomes, the research results and the visibility of Radiology through a fruitful interaction between radiologists and medical students.

Resumen

La enseñanza universitaria de la Radiología ha estado durante muchos años fuera de los Servicios de Radiología, que es el lugar donde se ejercita la profesión del radiólogo. Sin embargo, las necesidades de formación y el impulso de las Sociedades Científicas obligan cada vez más a los Servicios a implicarse en la enseñanza práctica en unas condiciones de sobrecarga laboral a la que los estudiantes de Medicina pueden contribuir y constituir un problema. Sin embargo, los radiólogos tienen una importante labor que hacer en la formación de los futuros médicos para optimizar el uso de las pruebas diagnósticas, y garantizar el porvenir de la especialidad despertando vocaciones en los más dotados para ella. El lugar donde conseguirlo es el Servicio de Radiología, que puede contribuir a conseguirlo aumentando su calidad clínica, los resultados de investigación y la visibilidad de la especialidad con una interacción adecuada entre radiólogos y estudiantes.

In 2008, RADIOLOGÍA published the results of a survey by the Training Committee of the Spanish Society of Clinical Radiology (SERAM) on the state of radiology education at Spanish universities.¹ The authors noted that SERAM has traditionally led the way in radiology postgraduate training, both in terms of radiology trainee programmes and continuous professional development for radiologists. However, it has not been as involved with undergraduate medical education. The vast majority of clinical radiologists, most of whom are members of SERAM, have not had any recent involvement in the university setting and any clinical or preclinical courses taken were studied decades ago.¹ The article attracted great interest especially thanks to SERAM’s specific focus on undergraduate radiology training and the way it highlighted the heterogeneity among radiology programmes and the different ways teaching was organised.¹ However, even after fifteen years, no more recent data has become available. Nor does undergraduate training appear to be a priority for SERAM² (Fig. 1).

Figure 1.

Screenshot of the Spanish Society of Clinical Radiology (SERAM) website in the section ‘Sections’ (https://seram.es/secciones-seram/). Of the 11 SERAM sections, FORA is the only one that does not have a website. The rest have websites which are kept reasonably up-to-date, except for the Spanish Society of Cardiothoracic Imaging (SEICAT) [consulted 1 July 2023].

The original article revealed the different ways radiology teaching was organised and the availability of human resources in Spanish universities based on information sourced from the internet and also that gleaned from SERAM members who also worked at the university. However, it did not include information on the degree of involvement of radiology departments beyond overall percentages of different types of radiology teaching staff at the universities. At that time, 199 radiologists were involved in subjects related to radiology and 155 (78%) of them were non-tenured clinical instructors. This percentage is clearly higher than the 2009 rate of 23% of non-tenured specialist instructors overall at Spanish universities,³ and it may have increased considering that, from that year up to 2019, the ratio of temporary fixed-contract teaching or research staff to the total number of staff members at Spanish universities rose by more than seven points.³ While in theory these figures only refer to the increase of non-tenured lecturers, it may also be indicative of impacts that go beyond the university classroom. In the medical context, it may reflect an increasing participation of university hospitals in the organisation of practical training, i.e. medical students are present in radiology departments.

Whether or not medical students should be allowed access to clinical services, such as radiology departments, is not up for debate. It would be difficult for doctors to openly express a desire for the contrary in this day and age because we accept that it is an integral part of training and therefore a moral issue.⁴ And yet there are some areas that should be discussed, however controversial they may seem. The aim of this article is to discuss when having medical students in radiology departments is a drawback and when it is an opportunity for progress. We will begin by briefly describing general aspects of the current situation of undergraduate radiology education, its objectives and the impact of involving radiology departments in this training.

Radiology training in Europe and the United States: uncertainty and heterogeneity

In 2012, the American College of Radiology (ACR) and the Alliance of Medical Student Educators in Radiology (AMSER) carried out a survey on the state of radiology education at medical schools in the United States. The survey was published in 2014⁵ and in it the authors approached three different professional groups: medical school deans, heads of radiology departments and recent medical graduates (within last two years). The low level of participation from the latter (66/4596, 1.4%) meant that their responses could not be considered representative of the group.⁵ This was a significant limitation when we consider that this was the group with the most recent exposure to radiology teaching and that the lack of response could indicate a lack of interest in radiology and in its training. However, the authors did not make any further comments on this (beyond the provision of the figures/data). There was also a low response rate among medical school deans (33/138, 24%), significantly lower than that of the department heads (57/124, 46%). Moreover, while both department heads and deans thought that radiology was often taught by non-radiologists in their medical schools, and while more than half of these two groups felt that radiologists should be more involved in university teaching, 75% of deans believed that non-radiologists could teach radiology, in stark contrast to 98% of department heads who insisted on the opposite.⁵

In 2011, the Undergraduate Training Working Group of the European Society of Radiology (ESR) published an official document⁶ which described the situation according to findings from another survey directed at radiologists and heads of radiology departments. A total of 21.6% (93/430) universities answered the survey but we do not have any other information on the representativity of the responses. The article established generic objectives for undergraduate training in radiology. Moreover, it referred to this training as one of the principal functions of a radiology department and posited that students often implicate themselves more in radiology when given access to the service. It emphasised the importance of teaching within this environment ‘wherever possible’.⁶

Ten years later, another ESR survey painted a more positive picture than that of the ACR-AMSER (98% of radiology lecturers were radiologists) but results were still heterogeneous according to geographic location and there was an even lower response rate than in 2011.⁷ It should be noted that the efforts of the ESR to make undergraduate radiology training homogeneous in Europe is exemplary and they have achieved significant results which include the ESR Curriculum for Undergraduate Radiological Education⁸ and the ESR eBook for Undergraduate Education in Radiology.⁹

Both the heterogeneity among radiology courses and above all the general issues concerning the teaching of radiology in Europe^6,7 and in the United States⁵ are similar to those of Spain.¹ In this situation, it is difficult to meet teaching expectations and guarantee the future of the radiology specialty.^10–12

Radiology training objectives and radiology departments

According to the ESR, if radiology is to increase the quality of healthcare, there needs to be continuous professional development which has a direct effect on clinical care.⁶ When it comes to medical students, there are several training objectives. The general objective is for students to acquire a basic level of interpretive skills which are unique to the specialty. However, the ESR Curriculum for Undergraduate Radiological Education⁸ goes a step further and sets out three levels of objectives (knowledge, skills, and competences & attitudes) which implies something that is no less relevant: teaching radiology also involves non-interpretative skills whose importance affects clinical practice.¹³ These skills include a knowledge of: technological developments, the advantages and risks implied in their use, and their appropriate use in the clinical setting; legal responsibilities derived from the use of imaging studies; the importance of the cost/benefit relationship; and the radiological profession itself, including how to establish productive relationships with a radiology department.^6,8 Teaching these skills, competences and attitudes is much more about transmitting knowledge than simply passing on information. This teaching process requires appropriate personal interaction,¹⁴ defined by Sir William Osler as the labour of the hospital instructor, practitioner and art teacher.¹⁵ These aspects are more likely to grab students’ attention when they are presented in a setting that makes them relevant and more comprehensible, as happens with radiology trainees in radiology departments.¹³

Radiology departments can also use teaching as the means to ensure the future of quality care. If the teaching experience showcases the relevance of radiological management and clinical practice, students will want to pursue radiology as a profession.^5,6,16 The aim of encouraging students to choose the profession should be focused on ‘attracting the best’ as a future investment in the specialty¹⁶ bearing in mind that ‘the best’ may not necessarily get the highest grades. Rather, they are the ones who choose the specialty because they have been inspired by a professional who was able to share their passion, dedication and creativity at work, as values to be prioritised over job security or quality of life.^12,17

It is therefore clear that radiologists are the best placed individuals to introduce students to the world of radiology and thus be able to meet all teaching objectives.^4–6,16,18 University classrooms are only the starting point because the importance of radiology in modern medicine is only understood when it is practised.

The impact of radiology departments on undergraduate training

Even though we have already highlighted radiology teaching objectives and the importance of actively involving radiologists and radiology departments in this training, there is not much evidence to prove its efficacy with students.¹⁰ This is most likely due to difficulties involved in research and methodological issues in studies to date. Some studies have suggested that direct interaction with radiology and radiologists may increase levels of interest among medical students whilst also proving relevant to their learning.^4,19–21 In our department, an end-of-degree project completed in 2020–2021 also suggested that it impacted student interest levels. The project included a questionnaire that asked medical students at the University of Murcia about their future specialty preferences. Respondents included students from all six years of study and doctors who were studying for the MIR specialty training entrance exam. The questionnaire was sent out during the last term of 2020 and was answered by 803 (64%) of a total of 1254 students. The percentage of respondents who considered radiology to be their first option for their future specialty was 2.7% overall. However, the distribution among year groups provided more concrete and interesting data (Fig. 2). Less than 1.5% (mean: 0.95%) students in the first two years of study chose radiology as their first choice. However, from the third year until the end of the course, the number increased. It rose among third-year students (2.8%), peaked among fourth-year students (6.8%), fell among fifth-year students (1.6%) and then rose again before stabilising at around 3.5% among sixth-year students and MIR students. It is important to note that since 2012–2013, the University of Murcia has taught radiology in the second term of the second and third years and included it within the first-year subject of Medical Physics. In the third year, it is a practical subject taught fully within the hospital radiology department while in the second year, it is a theoretical subject. Given that third and fourth-year students would have responded to the questionnaire the year after taking the subject is suggestive that the upwards curve is directly related to their exposure to clinical radiology and that the influence was especially felt when students experienced it firsthand. The stark drop among fifth-year students may be related to their first exposure to other clinical areas during the previous year, given the lack of exposure to radiology within that same year. Yet, it is worth highlighting that the percentage doubles in the sixth year compared to (the value represented by the) fifth-year students, and this level remained the same for the MIR students. It is possible that in some cases the novelty of the fourth-year hospital placements had started to wear off and that in other cases the seeds sown by the radiologists had taken root. This evolution seems to demonstrate that it is precisely when students experience radiology in person and come into contact with real radiologists that these aspirations surface and take hold. This appears to be reflected in the higher percentages of sixth-year and MIR preparation students who put radiology in first place, in contrast to those in the third year who had only been exposed to radiology through a theoretical course the previous year. The findings of the end-of-degree project are consistent with those of other publications which have suggested that more students choose radiology as a specialty when they have had direct contact with the field and radiologists,^19,20 in the first few years of their course.^4,22,23

Figure 2.

Evolution of radiology as the first-choice future specialty among undergraduate medical students and MIR specialty training entrance exam students. Data extracted from end-of-degree project: Zaragoza Ballester MA. Analysis of the sources of motivation of medical students in the region of Murcia concerning choice of specialty: results of a survey with a large population base. University of Murcia, 2020–2021 academic year.

Students from the medical school at the University of Murcia were exposed to radiology in the first three years of study through the subjects of Medical Physics, General Radiology and Special Radiology, respectively. The first two subjects are theoretical (the second is clinical) and the third is practical. The evolution of the percentage of students who chose radiology as their specialty seems to be related to exposure to the two clinical subjects, and more specifically to the subject involving hospital placements. After the third year, the relationship between the students and radiology takes place outside the radiology department and away from clinical radiologists (more information in the text).

Students in the radiology department: drawbacks and opportunities

The discussion above has laid the foundations to examine the drawbacks and opportunities that arise when medical students are placed in radiology departments.

A. Drawbacks. The three components that shape radiology education are the physical structure, the fundamental knowledge and the hidden curriculum.¹⁷ The physical structure refers to the radiology department whose changeable circumstances determine the context in which teaching happens over time. The hidden curriculum, however, is the factor that regulates this context.

The increasing workload, the lack of human resources to share it and the administration and paperwork involved are everyday features in the work of radiologists. This has led to a situation where radiologists have consistently been among those specialists to experience the most burnout over the last few years and there is no change in sight in this trend.^24,25 A shortage of time is theoretically the main reason that medical students in the radiology department could be considered a drawback, especially when considering the invisible extra time that would need to be dedicated to teaching.^{5,6,10–12,25} This is compounded by medical management’s evolution towards ‘managerialism’ in which only ‘measurable’ factors are taken into consideration, not the human factor.^11,26 But medical training is not easy to measure and depends largely on the human factor.^11,12 This unfavourable environment, together with other factors such as the leadership of the head of department^4–6,12,16 and the commitment required on the part of the radiologists⁴ mean that the result will be unpredictable because it will be more affected by the psychological profiles of the individuals involved than by any given indicators.²⁶ Accordingly, the ACR and AMSER surveys indicated, without going into detail, that not every problem in radiology departments can be explained by excessive workloads.⁵ It may be that the radiologists do not perceive educational aspects as important. A teaching objective cannot be met if it is not well understood.^12,16

In this professional context, the success or failure of radiological education among medical students will largely depend on the hidden curriculum.¹⁷ Therefore, the content of this curriculum can constitute a problem. Students should see enthusiastic professionals who do not merely permit students to enter the radiology department, but who are eager to welcome them and showcase it.^6,18 The activity should not be limited to passive shadowing. Instead, the radiology department should give the students an active role and the possibility to connect with it at a higher level^6,18 while producing worthwhile, visible achievements that they can be proud of.⁵ Is this the norm in a radiology department? Radiologists should regularly review the situation of university teaching within their services¹⁶ and pay it the attention it deserves. If this does not occur, students will be considered problematic and their presence will be paradoxically counterproductive to radiology teaching objectives.

B. Opportunities. The future of radiology as a specialty depends on the actions of today’s radiologists and those of tomorrow. Santiago Ramón y Cajal repeatedly wrote about progress as an essential characteristic of teaching.²⁷ For the future of radiology, because of the need to win over ‘the best’ and because we do not work in isolation but together with the other doctors, it would be good to follow the ESR recommendations and open up radiology departments to medical students.⁵ There is no better place to meet radiology teaching objectives than in a radiology department where students can have direct interactions with radiologists at their place of work and observe the multiple facets involved.^5,6,22,23,28 However, these final objectives will not be achieved by simply allowing students into the department but rather because this is where other intermediate objectives, which should be part of a radiology department’s day-to-day work, can be met successfully. Students can stimulate the achievement of these objectives whilst also benefiting from their contribution to them, seeing this can provide valuable learning and create a sense of belonging to a radiology department, thereby motivating them further.²⁹ These supporting objectives can provide significant opportunities for improvement:

• 1

  Symbiosis with scientific societies. Investing in and promoting excellence in the training of medical students should be a priority for radiologists and one of the main priorities for radiological societies.¹² If we start from the premise that radiology university education is important, the point to be made is that it is not about taking that training out of the university but rather about bringing scientific societies into it. As shown by the ESR, the involvement of scientific societies in undergraduate training leads to higher quality results.^8,9 The societies should be leaders and collaborate in the strategy and in the training resources, but this activity should take place in radiology services and it is there that the effects are seen. This creates a feedback cycle which cannot exist if there are no students in said departments.

• 2

  Research. Medical students can contribute to an increase in scientific productivity and high-quality services thanks to their participation in research projects and their own research in clinical improvement and medical education.^{5,7,8,18,22,23} The opportunity provided by end-of-degree projects which go on to be published in journals and doctoral theses³⁰ is something that university radiology departments should make the most of.

• 3

  Quality care. Radiology is a profession which comes into contact with a huge number of patients. Thousands of patients are seen during procedures each month in our services and this provides an opportunity to showcase positive contacts with medical students, leading to the perception of higher quality care among patients.^30,31 Treating patients requires skills other than interpretative ones and these are more knowledge-based than information-based and should therefore be transmitted in the context where they are used.³² As radiologists, we are the clinicians³³ who put these skills at the service of the patient and pass them on to the students.⁸ Therefore, medical students are a necessary stimulus to achieve this, in the same way as radiology trainees have always been.¹³

• 4

  Visibility. Radiological tests are highly relevant to doctors and patients, but radiologists themselves are not very visible to many patients.^34–37 Thus, students may paradoxically perceive radiologists to take on a peripheral role rather than a central one.¹² Demonstrating to students in situ the relevance that radiologists have in this activity and the clinical importance of their work is another opportunity to increase their visibility. We have seen how access to a committed radiology department can change student opinions favourably concerning the work of radiologists and their perception of the specialty. A happy student provides a better image. Another advantage to making radiology more visible is the possibility of changing perceptions of students and medical school deans on the relevancy of radiology teaching, the time it should be allocated in medical courses and who should deliver the subject.

• 5

  The meaning behind the work. Involving radiologists in university teaching can add to their workload and increase the risk of burnout. However, teaching—and teaching well—is part of the medical career¹⁶ and direct participation in this can be a way of countering burnout.³⁸ Radiologists with excessive workloads are more at risk of isolating themselves,³⁴ but students who are truly attracted to the specialty and have a genuine vocation, as well as being endowed with the appropriate intellectual capacity, will establish the type of fruitful teacher-student relationship that the educational process has always required.³⁹ People may be driven by various motives at work but there is an additional motive for doctors: ‘a way of educating that awakens motivation in young people and strengthens their focus on the pleasure that they get from the work thanks to the results they achieve and the impact that it has on others’.⁴⁰ Radiology departments have a significant opportunity to awaken students to radiology. This is what we mean by ‘winning over the best’.

Conclusion

While it is true that teaching within radiology departments may intensify the workload of radiologists, the impact that this can have on quality care, on the training of new doctors and on inspiring future radiologists to choose the profession means that the opportunities far outweigh the drawbacks. The combination of leadership from the department head and commitment on the part of the radiologists in the department, together with support from radiological societies, are the necessary components for achieving radiology teaching objectives at the universities.

Author contributions

Development of study concept, literature search, data collection, analysis and interpretation, drafting of article and approval of final version: JMGS.

Conflicts of interest

The authors declare that they have no conflicts of interest.