Breast radiology: New horizons in times of pandemics
More infoTo evaluate radiology residents’ opinions about breast imaging and the possibility of choosing this subspecialty after completing their residency.
Material and methodsWe elaborated a 15-question survey aimed at radiology residents in Spain. The survey was approved by the Spanish Society of Breast Imaging (SEDIM) and the Spanish Society of Medical Radiology (SERAM), and it was disseminated by the SERAM through links to Google Forms via social networks and emails. Responses sent between February 21, 2020 and July 31, 2020 were accepted.
ResultsA total of 72 residents responded to the survey (7.83% response rate); 69.44% of these were third- or fourth-year residents. Of the respondents, 73.61% knew about the SEDIM, and 18.06% knew about the European Society of Breast Imaging. The duration of training programs was three months for 70.83% of respondents. In 7.84% of the responses, residents stated that their supervision was less than 50%, and 70.59% of the residents stated that the rotation exceeded their expectations. One-third of the respondents would consider a fellowship in breast imaging. In all hospitals, residents did diagnostic mammography and breast ultrasound; not all did interventional procedures. Aspects of breast imaging that were rated negatively included the lack of CT studies and the possible legal repercussions of errors. Aspects that were rated positively were dynamics, interventionism, and the role of the radiologist in the process of care for patients with breast cancer.
ConclusionsMost residents considered that their rotations in breast imaging exceeded their expectations; however, only a small percentage of residents would consider specializing in the field.
Evaluar la opinión de los residentes de radiodiagnóstico sobre la imagen mamaria y su posible elección como opción profesional tras su formación de especialista.
Material y métodoSe elaboró una encuesta, con un total de 15 preguntas, dirigida a los residentes de radiodiagnóstico de España. El cuestionario fue aprobado por la SEDIM y se difundió en redes sociales y mediante correo electrónico por la SERAM, adjuntando en ambas vías un enlace a Formularios de Google. Se aceptaron las respuestas enviadas entre el 21 de febrero y el 31 de julio de 2020.
ResultadosUn total de 72 residentes respondieron a la encuesta (7,83% de tasa de respuesta), de los cuales el 69,44% fueron residentes de tercer y cuarto año. El 73,61% de los encuestados conocía la SEDIM y el 18,06% la EUSOBI. El 70,83% de los programas formativos de los encuestados duraron 3 meses. Un 7,84% declaró una supervisión inferior al 50%, y un 70,59% de los residentes calificaron la rotación como superior a sus expectativas. El 33,33% de los futuros especialistas consideraría unfellowship en mama. En todos los hospitales, los residentes realizan mamografías diagnósticas y ecografía mamaria, con menor porcentaje de procedimientos intervencionistas. De la radiología mamaria, se valora negativamente la no realización de tomografía computarizada o las posibles repercusiones legales de los errores. Positivamente, el dinamismo, el intervencionismo y el papel del radiólogo de mama en el proceso asistencial del cáncer de mama.
ConclusionesLa mayor parte de los residentes declaró que la rotación por radiología mamaria superó sus expectativas durante su formación. Sin embargo, solo un pequeño porcentaje consideraría subespecializarse en este campo.
Breast cancer is the most diagnosed cancer in women worldwide, with about two million new cases each year.1 Population screening programmes have reduced mortality and facilitated earlier diagnosis, allowing more conservative treatments to be carried out and reducing morbidity.2
According to the 2017 cancer early detection report drafted by the National Health Survey, 81.48% of Spanish women between 50 and 69 years old have had a mammogram in the last two years,3 a percentage only surpassed by Denmark and Finland according to Eurostat, the statistical office of the European Union.4
Currently, the Society of Breast Imaging (SBI), under the remit of the American College of Radiology (ACR), recommends the initiation of breast cancer screening with annual mammography in asymptomatic women from the age of 40.5 The European Society of Breast Imaging (EUSOBI) also developed a consensus recommending breast screening according to a priority system based on the woman's age and risk factors.6 These recommendations, together with double reading, require an increase in the number of radiologists specialising in breast imaging.
The average number of radiologists in the European Union is 12.7 per 100,000 inhabitants.7 Despite the fact that the number of radiologists specialising in breast imaging has progressively increased in recent years to 1085 EUSOBI members in 2018,8 the ratio of specialised radiologists to the number of mammography readings required has decreased by at least 10%.9
Today there are numerous job openings for radiologists specialising in diagnostic imaging, many of them in the field of breast radiology. The objective of this study is to ascertain the opinion of radiology residents about this subspecialty and their experience as residents in the different breast imaging techniques.
Material and methodThe study was conducted between January and July 2020. A survey was prepared with a total of 15 questions aimed at radiology residents at several hospitals in Spain. The questions included 14 closed-ended questions concerning the resident's knowledge of the Sociedad Española de Imagen Mamaria (SEDIM) [Spanish Society of Breast Imaging] and EUSOBI, the autonomous community where they were doing their residency, the total duration, current year, content and supervision of the residency, and their level of satisfaction with the rotation in breast radiology. They were also asked about their interest in embarking on a specific fellowship or their intention to pursue or avoid this field of radiology. A final open question was included for each resident to explain their view of the subspecialty. The complete survey is shown in Appendix A.
The questionnaire was approved by SEDIM and promoted at the 6th Jornada de Actualización en Imagen Mamaria [Breast Imaging Update Conference] (Madrid, February 2020). It was disseminated by the Sociedad Española de Radiología Médica (SERAM) [Spanish Society of Medical Radiology] on social media and by email, attaching a link to Google Forms in both channels: https://docs.google.com/forms/d/e/1FAIpQLSccbgjTSVFy_V3KyR9d9q0249VnmtMWpEn24igtHsniHFCl1g/viewform?usp=sf_link.
At the top of the survey, potential participants were informed that the purpose was to conduct a study on their opinion about training in breast radiology during their residency and their future prospects. They were also informed that their responses would be kept confidential. The duration of the survey was estimated at 3−5 min. Responses submitted between 21 February and 31 July 2020 were accepted.
ResultsA total of 72 responses to the survey were received. Taking into account that there were 919 radiology residents in Spain at the time of the survey, this implies a low response rate (7.83%).
The distribution of the respondents by autonomous community in which they were undertaking their diagnostic imaging specialty is shown in Fig. 1. It shows greatest participation in the Community of Madrid, Aragon and the Valencian Community, in contrast to other communities such as the Basque Country, the Balearic Islands and the Canary Islands, where there was no participation.
Fig. 2 shows that 73.61% of the residents reported that they were familiar with SEDIM, and 18.06% with EUSOBI.
Regarding distribution by year of residence, 51 respondents (70.83%) had completed their rotation in the breast imaging department and more than two-thirds were in the third and fourth years of their training. Two final-year residents had not yet started their breast imaging rotation and eight second year residents had already started or had completed the rotation. The data is shown in Fig. 3.
All of the breast radiology departments of the hospitals where the surveyed residents were being trained allowed the residents to read diagnostic mammograms and perform breast ultrasound. The percentage is somewhat lower in screening mammograms, magnetic resonance imaging and interventional techniques, as can be seen in Fig. 4. Of those surveyed, 70.83% had a three-month training programme in breast imaging and 11.76% dedicated time to research in this field. Two-thirds of the participants reported supervision greater than 75%, and 70.59% reported that the rotation had been better than expected. These data can be seen in Fig. 5.
Regarding breast radiology as a possible future career, one in three respondents would consider a fellowship in breast radiology and 15.18% would consider subspecialising in this field, defining the concept of subspecialisation as dedicating more than 50% of their professional time to working as a breast radiologist. In contrast, 19.44% of the residents surveyed did not contemplate working in the field of breast radiology. The most prominent reasons for not wanting to do so were, in order of frequency: preference for other radiological techniques such as computed tomography (CT), the need to subspecialise, legal liability and contact with the patient. The full responses are shown in Fig. 6.
DiscussionThe increased demand for radiology specialists in Spain, and specifically breast radiologists, requires us to offer our residents and fellows proper training, as well as to awaken their interest and motivate them early on to ensure that many go on to subspecialise.10
One positive outcome of the survey was that most of the residents (73.83%) were familiar with SEDIM, probably due to the involvement of the attending physicians at their hospitals with this society or because of the organisation of training courses aimed at residents, the journal of clinical cases or online courses, among other reasons. However, only 18.06% of those surveyed knew of EUSOBI.
Overall, 70.59% of the residents surveyed considered that the rotation in breast radiology was better than they expected, with only 5.88% reporting that it did not meet their expectations. Although this outcome is positive, it may be due to the low response rate (7.84%) and because the most motivated residents in this field were the ones who completed the questionnaire.
Regarding the year of residence, it should be noted that two final-year residents had not yet started their breast imaging rotation. In general, residency programmes tend to delay this rotation so that residents can train the first two years in subspecialties that prepare them for duty shifts.11 This leads to ignorance of this organ-system until the end of the rotation.
Basset et al. conducted a survey of radiology residents in which 81% reported that preparing a mammogram report was more stressful than compiling a report for other techniques.12 Some authors propose completing most of the rotation in the first three years, delaying between one and three weeks of reading mammograms until the end of the residency.13
Breast imaging diagnosis has evolved over the last decade with the incorporation of new imaging modalities and interventional procedures, which entails a change in objectives, knowledge, skills and attitudes.13 In the breast radiology rotation, communication with the patient and their family is particularly important, and residents ask for more training in this regard.14,15
Approximately 80% of the respondents interpreted screening mammograms during their training and 70% positively valued performing radio-pathological correlation. However, research has not yet been integrated into the residency, since only 11.76% of those surveyed conducted some type of study during this period.
One third of the residents would consider a fellowship in breast imaging, 15.28% would like to subspecialise and more than two-thirds advocated combining breast imaging with another area of radiology in their daily practice. These data show that the double subspecialisation, which has already been implemented in other countries of the European Union, encourages team flexibility and may be an option for the future.
Some authors define breast radiology as a subspecialty difficult to cover,12,16 whereas other authors cite it as one of the three most coveted subspecialties, along with musculoskeletal and interventional radiology.7 Although teleradiology can be one solution to the increased demand for mammograms, breast imaging subspecialists are nonetheless necessary to guarantee the correct and comprehensive management of breast disease.
The main reasons given by the respondents for not committing themselves to this field of radiology, despite being aware of the job opportunities, were, in order of frequency: greater interest in CT, the need for subspecialisation, legal liability and communication with the patient.
Concern about the legal repercussions of diagnostic error in breast radiology is described in numerous articles.12,17–19 The Civil Liability Guide prepared by SEDIM analyses the 95 sentences on breast radiology passed in the last five years and establishes that two-thirds of the proceedings filed for medical civil liability are based on a lack of information given to the patient by the radiologist.20 As such, we believe there should be a focus on this aspect during the residency. Along these lines, in 2006 a survey was carried out in which 36% of radiologists estimated that they would be accused of malpractice in the next five years. However, the final percentage was 10%.18
The residents surveyed see as strengths of the subspecialty the dynamism and multidisciplinarity of the department, the interventional aspect, the follow-up of the patient throughout their care process, the self-management of time, the future opportunities given the guaranteed role of the radiologist within healthcare pathways and, in some hospitals, the good work-family life balance as they do not have to work on-call duty shifts.
A breast radiologist needs to acquire skills in communication, task delegation and protocol implementation, and has the potential for success in research, education, administration and teamwork, as well as participating in the scientific community and patient associations.21
The study has several limitations, the most important being the low response rate (7.83%), which was not homogeneous in all the communities, probably due to its greater promotion in some autonomous communities such as Madrid and Aragon. The possible non-completion of the survey sent by email to residents with less interest in breast radiology must also be considered. Another probable factor for the low participation is the pandemic caused by the SARS-CoV-19 virus, which has revolutionised all diagnostic imaging departments. A total of 20 respondents (29.27%) had not started the rotation. Their opinion was deemed less reliable due to their lesser knowledge of the subspecialty. However, more than two-thirds of those surveyed were residents in their last two years, perhaps due to a greater concern for their professional future as a specialist, which is closer for them than for younger residents. Finally, regarding errors in the surveys, 52 responses were recorded for some questions that should have been answered by 51 people (those who had completed the rotation), although we interpreted this error as minimal.
In conclusion, the majority of the participants positively rated their rotation in breast radiology and would not be averse to devoting part of their time to breast imaging. The non-performance of CT was negatively valued, as were the possible legal repercussions of making errors, while the dynamism, interventional aspect and role of the radiologist within the clinical-surgical breast care process were positively valued.
Authorship- 1
Responsible for study integrity: IS, MCGM.
- 2
Study conception: IS, ART, AIGB, MCGM.
- 3
Study design: IS, ART, AIGB, MCGM.
- 4
Data collection: IS, JGM, ID, MC.
- 5
Data analysis and interpretation: IS, JGM, ID, MC.
- 6
Statistical processing: IS.
- 7
Literature search: IS, JGM, ID, MC.
- 8
Drafting of the manuscript: IS, JGM, ID, MC.
- 9
Critical review of the manuscript with intellectually relevant contributions: ART, AIGB, MCGM.
- 10
Approval of the final version: MCGM.
The authors declare that they have no conflicts of interest.
The authors would like to thank SEDIM and its president, Dr María Martínez Gálvez, for supporting this initiative, and Dr Luis Gorospe Sarasúa, head of training at SERAM, for his help in disseminating the survey.
Please cite this article as: Suñén I, García Maroto J, Dieste I, Ciotti M, Romeo Tris A, García Barrado AI, et al. Visión del residente de radiodiagnóstico en España sobre la radiología mamaria. Radiología. 2022;64:4–10.