The Big Squeeze: Factors Contributing to Moral Distress Among Radiologist Clinician-Educators

Moral distress is a term used to describe the cognitive-emotional dissonance that is experienced when one is compelled to act contrary to one's moral requirements. This occurs as a result of systemic constraints that prevent an individual from taking actions that they perceive as morally right, resulting in a perceived violation of one's core values and duties. There has been a growing interest in the prevalence of moral distress in healthcare, particularly as a root cause of burnout. A recent national survey on moral distress in radiology found that 98% of respondents experienced at least some degree of moral distress with 18% of respondents having left a position due to moral distress. One of the scenarios associated with the highest degree of moral distress related to the conflict that arises when one feels unable to fulfill teaching responsibilities due to high clinical demands. Now more than ever, clinician-educators are asked to do more with less time, fewer resources, and in an increasingly demanding work environment that is often discordant with providing quality education to their learners. In this manuscript, we aim to discuss the factors contributing to moral distress in radiologist clinician-educators as a framework to better understand the implications of these drivers, and to offer our perspective on potential mitigating measures.

Creativity, Connection, and Community: Reimagining the Radiology Society Meeting

RATIONALE AND OBJECTIVES

With the shifting needs of radiologists due to escalating healthcare demands, the impetus for an increased focus on wellness and the benefits of the humanities in medicine inspired a novel approach to curricular planning of the 2023 Association of University Radiologists (AUR) annual meeting. In this manuscript, we describe the creative process behind planning and executing this innovative meeting format.

MATERIALS AND METHODS

Reimagining the annual meeting was a collaborative effort centered around the development of an innovative Arts and Wellness Program, with the goal of integrating opportunities for artistic expression and experiential wellness throughout the meeting.

RESULTS

Of the 1313 meeting attendees, 423 (32.2%) completed the annual meeting evaluation, of which 244 were in-person and 61 attended virtually. 178 of 423 respondents (42.1%) participated in the arts and wellness programming. 160 of 203 respondents (78.9%) reported that the arts and wellness programming enhanced the overall meeting experience. 164 of 197 respondents (83.2%) gained greater appreciation for the talents of radiology colleagues. 97 of 195 respondents (49.7%) stated that the programming gave them ideas as to how to cope effectively with stress.

CONCLUSION

The incorporation of art, music, and other wellness activities into a national radiology meeting was well-received by meeting attendees. For many radiologists who participated in the various musical and artistic offerings at the AUR 2023 meeting, sharing artistic talents with the radiology community and colleagues represented the most fundamental way to be fully seen, express authenticity, and connect with others.

American College of Radiology Paid Family/Medical Leave Policy: A Call to Action for the House of Medicine

The American College of Radiology (ACR) passed a historic paid family/medical leave (PFML) resolution at its April 2022 meeting, resolving that "diagnostic radiology, interventional radiology, radiation oncology, medical physics, and nuclear medicine practices, departments and training programs strive to provide 12 weeks of paid family/medical leave in a 12-month period for its attending physicians, medical physicists, and members in training as needed." The purpose of this article is to share this policy beyond radiology so that it may serve as a call to action for other medical specialties. Such a PFML policy (1) supports physician well-being, which in turn supports patient care; (2) is widely needed across American medical specialties; and (3) should not take nearly a decade to achieve, as it did in radiology, especially given increasing physician burnout and the ongoing COVID-19 pandemic. Supported by information on the step-by-step approach used to achieve radiology-specific leave policies and considering current and normative policies at the national level, this article concludes by reviewing specific strategies that could be applied toward achieving a 12-week PFML policy for all medical specialties.

Meeting Faculty Development Needs: Review of Current Resources and Opportunities for Program Development

This paper will review faculty development focus and programming at the early, mid and late career stages. Topics covered include challenges at each career stage, institutional and national programming currently available for the needs of faculty at that stage, and suggested best practices for development of new career focus and potential programs for each stage.

Ensuring a Smooth Transition for Trainees Returning from Parental Leave - A Guide for Program Directors

Transitioning from parental leave during radiology residency training can be a time of stress and uncertainty. However, there are ways that program directors can help make the transition smoother and less overwhelming. Trainees report numerous stressors upon returning from leave involving childcare, lactation concerns and logistics, and discrimination. Program directors can help alleveate these stressors by counseling trainees returning from parental leave and providing reseources and a supportive enviroment. This article provides a structured frame work with tool for programs directors to ensure the transition from parental leave back to training is a smooth one.

Self-Care and Storytelling for Radiologists: A Feasibility Study

RATIONALE AND OBJECTIVES

Physician wellness and burnout mitigation strategies have become priority practices in recent years. Despite these efforts, however, physicians living with the psychological effects of the current COVID-19 global pandemic, political stressors, and social injustices, face ever increasing threats to their personal and professional well-being. This manuscript investigates the process of storytelling as a self-care practice for radiologists.

MATERIALS AND METHODS

The AUR Well Being Ad-Hoc Committee introduced and approved Storytelling Geek Week, a virtual workshop held by The Moth, a Peabody award-winning storytelling nonprofit group. Nineteen AUR members applied and were selected for participation in the workshop which occurred over 5 days in November 2020. Anonymous electronic surveys were sent to participants before and after the workshop to gather feedback on their experience.

RESULTS

Of the 19 AUR member participants, 12 (63%) completed the pre-workshop survey and 8 (42%) completed the post-workshop survey. Participant current state of well-being was found to be increased between the pre- and post-course surveys, with a statistically significant adjusted P-value of 0.017. All 8 post-workshop respondents reported that they would recommend the workshop to others. With regard to how participation in the workshop impacted their wellbeing, representative free text responses include, "helped with processing emotions," and "felt more connected to strangers." Regarding shifts in perspective as a result of workshop participation, representative free text responses include, "more empathetic" and "started focusing on hope and gratitude rather than sadness and anxiety."

CONCLUSION

Participants in a storytelling workshop reported a positive impact on their perceived sense of well-being. Respondents also reports shifts in their sense of empathy and connectedness to others. This type of intervention may help to mitigate burnout and build community during challenging times.

Resident Clinician Educator Leadership Pathway Tracks in US Radiology Programs: An ADVICER 2021 Survey Study

RATIONALE AND OBJECTIVES

The purpose of this manuscript is to elucidate the prevalence, characteristics, outcomes, and perceptions of Alliance of Directors and Vice Chairs of Education in Radiology (ADVICER) members on Clinician Educator Leadership Pathway (CELP) tracks in diagnostic and interventional radiology residency programs in the United States.

MATERIALS AND METHODS

IRB exemption was obtained for this study. A 17-question anonymous survey was administered to the ADVICER members, an Association of University Radiologists (AUR) affiliate group, via email once, and then as a reminder 14 days later. Statistical analysis occurred via built-in analytics of the survey vendor, SurveyMonkey.

RESULTS

Thirty five of 72 ADVICER members (48.6%) responded to the survey. 45.7% (16/35) respondents indicated the presence of leadership or specialty pathways in their respective residencies. 28.6% of respondents indicated a CELP (10/35) in their residency programs. 92.0% of respondents endorsed CELP as preparatory for an academic career, and 93.6% endorsed development of a national CELP curriculum.

CONCLUSION

The majority of radiology residency programs do not have a CELP in their training curriculum. ADVICER leaders overwhelmingly support CELP for professional development of the future educational leaders in radiology and endorse the creation of a national CELP curriculum.

Brave New World: Challenges and Opportunities in the COVID-19 Virtual Interview Season

The COVID-19 pandemic has forced the transition of the traditional residency interview to a virtual format. This new interview format creates additional challenges and opportunities for both programs and applicants. The specific challenges of the virtual interview format are described, as well as means to mitigate those challenges. In addition, opportunities to improve residency selection from the program end are described.

Diagnostic Radiology Resident Recruitment Part II: Advice to Applicants From Vice Chairs for Education

Applicants to diagnostic radiology residencies often obtain advice regarding the process, typically from local individuals. Materials available on the Internet contribute to this process as well. We are a group of current and former Diagnostic Radiology Residency Program Directors and current Vice Chairs for Education who commonly advise medical students, including regarding radiology as a career. This work is meant to provide a "plain talk" resource for those considering a career in radiology via a radiology residency, written from the point of view of an advisor with lots of experience.

Attitudes of Radiology Program Directors Toward MD-PhD Trainees, Resident Research Productivity, and Dedicated Research Time

RATIONALE AND OBJECTIVES

The percentage of clinical scientists in radiology has historically been low. Increasing the pipeline of trainees interested in research could occur by recruiting MD-PhD trainees and providing protected research time during residency. The purpose of this work is to assess the attitudes of radiology program directors toward MD-PhD trainees, resident research productivity, and dedicated research time.

METHODS

An online survey was sent to residency program directors of all diagnostic radiology departments that received National Institutes of Health (NIH) awards in 2014 (n = 63). Survey questions included program size; perception of overall performance, clinical performance, and research productivity of MD-PhD residents compared to non-PhD residents; and presence of dedicated research time. Responses comparing MD-PhD residents to non-PhD residents were reported as a five-point Likert scale. Student t test was used to assess for significance (alpha = 0.05).

RESULTS

Response rate was 37%. Clinical performance of MD-PhD residents was judged inferior (P < .05) to non-PhD residents, although that of all residents engaged in research trended toward superiority compared to those not involved in research. Dedicated research time is offered by 61% of programs in years R1-R3 and all programs in year R4. Research productivity during residency was judged to be similar (P = .5) between MD-PhD and non-PhD residents.

CONCLUSIONS

Survey results suggest that clinical performance during residency and research involvement is often individually based and difficult to generalize based on prior PhD training. All programs offered dedicated research time, and the vast majority of residents were reported to engage in research during residency, which may increase the pipeline of trainees interested in an academic career.

A Leadership Intervention to Further the Training of Female Faculty (LIFT-OFF) in Radiology

RATIONALE AND OBJECTIVES

Women are under-represented in the field of radiology, occupy a minority of leadership positions, and, at our institution, have not achieved the same level of academic success as their male counterparts. Consequently, the authors designed, implemented, and evaluated the Leadership Intervention to Further the Training of Female Faculty (LIFT-OFF) program to (1) improve access to opportunities for women's faculty development and advancement, and (2) improve clarification of expectations about the role and path of advancement.

MATERIALS AND METHODS

LIFT-OFF was developed based on the results of a needs assessment survey. The results generated 14 priority topics, which served as the basis for educational modules conducted by expert speakers. Module effectiveness was assessed with pre- and postsurveys to elicit participant knowledge about the targeted subject matter. A formative program evaluation was performed at the completion of year 1 of 2 to assess outcomes and impacts to date.

RESULTS

Seventeen of 55 (31%) educational module post-survey questions demonstrated a statistically significant (P < 0.05) increase in "yes" responses, indicating an improved understanding of targeted information. At year 1, 75% of the participants indicated that the program improved access to faculty development opportunities and 62% reported improved access to career advancement opportunities. Satisfaction with pace of professional advancement increased from 25% to 46% for junior women faculty (P = 0.046).

CONCLUSIONS

Faculty development programs such as LIFT-OFF can provide career development opportunities and executive skills necessary for women to achieve academic career success and assume leadership positions.

Locating the optimal internal jugular target site for central venous line placement

STUDY OBJECTIVE

Historically, the placement of internal jugular central venous lines has been accomplished by using external landmarks to help identify target-rich locations in order to steer clear of dangerous structures. This paradigm is largely being displaced, as ultrasound has become routine practice, raising new considerations regarding target locations and risk mitigation. Most human anatomy texts depict the internal jugular vein as a straight columnar structure that exits the cranial vault the same size that it enters the thoracic cavity. We dispute the notion that the internal jugulars are cylindrical columns that symmetrically descend into the thoracic cavity, and purport that they are asymmetric conical structures.

DESIGN

The primary aim of this study was to evaluate 100 consecutive adult chest and neck computed tomography exams that were imaged at an inpatient hospital. We measured the internal jugular on the left and right sides at three different levels to look for differences in size as the internal jugular descends into the thoracic cavity.

MAIN RESULTS

We revealed that as the internal jugular descends into the thorax, the area of the vessel increases and geometrically resembles a conical structure. We also reconfirmed that the left internal jugular is smaller than the right internal jugular.

CONCLUSIONS

Understanding that the largest target area for central venous line placement is the lower portion of the right internal jugular vein will help to better target vascular access for central line placement. This is the first study the authors are aware of that depicts the internal jugular as a conical structure as opposed to the commonly depicted symmetrical columnar structure frequently illustrated in anatomy textbooks. This target area does come with additional risk, as the closer you get to the thoracic cavity, the greater the chances for lung injury.

Entrustable Professional Activities: Ten Things Radiologists Do

RATIONALE AND OBJECTIVES

Learner assessment in medical education has undergone tremendous change over the past two decades. During this time frame, the concept of Entrustable Professional Activities (EPAs) was introduced to guide the faculty when making competency-based decisions on the level of supervision required by trainees. EPAs are gaining momentum in medical education as a basis for decisions related to transitioning from residency training to clinical practice. The purpose of this article is twofold: (1) define EPAs for radiology (EPA-R) and (2) illustrate radiology-specific examples of these EPAs.

MATERIALS AND METHODS

A multi-institutional work group composed of members of the Alliance of Directors and Vice Chairs of Education in Radiology convened at the 2015 Association of University Radiologists annual meeting to discuss radiology EPAs. The EPAs initially developed by the Accreditation Council for Graduate Medical Education (ACGME) Radiology milestone work group and the resultant ACGME Radiology milestones formed the basis for this discussion.

RESULTS

A total of 10 radiology EPAs and illustrative vignettes were developed to help radiology educators and trainees better understand milestone assessment and how this translates to the necessary skills and responsibilities of practicing radiologists. Examples of EPA mapping to the ACGME subcompetencies and methods of assessment were included.

CONCLUSIONS

EPAs offer an opportunity to improve our approach to training by increasing our focus on how we provide appropriate supervision to our residents and assess their progress. In this work, through suggested lists and vignettes, we have attempted to establish the framework for further discussion and development of EPA-Rs.

"What Program Directors Think" II: Results of the 2013 and 2014 Annual Surveys of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors.

MATERIALS AND METHODS

This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7-29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3-21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)-diagnostic radiology (DR) training programs.

RESULTS

Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014.

CONCLUSIONS

With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

What program directors think: results of the 2011 annual survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) conducts an annual survey to monitor and evaluate issues pertaining to radiology residents' educational experiences, work responsibilities, and benefits. Data are used to identify emerging trends and patterns of change to plan and provide resources that support radiology residency programs and their directors.

MATERIALS AND METHODS

The APDR Annual Survey Committee selected 59 items for an observational, cross-sectional study using a Web-based survey. Topics of interest included program director satisfaction, resident recruitment, social media, program requirements, curriculum, the new American Board of Radiology exam process, call, and residents-as-teachers programs. All active APDR members (n = 296) were invited to participate in survey between February 20 and March 11, 2011.

RESULTS

The response rate was 47% (140 of 296). Descriptive results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 59th annual meeting of the Association of University Radiologists.

CONCLUSIONS

Data generated by the annual survey enable the APDR to accrue data pertaining to residents' real-time educational experiences. In 2011, program directors were satisfied with their jobs but not convinced that competency-based program requirements had positive effect on residency training. Programs plan to use the Radiological Society of North America and American Association of Physicists in Medicine Web-based physics training modules. Most radiology programs do not have residents-as-teachers programs, nor do they plan to initiate them. During recruitment, programs use an applicant's location as a proxy for true interest in the program, and interest in the program is important for granting interviews and final ranking. Qualified international medical graduate applicants have access to radiology training in the United States and Canada. Almost half of radiology programs have in-house reading by attending radiologists with residents on call. Residency programs have been slow to embrace social media.

Email notification combined with off site signing substantially reduces resident approval to faculty verification time

RATIONALE AND OBJECTIVES

Attending radiologist signature time (AST) is a variable and modifiable component of overall report turnaround time. Delays in finalized reports have potential to undermine radiologists' value as consultants and adversely affect patient care. This study was performed to evaluate the impact of notebook computer distribution and daily automated e-mail notification on reducing AST.

MATERIALS AND METHODS

Two simultaneous interventions were initiated in the authors' radiology department in February 2010. These included the distribution of a notebook computer with preloaded software for each attending radiologist to sign radiology reports and daily automated e-mail notifications for unsigned reports. The digital dictation system archive and the radiology information system were queried for all radiology reports produced from January 2009 through August 2010. The time between resident approval and attending radiologist signature before and after the intervention was analyzed. Potential unintended "side effects" of the intervention were also studied.

RESULTS

Resident-authored reports were signed, on average, 2.53 hours sooner after the intervention. This represented a highly significant (P = .003) decrease in AST with all else held equal. Postintervention reports were authored by residents at the same rate (about 70%). An unintended "side effect" was that attending radiologists were less likely to make changes to resident-authored reports after the intervention.

CONCLUSIONS

E-mail notification combined with offsite signing can reduce AST substantially. Notebook computers with preloaded software streamline the process of accessing, editing, and signing reports. The observed decrease in AST reflects a positive change in the timeliness of report signature.

What is the preferred central venous pressure zero reference for hepatic resection?

BACKGROUND

The common practice of maintaining central venous pressure (CVP) below 5 mm Hg to reduce blood loss during hepatic resection increases the risk of venous air embolism (VAE). We initiated this study after observing that the anteroposterior (AP) diameter of the liver can be much larger than 7 cm, which is the approximate hydrostatic pressure corresponding to a CVP of 5 mm Hg (1 mm Hg = 1.36 cm H(2)O). The purpose of this study was to characterize the liver AP diameter and thereby describe how this might affect the placement of the CVP transducer to balance the risks of bleeding and VAE.

METHODS

We measured the AP liver diameter and its distance from other anatomic sites using consecutive archived chest tomograms with IV contrast from 100 adults.

RESULTS

The results of our study demonstrate a large interindividual range in AP liver dimensions (17.9 + or - 2.8 cm, range = 12.0-28.5 cm) and standardized anatomic landmarks relative to the portal triad.

CONCLUSIONS

The significant variability in AP liver diameter, along with the variability in the liver surgical site, suggests that we rethink the zero reference point for the CVP transducer during hepatic surgeries. By considering the actual hepatic venous pressure itself, rather than the CVP, we can minimize the risks of VAE and hemorrhage. Two methods for zeroing the reference transducer are suggested.