The following comments are especially relevant for the unstructured observation sessions in chest, abdomen, neuroradiology, and musculoskeletal radiology.
Radiology can be a difficult medical student rotation in a very different sense than one might expect. With internal medicine, general surgery, and most other third year rotations, the responsibilities and tasks assigned to the medical student, while often challenging, afford the hard-working, diligent student ample opportunities to shine, to feel like a valuable part of the team, and to earn a glowing evaluation. The challenge with many radiology rotations is that there often seem to be regrettably few opportunities for the medical student to assume responsibility, which can lead the generally competent and confident student to start to not feel like part of the team and to have misgivings about “How could anyone possibly evaluate me when I just sit here and listen?”
The reality, however, from this resident's standpoint is that there ARE ways for a medical student to contribute to the team, to make a positive impression, to maximize the teaching they receive from the residents and attendings working with them, and to ultimately earn a strong evaluation (key principle #1). In this section I will try to suggest ways in which all of this can be best accomplished. Many of my suggestions assume a basic understanding of the daily workflow in radiology and so in deference to principle #2, I feel compelled to provide some background that I hope you will also find useful in terms of what to expect when you're in the reading room.
The radiology department at the Brigham is divided into “sections,” generally based on organ system (see Section 5), and in general each section has a dedicated reading room which houses a number of “workstations.” A detailed understanding of the workstations is not necessary, but it is worth knowing that the right-most monitor in most reading rooms is separate from the PACS (radiographic images) component. The right-hand monitor is used for reviewing clinical history (EPIC) and reference materials (UpToDate, PubMed etc.).
In most sections, you will observe residents and fellows working within what is referred to as the “preview system,” in which the trainee is responsible for viewing the study, formulating an impression, and dictating a report prior to reviewing the images and report with the supervising attending. These review sessions with the attending are also referred to as “sign out” or “read out.” This is the Radiology equivalent of presenting a new admission on rounds. Read out affords the day's highest yield teaching and it is not only acceptable but expected for you as the medical student to drop whatever you're doing in the reading room to join any and all attending read out sessions (with junior residents, senior residents, and fellows).
When none of the trainees is being read out, you will be expected to sit with one of them while s/he previews cases. As residents, we generally enjoy the opportunity to teach medical students, however, performing our clinical work to the highest possible standard (patient care) is our first priority, and if things are particularly busy, this can unfortunately get in the way of teaching. Much of this is out of your control (and ours too), but it is a fact of modern radiology and one worth knowing about before you get to the reading room in my opinion.
After introducing yourself, ask the resident or fellow whether it is ok for you to observe for “a few minutes.” This not only offers the trainee the opportunity to say “Things are really busy for me right now. It’d probably be better for your learning if you sat with someone else right now and tried back with me a little later” but also lets the trainee who is available and willing to teach but may worry about things getting busier later in the day that s/he is not committing to having you alongside for the entire day. If after 10 or 15 minutes, working with that trainee seems unproductive for any reason, this approach allows you a way of politely excusing yourself to go try another station/trainee.
While many sections are generally very busy, it is not entirely uncommon for there to be a lull in the work flow at some point during the day. For this reason, I would also suggest asking the trainee you’re sitting with up front “If there happens to be a lull in the list, would you please consider going over some interesting cases from your teaching file with me?” This will worst case show that you're considerate and interested and best case improve the teaching you receive and make you a little more memorable when it comes to evaluation time. It is also a good idea, when possible, to gravitate toward the more senior trainees, as they are more likely to have pearls of wisdom to impart and are also more likely to be relatively proficient with their interpretations and less likely to fall behind if they are also doing some teaching.
Regarding tips for being helpful in the reading room, I suggest asking the trainee you are reading with whether it would be helpful if you pulled up the clinical history for the patients whose exams s/he is interpreting. One common myth about radiology is that images are all that matter; in reality, we rely heavily on daily progress notes, surgical operative notes, lab results, and pathology to guide our interpretation and assessment. For each case, you (along with the resident) should develop a quick assessment of all pertinent available information in the EMR. By offering to help digest this information, you can help with the resident’s workflow and learn how to efficiently “scroll” a patient’s chart (a valuable skill for ALL rotations). We always love to have medical students who take initiative like this (when feasible) and the clinical information you review will help you generate a differential diagnosis, relevant questions for teaching, and maybe even a topic for your final presentation.
Clinical teams frequently visit the reading room with questions about some of their most challenging and interesting patients. These consultations can be stressful for the trainees who are being put on the spot with generally difficult questions, but they are frequently excellent learning opportunities for you as students. I recommend gravitating toward these consultations as a second priority after read out. The trainee you are sitting with will not be offended, and you can even use these consultations as an “out” if the time you are spending with a trainee is unproductive.
If you have tried all of the above ideas and still feel that you’re not learning, don’t feel compelled to stay in the reading room. While we feel the reading room observations are important to appreciating the “real life” practice of radiology, we don’t want you to be unhappy or feel like your time is wasted. Remember that in such circumstances, it is acceptable to politely excuse yourself from the reading room and have some self-learning time in the BWH Medical Student Room using the supplemental learning modules (SLMs) directed toward your PCE log cases in Chest, Abdomen, Neuro, and MSK or any of the other available resources.