Image-Based Teaching: Techniques, Tips and Tricks 3031118898, 9783031118890

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Image-Based Teaching Techniques, Tips and Tricks Tara Catanzano Editor

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Image-Based Teaching

Tara Catanzano Editor

Image-Based Teaching Techniques, Tips and Tricks

Editor Tara Catanzano Department of Radiology University of Massachusetts Chan Medical School-Baystate Springfield, MA, USA

ISBN 978-3-031-11889-0    ISBN 978-3-031-11890-6 (eBook) https://doi.org/10.1007/978-3-031-11890-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

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Brain Friendly Teaching��������������������������������������������������������������������������    1 Petra J. Lewis

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 Teaching and Communicating with Millennial Learners��������������������   15 Ami A. Gokli

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 Engagement of Generation Z Learners ������������������������������������������������   33 Dane Gunter, Nikhil Patil, and Natasha Larocque

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Helping Nonteaching Faculty Teach������������������������������������������������������   45 Kirang Patel and Courtney Cheng

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 Teaching Clinicians and Patients������������������������������������������������������������   69 Amy Fioramonte, Amy Garvey, and Fiza Khan

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 and Drawing in Radiology Education ��������������������������������������������   87 Art Kitt Shaffer and Nicholas Spittler

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Workstation Teaching������������������������������������������������������������������������������  101 Susan Hobbs

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 Effective Feedback in Radiology Education������������������������������������������  113 Smyrna Tuburan

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 Writing High-Quality Multiple-Choice Questions��������������������������������  123 Georgios A. Sideris, Amninder Singh, and Tara Catanzano

10 Leveraging Technology����������������������������������������������������������������������������  147 Allison Grayev 11 The  Flipped Classroom, Inclusively ������������������������������������������������������  161 Sheryl G. Jordan, Umer Ahmed, and Eric J. Fromke 12 Gaming in Radiology ������������������������������������������������������������������������������  175 Ravi Kagali

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13 Teaching Procedure Skills ����������������������������������������������������������������������  187 Erin Priddy 14 Simulation  in Radiology Education��������������������������������������������������������  201 Joseph Makris 15 Teaching  Quality, Safety, and Professionalism��������������������������������������  217 Shamseldeen Y. Mahmoud 16 Teaching  Research Techniques and Critical Assessment of the Literature��������������������������������������������������������������������������������������������������  239 Sheryl G. Jordan and Gary L. Beck Dallaghan 17 Teaching  the Next Generation of Teachers: Residents and Fellows����  253 Roopa Ram and Alisa Kanfi 18 Social  Media in Radiology Education����������������������������������������������������  269 Devrim Ersahin and Dan Kowal 19 Lessons  Learned from COVID-19 (Remote Teaching Techniques)����  285 Martha Lopez Index������������������������������������������������������������������������������������������������������������������  297

Contributors

Umer  Ahmed  University of North Carolina School of Medicine, Chapel Hill, NC, USA Gary  L.  Beck  Dallaghan  University of Texas at Tyler School of Medicine, Department of Medical Education, Tyler, TX, USA Tara  Catanzano  Department of Radiology, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA Courtney Cheng  Royal College of Surgeons in Ireland, Dublin, Ireland Devrim  Ersahin  Department of Radiology, University of Massachusetts Chan Medical School-Baystate Campus, Springfield, MA, USA Amy  Fioramonte  Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA Eric  J.  Fromke  University of North Carolina School of Medicine, Chapel Hill, NC, USA Amy Garvey  Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA Ami A. Gokli  Division of Pediatric Radiology, Staten Island University Hospital, Staten Island, NY, USA Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, USA Allison  Grayev  Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA Dane  Gunter  Department of Radiology, McMaster University, Hamilton, ON, Canada Susan Hobbs  Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA vii

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Sheryl G. Jordan  Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA Ravi Kagali  Geisinger Medical Center, Danville, PA, USA Alisa Kanfi  Department of Radiology, University of Cincinnati, Cincinnati, OH, USA Fiza  Khan  Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA Dan Kowal  Department of Radiology, University of Massachusetts Chan Medical School-Baystate Campus, Springfield, MA, USA Natasha  Larocque  Department of Radiology, McMaster University, Hamilton, ON, Canada Petra J. Lewis  Geisel School Medicine at Dartmouth, Hanover, NH, USA Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Martha Lopez  Diagnostic Radiology Department, UMass Chan Medical School-­ Baystate, Springfield, MA, USA Shamseldeen Y. Mahmoud  Radiology Department, Saint Louis University School of Medicine, St. Louis, MO, USA Assiut Governorate, Assiut University School of Medicine, Assiut, Egypt Joseph Makris  Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA, USA Kirang Patel  University of Texas Southwestern Medical Center, Dallas, TX, USA Nikhil  Patil  Department of Radiology, McMaster University, Hamilton, ON, Canada Erin Priddy  University of Arkansas for Medical Sciences, Little Rock, AR, USA Roopa  Ram  Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA Kitt Shaffer  Department of Radiology, Boston Medical Center, Boston, MA, USA Georgios A. Sideris  Department of Radiology, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA Amninder  Singh  Department of Radiology, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA Nicholas  Spittler  Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA Smyrna  Tuburan  Department of Radiology and Imaging Sciences, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA

Chapter 1

Brain Friendly Teaching Petra J. Lewis

If you are reading this book, then like me, you love to teach. We often assume that because we have taught something to our learners, they now know it. Unfortunately, this is a very simplistic assumption, as there are many factors which can reduce or negate learning. Some of these are inherent to the learner, some apply to the material and some to the learning environment, but many are under the control of the instructor. How the material is conveyed to the learners is often as important as what is being taught. To explore this further, we need to discuss the concept of “cognitive load,” and how it relates to didactic teaching. Interactive teaching will be discussed in other chapters.

Cognitive Load Cognitive load is the stress put on our brain when we learn new data or skills which is due to the limitations of our working memory [1]. Working memory (formally called “short-term memory”) is the part of our brain which enables the processing and storage of information into long-term memory. An appropriately functioning working memory is absolutely key to effectively processing information and is impaired in a number of conditions including Attention Deficit Disorder and Alzheimer Disease [2]. Working memory has a very small capacity—it is thought to be able to hold only seven to nine pieces of information at any one time [3]. Due to

P. J. Lewis (*) Geisel School Medicine at Dartmouth, Hanover, NH, USA Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_1

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this limitation, information contained in short-term memory must be either moved quickly to long-term memory or it is lost. I like to make analogies to computer processing (realizing that this is a very simplistic way of describing memory). Working memory can be thought of acting like the “RAM” (random access memory) on your computer. This RAM is responsible for processing information, running applications, and getting information stored on the hard disc. I will use this computer analogy in further discussions. The cognitive load on our brain can be affected by many things. The load may depend on what we are trying to learn (simple versus complex data); how much we try to learn in any one session (volume); how the data is presented to us (teaching style) and finally who is learning it (is the information new to us?). Cognitive overload is what happens when our working memory is overloaded by too much data too fast for our particular processing level. When this happens, processing slows down or even stops and key information is not stored. This is like your computer grinding to a halt when you what you are asking it to do exceeds the capabilities of the RAM. Programs won’t run and data is lost. As teachers, we often underestimate the significance (or even existence) of cognitive overload. We might see our learners as partially empty vessels that are eagerly absorbing the information that we deploy. We often want to provide a fully comprehensive review of the topic, as if this is the students only chance to learn about this subject. We want our didactic talks to look attractive to ourselves and learners. We may have misconceptions about the “number of slides” that our [X] minute presentation should contain, leading to slide crowding. We frequently underestimate the time that we need to teach this session.

Didactic Teaching Despite increasing awareness of active learning and interactive methods of teaching, didactic teaching using slide programs such as PowerPoint™ (Microsoft, Redmond, WA) or Keynote™ (Apple, Cupertino, California) remain the mainstay of education at both the undergraduate and post graduate levels. I will only refer to PowerPoint but the same principles apply to all digital slide software. These programs were a huge leap forward for educators – they gave us the ability to make and edit colorful talks much faster and cheaper than previously when slides had to be typed and photographed. The advent of digital projection also brought with it a whole new potential world of presentation excess. Each version of PowerPoint or Keynote comes with yet more fancy templates, bells and whistles that enable us to employ an incredible array of irresistible color schemes and fonts; add slide transitions, animations, and even sound effects. Unfortunately, these programs also give us plenty of opportunity to inadvertently increase the cognitive load on our learners thus reducing the long-term retention of information.

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There are multiple components to a successful teaching session as well as the slide content such as: the development of appropriate and focused learning objectives; using active learning methods and oral presentation skills. In this article, however, I am going to focus on the concept of “cognitive overload,” and how we can change the format and content of conventional didactic lectures to reduce cognitive overload while maximizing learning.

Learning Objectives Focused learning objectives that use achievable action verbs should be written before the rest of the session is developed. Objectives should describe what the student should learn by the end of the session, not what the instructor is planning to teach, i.e., be learner-centric not teacher-centric. These objectives should be “SMART”—Specific, Measurable (even if you don’t actually measure the learning), Attainable in the time and setting available, Relevant (directed towards important material), and Targeted to the learner level. Learning objectives should include some that aim at the higher levels of Bloom’s Taxonomy of Learning Objectives [4], i.e., not rely on pure memorization of facts but more on the application, analysis, and synthesis of information. Many active verb lists can be found on the internet that help instructors develop appropriate learning objectives. Of note, “learn XXX” is not considered a focused objective. An example of appropriate learning objectives is shown in Table 1.1. These learning objectives provide the framework and focus for the subsequent content. They also prime learners to be ready to acquire the identified information which results in increased learning [4]. Generally, more than three to five learning objectives are unlikely to be achieved in a single learning session. Spend a minute or 2 going through these or give the audience time to read to provide maximal benefit. After the session, review if you feel that you have achieved those objectives—or even better survey the learners.

Table 1.1  Example of appropriate learning objectives for a teaching session on breast calcifications

1 2 3 4 5

Learning objective Apply the BIRADS 2013 morphology lexicon to breast calcifications seen on mammography Apply the BIRADS 2013 distribution lexicon to breast calcifications seen on mammography Categorize calcifications into benign, indeterminate, and suspicious categories Compare and contrast features of benign and malignant calcifications Plan appropriate management for breast calcifications

Bloom’s level 3 (apply) 3 (apply) 3 (apply) 4 (analyze) 5 (evaluate)

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Information Quantity By trying to teach everything about the subject at hand in one session (often presenting large quantities of information in a format that might work well in a handout that would be better studied at leisure) it overwhelms learners during a 45- or 60-min lecture. This cognitive overload can be severe enough, particularly for novices, that they absorb only minimal information from the session. We forget that for most, this is not their only opportunity to gain this knowledge and by flooding them with data, we unfortunately reduce the learning of key information. We need to ask ourselves: what do we really want to them to know about this condition, process or modality? What is the minimum information that you want them to take out of this learning session? By emphasizing these key facts and reducing the amount that we teach in any one session the overall learning can be significantly improved [5]. Splitting the talk into two shorter sessions, that allow more time for information digestion and discussion can be very effective. We may teach 20 facts, but them only learn 4, or we could teach 10 and have them learn 8. Which is better? Information quantity overload during a teaching session can occur through different mechanisms. We may pack too many topics and facts into a single teaching session, or we may crowd each slide with too many words, images or diagrams. We may display huge tables or complex diagrams. The next sections break these down further.

Reducing Text Volume Slides should not contain every word that you are going to say. For less experienced instructors, or with new talks that you are unfamiliar with, use the notes section to add the additional detail. Using “Presentation Mode” will then provide a reference for the speaker. This will also provide additional information to learners after the talk if you are willing to share slides (which I highly recommend as it has become “the standard expectation” for most learners). Review each sentence and see how much you can shorten it while keeping the key information intact. You will be surprised how much you can shorten the text. Remove redundant and extraneous information. If they don’t need to remember it, and certainly if they don’t need to know it, take it out. I don’t specify a specific line limit, but if you use a minimum of 28 font for indented font (with 32–40 font for the main text), it will force you to limit word counts. See Fig. 1.1 for an example of how text can be précised. Split the text into multiple slides if there are too many lines or if it covers more than one topic (see below). There is no magical “slides per minute” number. It depends on the amount of information, not the number of slides. I have 45-min talks with 150 slides—but many are single images or contain very little text. Of note, the commonly stated “60 slides for a 1-hour talk” originally came from the number of slides that can be fitted into a slide carousel. Interestingly, this immediately became 120 during the painful period when dual projection was a common means of display. Remember, your audience can read faster than you can talk, and you want them focused on what you are saying.

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6. Strengths Cadre of high quality, dedicated course directors and teachers Very dedicated administrative staff who help all of the courses (master scheduling, rooms, quirks of each group of faculty, etc.) Each course is multidisciplinary by nature Strong cooperation and cooperation among courses Strong cooperation and coordination with courses in other years Very strong rating by students in GQ, end-of-course surveys Very strong performance by students in Step 1, Step 2 CK PBL groups with detailed feedback to students, with tutoring across courses and terms (fall and spring) PBL groups and experience rated by many students as the educational highlight of the first two years Clinical relevance of course material, with frequent patient sessions Quality control and coordination through central administrative office-of schedule, polices e.g. grading, exam periods), review of exam questions Central appointment of course directors Flexibility to try out many new initiatives Many initiatives have been piloted due to its flexibility (esp. within PBL) Pediatrics, imaging, improvement (HCDS), nutrition, neoplasia, genetics, rehabilitation Hearts and Minds Rounds now part of courses Observation and analysis of physiologic phenomena (e.g. PFTs)

b Strengths Quality teachers and administrators Flexible course integration Excellent Step 1 scores and evaluations Clinical relevance of material New initiatives

Fig. 1.1  Example of how text can be précised to reduce cognitive load but still maintain the key learning points. Image a shows the original slide which was very word intense and was effectively “read out” by the instructor. Image b shows the amended slide

Dealing with Tables It is tempting to take a screenshot of a table from a research paper and paste it into your slide. These tables are usually large and detailed as is appropriate for a journal article but they are inappropriate to use during a lecture. Nothing is more frustrating for the audience than the speaker saying “I know that you can’t read this, but…” as they display one of these tables. It is highly recommended that you extract the important information from the table and insert into a small table of your own within the slide software. This should be the minimal data to convey the teaching point. Make the table clear and large, and highlight (“signal”) the key data with highlighting or a different font color. Obviously, the original source needs to be cited appropriately.

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Chunking We can reduce cognitive load and improve memory retrieval by “chunking” related information together both visually and in our verbal presentation. Presenting related elements together ties them together in our memories, making for efficient storage and retrieval [6]. On a practical front, this means that you should avoid combining elements from multiple learning objectives into one slide. For example, focus on the imaging features of only one disease within a specific modality on a slide. See Fig.  1.2. If you can relate the information to something that they would already know, again this will also help them “chunk” the information together. This is a

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Current Uses of Breast MRI High risk screening BRCA 1+2 Other genetic syndromes Chest radiation in teens/20’s Annual risk >20% Dense breasts – abbreviated MRI? Staging new diagnosis breast cancer Additional ipsilateral malignancy found in 15% patients Contralateral malignancy in 5% Occult breast cancer Axillary nodal adenocarcinoma, Negative on mammography Neoadjuvant chemotherapy Monitoring response Assessment for less invasive surgery Bloody nipple discharge Negative on mammography

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Current Uses of Breast MRI High risk screening BRCA 1+2 Other genetic syndromes Chest radiation in teens/20’s Annual risk >20% Dense breasts – abbreviated MRI?

Fig. 1.2  Focusing slides to a single learning objective. Slide a while seeming to be all on one topic, actually has five different topics, each of which deserves one or more slides as shown on slide b

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powerful memory enhancing technique called “elaboration” [7]. For example, if the talk is on “MRI of pancreatic cancer” then compare the findings to CT, which they are likely more familiar with.

Leverage the Modality Effect Our working memory can process information down two synergistic pathways: verbal (auditory and written text) and visual (graphs, diagrams, images) [8]. Think of this like the Intel RAM dual processor—improving the efficiency of the processing and speeding up “your computer.” We can leverage this effect to our advantage by presenting information synchronously in two different ways, one visual and one verbal. For example, by showing an image and talking about it. We can also impair information storage by presenting the same information in two verbal forms—e.g., by putting up a text heavy slide and then reading the slide aloud. Your learners can read the information on the slide faster than you can read it, so their brains are trying to process two discordant verbal information streams. By only putting the key words (and images) on a slide, the written words can be used as memory “hooks” for the more detailed verbal information that you are saying. There is nothing more painful to the audience than the lecturer reading the slides (or worse, following the words with a laser pointer!). As John Sweller, an educational psychologist in New South Wales, said, “If your presentation can be perfectly and completely understood without your narration, then it begs the question: why are you there?” [9].

Extraneous Information Extraneous information is visual or verbal information that is not needed to teach the learning objective. By adding extraneous information, we are increasing the cognitive processing that our learners are required to do. This extra cognitive work (load) impairs the processing of the important information. Again, think about your computer and how sometimes it slows down for no obvious reason until you open the task manager and discover that it is running 127 processes that you were unaware of—your brain acts the same [10]. The temptation to inadvertently include extraneous information on slides is huge. We frequently add icons, extra images and figures that are not needed to convey the teaching. How often has your conscious attention (let alone unconscious) been drawn to looking at the icons or pretty pictures on the slide rather than listening to the speaker? Nothing should be on that slide that does not relate to the learning objectives for that slide. In contrast, images used appropriately can be very impactful (see below). We can further distract learners by using slide transitions, complex animations and (worst of all) sound effects - the only slide transition that is needed is “None.”

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Using Images Effectively We remember images much better than we remember written words or numbers [11]. The more emotion that can be generated by an image, the more memorable it is. For example, photographs are more memorable than clip art. A photograph of a patient with inflammatory breast cancer is much more memorable than the description. In radiology we obviously have the significant advantage in that much of our teaching is image-based. Unfortunately, you can induce cognitive overload with images as easily as you can with text. Too many images on a slide, too small images, unclear findings, or images combined with extensive text can all increase the cognitive load. Wherever possible, split images and graphs onto separate slides, preferably with no text. Use the modality effect to describe the imaging findings rather than write them. Obviously in radiology there are times when you need 2 or 3 images on a slide—e.g., pre- and post-contrast, or three different MR sequences—but as you increase the number beyond that, you will overwhelm their ability to process and retain the information. See Fig. 1.3. They will also tend to be analyzing a different image than the one you are talking about, splitting their attention (see below). Light colored backgrounds while helpful to show text in a brighter room, reduce the visibility of radiological abnormalities as the audience’s pupils will be constricted. Use a plain black background on slides that contain radiographic images (see Fig. 1.4). Having slides that alternate from light to dark backgrounds is similarly challenging to viewer’s ciliary muscles and results in eye strain. Incorporating simple animations can aid learning, e.g., arrows that appear and disappear. These can easily be done by using sequential slides (the same image without and with the arrow) for the many of us who find animation techniques challenging. Select images that clearly show the findings and that will project effectively. This can be particularly challenging with radiographs with subtle findings. Whenever possible check images project well using the projector/screen and lighting that you will be using. Make the images as large as possible—removing any dead space

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Fig. 1.3  Reducing the number of images on a slide. Slide a has too many images and too much text, a distracting background and institutional icon, too low contrast text color and unnecessarily fancy font. Slide b has focused the learner’s attention on a single topic—mammography in DCIS, simplified the design, reduced the text and enlarged the image. Further slides can be made to cover ultrasound and MRI

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Fig. 1.4  Using a dark background enlarges the audience’s pupils which improves visualization of imaging abnormalities. Cropping images to the area of interest reduces cognitive load. Adding the arrow helps “signal” the abnormality. See the improvement between the original image (a) and revised (b)

around the image. Crop images to show the area of interest where appropriate and then zoom it up (Fig. 1.4). Teaching a case-based session is not the same paradigm as interpretation at the workstation, and it is important to focus on the key learning findings. Using techniques that have been shown to improve learning such as “compare and contrast” can be very effective in this situation [12]. For example, show two CT scans with two different but similar diagnoses and ask learners to describe the differences and explain how they lead them to the correct diagnosis. Images of all types can also effectively used as brief “brain breaks” between topics, particularly if they relate to the upcoming topic. They prime the brain to be ready to acquire the new information and tell it that the discussion of the prior topic has ended. For example, in a lecture about brain tumors, pathological photographs of the tumor themselves could be used as the transition images.

KISS: Keep It Simple Stupid The more difficult a slide is to read, the more difficult it is to learn. Small and fancy fonts, low contrast color schemes, small and poor-quality images, and large tables all challenge the learner and add nothing to the presentation. The vast majority of templated designs that are provided in presentation software are unnecessarily busy and distracting. Most also have too small font sizes for projection in a large room. Remember that while you are making these slides from 30 cm away, your audience may be (and usually is) reading them from the back of the room. Keep font sizes to 28 or more for adequate visibility. The audience should never remember your color scheme or slide template when they leave the room, only your content. Some color combinations project particularly poorly e.g.: yellow and green, or red and blue.

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Red-­green color blindness can make these color combinations “invisible” to these learners. I recommend for radiology that a plain dark gray, dark brown or black background with a light-colored font displays best and is the least distracting. Keep fonts simple. Sans Serif fonts (e.g., Arial, Helvetica) are more readable on computer displays than Serif fonts (e.g., Times Roman). There is rarely any advantage to using more fancy fonts. Never use all caps - the audience receives this as shouting (similar to receiving emails in this format) which becomes mildly stressful after a few minutes. Remove all unnecessary icons and institutional names from all but the first slide—the learners already know where you are from. Abbreviations and acronyms should be minimized unless very common. Do not assume that all members of the audience know what they mean, and it is frustrating and sometimes humiliating to learners if they must ask for an interpretation. Slides with multiple abbreviations or acronyms are very challenging to read as they have to be “decoded” before they can be understood and memorized.

Split Attention Like teenagers doing their homework while watching Netflix, by splitting the attention of our audience, we increase cognitive load and decrease the learning. There are several ways this can happen. We may have multiple teaching points, images, or graphs on a single slide so that they are focusing on a different component than we are talking about as discussed above. Learners may be trying to remember the findings from a prior slide while interpreting images - image annotations can be integrated into the images negating this split attention (see Fig. 1.5). An excellent way to engage the audience attention is to actively annotate the images during the talk by drawing on a linked tablet or graphical pad using a variety of readily available software or hard-connecting the device to the projection system. An example can be seen at https://www.youtube.com/watch?v=sDmCK9lMLSE. In this way you are visually “describing” the findings in a way that focuses learners totally and is easily erased and repeated. Taking notes, especially in a high cognitive load lecture has been shown to be as cognitively challenging as playing chess [13]. When taking notes, a learner is trying to listen to the lecturer, identify the important points, read the slide and yet get notes written, often while the next slide is being presented. There are a couple of ways to help reduce split attention. You can provide lecture notes (e.g., your slides with additional information in the notes section) or you can signal the key information.

Signaling During Lectures Signaling is a verbal or visual way of highlighting key information. Visually this can be achieved by bolding, highlighting, or colorizing the key words, e.g., the most important cell in a table. Verbally it can be achieved by using phrases such as: “this

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Fig. 1.5  This image shows how incorporating annotations into the image rather than being on a different slide can reduce cognitive load, especially when used for lecture notes

is the most important thing to remember,” “forget this and your patient may die,” “if you only remember one thing,” “the key imaging differences are,” or of course, “this will likely be on the exam.” Even just pausing and raising the volume of your voice for those key portions can be effective. Signaled lectures have been shown to reduce cognitive load and improve learning [14].

Experts Versus Novices Experts and novices learn differently. This can be very challenging as our audiences frequently include mixed learner groups, such as first to fourth year residents, fellows, and faculty. Novices need a clear framework of information built in their brains before they can add the details. Experts assimilate information in a much more complex manner, as they have pre-existing patterns or schema in their long-­ term memories to which they can retrieve and add information [15, 16]. It is very easy to induce cognitive overload in novices to a degree that they learn little from the lecture. We need to be aware of the expertise level(s) of our audience and adjust how we present the information. Junior learners may need to be given some form of pre-learning to provide that framework to avoid cognitive overload during a lecture that is more geared to senior residents. Using flipped classroom techniques (see Chap. 11) is an effective way to “level the playing field” for learners of different stages. This pre-learning can be in the form of a basic short, recorded lecture, a paper, chapter, or digital module. Give learners at least a week’s notice to review this material—and a reminder!

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Summaries Providing a good summary is important to consolidate and repeat key information. A summary should not be a repeat of the learning objectives. Use the summary as an opportunity to ensure that all attendees have this minimal information.

Rehearse, Rehearse, Rehearse The more fluent that you are, and the more conversant with the information that you are conveying, the easier that your audience will understand and learn. Even the most experienced lecturers need to practice talks. I highly recommend that you practice talks out loud, as mental rehearsal is not as effective. Practice to the dog, the kids, your partner or no one at all. Depending on the length of the talk and the anticipated audience (e.g., local versus national), I will fully rehearse a new talk at least four times, even more for abstracts. Usually this identifies flow or content issues that are easily corrected at this point.

Step by Step on Making Your Slides Brain Friendly [17] 1. Start with your learning objectives (using active verbs from Bloom’s Taxonomy) so the audience can focus on what they need to learn from this session. 2. Don’t worry about the number of slides, the talk length is dependent on the words you will say, not the number of slides. Slides cost nothing, and it is much better that you have less information (hence less time spent) on each slide. 3. Make your slide format as boring in format as possible. Remove all icons from all but the title slide. Use a standard Sans Serif font. Remove all unnecessary images unless you are using them as “mental breaks” between topics. NO slide transitions. Remove unnecessary animations—having one line appearing at a time is annoying to the audience and requires you to click slide advance so repetitively that it defocuses your attention. Simplify the bulleting, bullets are not needed on every indent level. 4. Pick a high contrast, dark background color scheme. This will show abnormalities in radiology images better. 5. Put each image, diagram, or graph on its own slide where possible. Images can be paired if you need the pre- and post-contrast or two different MR sequences but if you are thinking of more than two images, consider if that is really necessary. Enlarge them to use all the screen real estate. Crop down to the area of interest when possible. 6. Reduce the amount of text overall, and markedly reduce the number of words per slide. In my experience most lecturers need to cut out at least 50% of text if

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not more. Remember, you do not need to have every word that you want to say on each slide—only the key information. Put any additional text in your speaker notes and use “presentation mode.” To edit an old talk, copy and paste the current text into the speaker note area. Use 28–40 font, which will limit how many words you can put on each slide. Never capitalize all text. 7. Summarize tables. Pull out the key information, put into a PowerPoint table and highlight (color, font) the data you will focus on. Try to keep tables to 4 × 4 (plus headers) or less. 8. Only one learning point per slide. Have the audience focus on that before you move on. This helps with chunking for memory retrieval. 9. Remove acronyms and abbreviations unless they are very familiar with the audience, or you have explained them. 10. Signal key content either verbally or with highlighting on the slide with color, underlining or bold. This reduces the cognitive load for note takers. 11. Replace some text slides with images—radiographic, clinical, pathological or other. This utilizes the modality effect as you talk about the slide. 12. Provide a summary at the end to reinforce the major learning points.

References 1. Sweller J. The evolution in cognitive load theory. In: Clark R, Nguyen F, Sweller J, editors. Efficiency in learning. San Francisco, CA: Pfeiffer (Wiley); 2006. p. 313–29. 2. Baddeley A. Working memory. Science. 1992;255:556–9. 3. Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev. 1956;63:81–97. 4. Writing objectives using Bloom’s taxonomy. http://teaching.uncc.edu/learning-­resources/ articles-­books/best-­practice/goals-­objectives/writing-­objectives. Accessed 13 Dec 2021. 5. Mayer RE, Bove W, Bryman A, Mars R, Tapangco L. When less is more. When less is more: meaningful learning from visual and verbal summaries of science textbook lessons. J Educ Psychol. 1996;88(1):64–73. https://doi.org/10.1037/0022-­0663.88.1.64. 6. Mayer R. Segmenting principle. In: Mayer R, editor. Multimedia learning. 2nd ed. Cambridge, MA: Cambridge University Press; 2008. p. P175–88. 7. Bartsch LM, Singmann H, Oberauer K. The effects of refreshing and elaboration on working memory performance, and their contributions to long-term memory formation. Mem Cogn. 2018;46(5):796–808. 8. Use visuals and audio narration to exploit working memory resources. In: Clark R, Nguyen F, Sweller J, editors. Efficiency in Learning. San Francisco, CA: Pfeiffer (Wiley); 2006. p. 47–75. 9. Sweller J in the Sydney Morning Herald. [2007 Apr 4]. http://www.smh.com.au/news/technology/powerpoint-­presentations-­a-­disaster/2007/04/03/1175366240499.html. Accessed 13 Dec 2021. 10. Coherence principle. In: Mayer R, editor. Multimedia Learning, 2nd ed. Cambridge, MA. Cambridge University Press; 2008. p. 89–107. 11. Dewan P. Words versus pictures: leveraging the research on visual communication. Partnership. 2015;10:1. https://doi.org/10.21083/partnership.v10i1.3137. 12. Chin DB, Chi M, Schwartz DL. A comparison of two methods of active learning in physics: inventing a general solution versus compare and contrast. Instr Sci. 2016;44:177–95.

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13. Piolat A, Olive T, Kellogg RT.  Cognitive effort during note taking. Appl Cogn Psychol. 2005;19:291–312. 14. Signaling principle. In: Mayer R, editor. Multimedia Learning, 2nd ed. Cambridge, MA: Cambridge University Press; 2008. p. 108–117. 15. Accommodate differences in learner expertise. In: Clark R, Nguyen F, Sweller J, editors. Efficiency in Learning. San Francisco, CA: Pfeiffer (Wiley); 2006. p. 247–73. 16. Chase WG, Simon HA. Perception in chess. Cogn Psychol. 1973;4(1):55–81. 17. Death by Powerpoint. http://www.slideshare.net/thecroaker/death-­by-­powerpoint. Accessed 13 Dec 2021.

Chapter 2

Teaching and Communicating with Millennial Learners Ami A. Gokli

The children now love luxury; they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers. —attributed to Socrates by Plato

Background Younger cohorts are often stereotyped as being lazy, entitled, or self-absorbed and have been for thousands of years. Although the concept of generational differences has been contested, “generations” are groups of people impacted by world and cultural events which shape their lives and can influence their preferences, priorities, and responses. Although discussion of generations in general terms feeds into stereotypes which may not represent all people, it can be beneficial to look at a generation as a whole and identify commonalities to better serve them in a teaching format. We will briefly review some of the currently working generations here. Generation X, also known as latch key kids, grew up in an “empty home” environment as it became standard for mothers to be working. Gen X often found themselves taking care of themselves and their siblings and were not coddled. They can be a bit jaded and cynical, as many things did not turn out the way they may have planned: The AIDS epidemic hit when they were in their younger years potentially

A. A. Gokli (*) Division of Pediatric Radiology, Staten Island University Hospital, Staten Island, NY, USA Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_2

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trying to start families; and when they were striving to hit career goals, the economic turndown of 2001 and the 2008 recession affected them. This spurred a self-­ reliant, independent generation, adaptable to various environments. This can also make them less prone to coddling their students. In 2019, Generation Y (colloquially called millennials) surpassed prior generations as America’s largest generation ever [1]. They grew up with climate change, 9/11 attacks, the Columbine shootings, and the 2008 financial crisis. This generation comes with fast-paced change due to the explosion of technology during their younger years. This tech heavy environment has molded them, which is evident in their relationships, at the workplace and in their learning environments. Their digital fluency has made them more impatient and demanding than prior generations as they are used to immediate answers at the click of a button. They also require higher levels of stimulation to maintain attention and they have a low tolerance for boredom. They were raised by “helicopter parents” who were always present and attending to their every need, which can translate to a need for excessive affirmation in their workplace or learning environment. Generation Z has grown up as digital natives. While millennials can remember a time without computers, Gen Z has been surrounded by screens their entire lives. Information is shared or streamed in real time, and civil uprisings are organized on social media. This has resulted in very short attention spans, extreme multitasking, and early adoption of AI. This generation may have more in common with Gen X than with millennials as they tend to be practical and driven. Having been influenced by “fake news” in politics and the #metoo movement, they value full transparency and mental health, and expect these in their work environments. A poll by the Pew Research Center asked the four working generations what makes their generation unique. Traditionalists, Boomers and Generation X all responded that they were unique because of their work ethic. Millennials and Gen Xers both listed technology use. All four generations thought they were unique because they are “smarter” than the other generations. The second and third most common responses from millennials included music/pop culture and the belief that they are more tolerant/liberal; these responses were not listed by other generations [2]. Characteristics Years Childhood

Baby boomers 1946–1964 Post WWII, hippie movement

Positives

Work hard, motivated to succeed

Generation X 1965–1980 Latch-key kids (working moms), energy crisis, Watergate scandal Self-reliant, independent, adaptable

Millennials 1981–1996 Helicopter parents, terrorist attacks, school shootings

Generation Z 1996–2012 Digital natives, #metoo movement, fake news

Realistic, innovative, value education, likes challenges

Multi-taskers, ethical, don’t define themselves in only one way, value transparency, mental health

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2  Teaching and Communicating with Millennial Learners Characteristics Negatives

Baby boomers Materialistic, competitive, workaholics

Communication Face-to-face, style telephone

Generation X Slackers, aggressive, pessimistic, disloyal, cynical

Email, text

Millennials Over-confident, require excessive affirmation, impatient, demanding Text, social media

Generation Z Very short attention span (8 s)

Hand held communication, in-person meetings

The Millennial Learner To understand how to teach millennials, we must delve into what influenced them and how they differ from earlier generations. Millennials were raised with the so-­ called helicopter parents who were omnipresent during their childhoods setting up playdates, resolving issues, and offering constant advice [3]. This is a marked difference from Generation X who were raised in empty homes and had to fend for themselves. As a result, millennials require frequent affirmation, feedback, specific instructions, and may struggle with conflict resolution. They have grown up in a world filled with instant feedback—whether that is through electronic testing that displays their score at the end of an exam, playing video games, or tracking an uber order. Feedback need not be the typical lengthy yearly review that older generations expected, however. Their short attention spans and reliance on technology make even a quick text or email with feedback acceptable. Because Generation Xers and Baby Boomers may not have experienced receiving/giving feedback, they can be less comfortable giving it effectively. Parents have taught this generation the importance of believing in themselves, that anything is possible, and that self-confidence is essential for success. This shower of constant praise seems to have resulted in overconfidence [4] at times. They are also the first generation to grow up in a less hierarchical family environment—one with parents encouraging open dialogue and allowing disagreement [5]. They are therefore much less comfortable with a hierarchical structure in their learning environment and will not be shy about questioning their teachers or challenging testing methods. They may freely share their opinions in the lecture room or reading room even as junior members, which can be grating on older generations who respect the traditional top-down hierarchy [6]. Millennials’ heavy parental involvement was also paired with the youth safety movement, characterized by “Baby on board!” signs, child safety locks and “safe spaces” in college campuses [7]. Millennial children were told they could never be too safe, leading to a sheltered environment and the expectation that rules and regulations must be in place and enforced. As a result, they can become paralyzed or unable to move forward without direction. Additionally, they can become quickly frustrated if they do not meet their expectations, and they lack the patience that’s

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characteristic to older generations. Creating a strong, supportive teaching environment with coaching and mentorship can help keep them motivated [8]. A side benefit of coaching/mentoring is its ability to facilitate open communication between trainees and faculty, which can create a more productive and engaged training program. Perhaps also related to their overly sheltered upbringing, millennials are known to have notoriously poor long-term planning skills, critical thinking and problem solving skills, known as a short event horizon [9]. Educators may need to help cultivate these “soft” skills to improve their ability to analyze images and think critically about their patients. Millennials were raised in the consumer age, and have had access to a virtually unlimited number of choices as well as the ability to pick and choose what perfectly suits their needs [9]. At times there may be so many similar products to choose from that they will happily make comparisons and drop a brand that doesn’t “feel right” to them. In the educational setting, as in other areas of life, this “consumer is right” mentality pervades. They expect their education to be the same: a variety of resources conveniently laid out, of which they can pick and choose what they feel is best for them and when to use it. When compared to prior generations, millennials value meaningful work and personal development over monetary compensation. They are motivated and eager to learn, but want to know they are making a difference, their voice is heard, and they have purpose. In the learning environment, one way to respond to this could be to stress meaningful contributions our learners have made [6], for example, emphasizing how your radiology teachings affect patients across the continuum of care, or giving recognition when an overnight resident makes a great call and positively changes patient management. Another common trait of this generation is working in collaboration. They have a team-oriented nature likely developed from television role models like Mr. Rogers, high participation in team sports, school uniforms, and classroom emphasis on group work [10]. Opportunities for collaborative learning such as participating in interdisciplinary conferences will likely be appealing due to their integrative nature and immediate clinical applicability. In addition, collaborative learning experiences such as a residency class blog, wiki or Facebook group could be appealing. Faculty should be aware that although group work may provide them with a sense of unity and security, it can also give them a way to hide and avoid risks. A survey by Deloitte found that millennials value on-the job-learning and continuous employer-led training as vital instruments that help them perform better [11]. Because of this, the learning landscape has shifted from theoretical learning to experiential learning. This makes sense when thinking of the way younger generations interact with their environment. When they received their first cell phone, rather than reading an instruction manual like older generations, millennials tinkered and learned by using the device. Probably the most striking difference between millennials and other generations involves their communication style. Face-to-face interactions, phone conversations, and 8–5 business hours are increasingly being replaced by intranet software, social media, chat, email, and instant messaging. Millennials operate on a different

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schedule than the traditional work timetable. As products of the digital revolution, they tend to prefer 24/7 availability and have been known to be reachable “after business hours” via email, text, or social media to a much greater extent than prior generations. This constant availability and flexibility suits the millennial preferences of wanting to set their own schedule. Smartphones have made 24/7 availability much more mainstream, and millennials even take pride in their quick, after hours responsiveness—my cousin who works in investment banking brags about how she sets an alarm for herself at 2, 3, and 4 am just to check work email and send off a quick response if anything is in her inbox.

Millennial characteristics Helicopter parents

Resultant behavior Feel they are “special” Strong desire to achieve Short event horizon Participation awards

Lack of parental hierarchy Allowed to question parents and call them “wrong” Overconfidence Prefer informal and stimulating environments Authority must be earned, hierarchy is not assumed based on seniority

Youth safety movement (baby on board stickers, child safety locks, etc.)

Sheltered

Emphasis on team-work growing up

Sharing, collaborative nature Value meaningful work and personal development Abundance of choice, options Entrepreneurial spirit Comfortable with technology Instant gratification Multitaskers Work/life integration, 24/7 availability

Consumerism

Tech heavy childhood

How it relates to learning Need for constant feedback Need for positive reinforcement Decreased opportunities for independent and creative thought/ decision making poor long term planning skills and problem solving skills Can be overly confident and quickly frustrated when under achieving Challenge grading/testing methods Prefer casual, friendly relationships with teachers They respond to competent leaders who show mutual respect Do not demand respect without earning it Encourage a culture of transparency and respect (encourage them to respect each other’s skills/abilities, and those of their other faculty) Expect rules/regulations along with their enforcement Can become paralyzed or unable to move forward without direction Prefer collaborative learning

The expectation that this abundance of choice should extend to the learning environment Prefer interactive, experiential learning Expect technology integration in teaching/learning Need for instant answers to questions More well-rounded but with less in-depth knowledge Short attention span

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The Millennial Learning Environment Although previous generations were forced to adapt to a structured educational system, the boom of technology and specific traits of the millennial generation has flipped this construct, and educators are scrambling to adapt their learning environments to better suit these learners. The demanding reputation of millennials might be considered the impetus for this change; however, the seamless integration of technology has been the true push for our educational system. With the advent of online learning, information is more easily accessible than ever, and there has been a flood of online educational resources of varying quality. In addition, millennials have a strong preference towards observational learning and experiential practice [12] which drives them more towards depending on the internet for retrieving instant answers rather than combing through a book. Learning environments can be formal or informal, physical or virtual. Research has shown that millennials have shifted more towards informal learning settings— impromptu learning or “just-in-time” learning that takes place as the need arises in the moment [13]. This is likely related to the fast-paced, technology-driven environment they grew up in and faster work environments that require high imaging turnover and demand quicker information gathering. Millenials are used to shopping online rather than in a store or listening to an informational podcast while walking to multitask. Just-in-time learning in radiology occurs often at the workstation, for example, when a resident uses e-anatomy to help her read a knee MRI for the first time. Residents can pull up a quick, 5-minute YouTube lecture describing findings of a meniscal tear and immediately apply this learning to her report. Just-in-time learning enhances the relevance and relatability of information, which holds their attention and provides adequate motivation for learning. To cater to this type of learning, the teacher must be ready to supply the exact resources that may be needed at the exact time they are needed. It is essential to equip yourself with a number of online resources to answer various questions, or to ensure your trainees have access to sites they may frequently turn to (this means buying subscriptions to online sites like Statdx, e-anatomy or Radprimer). It also means teachers will need to stay abreast of new and relevant resources that arise and vet them in advance. It may be beneficial to replace some formal learning with informal or interactive learning. For example, consider replacing a formal lecture with experiential learning: have a trainee follow a technologist for 30 min to see how patients are positioned for radiographs, how much time it takes and what is involved to perform a portable radiograph, or how an MR technologist manipulates an image to improve signal to noise. Millennials will find it much more impactful to go up to the NICU and attempt to perform a hip ultrasound with a Pavlik harness in place, rather than hearing you explain how it is done. The primary learning environments in which a radiology trainee might find herself include the traditional lecture, learning at the point-of-care (at the workstation teaching, day-to-day teaching), and asynchronous learning. Much of radiology education has traditionally taken place at the point-of-care in the reading room

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following an apprenticeship model. This model suits millennial learning preferences well given its experiential nature, immediate feedback style and just-in-time format. The COVID pandemic has accelerated online learning into a more central role, with teachers shifting more towards facilitating learning rather than being a primary source of education. Consequently, a new category that could be introduced is remote learning, which can be synchronous or asynchronous. Currently, residents at some radiology programs have moved to completely remote learning—working from home on workstations and reviewing cases via Microsoft Teams® or over the phone.

Teaching the Millennial Learner The three main teaching settings include workstation teaching, lecturing, and asynchronous learning outside the classroom. We will discuss tips and tricks to enhance learning in each setting. Some advice can be applied to all three settings, which we will review below.

Overarching Advice Facilitate a positive learning environment. Medical culture has often been thought of as a competitive place, with “gunner” medical students trying to sabotage each other for a good grade. Gen Y students don’t agree with that cutthroat mentality; they prefer to work with their colleagues rather than against them, with 88% of them advocating that they prefer a collaborative workplace over a competitive one [14]. Encouraging trainee collaboration can help facilitate the positive environment they are looking for. Consider pairing up junior and senior trainees as mentors, asking trainees at different levels to pair up and work on a case together prior to a lecture, or have senior trainees formally teach junior trainees for a set amount of time during the workday. A formal mentoring network can also help facilitate more frequent feedback. Create understanding and build rapport. Another aspect of a positive workplace for millennials includes transparency. Prior generations are accustomed to automatically respecting authority; however, millennials have no problem asking for proof that their leaders deserve that respect. This “show me” attitude has resulted in millennials suffering from the misconception that they disrespect authority, but on the contrary they can be fiercely loyal and respect leaders who are transparent and capable [15]. Part of earning their respect will involve creating an open, honest, and safe learning environment that is not punitive or publicly humiliating. Encourage trainees to respect each other’s skills and capabilities, get to know your trainees on a more personal level and call on them by name. Keep constructive criticism conversations private between you and your students and avoid sarcasm. Finally, millennials are social creatures, although mostly in the virtual environment. Rather than

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going outside to play, they grew up in the gaming or online environment, meeting friends online and chatting on internet platforms. Whether it is making friends, finding a job or setting up a meeting, they cannot go one day without interacting with others virtually. Consider facilitating social interaction inside and out of the classroom to add to the positive environment they want to work in. Create a structured learning environment. Despite the trend towards more individual, just-in-time learning, millennials are still most comfortable in a structured, supervised environment similar to how they grew up. Although trainees are capable of learning radiology via the internet, it will be important for teachers to provide direction, guide resource choices, and most importantly be available for questions. Creating structure around your rotation will also be appreciated: provide written expectations on the first day of rotation that students can refer back to at any time and a structured educational day so they know what to expect (ex: individual reading of studies with a formal read-out at 10 am followed by rounds with the team and then procedures). Provide them with a list of educational resources you prefer they use; giving them vetted resources can help save time swimming through unvetted sources while also reading studies. Give them daily, immediate feedback on cases, but also provide summative feedback mid-way and at the end of the rotation. For lectures and daily teaching sessions, have a set yearly lesson plan, give lecture topics ahead of time (consider offering pre-reading), and march through the yearly lesson plan in order. Establish learning outcomes for the end of the rotation and possibly the end of the year; Radexam (American College of Radiology, Virginia) is an easy way to assess knowledge for the student’s year, but putting a fun spin on assessment can help with engagement; consider having them make a video of an interesting case, or create multiple choice questions based on missed cases, or have them teach the top five things they learned to the incoming resident for your rotation. Tailor teaching methods to optimize adult learning. We sometimes forget that our medical students and radiology trainees are adults and as such, require slightly different teaching methods to optimize their learning. Neuroplasticity is a term used to describe the ability of the brain to form and reorganize synaptic connections, for example, in response to learning. When we learn something new, we make new connections between neurons and adapt to different circumstances. This happens daily, but we as learners and teachers can encourage and cultivate this process actively. To promote adult neuroplasticity, enriched environments (saturated with novelty, challenge, and focused attention) are critical [16]. Focusing on learning rich subjects (ex: a new language) rather than rote memorization is also helpful. Try to steer trainees clear of simply memorizing facts and help them make connections to the clinical picture and pathology to create a story in their brains about the process of disease. Helping trainees tap into pre-existing pathways will help solidify knowledge. Research has shown that learning a musical instrument and creating artwork can enhance connectivity in the brain [17, 18]; encourage students to tap into their creative sides by enlisting their help creating digital artwork for research papers or lectures, or consider involving them in activities such as the American College of

2  Teaching and Communicating with Millennial Learners

Memory Retention (%)

100

23

Immediate recall

80 20 minutes

60

1 hour 40

9 hours

20

2

4

6 8 10

15

20

25

31

Elapsed time (days)

Fig. 2.1  The forgetting curve. The “forgetting curve” was developed by Hermann Ebbinghaus in 1885. Ebbinghaus memorized a series of nonsense syllables and then tested his memory of them at various periods ranging From 20 min to 31 days. This simple but landmark research project was the first to demonstrate that there is an exponential loss of memory unless information is reinforced. Stahl SM, Davis RL, Kim D, et al. CNS Spectr. Vol 15, No 8. 2010

Radiology (ACR) Art task force, which integrates the arts into the annual ACR meeting. Finally, Hermann Ebbinghaus was the first to describe the “forgetting curve” which is based on the observation that the sharpest decline in knowledge retention occurs within the first 20 min after learning, and we tend to forget 50–80% of all new information after a few days (Fig.  2.1). We recall more when using a “spaced repetition” method: utilizing/remembering/repeating the information over increasing intervals of time; in fact it has been shown to improve long term retention by 200% [19]. For those teachers who develop radiology online learning modules or apps, this spaced repetition model can be exploited by automating repetition for those concepts/questions the student missed. Overarching Advice: Summary Box • Create a positive learning environment –– Build rapport by calling on students by name, keeping constructive feedback private, avoiding sarcasm –– Encourage trainee collaboration: Junior-senior trainee mentors, formal teaching opportunities –– Facilitate a transparent environment that is open, honest and safe –– Promote social interaction inside and outside of the classroom

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• Create a structured learning environment –– Rotation written expectations given on first day include when feedback will occur –– Provide a (short!) list of educational resources for your section –– Formative feedback daily, summative feedback in set increments –– Have a set yearly lecture plan and provide topics in advance • Optimize adult learning –– Create an enriched, challenging learning environment –– Teach information richly—with clinical context and connections to prior learning –– Tap into trainees’ creative sides, incorporate art and music into learning –– Use spaced repetition The Lecture Skipping lectures is the new normal. When I was a medical student, I spent my mornings on the treadmill, listening to the recorded lectures from the day prior at 2× speed while I worked out, pausing to look something up if it was unclear. I found it less distracting than being in a classroom with noises, interruptions, and socializing. In 2017 nearly 1/4 of second year medical students reported they “almost never” attended class [20]. Students find it more efficient to get through the material at their own pace with faster speed or re-listening to a section they didn’t understand. Moreover, millennials are 75% more likely to watch a video than to read documents, emails or other written sources [8, 21]. Consider recording basic lectures, especially those which you need to frequently repeat. This will save you a significant amount of time avoiding repetition, and also allow you to build on the basics during live lectures. Examples of content for recorded lectures include anatomy reviews, pediatric on call cases, or how to perform an emergent fluoroscopy exam. This 7-minute Khan Academy cervical spine alignment video is a good example [22]. These resources can then be re-visited by the student when needed, for example on overnights as a third year when they need to remember how to perform a retrograde urethrogram. Providing structure for your lecture will be appreciated by millennials. If you are not using a flipped classroom format, at least send out the agenda or topic of the lecture ahead of time. Our institution receives constant positive feedback about lecturers who do this, as it allows the students to mentally contextualize what they will be learning, and pre-read on their own so they can build on that knowledge in lecture. One of the biggest challenges we may run into as educators is keeping our students’ attention. In fact there are many books and resources dedicated to the topic of how to engage today’s learners. Millennials have a bad reputation of having a short attention span—on the order of 12 s [23]. This may be true if they are disengaged, however, millennials are excited to learn and if any readers have witnessed a millennial binge-watch a netflix show or play a video game for hours, we know they can apply themselves if they are interested. The key to engaging content is a compelling

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narrative combined with stimulating visuals and active dialogue [24]. Cater to attention span—convey your point within 5 s of starting the lecture. Often, using a case, story or other “hook” will pique their interest. Avoid didactic lectures longer than 10-min blocks; instead fill the remainder of your lecture time with case based questions or other interactive format. Do not try to cover everything! Boil the lecture down to the most important things they should take home and delve into those in depth while repeating information multiple times in different formats. Remember, technology savvy younger generations prefer to process information visually (communication has moved from emails to short texts to emojis) so images should be the primary method of disseminating information. Be interactive and shift trainees from passive to active learning. In a resident survey, one resident stated “lecturing is frequently a one-way process, unaccompanied by discussion, questioning or immediate practice, which makes it a poor teaching method” [25]. Avoid “spoon-feeding” [26] information to trainees without allowing them to think critically. Creating a classroom environment focusing on active learning improves trainee engagement and prevents spending the majority of class time reviewing the basics. Assigning self-guided study prior to lecture (a pre-­ recorded video, manuscript, or book chapter) in a “flipped classroom” style, where the trainee then must apply that learning to lecture will allow trainees to take control of their learning and accelerate a greater depth of understanding. Interactivity can also be encouraged by providing opportunities for trainees to be creative. Allow them to suggest methods of evaluation they find compelling—our residents expressed interest in creating a meme about something they learned in lecture to bring in for the next lecture. Breaking down case-taking into specific tasks rather than full image interpretation can build in teamwork and promote active learning. One example our trainees loved was when all residents were blindfolded except first years. The first years described the case and third years provided a differential based on the description. Another example is forming teams of juniors paired with seniors and having each team tackle a different case. Other interactive ideas include pausing for (sub)group discussion, intermittent questioning, pausing to show an example video or telling a story. Use new, engaging formats for teaching, even within the same lecture, to keep interest levels high—transition from didactics to video clips, concept charts, maps clickers or other visual aids. Consider a topic of controversy and create teams where students can debate the pros and cons of each approach (ex. upper GI technique in peds). Rich, complex topics tied in with clinical stories helps students gain a more in-depth understanding and promotes neuroplasticity. Peer-topeer teaching can be a very successful learning method when accompanied with faculty guidance and oversight. It promotes creativity, a full understanding of the material, and educational leadership. Moreover, peer-to-peer teaching is often highly rated by students and some studies show greater learning retention using this method [27], potentially related to the low-threat environment. Finally, as we have discussed, millennials can quickly lose interest without instant gratification, and they crave immediate applicability to their learning. Rather than sitting through ten cases without answers, millennials prefer answers that are provided immediately after going through a case, and before moving on to the next case/topic.

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It is a common sight to look up during a lecture and see most trainees focused on an open computer or looking down at a phone rather than the slides you prepared. This can be frustrating and demotivating for Gen Xers and Boomers, as it gives the perception that no one is listening. It is important to understand the millennial compulsion for multitasking in this scenario. Having been constantly surrounded by technology and consumerism, they have become expert multitaskers. You might come across a millennial radiology resident with earbuds in, scrolling through an MRI with multiple internet tabs open and looking at their phone intermittently. Although we, as lecturers, may become annoyed when seeing a resident playing a game on their cell phone rather than paying attention to the lecture, it is important to understand that this is not always an indication that they are not paying attention. To a certain extent, lecturers should not feel competitive with millennial multitasking—you may realize that when you ask that trainee a question about a case, she will still be able to answer you even if she is also playing Candy Crush®. Slide content. Although PowerPoint is not a millennial favorite, it is a convenient and quick way to convey information. That being said, presentations with heavy text or no visual aids causes disengagement, makes remembering information from the speaker challenging, and makes retaining what’s on the screen difficult. To help reduce PowerPoint fatigue and frustration, consider the 7 × 7 rule. A lecturer should have no more than seven lines of text on each slide, and each line of text should have no more than seven words maximum. As the lecturer becomes more adept delivering lectures and material, she can move towards the ideal lecture PowerPoint that might have only one picture and no words at all. This helps facilitate trainees listening to your words rather than trying to read your slides while you speak. Including images in your PowerPoint increases impact and will help your visual learners form connections by analyzing the image while listening to what you have to say about it.

The Lecture: Summary Box • Record basic lectures rather than giving them live yearly • Send out lecture topics ahead of time • Flipped classroom format • Compelling narrative combined with stimulating visuals and active dialogue • Shift towards an active learning format • Discuss debatable or controversial topics • Have trainees suggest creative methods of evaluation • Break down case-taking into smaller parts • Facilitate collaboration: groups taking cases, jeopardy, junior/senior teams • Peer-to-peer teaching • Do not feel competitive with multitasking • Slides with visual stimuli, less text is better

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Workstation Teaching Radiology is perfectly positioned for adult learning and millennial learning in many ways. Our apprenticeship model with at-the-workstation teaching is exactly suited to the just-in-time, real-life example learning with the immediate feedback that they are looking for. Unfortunately, given current workloads, trainees may forgo workstation education in an effort to interpret studies as fast as possible. Because faculty are also overwhelmed with workload, they can find themselves too busy for “non-­ RVU” activities such as teaching during the workday [28, 29]. The apprentice model thus breaks down with trainees no longer learning from the expert at the point of care, forced to trade in this experience for after-hours self-study. We must make efforts to prevent this workstation teaching from deteriorating and preserve the valuable daytime learning environment for our trainees. Immediate feedback during case read-outs is a key way to convey concepts and establish learning context to real life experiences. Millennials are unusually open to constructive criticism and feedback, as they know it will improve their individual performance. Formative, daily feedback can manifest as verbal feedback at the workstation, reviewing overnight cases for your specialty at the end of the week of nights, working out a case in front of the trainee either at workstation or in lecture, comments/markups of research drafts or assignments, student reflection/self-­ assessment or immediate feedback after a procedure. They will expect the feedback they receive to be honest and constructive; give them concrete things to work on with their search pattern, or a better technique to tackle a multiple-choice question. Tailoring your approach to fit the millennial style—clear, direct, and collaborative, will also earn you respect. Because of their short attention span, millennials (and gen Z) tend to be most productive in short bursts, and offering content in bite-sized amounts can be an effective training method. This technique is called microlearning and benefits include better focus on the goal, increased motivation and improved topic understanding. Many companies have already employed this method with resources such as Highbrow® or GoSkills® to provide information in small chunks. In the medical community, this concept can been seen on social media such as instagram (Meta, Menlo Park, CA) and Twitter (San Francisco, CA) learning, with accounts such as @pedsimaging or @cincykidsrad posting daily teaching cases online, or medical students posting vlogs of their digital artistic representation of couinaud segments of the liver—students need only follow hashtags to get the learning they want delivered to them. Remember that microlearning is not ideal for complex concepts or in-depth training; do use it for anatomy reviews or short specific topics such as the appearance of a meniscus tear on MRI. During morning read-outs, I will often go off on a microlearning “tangent” when coming across a good topic. For example, a NICU chest radiograph will prompt a 10-min teaching session on the differential diagnosis for NICU chest films and common radiologic findings.

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Workstation Teaching: Summary Box • Preserve at-the-workstation teaching and learning • Frequent, immediate and honest feedback with clinical context • Work-out cases verbally in front of trainees • Utilize microlearning concept

Asynchronous Learning Asynchronous learning, or learning that occurs outside of the workplace, has always been an essential part of learning in radiology, as it is unrealistic for trainees to get through the volume of studies and the reading needed to make them radiology experts all in the constraints of an 8–5 workday. As we have mentioned before, millennials like to set their own schedule and operate on a 24/7 timeframe, blending work and leisure across the day, also known as work-life integration [30]. This can translate into trainees waiting to read or finish lectures from home, or expectations that teachers should answer questions after hours. Teachers should be transparent about when and for how long they can be available for their students, including after work hours. As we move towards more self-directed learning styles, the faculty role shifts from primary source of learning to facilitator of learning. Part of this process requires the vetting of resources for accuracy, authenticity, and relevance. Crafting a short list of reliable online resources such as RadiologyAssistant or MRI Questions will help direct everyday learning. For more immersive learning, interactive, online communities such as Discord® are becoming hugely popular, especially for board preparation. Communities such as these consist of hundreds of residents, fellows and faculty around the world who are constantly exchanging knowledge, sharing resources, asking/answering questions, studying together, and hosting high yield lectures. Note-taking apps have now become essential and giving trainees examples of what has worked best for their peers will help save time. Poll your residents for what has worked best for them, and consider looking into google docs®, Evernote® or other apps that allow note tagging (example note tags: !! = forgettable, come back again; ~F = formula). Cell phone apps are also very popular as multitasking millennials can use them during downtime such as their work commute or while waiting for a friend to arrive to dinner. Faculty will also need to encourage best study practices. For example, short attention spans and the need for instant gratification may prompt trainees to rush through multiple choice questions, only looking at the correct answer choice before moving on. Encourage trainees to read all answer choices—pick out why wrong answer choices were related to the question stem, how they are incorrect, and look up answers they don’t recognize. Engaging in more active learning will help synthesize information and speed up understanding of complex topics. Another successful study practice is spaced repetition. Each time adult learners encounter information again in a spaced format, the memory becomes stronger and more stable. A

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YouTube® video by Thomas Frank is a great, quick resource for students to learn about spaced repetition [31]. To encourage spaced repetition during asynchronous learning, encourage students to utilize online platforms or apps such as Anki flashcards® or Tinycards® which have this function built in. Over the years they can create a bank of flashcards that will be useful to them when studying for boards in third year. Gamification. This method has been successfully used in schools and companies with increasing popularity. The idea is to transform what could be a boring experience into an engaging game with rewards and levels of difficulty. Gamification also caters to the sometimes fragile ego of Gen Y and Z, as it reinforces the fact that failure is not an outcome but rather an indication that more work is needed to master the knowledge at hand [32]. The interactivity, hands-on method, and instant gratification of games such as Stanford’s “septris” could be easily applied to radiology cases [33] and can help hook the learner to continue learning outside of the classroom. Asynchronous Learning: Summary Box • Let trainees know what hours you are available for teaching/questions • Vet online educational resources and give them lists to use • Encourage interactive platforms like Discord® • Vet and suggest note taking apps, especially those with note tagging capabilities • Vet and suggest best radiology quiz-style apps, gamification • Encourage/model active learning with multiple choice questions • Promote spaced repetition

Summary Points • Provide ongoing and frequent feedback on performance • Create a collaborative learning environment • Bring learners from passive → active state • Shorten—keep didactic lectures 10 min or under • Incorporate experiential and real-life learning opportunities • Becoming a facilitator of learning; instead of acting as a sage on the stage, practice being a guide on the side • Include modern media in the classroom and work assignments • Include use of modern technology to increase learning • Outline and enforce course guidelines and expectations early on • Create a learning environment that encourages an open exchange of ideas • Create a social atmosphere though the use of peer to peer, team, and group assignments • Make your instruction student-and content-centered [34]

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Conclusion Optimal education for millennial trainees packages knowledge into bite-sized pieces and facilitates experiential and interactive learning in a collaborative environment. Because radiology is a technology driven field, we are particularly suited to use new technologies to enhance our learning experience. Although generational differences between educators and learners creates the potential for disconnect, we can learn to turn these differences into opportunities. Our role as educators is to maximize our students’ learning by adapting to their needs and recognizing our own personal biases. In doing so, we can help them develop their futures as physicians and inspire them to continue the process and become good teachers themselves.

References 1. Fry R.  Millennials overtake Baby Boomers as America’s largest generation. Pew Research Center; 2020. 2. Millennials confident, connected, open to change [Internet]. 2010. [cited 2022 Feb 8]. https:// www.pewresearch.org/wp-­content/uploads/sites/3/2010/10/millennials-­confident-­connected-­ open-­to-­change.pdf 3. Wroblewski MB, Ali I. Teaching millennials in the clinical environment faculty development series. Commitment to excellence in medical education: faculty development series. The University of Toledo College of Medicine and Life Sciences; 2012. 4. Schwartz AC, McDonald WM, Vahabzadeh AB, Cotes RO. Keeping up with changing times in education: fostering lifelong learning of millennial learners. Focus. 2018;16(1):74–9. 5. Shaw H. Sticking points: how to get 4 generations working together in the 12 places they come apart. Illustrated. Carol Stream, IL: Tyndale Momentum; 2013. 6. Krishnaraj A, Pesch AJ.  Navigating generational differences in radiology. Radiographics. 2018;38(6):1672–9. 7. Skenazy L. The fragile generation: bad policy and paranoid parenting are making kids too safe to succeed. Reason. 2017. 8. Rykun E. Training millennials in the workplace: 7 strategies that work [Internet]. [cited 2022 Mar 5]. https://www.goskills.com/Resources/Training-­millennials-­workplace 9. Taylor ML.  Generation NeXt comes to College: 2006 updates and emerging issues. A collection of papers on self-study and institutional improvement. Chicago: The Higher Learning Commission; 2006. 10. Howe N, Strauss W. Millennials rising: the next great generation. Highlighting. New York: Vintage; 2000. 11. Posard M, Kavanagh J, Edwards K, Efron S. Millennial perceptions of security: results from a National Survey of Americans. Santa Monica, CA: RAND Corporation; 2018. 12. Hannans L, Johnson J, Litton B, Torres I. How do millennials learn? An investigation of the learning styles, strategies, and perceived academic success among college-aged millennials. Papers Publ. 2018;7(7):10. 13. Schooley C. Informal learning garners acceptance as a legitimate learning approach. Forrester Research; 2011. 14. Asghar R.  What millennials want in the workplace (and why you should start giving it to them). Forbes; 2014. 15. Sledge CL. Influence, power, and authority: using millennials’ views to shape leadership practices. Defense Technical Information Center; 2016.

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16. Kempermann G. Environmental enrichment, new neurons and the neurobiology of individuality. Nat Rev Neurosci. 2019;20(4):235–45. 17. Wan CY, Schlaug G. Music making as a tool for promoting brain plasticity across the life span. Neuroscientist. 2010;16(5):566–77. 18. Bolwerk A, Mack-Andrick J, Lang FR, Dörfler A, Maihöfner C. How art changes your brain: differential effects of visual art production and cognitive art evaluation on functional brain connectivity. PLoS One. 2014;9(7):e101035. 19. Kelley P, Whatson T. Making long-term memories in minutes: a spaced learning pattern from memory research in education. Front Hum Neurosci. 2013;7:589. 20. AAMC. Medical school year two questionnaire: 2017 all schools summary report. Association of American Medical Colleges; 2018. 21. Schooley C. Update your learning strategy using digital tools: use technology to engage millennials as well as older workers. Forrester Research; 2016. 22. Assessing alignment of the lateral cervical spine (neck) X-ray | Health & Medicine | Khan Academy—YouTube [Internet]. [cited 2022 Mar 6]. https://www.youtube.com/ watch?v=PV5u5xskBKM 23. Hampton DC, Keys Y. Generation Z students: Will they change our nursing classrooms? J Nurs Educ Pract. 2016;7(4). Received: October 25, 2016 Accepted: November 17, 2016 Online Published: December 6, 2016. https://doi.org/10.5430/jnep.v7n4p111. 24. Global K. The 2018 state of attention report. Prezi; 2018. 25. Hart D. The millennial generation & “the lecture” on Vimeo. https://vimeo.com/24148123. 26. Rahim S, Ros P. Moving away from spoon-feeding as a teaching style in radiology. AJR Am J Roentgenol. 2016;207(6):1232–8. 27. Graziano SC.  Randomized surgical training for medical students: resident versus peer-led teaching. Am J Obstet Gynecol. 2011;204(6):542.e1–4. 28. Brady AP.  Measuring radiologist workload: how to do it, and why it matters. Eur Radiol. 2011;21(11):2315–7. 29. Clinical radiology workload: guidance on radiologists’ reporting figures | The Royal College of Radiologists [Internet]. [cited 2022 Mar 3]. https://www.rcr.ac.uk/publication/ clinical-­radiology-­workload-­guidance-­radiologists%E2%80%99-­reporting-­figures. 30. Boysen PG, Daste L, Northern T.  Multigenerational challenges and the future of graduate medical education. Ochsner J. 2016;16(1):101–7. 31. Frank T. The most powerful way to remember what you study. YouTube; 2016. 32. Hopkins L, Hampton BS, Abbott JF, Buery-Joyner SD, Craig LB, Dalrymple JL, et  al. To the point: medical education, technology, and the millennial learner. Am J Obstet Gynecol. 2018;218(2):188–92. 33. Evans KH, Daines W, Tsui J, Strehlow M, Maggio P, Shieh L.  Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management. Acad Med. 2015;90(2):180–4. 34. Turner P.  Teaching and engaging a new generation of learners [Internet]. Georgia State University J. Mack Robinson College of Business; 2016. [cited 2022 Mar 1]. https://robinson. gsu.edu/2016/05/teaching-­and-­engaging-­a-­new-­generation-­of-­learners/

Chapter 3

Engagement of Generation Z Learners Dane Gunter, Nikhil Patil, and Natasha Larocque

Introduction As we move into the third decade of the twenty-first century, the landscape of medical education is undergoing a generational shift. The majority of medical students, residents, and fellows who have been trained in the last decade and a half largely belong to the millennial generation. However, as of 2020, this will no longer be the case. Members of Generation Z (Gen Z) will be the next to be trained as medical practitioners and this could pose some major challenges for the medical educators who will be responsible for teaching them. There currently exist five generations including the Traditionalists, the Baby Boomers, Generation X (Gen X), Millennials, and most recently, Generation Z (Gen Z) [1] (Table  3.1). The majority of the active workforce is comprised of Millennials and Gen X. Baby Boomers are nearing or entering retirement, or are employed in very high-powered positions [1]. Millennials, Gen X, and to some extent the Baby Boomers, will also make up the educators of the incoming Gen Z. Understanding how these generations were educated, and how that will translate into the educational tactics they use for Gen Z is, therefore, important. Baby Boomers were born between 1946 and 1964 and lived during the time of massive economic growth and prosperity following World War II.  Based on the findings of Boysen et al., Boomers generally equate a successful career with a successful life and base their lives around a live-to-work ideology. They tend to be politically conservative and are more concerned with working as much as possible in order to save for retirement. This is very different from the wants and worries of subsequent generations [1].

D. Gunter · N. Patil · N. Larocque (*) Department of Radiology, McMaster University, Hamilton, ON, Canada e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_3

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Table 3.1  Generations and their generational characteristics Generation Baby Boomers

Gen X

Millennials

Gen Z

Birth year range Characteristics 1946–1964  •  Focused on achieving success through work  •  Accustomed to in-person learning  •  May be unfamiliar with newer technological innovations and how to use them 1965–1976  •  Focused on working to provide the ability to experience life  •  Accustomed to in-person learning  •  Grew up with technology (computers, television), albeit in a limited capacity 1977–1994  •  Achieving work-life balance is of high importance  •  Accustomed to in-person learning  •  Well acquainted with technology although social media and the widespread popularity of the internet did not necessarily exist through childhood 1995–2010  •  Achieving work-life balance is of high importance  •  Accustomed to in-person learning with the utilization of various technologies throughout their education  •  Life is dependent on technology, for daily life and communication purposes

Gen X was born between 1965 and 1980 and this generation has a more liberal view of the world than its predecessors. They grew up in an age where computers were more popular and television more widespread. As such, they were able to view the world through a different lens than the Baby Boomer generation, which may have contributed to their shift in lifestyle from a live-to-work approach to a work-­to-­live one [1]. Millennials, who were born between 1981 and 1996, shifted even further from the ideologies of the Boomer generation with a move to prioritizing a work-life balance. Arguably, the most definitive event that occurred during the lifetimes of the Millennials is the creation of the internet [1, 2]. There is no denying the profound impact that the internet has had not only on the human experience but also the way in which knowledge is shared and disseminated. The internet gave Millennials access to more information than any generation beforehand, and this has had profound impacts on the way they view the world. According to Boysen et al., Millennials tend to have more liberal and socialist views, which could be attributed to their access to a greater breadth of information about the rest of the planet and its inhabitants. As a result, Millennials are more socially conscious than previous generations [1]. This drastic shift from a more individualistic view of the world to a global community-based one has resulted in significant generational conflict between Millennials and Baby Boomers. It is no secret that generational divides create a foundation for many people’s identities and people tend to identify heavily with their respective generations. So much so that Boysen et al. found that every generation believed themselves to be more intelligent and hard-working than any of the others [1]. This generational conflict has an undeniable effect on the education of Gen Z. Gen Z is the youngest and most recent generation, being born in or after 1997 [1]. Being the youngest generation has its benefits. They have access to everything that previous generations only had access to later in life right from the beginning of

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theirs. This has allowed Gen Z to become the most technologically savvy generation. They are more socially aware and have developed a whole new way of communicating through social media [2, 3]. For example, nearly everyone in Gen Z has a social media account on platforms such as Instagram, Snapchat, and Tiktok. Even Facebook, which is often regarded as the original social networking platform, is no longer used primarily by Gen Z, most likely because its user base comes from a different generation. With the advent of social media and the internet, education has made significant shifts to keep up with emerging technologies and the learning styles of the people using them [3, 4]. These include changes to traditional didactic teaching, gamification of curriculums, and an emphasis on peer-based learning strategies to name a few. While there are some similarities between generations, there are also significant differences. But how do you engage Generation Z, when the way they learn is so different from what the people educating them are used to? This is the question we aim to address. Throughout this chapter, we will discuss the differences between Millennial and Gen Z learners as well as what motivates and engages Gen Z students. We will also address the different techniques being employed or suggested for use in teaching medical undergraduates that belong to Gen Z. Finally, we will discuss the benefits of intergenerational cooperation in the field of medical education and the importance of learning and growing as professionals together.

 enerational Differences in Learning and Attitude Towards G Higher Education Millennials and Gen Z have a very different view on education than previous generations and the ways in which they learn are becoming increasingly different from their predecessors. They have grown up in a world that is connected in ways that were, and sometimes still are, inconceivable to older generations. With Baby Boomers being the most senior educators within the medical field, this presents challenges because of the differences between Baby Boomers’ teaching strategies and how Gen Z learns optimally [2]. Most difficulties seem to arise from differences in technological prowess [2]. Some Boomers are notoriously resistant to learning how to use the technology upon which their students rely so heavily. This creates conflict where each generation believes that the other should adapt to their individual way of teaching or learning. In an attempt to reduce this conflict, suggestions have been made that older generations must adapt to the use of newer technologies to engage younger learners [2]. On top of this, it is also important that they continue to learn about what is available to them as educators [2]. With the advent of the internet and increased emphasis on technology-based learning, Millennials shifted away from traditional learning strategies. This means a shift away from didactic lectures and a shift towards digital learning through the use of apps, videos, podcasts, and reflective blogs [2, 5, 6]. Social media has also become increasingly more useful to young learners to keep them connected to their

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teachers and peers. Twitter and Tumblr have shown promise in their use as educational platforms and content sources [2]. YouTube has also become a common platform for learning, with channels devoted to teaching for free online [2, 5, 6]. While Millennials demonstrate preference for digital learning, Gen Z on the other hand seems to prefer a more personalized approach to learning [6]. They still use technology in the same ways that Millennials do but tend to value in-person mentorships and close personal connections with educators and peers more than previous generations. This may stem from social media’s influence on a desire to be constantly connected to their peers. However, Gen Z also uses social media more than any other generation and that has led to increase in reported social isolation and loneliness among young people [3, 6]. This loneliness in turn likely contributes to their desire to connect with their peers more than millennials, whether that be online or in-person. They also tend to value instant gratification and immediate access to information because they have grown up in a world that has provided them with that luxury. This has led to higher rates of procrastination and increased demand for 24/7 service availability from educators [3]. Due to their breadth of access to information, both accurate and inaccurate, Gen Z students have also shown difficulty with the ability to critically appraise the information they find online and throughout their academic careers. This defines a need for educators to focus on providing them with the skills to be able to think and learn in a critical way so as to ensure that they make decisions, not only about their careers but also their future patients, that are informed by evidence and not misinformation [3]. The generational differences that exist in our society have also led to a difference in the way that younger individuals view education in general. Higher education is less valued by younger people and many Gen Z individuals take issue with some requirements to achieve higher levels of education [3]. For example, they tend to believe that their educational experience should be more customizable and would prefer not to partake in courses or learning experiences that they believe do not service their ultimate goal [3]. They are also more aware of the financial burden of pursuing higher education due to watching their parents and siblings from the Boomer and Millennial generations suffer from economic collapse or student debt respectively [3]. With the increasing cost of higher education, Gen Z has become hesitant to pursue higher education unless it can be tailored to their needs. This need does not stem from a lack of desire to work hard. Gen Z learners are highly motivated and hard-working, but also appear to be more affected by psychological stress than previous generations [3]. This may have to do with a wider acceptance of mental health issues as true health problems than in previous generations, which leads to higher rates of reporting psychological distress in younger people [6, 7]. A study recently showed that mental health issues such as depression, anxiety, and suicidality are becoming increasingly more common in young people in general [7]. Regardless of why it seems to be present, mental health is a much bigger priority for younger generations and has a real bearing on how they make decisions about their education and future careers. They also strongly believe that mental health has a direct impact on their ability to engage and learn. In response to this, medical schools have begun making changes to

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accommodate the increased availability of counselling services. Even with these changes, however, existing services are generally overwhelmed and due to the inherently stressful nature of medical education, this problem is forecasted to worsen in the years ahead [3, 7]. In some cases, students may not even be aware that these services are available or may be self-conscious about accessing them.

Effect of Technology on Engagement of Gen Z Learners With the widespread adoption of personal cell phones, tablets, and laptops, most Gen Z students have been surrounded by technology for education and leisure alike. Furthermore, the use of electronic learning tactics has prompted a larger presence of technology within the classroom and as an integral component of most educational curricula. Most students report using technology to multi-task [8], and unfortunately, divided attention has been shown to cause reduced retention and subsequent lower academic achievement [8, 9]. Despite many students using their devices for academic purposes, they appear to simultaneously be concerned about their potential for distraction [10]. It seems as though their concerns are justified since it has been reported that nearly one-fifth of digital time for class activities is spent on non-­ class-­related activities with the average student using their devices over ten times a day for non-class purposes [10]. However, the optimal way for instructors to deal with students using their devices for non-class purposes is debated. Specifically, some suggest that instructors should not be focused on eliminating distractions directly, but should focus instead on delivering their content in an engaging format that promotes active involvement from students [11, 12]. Interestingly, students are able to identify that using devices for non-class reasons may lead to negative academic repercussions, but they still do not want any policies enforced to monitor device usage [10]. With many students citing boredom as a reason for turning to their devices, some suggest that instructors should turn to blended learning strategies to make classes more engaging [10, 13]. In times where almost every student has access to a number of technological devices during class, it is imperative to address the fact that barriers to distraction are reduced and find ways to promote a strong learning environment.

Teaching Strategies Adapting teaching strategies to the incoming wave of Gen Z medical students is of the utmost importance to ensure that these young learners can excel in their studies and ultimately become more competent physicians. A recent systematic review done by Cretu et al. proposes a number of teaching strategies that can be implemented to accommodate the transition from Millennial to Gen Z learners [5]. From subtle changes in didactic lectures to complete overhauls of curriculum structures,

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there are many different ways to approach the education of the next generation of doctors. Didactic lecturing has been a staple of medical education for centuries. In the pre-clinical years, this form of teaching has always dominated the educational experience of medical students [5]. However, with the influx of new technology and a new student body to utilize it, didactic lecturing has had to undergo some necessary changes to keep students engaged and to allow them to have an active role in their own learning. Most Gen Z students, and even younger Millennials, find the format of didactic lectures to be boring. Gen Z tends to be more experiential in their learning and prefers more practical and visual forms of teaching to solidify concepts and to hold their attention [5]. Technology has made it possible to present information in a more interactive and immersive format than traditional lecture-based teaching [5]. Due to the lack of enthusiasm for lecture-based teaching, a shift to a more visual or practical system would be of benefit to ensure that students remain engaged and continue to absorb the information that is being presented to them. This means using more images, graphics, and videos to teach rather than relying heavily on text-­ based educational tools [5]. These text-based resources still have a place in medical education but they should no longer be the focus when it comes to teaching Gen Z students. Cretu et al. also discuss the importance of connecting to students as an educator, and how important that can be in engaging them to learn [5]. This type of connection can foster a more positive learning environment and encourage students to participate more actively in their own learning. Gen Z students are very accustomed to multitasking and performing tasks in short bursts. They also seem to function better when doing tasks that require less sustained attention. This behavior indicates a need to shift to shorter, more meaningful educational experiences that provide higher levels of engagement on their part to learn the material. Cretu et al. suggest the use of online resources like Mentimeter and ClassFlow, which allow for presenters to incorporate short bursts of audience interaction into their presentation to promote student engagement and learning [5]. This can then be followed by quizzes and games to help solidify the knowledge that they have learned [5]. The way in which students can access lectures and educational material is also important. Gen Z learners are less concerned with reading information from a textbook or having a professor read it to them from a PowerPoint presentation. In an age where information is so freely available online, Gen Z learners prefer to have access to their study material anywhere and everywhere they go. The freedom to customize how and what they are learning is important to them [5]. Providing information in a way that can be incorporated into their everyday lives is also something that has been shown to be more effective than didactic lecturing. This means giving students the tools to access the material you provide wherever and whenever they need to. This does not mean that educators should simply provide online resources and leave the students to learn on their own. Guiding students on how to properly use them and how to effectively appraise and analyze the information they are given is, in some ways, even more important than the information itself. This is an essential skill that Gen Z learners will need in their futures as physicians that practice evidence-­based medicine [5].

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Besides restructuring the traditional lecture-based teaching methods, there are other suggested teaching strategies that have shown promise in engaging young learners. The COVID-19 pandemic put educators from many disciplines in a situation where they had to adapt and cater their teaching strategies to the virtual world [14]. With a shift towards an increased reliance on virtual platforms for education, the availability of asynchronous lecture recordings and online resources has increased [15]. Since the pandemic, we have seen an increase in the quality of these asynchronous resources, and educators have the opportunity to begin the shift to a flipped classroom model for learning [5, 16]. Gen Z students seem to prefer being given learning activities to complete instead of passive exploratory learning [4]. This preference translates well to the flipped classroom model, wherein students receive the required learning material with instructions prior to an educational session. This is then followed by structured sessions that encourage students to implement the information they have learned under supervision in activities like case-based discussions and small-group learning [5, 16]. However, it does require that all students review the required material beforehand, which can sometimes be difficult to achieve. This format of education has been shown to be more engaging than more traditional forms of teaching [5, 16]. The flipped classroom model is helpful for teaching students to teach themselves to an extent. However, it has also been shown that teaching peers can be a valuable educational tool as well. This could be an effective way of subverting the issues with the flipped classroom model by assigning certain roles to each student in a group and then having the students present this information to each other [5]. Providing this level of individual responsibility could be helpful in ensuring that each student contributes something meaningful to the group discussion. Educators are then responsible for monitoring and supporting the students in these peer-based teaching sessions by guiding the group discussion to focus on major learning points, and providing content expertise [5]. This type of teaching has been shown to be effective in both preclinical and clinical education for medical students and it also encourages the development of other skills such as presentation and collaboration skills [5]. Aside from the flipped classroom model, virtual learning and blended learning have gained increased relevance in recent years. In the past, access to knowledge held a primary role in education—as characterized by Sir Francis Bacon’s famous saying, “knowledge is power.” In the digital age, access to information is no longer a limiting factor for most people in the Western world. The gradual adoption of blended learning has led to a shift in the pedagogical approach in higher education to favor a more application-based approach [17]. Furthermore, blended learning is also more amenable to include a more diverse Gen Z population involved in higher education since a partially virtual model is generally more accessible [4, 18]. Gen Z students may be more interested in efficiency and ensuring that their education advances their career aspirations [3, 18]. As a result, some students may prefer the increased accessibility and efficiency associated with virtual learning, and further, many Gen Z students want even more integration of technology into their education [6]. Online learning allows students to learn at their own pace and to spend time focused on areas that they feel need more of their attention [19].

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With regard to pre-clinical education, the introduction of game elements into the way that medical students are educated is a process referred to as gamification. This tactic employs the use of addictive elements of games and applies them in a way that teaches the students [5, 20]. This can make the learning process much less tedious for Gen Z learners and can increase the engagement of students. These types of educational tools that use gamification are widely available online and are easily accessible to both students and teachers making them a useful resource. These game-like elements provide a way for educators to motivate their students as well as provide them with opportunities for immediate feedback, critical appraisal, and decisionmaking before having the chance to perform these tasks with real patients [5, 20]. When students eventually move beyond the pre-clinical stage and into clinical rotations, they will still require new ways of teaching. When the COVID-19 pandemic began, medical students were significantly affected by the resulting cancellation of core clinical and elective rotations. This resulted in the creation of more digital options for students to learn how to function in a clinical environment. Cretu et al. presented two options with regard to continuing clinical education without real patients. The first is virtual patient simulations that allow students to practice their clinical skills in a controlled environment [5]. Virtual reality could become of use in this domain but is expensive to implement. However, computer simulations that respond in real-time to the decision-making of the students are a technique that has allowed students to continue their education in the face of this pandemic and will be a useful tool when educating the Gen Z generation. The second strategy involves the use of surgical simulators that allow students to practice their surgical skills using physical models, laparoscopic simulators, and computer simulations [5]. Notably, these types of education tools allow the practicing of clinical and surgical skills without the medicolegal issues that arise from students practicing on real people [5]. The versatility of simulation-based education reaches far beyond just surgery and can be used to teach all forms of clinical skills across any specialty including radiology [5]. Particularly during the COVID-19 pandemic, simulation technologies have been explored as a virtual alternative to in-person learning for hands-on tasks due to the need for physical distancing [14]. It is likely that simulation technologies can serve to supplement traditional learning strategies and improve learners’ confidence in their skills [21]. However, the widespread adoption of simulation technologies remains uncertain as the development of high-quality simulation technology resources is still underway. Specifically, it appears that current simulation technologies may not adequately replace traditional in-person hands-on teaching but could be a useful supplementary option for students. However, simulation for tasks that do not involve a physical, hands-on element may be a viable future option for self-­ studying, as a preparation activity in a flipped classroom model, or for assessments [21]. Beyond simulation technologies, harnessing artificial intelligence to ameliorate the learning experience is also currently being investigated. Mentorship is a common avenue of teaching that has seen promise with both millennials and Gen Z learners. Particularly, Gen Z learners find benefit in building relationships with accomplished individuals within their given field and may be more open to learning from someone that is closer in age to them [5]. These relationships are, for the most part, virtual in nature via email and social media but can

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still be very valuable in terms of learning for Gen Z students [5]. Mentorship has been implemented in education across many areas of study and will likely continue to be useful moving forward. These are just some of the teaching strategies that have shown promise in educating Gen Z medical students, and a summary has been compiled in Table 3.2. It is important to remember that Gen Z learners have vastly different academic priorities from previous generations and place a large emphasis on interactivity and holistic

Table 3.2  Pros and cons of various teaching strategies Teaching strategy Pros Didactic teaching  • Can deliver a large amount and lecturing of information in a short period of time  • Instructor has control over the quality and information delivered to students  • Easily reusable from year to year by instructors

Flipped classroom and peer-based learning

Virtual teaching and blended learning

Cons  • Can bore learners, particularly from younger generations

 • Typically a less engaging style of learning that does not promote active engagement  • Can often contain extraneous information that is not relevant for students  • Comfortable and familiar  • Having to take notes of the speaker’s format for most instructors verbal content can add stress for and students students  • Students can focus on key  • Students with poor time areas of importance and management skills or poor relevance to tier education self-directed learning skills will suffer  • Promotes active learning  • Requires a large investment of time and self-directed learning and effort from the instructor to skills cultivate materials and facilitate collaborative sessions  • Mimics “real-world”  • Can be difficult for students to adjust learning more closely than to new learning styles didactic learning  • More flexible for students’  • Can be difficult to facilitate small unique learning styles and group sessions for large groups of life situation students  • Is amenable to gamification  • Technical difficulties can hinder and simulation technologies instructors and students to improve student engagement  • Improves flexibility for  • Requires access to high quality students, particularly with internet for students and instructors asynchronous, virtual activities  • Easily amenable to flipped  • Developing hands-on practical skills classroom model may be difficult  • Difficult to build relationships with peers and mentorship opportunities may be minimal

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approaches to their education. Given this information, it is crucial that educators strive to foster learning environments that promote the engagement of their students and that means using teaching strategies that young learners will respond well to.

Multigenerational Cooperation in Education As we move into an era of medical education dominated by Gen Z learners, educators and students will have to work together to ensure that the transition to new forms of teaching and learning is adopted in a practical and efficient way. This will require multigenerational cooperation in a world where there is often intergenerational conflict. It has been found that the majority of teachers in healthcare settings are of the Baby Boomer and Millennial generations. There will be a requirement for older generations that are responsible for teaching Gen Z learners to invest time and energy into using a larger variety of teaching methods and technologies that will help to engage their students [1, 2]. This entails moving away from traditional lecture formats and implementing more interactive learning experiences. This change is not one-sided. Gen Z students are avid users of technology and are more familiar with its role in education. With a shift to flipped classroom models and small-group learning opportunities, Gen Z students have an opportunity to help their teachers to better understand the role of technology in education and to help their educators transition to this new style of teaching [1, 2].

Summary of Teaching Points Section Teaching points Generational differences in learning   → Shift to a more digital learning experience will and attitude towards higher challenge current educators education   → Social media will play a pivotal role in the future of medical education   → Preference for a more customizable educational experience is common with young people   → Psychological well-being is becoming increasingly more important to a more satisfying educational experience Effect of technology on engagement   → Technology is an important vehicle for the of Gen Z learners education of young people   → Concerns have arisen regarding the distractions that this technology brings   → Suggestions have been made to utilize technology in an engaging way to minimize distractions and maximize educational potential

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Teaching points   → Didactic lecturing has become an outdated form of teaching for Gen Z learners   → Blended learning, peer-based learning, and gamification are effective alternatives that Gen Z learners respond well to   → Use of electronic learning platforms is of benefit to this technology-driven generation   → Simulation technology may be useful for clinical education   → Each generation is going to have to work with the others to ensure that the educational experience remains beneficial for all parties   → Significant educational adaptations will challenge educators and learners   → Collaboration is the only way to maintain and foster a positive learning environment

Conclusions Medicine has always been built on innovation and pushing the boundaries on what we know about human life and disease. This innovation should also be present when educating the new generations of doctors. It has become clear that Generation Z learns in a very different way from the generations that came before them. Many of the suggested teaching strategies mentioned in this chapter are not only helpful to the students but also to the educators. For example, the use of blended learning and flipped classroom models for teaching students can be beneficial to educators as well in that they provide more personalized engagement with students to help teachers better understand their needs. Older generations are also positioned to make a significant and positive impact on future generations of doctors and the medical field in general. Their use of more engaging teaching strategies could allow for a stronger bond between educators and students moving forward and thus improve the quality of the teaching and learning that occurs in medical schools. More intimate learning experiences will allow for a community to grow within the space of medical education that will have lasting consequences to the future of the discipline. This multigenerational cooperation can only help to further the drive for knowledge and ensure that we move towards the future of medical education as a team.

References 1. Boysen PG, Daste L, Northern T.  Multigenerational challenges and the future of graduate medical education. Ochsner J. 2016;16(1):101–7. 2. Shatto B, Erwin K. Teaching millennials and generation Z: bridging the generational divide. Creat Nurs. 2017;23(1):24–8.

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3. Eckleberry-Hunt J, Lick D, Hunt R. Is medical education ready for generation Z? J Grad Med Educ. 2018;10(4):378–81. 4. Seemiller C, Grace M. Generation Z goes to college. New York: Wiley; 2016. 5. Cretu I, Grigore M, Scripcariu I-S. Get ready for Gen Z, our next generation of medical students. Rev Cercet Si Interv Sociala. 2020;69:283–92. 6. Plochocki JH.  Several ways generation Z may shape the medical school landscape. J Med Educ Curric Dev. 2019;6:2382120519884325. 7. Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017. J Abnorm Psychol. 2019;128(3):185–99. 8. Wang Z, Irwin M, Cooper C, Srivastava J. Multidimensions of media multitasking and adaptive media selection. Hum Commun Res. 2015;41(1):102–27. 9. Glass AL, Kang M.  Dividing attention in the classroom reduces exam performance. Educ Psychol. 2019;39(3):395–408. 10. Mccoy B. Digital distractions in the classroom: student classroom use of digital devices for non-class related purposes. J Media Educ. 2013;4:5. 11. Sullivan A, Johnson B, Owens L, Conway R. Punish them or engage them? Teachers’ views of unproductive student Behaviours in the classroom. Aust J Teach Educ. 2014;39(6):43–56. 12. Gebre E, Saroyan A, Bracewell R.  Students’ engagement in technology rich classrooms and its relationship to professors’ conceptions of effective teaching. Br J Educ Technol. 2014;45(1):83–96. 13. Graham CR, Henrie CR, Gibbons AS.  Developing models and theory for blended learning research. Blended Learn Res Perspect. 2013;2:13–33. 14. Papapanou M, Routsi E, Tsamakis K, Fotis L, Marinos G, Lidoriki I, et  al. Medical education challenges and innovations during COVID-19 pandemic. Postgrad Med J. 2021:postgradmedj-2021-140032. 15. Brady AK, Pradhan D. Learning without borders: asynchronous and distance learning in the age of COVID-19 and beyond. ATS Sch. 2020;1(3):233–42. 16. Latorre-Cosculluela C, Suárez C, Quiroga S, Sobradiel-Sierra N, Lozano-Blasco R, Rodríguez-­ Martínez A.  Flipped classroom model before and during COVID-19: using technology to develop 21st century skills. Interact Technol Smart Educ. 2021;18(2):189–204. 17. Dziuban C, Moskal P, Hartman J.  Higher education, blended learning and the generations: knowledge is powerno more. In: Bourne J, Moore JC, editors. Elements of quality online education: engaging communities. Needham, MA: Sloan Center for Online Education. p. 17. 18. Barber VH.  Teaching and engaging generation Z during the coronavirus. Dep Chair. 2020;31(1):23–5. 30 June 2020 ed. 19. Yu E, Canton S. Student-inspired optimal design of online learning for generation Z. J Educ Online. 11. 20. Saxena M, Mishra DK. Gamification and Gen Z in higher education: a systematic review of literature. Int J Inf Commun Technol Educ. 2021;17(4):1–22. 21. Al-Elq AH.  Simulation-based medical teaching and learning. J Fam Community Med. 2010;17(1):35–40.

Chapter 4

Helping Nonteaching Faculty Teach Kirang Patel and Courtney Cheng

Introduction Nonteaching faculty are those who work in an academic practice but are not familiar with having a teaching role. This new teaching faculty role may be the result of a recent transition from a private practice to an academic setting, a career pivot, or late-stage career movement from a clinically productive role to a mentorship, or educational role as a bridge to retirement. For the purposes of this chapter, it is assumed that nonteaching faculty are individuals who have been in a private practice setting without trainees, and therefore have not had much experience teaching. Therefore, it is expected that these faculty are unfamiliar with central tenets of teaching, particularly when being tasked with educating young trainees such as residents and students, who, in many cases, are millennial learners. In a post-pandemic world, where social distancing is expected, there is even more isolation in the reading room compared to before. Many radiologists who are shifting to an academic setting are now required to take time off from clinical work to fulfill educational responsibilities, including providing feedback to residents, whether it is in person or virtual, giving presentations, and acting as a mentor. Given how the delivery of education and teaching have recently changed due to the COVID-19 pandemic, this chapter will outline several basic principles on adult learning theories and provide new skills and techniques that can help ensure optimal learning and education delivery to trainees by nonteaching faculty.

K. Patel (*) University of Texas Southwestern Medical Center, Dallas, TX, USA C. Cheng Royal College of Surgeons in Ireland, Dublin, Ireland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_4

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Adult Learning Theory Adult learning theory, also referred to as andragogy, is a concept that describes how adults learn differently than children [1]. As adult learners, radiology trainees learn best when implementing these established techniques, thus highlighting the different ways in which adults learn and understanding the principles of adult learning can help refine the way one teaches radiology. We aim to describe adult learning theory using broad categories outlined in the literature [2] and provide specific examples that nonteaching faculty can apply when teaching radiology to adult learners.

Instrumental Learning Theories Instrumental learning theories focus on individual’s external and internal environments, as well as their prior experiences [2]. Nonteaching faculty should consider the trainee’s external learning environment, i.e., the reading room, to ensure proper teaching and learning is taking place. Faculty should also acknowledge the trainee’s level of training because teaching higher level concepts may be too abstract for a less experienced trainee and thus prevent effective learning. A trainee’s internal environment is composed of their cognition, data processing and analysis, memory, behaviors, thoughts, and forms of self-reflection. It is a combination of these complex processes in the learner’s internal environment that allows meaningful learning, long term memory forming, and problem solving [3]. Asking trainees questions, preparing lesson summaries, and providing regular homework can help with their learning by taking advantage of their internal environment. Adults learn most effectively when they are actively involved in learning, thus, providing opportunities for learners to apply their learning through answering questions or completing exercises that can help with consolidating new knowledge [4]. For example, a great way to leverage a trainee’s internal environment is by creating a low stress, time sensitive competition between trainees. Using a secure texting application, such as Voalte Me/Messenger system (Batesville, IN), a case can be sent to a group of trainees to see who can recognize the correct findings and diagnosis first (see Fig. 4.1). This type of competition leverages the learner’s internal environment as trainees are encouraged to quickly analyze and interpret a case, use cognitive processing and self-reflection to win among their peers. Connecting trainees’ prior experiences to new information may further help with retaining new concepts [5]. As adults are generally seen as self-directed learners, the role of educators should not be to simply supply information but to facilitate learning through helping trainees make connections with prior knowledge. For example, a trainee who has had prior experience diagnosing and managing bowel obstruction may have a more positive learning experience when shown radiologic examples of such cases compared to trainees who are unfamiliar with the condition or have

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Fig. 4.1  The teacher can use a secure texting application (Voalte Me) to show cases or promote discussion or competition with a group of trainees

Fig. 4.2  Presenting supine and upright abdominal radiographs of a patient with typical features of small bowel obstruction is likely more beneficial for trainees with prior experience of diagnosing and managing patients with bowel obstruction

limited knowledge to apply to the radiology images. A trainee with prior experience is more likely to be able to draw on their knowledge and understand why there are radiologic features of small bowel obstruction such as dilated loops of small bowel and air-fluid levels, as demonstrated on Fig. 4.2.

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Transformative Learning Theories These theories involve transforming previous perspectives and understanding by integrating new information with existing knowledge through several stages [6]. The learner first encounters an unfamiliar concept, which then prompts them to think of past experiences to recognize a sense of familiarity or ways to understand the concept through critical thinking. If the learner is unable to do so, they will take an approach to understand the concept through active learning and incorporation with prior experiences and knowledge to help develop a new meaning and integrate it into their long-term memory. Understanding this process can help the educator recognize gaps in the learner’s knowledge and acknowledge that certain concepts need to be worked on. If the learner already understands a basic concept, then the teacher can help add a next level concept about the same topic to build on their knowledge, while going through the different stages of the learning cycle each time. For example, it may be of more benefit for students to understand normal anatomy prior to learning about different pathologies, as this new knowledge of pathological processes can prompt critical reflection, evaluation, and transformation of their prior knowledge to support more meaningful connections and learning. Figure 4.3 highlights how a trainee can learn the difference between intradural and extramedullary tumors of the spine via transformative learning. The trainee must first understand the difference between what is considered intradural versus extradural or intramedullary versus extramedullary by understanding the basic anatomy as seen in the left image of a normal thoracic spine. The trainee can then be presented with lesions within the spine and then localize them in an intradural and extramedullary location as seen in the middle image of the thoracic spine. Once the trainee can correctly localize lesions within the spine, a higher concept can be introduced of creating a list of differential diagnoses and then determining the most likely diagnosis based on the imaging characteristics. Differential diagnoses for

Fig. 4.3  Left (T2WI axial MRI), middle (T1FS contrast enhanced axial MRI), and right (T1FS contrast enhanced sagittal MRI) images of the thoracic spine are presented to the trainee sequentially to build concepts and understand differences between intradural and extramedullary tumors using transformative learning theories

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intradural and extramedullary tumors include (but are not limited to) meningioma, schwannoma, neurofibroma, and metastasis. Correctly characterizing tumors and their unique features can then help the trainee hone in on the most likely diagnosis. The right image of the thoracic spine demonstrates an enhancing tumor with a dural tail which is characteristic of a meningioma. This approach is how transformative learning theories use a sequential method of integrating new information with existing prior knowledge and experiences to support active learning and consolidating new concepts into long term memory.

Social Theories of Learning Social theories of learning emphasize the importance of the learner’s environment for optimal learning [7]. The environment does not necessarily need to be a physical environment. Given the increased use of social distancing, the faculty and trainee may not be in the same physical space. The “environment” can also be a state of the learner’s perception of their learning environment. This means the learner is having a positive educational feel of learning and teaching even if the faculty is off-site or in another room. This is often termed the learning climate. Faculty can help facilitate a positive learning environment, even in times of social distancing and remote teaching by frequent check-ins, use of open and bidirectional communication, and increased availability for case discussions and clarification of teaching points. Bidirectional communication can occur in many forms, including simultaneous case review side-by-side in the reading room or over a videoconference, secure text messaging as described above, discussions over the phone, email correspondences, direct messaging on virtual platforms such as Zoom (Zoom Video Communications, Inc., San Jose, CA) or Microsoft Teams (Microsoft Corporation, Redmond, WA), instant messaging on applications such as WhatsApp (WhatsApp Messenger Facebook Inc., Menlo Park, CA), and corrected reports. These methods allow students to become involved in conversations with their teachers to voice their opinions, ask questions, and take on a more active role to promote their learning. Social learning theories focus on observation and modeling, in which students learn through observing the behaviors and actions of their teachers. As such, educators have the responsibility of demonstrating and reinforcing expected behaviors to support trainees in learning the proper way to perform certain skills and techniques. For example, educators can offer shadowing experiences for trainees in which they walk through several cases and demonstrate their technique. These shadowing opportunities can be delivered virtually over platforms such as Zoom or Microsoft Teams, whereby a radiograph is displayed on the screen while radiologists use a pointer and verbally describe their approach. Advances in technology now have features that allow both presenters and participants in the session to annotate images on the screen, thereby promoting improved learning and comprehension (see Fig. 4.4).

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Fig. 4.4  The teacher can use the “annotate” feature on Zoom to indicate the pathology (in this case, the anomalous right pulmonary vein in Scimitar syndrome), which all other attendees will be able to see too

Motivational Model Adults are motivated to learn based on an intrinsic desire to learn about what would be relevant in their current and future endeavors [2]. Understanding what is relevant for the trainee and teaching those topics accordingly will have better long-term outcomes for the trainee based on their internal motivation and willingness to comprehend certain topics. For instance, it may be of more value to explain the differences between various cortical brain tumors to a resident who is also more motivated to learn about these concepts, as opposed to a body-imaging fellow who may never have to read a brain exam in the future. Likewise, the motivation for trainees to learn about certain topics can be further supported when they observe teachers who are interested in the topic and keen to learn more about the topic if it is a new condition for them as well. One can then give the student a homework assignment on the topic, and with the student bearing in mind that the teacher is interested to learn more, the student may be more eager to return the next day and impart their knowledge to the teacher.

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Reflective Models Learners are believed to understand and learn by reflecting on their experiences and knowledge [2]. Reflective thinking is a skill that can be nourished with supportive teachers who provide a structured approach to reflection. A well-known reflective model is Gibbs’ Reflective Cycle [8], which provides a structured framework for learning from experiences. The model includes six stages: description of the experience, feelings about the experience, evaluation (e.g., what went well or not so well), analysis (e.g. why did certain aspects of the experience go well or not so well), conclusion about what happened (e.g., what was learned from the experience or what actions could improve the outcome of the situation), and action plan (e.g., what could be done differently next time). This approach can be applied to various teaching settings, including conferences, where attendees can be provided with these prompts to reflect on their learning experience from the conference. Of note, this model may also be used for providing effective feedback (refer to Chap. 8). Teachers can also employ reflective models of learning by offering constructive criticism and objective feedback. For example, if a resident trainee missed a life-­ threatening finding overnight, one should not be aggressive and reprimand the resident with blameful and negative comments. Instead, one should understand their point of view and thought process, discuss the findings and end results objectively, and provide ways of improvement or solutions (i.e., learn how to find the missed findings) such that they learn from the mistake.

Adult Education Techniques Based on the aforementioned theories of adult learning, the following sections will discuss how basic adult learning principles can be adapted to education techniques in radiology that new teaching faculty can use. Principles will include learning through anatomy, learning through experience, learning differences between individuals, learning through interactivity, and learning through effective communication [4].

Learning Through Autonomy As previously mentioned, adults are seen as self-oriented learners who aim to learn knowledge and skills that will be applicable to their future work and responsibilities. Furthermore, adults are more motivated to learn when they recognize the benefits of why they need that certain knowledge or skill. The role of the

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Fig. 4.5  Two axial contrast enhanced CT chest images showing the typical features of empyema (left) and lung abscess (right) that can be shown to the trainee to emphasize importance of differentiation as treatment and management difference between the two entities

educator is therefore to facilitate autonomous learning by helping learners take ownership and responsibility for their own learning. One way educators can do so is by recognizing what is relevant to the learner’s goals and thus what will effectively motivate the learner. Once this understanding has been established, the educator can then develop specific learning outcomes to help learners reach their goals. Example: A fourth year resident who recently matched into an interventional fellowship is rotating in the Chest Section. The educator can take advantage of the trainee’s future goals of becoming an interventionist by providing teachable moments of chest imaging related topics. For example, the educator can teach imaging features that distinguish a lung abscess from an empyema, since management of placing a chest tube by an interventionist differs between the two conditions. Figure 4.5 shows two axial contrast enhanced CT chest images of classic examples of a lung abscess and an empyema, which can be shown to the trainee side by side to highlight the key features that differentiate the two entities. The left image shows typical features of pleural empyema including exhibiting obtuse angles with adjacent pleura and characteristic enhancing, thickening and separation of the parietal and visceral pleura (“split pleura sign”). The right image shows typical features of a lung abscess including demonstrating a round morphology and forming acute angles with the adjacent pleura and chest wall. By discussing how they could be asked to place a chest drain in the future, and the fact that distinguishing an empyema from a lung abscess is often a common imaging pitfall, the learner may be more motivated and eager to learn.

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Learning Through Experience Adults learn through repetitive experiences, regardless of whether an experience is positive or negative. Every experience prompts the adult to reflect on previous experiences and then integrate the current experience to form another connection. Similarly, integrating new knowledge with previous knowledge aids in long-term memory and learning. The educator should therefore be mindful of what training level a trainee is (i.e., what training experience that trainee has had) to help focus on relevant concepts that would benefit their learning. Example: A first-year resident is on the Neuroradiology service for the first time. The educator should be mindful that this resident is a neuroimaging novice. Therefore, teaching complex higher-level concepts would be of no benefit for someone without any neuroradiology experience. Instead, the educator should focus on teaching this trainee foundational building blocks such as anatomy so that they can then develop a strong knowledge base and early learning experiences to build on for high-level concepts in the future. Figures 4.6, 4.7, 4.8, 4.9 outline the examples of different neuroradiology cases and topics that the educator can teach depending on the trainees’ training level and experience. Fig. 4.6  Noncontrast axial CT of the brain is shown to a first-year trainee to highlight different normal anatomical structures. An arrow can be provided (as shown in this case over the thalamus) for questioning purposes

54 Fig. 4.7  Noncontrast axial CT of the brain is shown to a second-year trainee to characterize and recognize the left frontal epidural hematoma in order reinforce the differences between different types of intracranial hemorrhages

Fig. 4.8 Post-contrast T1FS MRI axial image of the brain reveals a ring enhancing lesion over the left temporal lobe. Showing this case to a third-year trainee is appropriate in the attempt of creating an exhaustive differential list of ring enhancing lesions

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Fig. 4.9 Post-contrast T1FS MRI axial image of the brain would be an appropriate case to show to an advanced level trainee (such as a fourth-year trainee) to determine the most likely diagnosis. In this case, the trainee must come up with a differential diagnosis list for posterior fossa cystic lesions with enhancing mural nodules and then subsequently come up with the most likely diagnosis of hemangioblastoma after being provided pertinent patient clinical history (this patient had a history of Von Hippel-Lindau disease)

Differences in Learning Between Individuals The educator must understand that individual adult learners comprehend topics differently, thus teaching must accommodate these differences in methods of learning. There is no one size fits all teaching method for the adult learner population. Some adults prefer learning through reading textbooks, while some learn through answering questions. Recognizing different learning styles can help the educator tailor instruction to the way individual adults prefer to learn. Therefore, discussing personal preferences on what types of teaching method a trainee prefers during their clinical service can help encourage more teaching and learning in the most optimal way. If a trainee does not know what they prefer, then the educator can try different methods and see which works best or which combination of strategies works best for that trainee’s education. This can be challenging to assess, however, through application of different teaching methods with testing for understanding of the concepts, the educator can often hit upon the correct teaching approach for that individual. Example: A first-year resident is on the mammography rotation for the first time. The trainee explains that they learn best through reading material. During the first week, the educator assigns different chapters of textbooks and articles to read about types of calcifications. However, the resident fails to recognize calcifications when asked during a case conference. The following week, the educator decides to give the resident different video lectures on breast calcifications. The trainee then does better at recognizing these calcifications. The educator realizes that this trainee may learn better through a different approach than what the trainee initially thought was

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the best way of learning and may therefore provide more video-based instructional material in the future as opposed to textbook chapters to read.

Learning Through Interactivity Adults learn through interactive-based learning. Interactive learning is multifaceted and includes answering questions, participating in case conferences, interpreting active clinical cases, and receiving feedback. There are newer methods of interactive teaching such as the flipped classroom model or gamification which will be discussed in depth later in this chapter (see section “Teaching Methods”). Example: The educator promotes interactive learning by changing the traditional case conference platform and instead creates a competition with partnering junior and senior residents together to work as a team. The senior resident is blindfolded while the junior resident describes the image to the senior resident, who is then tasked with making the correct diagnosis. This education technique helps junior residents learn basic skills of describing imaging, as well as encourages them to use their knowledge of key imaging features, while encouraging senior residents to use critical skills to reach the correct diagnosis without having an image in front of them.

Learning Through Effective Communication Utilizing effective communication while teaching can help optimize the learning environment. Negative and ineffective communication skills can lead to a negative learning environment, including learner demotivation and lack of desire to learn. There are many essential effective communication skills that the educator can utilize and they are detailed later in this chapter (see section “Communication Skills”). Example: A new faculty member without prior teaching experience or trainee interaction has joined the department. A third-year resident starts their rotation and introduces themselves to the new faculty, however, the faculty member is dismissive and seems to be uninterested in the resident. The resident has some questions and asks the faculty member, but they only give short responses in a rather judgmental and annoyed tone. The resident feels very uncomfortable in this seemingly negative learning environment. A more optimal scenario would be for the faculty member to foster a positive learning environment by addressing learners by name, communicating in a nonjudgmental and polite manner, and providing feedback and teaching pearls. It must, however, be recognized that this is often a learned process for those without such prior experience and constructive feedback and support should be offered to this faculty member to allow for improvement in their expected interactions.

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Teaching Methods: Generational Considerations The teaching approach that is used may depend on the generation to which the learner belongs. In the current workforce, the most predominant generation is millennial (individuals born between 1981 and 2000), followed by Generation Xers (those born between 1965 and 1980), and finally, baby boomers (those born between 1946 and 1964). Each generation has unique needs, motivators and communication preferences, and thus, different teaching methods are required to support their learning. As millennials form the largest proportion of the current workforce and have not received as much training relative to those who belong in the other generations, we will mainly focus on teaching methods that are most effective for this cohort.

Millennials Flipped Classroom The “flipped classroom” model involves students learning the information on their own time and then working on problem-solving activities in a group setting. This approach has been shown to motivate independent learning, encourage peer discussion and interaction, as well as facilitate a deeper understanding and memory of the content attributable to the critical thinking involved in problem-solving tasks [9]. This teaching strategy can also allow educators to use class/group time efficiently to carry out case discussions rather than teach material, which can be completed by students prior to in-class sessions, such as through recorded lectures. Other strategies that can be used are providing trainees with resources such as peer reviewed journal articles or links to online educational videos, such as YouTube videos (San Bruno CA), about a specific topic beforehand so that the teacher can focus on teaching higher level concepts instead of spending time reviewing basics or foundational topics [10]. Gamification Gamification is an educational strategy that aims to motivate students by incorporating healthy competition into the learning environment. For example, students may earn virtual points for correct responses and compete with peers on a leaderboard. By recontextualizing curriculum learning objectives as a contest, gamification can offer immediate feedback, as well as support teamwork and knowledge retention [11]. For example, a Jeopardy game can be created on PowerPoint to test students’ knowledge on certain topics that require review (see Fig. 4.10).

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Fig. 4.10  Sample radiology Jeopardy game

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Student Interactivity Passive learning occurs when students are simply exposed to knowledge through watching and listening. On the other hand, active learning involves students participating in the learning process, which can promote information retention. Several teaching strategies to incorporate active learning among students include interactive Jeopardy style games, virtual polls using Poll Everywhere (San Francisco, CA), and multiple-choice quizzes on Kahoot! (Oslo, Norway). This teaching approach may be most suitable for millennials, as most of them are accustomed to interactive, online video games.

Regular Review (Spaced Interval Repetition) As we age, the brain becomes less plastic and less amenable to forming neuronal connections to learn new information. Therefore, it is even more important that adult learners regularly review material to create new neuronal pathways to learn and consolidate information. One way to promote frequent review is to use the interactive strategies described above, such as including a game of Kahoot! at the start of a teaching session (see Fig.  4.11) or a poll on Blackboard Collaborate (Blackboard Inc., Washington, DC) with questions based on information that was taught during previous lessons. Digital flashcards through online tools such as Quizlet (Quizlet Inc., San Francisco, CA) and Anki (Ankitects Pty. Ltd., Sydney) (see Fig. 4.12) can also support regular review, particularly spaced reputation, where new flashcards with more difficult topics are displayed more frequently compared to older flashcards with

Fig. 4.11  Sample slide of a Kahoot! Quiz

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a

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Fig. 4.12  Front (a) and back (b) sides of a sample Anki digital flashcard that students can use to review concepts

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concepts that have been previously mastered to promote memory consolidation. Teachers can encourage the use of these tools by introducing or mentioning their efficacy to students, or even creating flashcards to share with students that they can then use to study on their own time. Teachers may also display them during teaching sessions and allow students to answer the flashcard prompt in their own heads before revealing the other side of the card. Generation X Compared to millennials, Generation X radiologists are either early- or mid-career individuals who are interested in further developing their skills and expertise and taking on more senior leadership positions. This cohort of radiologists may prefer to learn from a peer network of mentors with mutual mentoring [12]. Baby Boomers Baby boomer radiologists are often late career faculty who have completed their formal training but who are still involved in obtaining continuing medical education credits. Traditional group-based meetings to relay important information will likely be the most effective teaching method for this cohort.

Communication Skills Effective communication between the learner and teacher is key for a positive learning environment, especially for virtual learning formats that have been increasingly used in response to the COVID-19 pandemic. Therefore, understanding the different aspects of effective communication and mastering key communication skills is particularly pertinent currently to optimize the learning environment for adult learners. In this section, we will describe key aspects of effective communication, including tone, respect, active listening, feedback, motivational comments, personalization, encouragement, empathy, goals, nonverbal behaviors, and bidirectionality.

Tone The tone of one’s voice as the teacher is how you sound as opposed to the syntax of what is said. Some examples of tones that are encouraged to be exhibited by the teacher are being neutral, positive, respectful, friendly, and enthusiastic. Tones to avoid are negative, assertive, aggressive, snarky or irreverent.

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Respect Being a teacher is in essence a state of authority, however, respect should be mutual and bidirectional. Communicating with respect encourages a positive learning environment for the trainee. Respectful communication includes speaking in a nonjudgmental way, using a neutral or positive tone, and displaying respectful nonverbal communication such as making eye contact when speaking with the trainee. It is important to be mindful of cultural differences when showing respect. For instance, in some cultures, making eye contact is not socially acceptable.

Active Listening Active listening is an important skill for the teacher, as trainees may approach the teacher with questions or concerns, and thus the role of the teacher is to actively listen to fully understand the learner’s needs. Active listening involves focusing on what the speaker is saying without any concurrent distractions, facing the speaker and making direct eye contact (if culturally appropriate), showing attentiveness and comprehension through body language (e.g., nodding), and clarifying the learner’s message by paraphrasing or asking questions.

Feedback Providing regular and honest feedback is important to communicate to the learner how they are progressing and how they can improve, which can help promote autonomous learning. Positive feedback builds confidence, increases students’ belief that they can succeed, and supports a positive learning environment. However, negative feedback is also important to help the learner recognize gaps in their knowledge and areas to improve. Negative feedback should be honest, but at the same time, constructive and objective since it can often be a sensitive topic or issue for the student. Communicating with only negative feedback is discouraged, in fact, it is highly recommended that one should initially provide positive feedback before negative feedback [13]. An example may be as follows, “I am impressed by your ability to gather the relevant patient information and provide a succinct summary of key radiographic findings. However, I think your case presentation would be more effective if you organized the investigations into bedside tests, blood tests, and then imaging” [14]. One way to tackle communicating negative feedback is through a “sandwich” approach, which involves giving a positive comment first, followed by negative comments, and then ending with another positive comment. However, this approach has been debated, as it has been thought to distract the learner from the critical

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feedback and only remember the positive comments [15]. Alternatively, some authors have suggested giving the positive and negative comments on separate occasions to avoid confusing the learner. It can also be valuable to obtain feedback from trainees regarding lessons and educators’ teaching styles. Not only will this help improve the delivery of education and therefore trainees’ learning, but it also shows trainees that the educator cares about providing optimal teaching and that their opinion is valued.

Motivational Comments Motivation is the intrinsic push to want to complete a task. Providing motivating comments to the trainee is beneficial to drive them to their goals. Communicating simple statements such as, “Great job” or “Great pick up” can support a positive learning environment, but they may not exactly inform the learner on what was done well [14]. A more effective approach may be to follow-up these statements with specific reference to the behavior that was performed well, which can further motivate the learner to continue doing that particular behavior. It is important that these comments be delivered at the time of the event so that they are relevant and can promote reinforcement of the behavior.

Personalization Teaching in a personalized way by knowing the learner’s strengths and weaknesses, relevant past experiences, and level of training can help optimize teaching potential. A learner is more likely to learn something when there is some baseline understanding of a concept rather than a concept without any foundational knowledge. Thus, knowing these aspects about the learner will help streamline which topics to place more emphasis on.

Encouragement Encouraging comments are similar to motivational language, however, the purpose of encouraging comments is to support and uplift the learner. The goal of this type of communication is to encourage the learner to not give up and to promote intrinsic motivation. If a trainee does not answer questions correctly during a case conference, using encouraging comments such as, “You are doing great” or “You will get it next time” are recommended, as opposed to giving no comment or only commenting on the fact that the trainee answered incorrectly [16].

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Empathy Empathy involves understanding what the other person is experiencing by placing yourself in their shoes. If a learner is struggling to understand a certain concept and is taking longer to comprehend it compared to their peers, it is imperative that the teacher recognizes which aspects the learner is having trouble understanding and what their thought process is instead of being frustrated with the learner. The teacher can then alter the method of explanation of those concepts in such a way that it can help the learner to understand that specific concept.

Setting and Monitoring Goals Discussing expectations and goals with the learner from the first day of a rotation block or call day can avoid miscommunication and missed learning opportunities in the future [16]. For example, establishing a learning outcome such as, “To recognize all types of renal tumors and their manifestations” from the start enables the teacher and trainee to each set their own goals accordingly.

Nonverbal Communication Not all communication is verbal. There are many nonverbal communication cues that can encourage a positive learning environment not only in the reading room but with video-based learning platforms such as Zoom or Microsoft Teams. Positive nonverbal communication includes maintaining direct eye contact with the learner while speaking instead of looking elsewhere or on one’s phone. In addition, being aware of one’s facial expressions is also important when teaching. For example, if a trainee gets a case wrong during a case conference or answers a question incorrectly, having a disappointing facial expression should be avoided, as that can lead to a hostile and uncomfortable learning environment. Instead, a neutral or empathetic facial expression should be used. Furthermore, posture is also important while teaching. Specifically, slouching should be avoided as it may give the impression of disinterest and lack of value towards the student’s learning.

Bidirectional Communication It is important to recognize that a learner’s preferred way of communication may be different from that of a faculty member. Many new learners prefer to communicate with faculty bidirectionally, whereas faculty members have traditionally preferred a

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unidirectional dialogue with the learner [17]. Unidirectional dialogue includes simply providing information to learners without any discussion or feedback from learners. This kind of communication is most similar to a lecture format where a teacher presents their slides while students listen passively. On the other hand, bidirectional communication involves providing opportunities for learners to engage in discussion while learning new concepts. Bidirectional communication can be supported by teachers by using prompts, such as “What are your thoughts on this concept? How would you approach this case? Is there anything you would do differently?” This approach allows teachers to challenge students’ understanding, engage in discussion with students, prompt students to reflect on their knowledge and understanding, and take on a more active role in their learning. Bidirectional communication can be used during teaching sessions that occur in-person and online using platforms such as Zoom and Microsoft Teams, which include chat features that allow for immediate two-way conversations between learners and educators.

Conclusion Adults are unique in that they are motivated to learn and educate themselves in topics that are relevant to their job and future. The role of the educator is to understand different adult learning theories, communications skills and utilize different education techniques to their advantage to help teach each student through an individualized approach in the attempt to meet that learner’s end educational goals.

Summary Table Adult learning theories/principles Instrumental learning theories (learners’ external and internal environments, as well as their prior experiences) Learning through experience Transformative learning theories (transforming previous perspectives and understanding by integrating new information with existing knowledge) Social theories of learning (observation and modeling) Motivational model (motivation and reflection) Learning through autonomy

Actionable tips and tools Ask learners questions, prepare lesson summaries, and provide regular homework assignments Connect trainees’ prior experiences to new information

Recognize what learners already understand and build upon that knowledge by introducing next-level concepts

Demonstrate how behaviors and skills should be performed so trainees know the expected and proper way to perform skills and techniques Ask trainees what they want to learn to understand what is relevant for their current and future endeavors

66 Adult learning theories/principles Reflective models (learning occurs by reflecting on one’s experiences and knowledge)

Learning differs from person to person Learning through interactivity

Learning through effective communication

K. Patel and C. Cheng Actionable tips and tools Encourage learners to use the six stages of Gibbs’ reflective cycle to reflect on learning experiences: Description of the experience, feelings about the experience, evaluation, analysis, conclusion about what happened, and action plan Recognize learners’ different preferred styles of learning and use the teaching method that is most effective accordingly Incorporate interactive jeopardy games, virtual polls using poll everywhere, multiple-choice quizzes on Kahoot!, and quizzes via RSNA diagnosis live into teaching sessions and conferences Use neutral, positive, respectful, friendly, and enthusiastic tones Demonstrate active listening, such as facing the speaker, showing attentiveness and comprehension through body language (e.g., nodding), and clarifying the learner’s message by paraphrasing or asking questions Provide feedback, preferably positive comments before negative feedback, that is constructive and objective Use motivational comments that specify what the learner did well Provide words of encouragement to support the learner and promote intrinsic motivation Recognize the learner’s thought process to understand how to explain a concept more effectively so that the student can understand that concept Use positive nonverbal communication skills, such as direct eye contact with the learner while speaking instead of looking elsewhere or on one’s phone Use bidirectional communication strategies, such as chat functions on virtual platforms (Zoom, Microsoft teams)

References 1. Knowles MS. The modern practice of adult education: andragogy versus pedagogy. New York, NY: Association Press; 1970. p. 104–15. 2. Mukhalalati BA, Taylor A.  Adult learning theories in context: a quick guide for healthcare professional educators. J Med Educ Curric Dev. 2019;6:2382120519840332. 3. Arab M. Learning theory: narrative review. Int J Med Rev. 2015. http://www.ijmedrev.com/art icle_68672_9a2c1b5b7fac9fe1fb411b3084513736.pdf 4. Collins J.  Education techniques for lifelong learning: principles of adult learning. Radiographics. 2004;24(5):1483–9. https://doi.org/10.1148/rg.245045020. PMID: 15371622. 5. Mezirow J.  How critical reflection triggers transformative learning. In: Fostering critical reflection in adulthood. San Francisco, CA: Jossey-Bass Inc; 1990. p. 1–6. 6. Tims M. Transformative learning: the role of research in traditional clinical disciplines. Integr Med (Encinitas). 2014;13(4):24–8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566448/

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7. Edinyang S. The significance of social learning theories in the teaching of social studies education. Int J Sociol Anthropol Res. 2016;2(1):14–45. https://www.eajournals.org/wp-­content/ uploads/The-­Significance-­of-­Social-­Learning-­Theories-­in-­the-­Teaching-­of-­Social-­Studies-­ Education.pdf. 8. Gibbs G.  Learning by doing: a guide to teaching and learning methods. Oxford: Oxford Further Education Unit; 1988. 9. Ge L, Chen Y, Yan C, Chen Z, Liu J. Effectiveness of flipped classroom vs traditional lectures in radiology education: a meta-analysis. Medicine (Baltimore). 2020;99(40):e22430. https:// doi.org/10.1097/MD.0000000000022430. 10. Awan OA.  The flipped classroom: how to do it in radiology education. Acad Radiol. 2021;28(12):1820–1. https://doi.org/10.1016/j.acra.2021.02.015. PMID: 34794728 11. Wu X, Peterson RB, Gadde JA, Baugnon KL, Mullins ME, Allen JW. Winter Is Here: A Case Study in Updating the Neuroradiology Didactic Curriculum Through a Gamification of Thrones Solution. J Am Coll Radiol. 2020;17(11):1485–1490. https://doi.org/10.1016/j. jacr.2020.05.028. Epub 2020 Jul 4. PMID: 32628902; PMCID: PMC7334136. 12. Arun K, Pesch AJ.  Navigating generational differences in radiology. Radiographics. 2018;38(6):1672–9. 13. Ramirez J. J. The intentional mentor: effective mentorship of undergraduate science students. 2012 11(1):A55-A63. 14. Emory CL. Pearls: giving and receiving feedback. Clin Orthop Relat Res. 2019;477(1):35–6. https://doi.org/10.1097/CORR.0000000000000538. 15. Von Beren CW, et al. The Sandwich feedback method: not very tasty. J Behav Stud Business. 2017;(7). 16. Patel K, Gupta Y, Patel A.  Key communication skills for mentors. J Am Coll Radiol. 2022;19(7):903–4. https://doi.org/10.1016/j.jacr.2022.03.001. PMID: 35430242. 17. Germaine P, Catanzano T, Patel A, Mohan A, Patel K, Pryluck D, Cooke E. Communication strategies and our learners. Curr Probl Diagn Radiol. 2021;50(3):297–300. https://doi. org/10.1067/j.cpradiol.2020.10.009. Epub 2020 Nov 15. PMID: 33257097.

Chapter 5

Teaching Clinicians and Patients Amy Fioramonte, Amy Garvey, and Fiza Khan

Teaching Clinicians Ordering Appropriate Imaging Ordering appropriate imaging is a persistent challenge for radiology departments and referring providers. As imaging services expand and improve, there are growing clinical contexts where imaging can assist in disease screening, diagnosis, management, and surveillance. Recent studies demonstrate a steady increase in ultrasound, CT, and MRI utilization from the years 2000 to 2016 in US adults [1], with the use of CT (computed tomography) and MRI (magnetic resonance imaging) tripling in American Emergency Departments from 2001 to 2010 [2]. However, there are many clinical scenarios where only certain imaging modalities are helpful, or imaging is not necessary at all. Although medical imaging is crucial for quality health care, one cannot ignore the medical and economic risks of inappropriate usage. Many medical specialties have their own criteria for appropriate imaging use, which play a key role in guiding clinical management [3, 4]. One central, important radiology resource for guiding clinical decision-making regarding imaging use is the American College of Radiology (ACR) Appropriate Imaging Criteria, an online resource which provides evidence-based guidelines [5]. The ACR appropriateness criteria came into existence in 1993 to eliminate inappropriate utilization of radiologic services and is reviewed annually by an expert panel in both diagnostic and interventional radiology to ensure that it offers current guidance [5]. In

A. Fioramonte (*) · A. Garvey · F. Khan Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA e-mail: [email protected]; [email protected]; [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_5

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addition to compiling data with regard to the usefulness of various imaging modalities based on disease process, the ACR appropriateness criteria include summary tables that assign appropriateness level and radiation exposure for each radiologic examination. Health care providers have free access to this service through the ACR website and can sort information anatomically or based on clinical scenarios or procedures. However, as we will discuss in the next section, there is still much work to be done to introduce non-radiology providers to resources like this one. In clinical practice, questions synthesized from the patient’s history, symptoms and physical exam guide health care providers in selecting appropriate radiologic scans and services. Let us compare two scenarios: (1) a patient presents with 24 h of epigastric abdominal pain and serum lipase levels five times the upper limit of normal, and (2) a patient with a history of hypertension presenting in hypertensive urgency with 2 h of severe chest pain radiating to the back. What imaging should the clinician order? In scenario one, there is high suspicion for acute pancreatitis. Imaging is not required to make a diagnosis and a contrast-enhanced CT abdomen and pelvis has not been shown to improve clinical outcomes. However, an abdominal ultrasound may be performed to look for gallstones, a common cause of pancreatitis [6]. In scenario two, there is high suspicion for acute aortic syndrome and several imaging studies can be appropriate, including a CT angiogram of the chest, abdomen, and pelvis. Apart from appropriateness criteria and guidelines, there are new US federal government requirements for the use of advanced imaging, which includes CT, MRI, and PET (Positron emission tomography) and other nuclear medicine studies. The Appropriate Use Criteria Program (AUC) was created under the Protecting Access to Medicare Act of 2014, where providers ordering advanced imaging, in both inpatient and emergency settings, will be required to consult a Centers of Medicare & Medicaid Services (CMS)-approved Clinical Decision Support Mechanism (CDSM) [7]. The CDSM will determine if the ordered study meets AUC criteria for payment. If a study does not meet these criteria, it will undergo traditional prior authorization. This program has been rolled out on a volunteer basis since July 1, 2018, and at the time of publication, this program is to be implemented on January 1, 2023 or the year following the declared end of the COVID-19 public health emergency. Currently, there are institutions working to integrate CMS-­approved CDSMs into current electronic medical record ordering systems [8]. The tools discussed here demonstrate resources throughout different steps of appropriate imaging ordering. In addition to these resources, medical providers would benefit from increased medical education in radiology, including examination indications. As we will discuss next, dedicated radiology education is limited or oftentimes absent in the medical education curriculum; therefore, there are many opportunities for educational programming in appropriate imaging use to better support patient outcomes.

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Where Is Radiology Education Occurring? Even with the existence of the ACR Appropriateness Criteria, it is important to ask how often this platform is utilized by clinicians in their decision-making process and to identify barriers, if any such exist. Multiple studies have demonstrated that there is low utilization of the ACR appropriateness criteria and, for the most part, attributed their findings to general lack of awareness of ACR appropriateness criteria [9, 10]. They further ascribed this low rate of incorporation of ACR appropriateness criteria in actual clinical practice as resulting from an absence of formal training in appropriate imaging selection at both undergraduate and graduate medical training levels. A study conducted by Retrouvey and colleagues tried to get to the core of the problem and look for a possible solution. They enrolled a cohort of residents of varying postgraduate levels and specialties (internal medicine, family medicine, psychiatry, and emergency medicine) in an educational course focused on increasing awareness of the ACR appropriateness criteria and its clinical implication. Each participant took a pre- and post-test consisting of three sections. Section one focused on ACR appropriateness criteria awareness and usefulness. Section two focused on knowledge of basic radiology concepts including indications, contraindications, and use of contrast. Section three assessed the residents’ opinions regarding the importance of radiology in their respective field, their comfort level when ordering studies, and the appropriateness of undergraduate as well as postgraduate training exposure to radiology. Only a few resident clinicians were aware of the ACR appropriateness criteria. Most residents felt that diagnostic imaging was important to their field, however, they did not feel comfortable ordering the tests due to lack of adequate radiology exposure during their training. The authors found a didactic lecture series to be an effective tool in exposing clinicians in all specialties and postgraduate levels to the ACR appropriateness criteria and increased their confidence level when it came to basic radiology and ordering practices [11]. Similarly, Pfeifer and colleagues also found that a radiologist-driven lecture series played an important role in pediatric residents’ understanding of appropriate ordering practices [12]. Considering these findings, greater importance is being placed on creating learning opportunities to teach about appropriate ordering practices. In recent years, ACR has partnered with Baylor College of Medicine to develop an online archive of casebased modules to teach students and clinicians at all levels of training and across a variety of specialties about appropriate imaging selection through simulation scenarios. The initiative is better known as Radiology-TEACHES (Technology Enhanced Appropriateness Criteria Home for Education Simulation) and its goal is to increase undergraduate and postgraduate trainees’ exposure to radiology. An initial pilot study and a recent multisite study have demonstrated the potential value of these modules as useful educational resources increasing learner exposure to ACR appropriateness criteria and its utilization in clinical decision-making and treatment [13].

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Teaching the Basics of Imaging Interpretation In addition to appropriate ordering, many providers are expected to demonstrate and perform basic imaging interpretation as part of their clinical duties, especially in emergency situations. However, many medical providers do not have access to dedicated radiology curricula. Formal exposure to radiology is often limited due to the extensive wealth of knowledge that needs to be covered during graduate and postgraduate medical training with only 5% of total teaching time dedicated to radiology [14]. Students are exposed to diagnostic images during current core clinical rotations (i.e., surgery, internal medicine, family medicine, obstetrics and gynecology, emergency medicine, and pediatrics), but often do not receive formalized education in the field of radiology. From 2011 to 2018, only 20% of American medical schools had a required radiology clerkship [15]. Similarly, during residency, residents order diagnostic images every day and are expected to interpret these images for either surgical planning, disease diagnosis and severity, or explaining medical conditions to patients. However, residents typically receive little formal education in image interpretation, and usually rely on knowledge acquired during everyday tasks or informal teachings during rounds. This does not necessarily mean that nonradiology clinicians are not receiving quality radiology training on their clinical services, but that there is much room for improvement. Clinicians often voice the desire for dedicated education on imaging interpretation. For example, in a multi-institution survey of almost 1000 surgical faculty and residents, most respondents reported making treatment decisions based on independent reads, especially in emergent situations, and expressed a need for dedicated radiology curricula [16]. A cross-sectional survey of emergency medicine residency programs found that 62% of responding programs did not have formal radiology education even though 95% of respondents felt imaging interpretation was an important skill for trainees [17]. This survey highlighted the need for dedicated radiology imaging, and respondents especially voiced the need for radiograph interpretation skills when caring for patients in critical condition. Some medical schools and residency training programs do offer elective time where a trainee may choose to supplement their education/training with a radiology elective. This means that even when there is no formalized longitudinal curriculum in place, opportunities for sporadic and intentional formalized teaching exist. The next question to ask is how well these opportunities are being utilized. Current traditional radiology electives generally have a passive observation structure. In this traditional format, medical students or residents are paired with a radiology attending physician or resident to shadow for a day. The medical student/ resident sits behind the radiologist’s workstation and observes as they go through cases, being exposed to various imaging modalities, anatomy, and pathology. In the absence of a firm foundation in radiology and anatomy, this information may be overwhelming for a new learner and, at times, may hinder their participation in the learning process.

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To develop an effective radiology elective, we first need to make sure that the goals and objectives are in line with our audience’s needs. Work done by Laura Zwaan and colleagues and other researchers have done just that by outlining key goals that can be applied to any radiology elective [18]: 1. Focusing on interpreting common abnormalities on chest and skeletal radiographs to distinguish normal from abnormal images. 2. Focusing on teaching appropriate ordering of radiology images. 3. Understanding when to consult a radiologist. The next question we should address is how we should effectively deliver these goals and objectives. A sample curriculum can involve both didactic lectures and real-time interpretation exercises. For example, a 30-min didactic lecture can be devised focusing on appropriately ordering diagnostic images centered around the clinical question, basic anatomy, and basic search patterns for chest and skeletal radiographs. However, we should not stop there; students need to apply the knowledge taught during lectures to real world cases. This can be accomplished through in-person case sessions or E-learning modules where the students/residents are exposed to common pathology via image interpretation exercises with immediate feedback [19, 20]. Other potential avenues for early intervention include incorporating diagnostic imaging into anatomy labs, which can supplement cadaver dissection and establish the basics for vertical learning during the clinical year and beyond. Additionally, adding lecture materials that emphasize various imaging modalities, as well as their utility in diagnosis and management, during pre-clinical years can improve clinical application of anatomy. For example, a system-based curriculum on pulmonology should include lectures or small group-based sessions led by radiologists, focusing on chest radiography interpretations to review basic anatomy while incorporating various clinical presentations and pathology. In this section we have explored the resources and opportunities available to non-­ radiology clinicians and trainees. In the next section, we turn our attention to the patient to examine resources and techniques that can be utilized for effective patient education.

Teaching Patients Public Resources for Patient Education When patients need an imaging study, it is essential that they know what to expect in preparation for and ahead of the study. When patients know what to expect they are more likely to comply with the ordered examination and may be less anxious during the imaging study or procedure, which can lead to high-quality imaging

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studies and better overall outcomes for the patient [21, 22]. Several public-facing resources have been developed to help patients become educated about different imaging modalities, the imaging process, and what to expect when having a study completed. RadiologyInfo One free resource that healthcare providers can recommend to patients is RadiologyInfo.org (www.radiologyinfo.org) [23]. The ACR and the Radiological Society of North America (RSNA) collaborated to develop RadiologyInfo as a patient education resource. RadiologyInfo is a website that provides information about how various radiologic studies—X-ray, CT, MRI, ultrasound, radiation therapy, and other procedures—are performed. RadiologyInfo provides information via text, photos, and videos. Radiologists have vetted all content provided on the website. For the more than 260 procedures documented on the website as of this writing, RadiologyInfo addresses many areas patients may have questions about, such as: • • • • •

How should a patient prepare for the study or procedure? What does the radiologic equipment look like? How will the procedure be performed? What will the patient experience during and after the procedure? What are the benefits and risks of the procedure?

RadiologyInfo contains several features, which make the website more useful and easier to use. These features include: • The website provides information on common diseases or conditions. For example, if we look up the condition of blood clots, we will retrieve answers to the following questions: What are blood clots? How are blood clots diagnosed and evaluated? How are blood clots treated? Which test, procedure, or treatment is best for me? • Pediatric care and topics are covered on the website. • All textual information can be viewed and saved in PDF format making it convenient for radiologists, referring physicians, or others to provide the information directly to patients and family members. • A search function and site index are provided to help retrieve information easily. • Information is provided in English and Spanish. Radiology practices can use and implement RadiologyInfo in a variety of ways. For example, in a 2018 ACR Imaging 3.0 case study, Wereschagin explains how he and his practice use RadiologyInfo to inform patients and calm their fears when they are anxious about undergoing an imaging study. Wereschagin suggests the following ways practices can use RadiologyInfo:

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• A practice’s scheduling team or others can share RadiologyInfo with patients prior to the scheduled visit and encourage patients to visit the website prior to their imaging appointment. The information about RadiologyInfo can be provided via email, text, or other written communication. • Share RadiologyInfo with referring physicians and medical students and ask them to provide information about the website to patients. • Become a RadiologyInfo.org affiliate [22]. Though RadiologyInfo provides useful and much-needed information to patients, it does have a few downsides. The website’s developers have attempted to use plainspoken, jargon-free language; however, the site has been critiqued for writing educational materials that are difficult for patients to understand and above recommended health literacy levels [24, 25]. Therefore, patients could benefit from reviewing materials together with primary care physicians to help answer questions and clarify information. Additionally, RadiologyInfo does not provide information about imaging costs.

 esources for Radiologists to Develop R Patient-Centered Practices Focusing on the patient experience and providing patient-centered care is a social imperative and most recently it has also become a financial imperative as payment systems and models increasingly demand it. With this in mind, the ACR has put together a compilation of patient-centered resources to educate radiologists and other clinicians on patient- and family-centered care practices and on patient-­ centered radiology. ACR’s Patient- and Family-Centered Care Toolkit One resource offered by the ACR is the Patient- and Family-Centered Toolkit (ACR PFCC Toolkit) [26]. This toolkit offers a wealth of online resources to aid radiologists and radiology practices in enhancing patient-engagement skills and offering patient-centered care. The ACR PFCC toolkit provides a variety of resources, such as articles, videos, infographics, case studies, and others that share best practices and practical strategies for developing patient-centered radiologic care. For example, the toolkit offers guides on how to establish and recruit for patient and family advisory groups, infographics explaining who radiologists are and how they help patients (to be displayed for patients), and a video describing the PFCC central tenants, to name just a few resources. The resources can be browsed by practice setting (e.g., private practice), topic (e.g., educational tools, evaluation), or format (e.g., article, activity).

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Radiology Cares Another resource similar to the ACR PFCC toolkit is Radiology Cares [27]. This patient-centered resource is an RSNA initiative designed to provide resources and educational materials to radiologists. The goal of the initiative is to cultivate a more patient-centered practice so that the needs and wants of patients are addressed and met. Radiology Cares provides materials in three main areas, which are summarized below. A light-hearted video was also produced on the serious topic of patient-­ centered care. • Communication toolkit—a variety of patient-centered resources and materials focusing on communication are provided in this section. The examples (e.g., handouts, letter templates, and patient thank you cards) can be used directly with patients or used within practices to promote patient-centered care principles. • Patient-centered care reading list—a list of scholarly articles, consumer publications, and videos on various subject areas related to patient-centered care in radiology. Some example subject areas contained in the reading list are: radiologist-patient communication, patient preferences and radiologic practice, and the use of technology to enhance communication. • Patient-centered care learning set—a curriculum (13 learning modules) designed for resident education. The learning modules are intended to sensitize residents to patient-centered care principles, equipping them with methods and tools to provide patient-centered care. These public-facing and free online tools can serve as beneficial resources for both patients and clinicians. Table 5.1 provides a summary as well as links to the patient education resources discussed in this section. In the next section, we examine several different ideas and techniques the radiology educator can use to take this practical information and present it to patients and family members in a supportive Table 5.1  Summary of patient education resources Resource Website link RadiologyInfo English: https://www.radiologyinfo. org/en Spanish: https://www. radiologyinfo.org/es

Audience Patients

ACR PFCC toolkit

Radiologists

Radiology cares

Brief description A website providing information about how various radiologic studies are performed. It also provides information on common diseases or conditions https://www.acr.org/Practice-­ Educational materials and Management-­Quality-­Informatics/ resources focused on Patient-­Family-­Centered-­Care/ patient-centered care and PFCC-­Toolkit patient-centered radiology https://www.rsna.org/practice-­tools/ Educational materials and patient-­centered-­care resources focused on Video: https://www.youtube.com/ patient-centered care and watch?v=IBKQtmw4yMk patient-centered radiology

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and empathetic way. The patient-centered care model in which providers respect patients’ needs and preferences, address their emotional and social needs, and involve them and their families in decision-making guided the selection of the educational considerations presented here [21].

Educational Considerations for the Patient Encounter There are many pedagogical techniques that can be considered when physicians meet with patients to discuss diagnoses and treatment options. Importantly, these considerations depend on the clinical situation and the patient’s wants and needs. Regardless of the approach used, it is necessary for medical providers to continuously work towards recognizing and rectifying physician-patient power imbalances, which can be achieved by prioritizing patients’ wants and needs, supporting patient autonomy, and respecting patients as the experts of their own bodies. In this section, we explore several concepts from the education literature that can be useful during patient encounters, making us better at educating and communicating with patients. The Expert Blindspot It is easy to assume that it is best to learn from your field’s experts, but that is often not the case. Just because someone may push the field in terms of knowledge does not mean they have the necessary experience and skills to be an effective educator. In fact, the more entrenched you are in the minutia of your field, the harder it can be to teach basic skills without practice. This is known as the expert blind spot—the idea that one forgets the process of learning and, in turn, teaching or explaining a skill or idea that has become second nature to them. Let us try an exercise. Choose a skill that you do daily or weekly. For example, performing a breast biopsy, protocolling a study, or performing a barium swallow. On a piece of paper, take a few minutes to write down all the steps. When you are done, read over your list and ask yourself: if someone else, who is not in your field of study, would be able to perform the task. Are there any steps that are combined? Any that are missing? Is there any jargon that needs to be removed? Would the individual know all the materials they would need? With these questions in mind, rewrite your instructions making sure that each step is broken down, all materials are listed, and all jargon is replaced with commonplace terms. How do these instructions compare? Can steps be broken down even further? This exercise to break down the expert’s blindspot is helpful in that: (1) It reminds us of the complexity of tasks that we take for granted or have become second nature to us, and (2) It gives us an opportunity to foster greater empathy for the learning process. By continuously putting ourselves in the mindset of “first learning,” we can create the support needed to help others build foundational knowledge and skills that we had to learn ourselves.

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Every time we teach or explain a concept or skill to our patients, most of whom do not work in our field, we should put ourselves in the mindset of learning. Empathy is important to being an effective clinician-educator. What are our patient’s contexts? How do they want to be supported? What language and vocabulary do they prefer to use? As we have previously discussed, most medical knowledge in the USA is systemically guarded, and while we work to democratize that knowledge, we must think about how to best facilitate our patient’s learning as partners. This involves the continual breakdown of power imbalances, respecting patients as the experts of their own bodies, and breaking down the expert blind spot as part of our pedagogy. Patient-Centered Education Techniques Breaking Down Information A basic educational technique a provider can use with patients is to break down large chunks of information or questions into smaller, manageable chunks. Research suggests that our working memory can retain only three or four pieces of information at most at once [28, 29]. Therefore, breaking down information into smaller parts can increase the likelihood that it will be remembered and transferred into long-term memory. As we know, medical information is complex and is oftentimes presented to patients, who are sick and anxious, using jargon, acronyms, and difficult vocabulary. Therefore, the ability to communicate clearly by breaking down complex medical information and translating it using vocabulary and phrases that are comprehensible to the patient is ideal [30]. Ask-Tell-Ask Ask-Tell-Ask is an educational, feedback, or communication model that can be applied to many different settings (e.g., classroom, coaching). The model can be used as an effective technique when you want to explain or teach something to someone. In the healthcare setting, the Ask-Tell-Ask model can be used as a collaborative communication technique to include the patient in the conversation. Thus, it can serve as a good technique to use during provider-patient encounters. In typical provider-patient encounters, the traditional communication model uses a directive approach with providers telling patients about diagnoses, treatments, and medications, etc. and with little input from patients. Using the Ask-Tell-Ask model, providers “ask” what the patient already knows about the topic or alternatively ask what the patient wants to hear (be sure to include this in the “Tell” step). This first “Ask” is exploratory in nature to help elucidate what the patient already knows or understands. It can also help to identify any knowledge gaps or the patient’s capacity to understand. In the next step, “tell” the message simply. Avoid unnecessary jargon. Providers should also breakdown

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5  Teaching Clinicians and Patients Table 5.2  Additional Ask-Tell-Ask model resources Description IHI Open School video This 1-min video produced by IHI Open School explains how providers can utilize the Ask-Tell-­ Ask technique with patients American Medical Association’s “Steps Forward” educational toolkit The educational toolkit provides a document with a sample provider-­ patient conversation using the Ask-Tell-Ask model and additional references University of California San Francisco’s Center for Excellence in Primary Care developed a sample Ask-Tell-Ask curriculum, which include scenarios, exercises, and discussion questions

Resource https://www.youtube.com/watch?v=cTwektQpxUg

https://edhub.ama-­assn.org/data/journals/steps-­forward/93 7327/10.1001stepsforward.2017.0048supp3. docx#:~:text=Ask%2Dtell%2Dask%20is%20the,what%20 they%20want%20to%20know

https://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Curriculum_ sample_14-­0602.pdf

complex pieces of information into understandable chucks so that the message, or most of it, can be understood by the patient. Also, in the Tell, the provider can correct any misinformation or misinterpretation the patient presented in the initial Ask. Be specific and try to personalize the message to the patient. Finally, “ask” the patient what she or he thinks about the message. Or, alternatively, what she or he understood. Here, the teach-back method can also be used to confirm that patients understand the information and/or what is being explained. If patients understand, they are able to “teach back” the information accurately. Table 5.2 provides some additional Ask-­Tell-­Ask model resources. Basic Communication Strategies Good communication skills are critically important to daily clinical practice and to provide quality care to patients and their families. Moreover, practicing good communications skills is not solely reserved for the more patient-facing clinicians, such as internists pediatricians, and psychiatrists but rather radiologists need to have and practice good communication skills too [31]. And, just as developing good clinical and procedural skills require that they be learned and practiced, good communication skills require the same type of dedicated attention. The strategies presented below are not intended to be an exhaustive list or overview, as much as been written on the topic of healthcare communication skills. However, they aim to address the central tenants of the patient-centered model, focusing on providing patients with emotional and social support, hearing and meeting their needs and preferences, and working collaboratively to make care and treatment decisions based on patients’ values.

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Use open-ended questions instead of yes/no questions to elicit more detailed information from the patient. Open-ended questions can also be used to attend to patients and engage with them about their feelings, ideas, concerns, and expectations. Also, encourage patients to ask questions. Talk less and do more active listening. Talking less is not always easy as providers have to elicit and provide a lot of information to patients in a short amount of time. However, in an attempt to get at and really address patients’ needs and wants, this requires more listening and less explaining. Pay attention to the patient and do not interrupt. Stay engaged with what the patient is saying and do not start formulating your response before the patient has finished. Use different non-verbal strategies. Try to decrease the physical space between you and the patient. This can include sitting close to, or as near as possible to, the patient during the encounter. Try to avoid, as much as possible, looking at or using the computer during the encounter. Use a sympathetic tone of voice when talking with the patient and show a concerned or distressed facial expression when listening. These non-verbal strategies convey a willingness to build rapport and establish a relationship with the patient. Involve patients in decision-making to the extent that she or he is willing. Patients’ desires and willingness to participate in decision-making will vary, so be open to these differences and respond accordingly. Discuss with patients if others (e.g., family member, friend, and partner) will participate in decision-making. Offer and explain option choices in simple, plain language. Agree jointly on short- and long-term goals.

Towards Anti-Oppressive Medical Education The concept of cultural competence started emerging in dominant American literature in the 1980s [32]. While it has circulated in various forms and definitions around the world, in the health care setting, cultural competence can be defined as understanding the sociocultural factors that impact health and creating systems that utilize this awareness to ensure quality care for all patients, regardless of identity or background [33]. While some medical scholars speculate that these ideas emerged in response to an increasingly diverse American population [34], there are a few important facts to keep in mind: (1) The USA has always been diverse, however, the idea of who is considered American has been historically exclusionary (e.g., the genocide and displacement of Indigenous populations in the creation of the “New World” and the millions of Africans transported to North America via the transatlantic slave trade); and (2) Dominant (Allopathic and Osteopathic) American medicine was purposefully built to exclude marginalized populations. While many of these exclusionary practices continue today, through the tireless work of community and health activists, this medical discrimination is becoming increasingly less acceptable.

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While we will not elaborate on this fundamental medical history in this chapter, it is important to understand the environments in which we have inherited our current medical system and its educational traditions. This requires understanding the oppressive systems that form the foundation of American medicine and actively combatting this legacy with the goal of providing equitable medical care for our most marginalized patients. If we focus just on medical literature, for instance, providers have pushed cultural competence to keep patients’ complex social, political, and economic circumstances in mind to provide more equitable and comprehensive medical care. Understanding that we can never claim to achieve competence over such a dynamic and personal concept such as culture, some scholars, and medical providers have advocated for cultural humility as an alternative framework [32, 34]. Through cultural humility, a medical provider commits to lifelong learning and sensitivity to each patient’s individual circumstances and is not assumed to be culturally competent after completing certain prerequisite training. Admittedly, there is often overlap in these practices, which work towards similar goals. Both cultural competence and cultural humility take important steps towards training humanistic medical providers, however, they do not go far enough in ensuring health equity when taught in isolation. Structurally, inequitable medical care and education will not be rectified without addressing systemic oppression [35]. We must push our frameworks further to examine and correct fundamental power imbalances that underlie patient care. Without this work, we cannot hope to partner with patients in a way that allows full access to the health care, information, and resources necessary for self-determination, the ability to choose the lives they want to lead [36]. Historically, Black activists and communities have created models for community health care and education that redistributes power and medical knowledge [37]. For example, the Black Panther Party created the Peoples Free Medical Clinics as a way for Black communities to provide themselves with much needed and historically denied health care. In 1972, the Black Panthers demanded “completely free health care for all Black and oppressed people” [38], and public access to health education, medical research, and scientific literature. As part of the Black Lives Matter movement, Movement for Black Lives (M4BL) has continued the call for universal, culturally sensitive health care that allows marginalized populations, specifically trans and cis Black women complete agency over their bodies and health [36]. As part of a long legacy of Black American midwives and doulas, organizations like Black Women Birthing Justice and Uzazi Village provide anti-oppressive health care that centers patient autonomy and empowerment, dignity, and community engagement [39, 40]. These examples are reminders that there are alternative forms of medical education and health care that directly challenge and attempt to mitigate the causes of health inequity. Truly equitable medical care will require medical providers to continuously dismantle power imbalances and uplift patients’ wants and needs. This includes

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respecting patients as the experts of their own bodies and supporting patients in obtaining the information they need for health decision-making. However, truly revolutionizing medical education for providers and their patients requires coalition-­ building and organizing outside of medical institutions to break down the systemic oppression that leads to health inequities and democratize health education and research.

Summary: What Makes an Effective Radiologist-Educator? Teaching clinicians Ordering As imaging services expand and improve, there are growing clinical appropriate contexts where imaging can assist in disease screening, diagnosis, imaging management, and surveillance. However, there are many clinical scenarios where only certain imaging modalities are helpful, or imaging is not necessary at all. Resources such as the ACR appropriateness criteria are important for clinical decision-making regarding imaging use Where is radiology On a local level, radiology departments are pairing up with other education departments to create lecture series to increase awareness of the ACR occurring? appropriateness criteria and to improve ordering practices at their institution. On a national level, ACR has partnered with Baylor College of Medicine to develop an online archive of case-based modules to increase exposure to ACR appropriateness criteria and teach students and clinicians at all levels of training and specialties about appropriate imaging selection through simulation scenarios Teaching the Many clinicians are expected to perform their own imaging interpretation, basics of imaging however few receive dedicated instruction. Several programs have interpretation radiology clerkships or electives, but there is still a need for more robust and active radiology education Teaching patients Public resources Radiologists, primary care physicians, and others can incorporate into their for patient practice informing patients about the RadiologyInfo website so that they education can become educated about the different imaging modalities, the imaging process, and what to expect when having a study completed. Additionally, radiologists can rely on various patient-centered resources, such as the ACR PFCC toolkit and radiology cares to become educated in these practices and utilize them with patients Educational A variety of educational resources and techniques are available for considerations for radiologists and other clinicians to incorporate into their patient education the patient toolkit. In this chapter we reviewed the expert’s blindspot, breaking down encounter information, the Ask-Tell-Ask model and basic communication skills Towards anti-­ Moving beyond cultural competence and humility, truly equitable medical oppressive medical care will require medical providers to continuously dismantle power education imbalances and uplift patients’ wants and needs. This includes respecting patients as the experts of their own bodies and supporting patients in obtaining the information and resources they need for self-determination

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References 1. Smith-Bindman R, Kwan ML, Marlow EC, et  al. Trends in use of medical imaging in US health care systems and in Ontario, Canada. 2000–2016. JAMA. 2019;322(9):843–56. https:// doi.org/10.1001/jama.2019.11456. 2. Talwalkar A, Ashman JJ.  QuickStats: annual percentage of emergency department visits with selected imaging tests ordered or provided—National Hospital Ambulatory Medical Care Survey, United States, 2001–2010 [internet]. MMWR Morb Mortal Wkly Rep. 2013;62(22):455. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6222a6.htm. 3. Hirshfeld JW Jr, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT expert consensus document on optimal use of ionizing radiation in cardiovascular imaging: best practices for safety and effectiveness: a report of the American College of Cardiology Task Force on expert consensus decision pathways. J Am Coll Cardiol. 2018;71(24):e283–351. https://doi.org/10.1016/j.jacc.2018.02.016. 4. Hoffman J. Nexus criteria for C-spine imaging [Internet]. MDCalc. https://www.mdcalc.com/ nexus-­criteria-­c-­spine-­imaging. Accessed 10 Feb 2022. 5. ACR Appropriateness Criteria [Internet]. American College of Radiology. https://www.acr. org/Clinical-­Resources/ACR-­Appropriateness-­Criteria. Accessed 10 Feb 2022. 6. American College of Radiology. ACR appropriateness criteria: acute pancreatitis. J Am Coll Radiol. 2019;16(11S):S316–30. https://acsearch.acr.org/docs/69468/Narrative/. 7. Centers for Medicare & Medicaid Services. Appropriate use criteria program [Internet]. CMS.gov. 2021. https://www.cms.gov/Medicare/Quality-­Initiatives-­Patient-­Assessment-­ Instruments/Appropriate-­Use-­Criteria-­Program. Accessed 10 Feb 2022. 8. Johns Hopkins Medical Imaging. Appropriate use criteria for advanced imaging. Johns Hopkins Medicine Imaging. 2021. https://www.hopkinsmedicine.org/imaging/provider-­ information/appropriate-­use-­criteria.html. Accessed 10 Feb 2022. 9. Bautista AB, Burgos A, Nickel B, Yoon JJ, Tilara AA, Amorosa JK.  Do clinicians use the American College of Radiology appropriateness criteria in the management of their patients? Am J Roentgenol. 2009;192(6):1581–5. 10. Sheng AY, Castro A, Lewiss RE. Awareness, utilization, and education of the ACR appropriateness criteria: a review and future directions. J Am Coll Radiol. 2016;13(2):131–6. Epub 2015 Oct 21. https://doi.org/10.1016/j.jacr.2015.08.026. 11. Retrouvey M, Trace PT, Shaves S.  Radiologic knowledge and ordering habits of clinical residents: ACR appropriateness criteria awareness and perceptions. J Am Coll Radiol. 2016;13-6:725–9. https://doi.org/10.1016/j.jacr.2015.12.029. 12. Pfeifer CM, Castillo SM. Pediatric radiologist-driven didactics for a pediatric residency program: a quality initiative. Pediatr Radiol. 2020;50(3):397–400. Epub 2020 Feb 17. https://doi. org/10.1007/s00247-­019-­04559-­2. 13. Willis MH, Newell AD, Fotos J, Germaine P, Gilpin JW, Lewis K, et  al. Multisite implementation of radiology-teaches (technology-enhanced appropriateness criteria home for education simulation). J Am Coll Radiol. 2020;17(5):652–61. Epub 2020 Jan 10. https://doi. org/10.1016/j.jacr.2019.12.012. 14. Heptonstall NB, Ali T, Mankad K.  Integrating radiology and anatomy teaching in medical education in the UK—the evidence, current trends, and future scope. Acad Radiol. 2016;23(4):521–6. https://doi.org/10.1016/j.acra.2015.12.010. 15. Lee H, Kim DH, Hong PP. Radiology clerkship requirements in Canada and the United States: current state and impact on residency application. J Am Coll Radiol. 2020;17(4):515–22. https://doi.org/10.1016/j.jacr.2019.11.026. 16. Butler KL, Chang Y, DeMoya M, et  al. Needs assessment for a focused radiology curriculum in surgical residency: a multicenter study. Am J Surg. 2016;211(1):279–87. https://doi. org/10.1016/j.amjsurg.2015.05.027.

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17. Villa SE, Wheaton N, Lai S, Jordan J. Radiology education among emergency medicine residencies: a National Needs Assessment. West J Emerg Med. 2021;22(5):1110–6. https://doi. org/10.5811/westjem.2021.6.52470. 18. Zwaan L, Kok EM, van der Gijp A. Radiology education: a radiology curriculum for all medical students? Diagnosis (Berl). 2017;4(3):185–9. https://doi.org/10.1515/dx-­2017-­0009. 19. Larocque N, Lee SY, Monteiro S, Finlay K.  Reform of a senior medical student radiology elective using a needs assessment. Can Assoc Radiol J. 2018;69(3):253–9. https://doi. org/10.1016/j.carj.2018.01.005\. 20. Wu Y, Theoret C, Burbridge BE. Flipping the passive radiology elective by including active learning. Can Assoc Radiol J. 2021;72(4):621–7. https://doi.org/10.1177/0846537120953909. 21. Itari JN. Patient-centered radiology. Radiographics. 2015;35:1835–48. 22. Wereschagin M.  Calming patients’ fears [Internet]. American College of Radiology. 2018. https://www.acr.org/Practice-­Management-­Quality-­Informatics/Imaging-­3/Case-­Studies/ Patient-­Engagement/Calming-­Patients-­Fears. Accessed 1 Feb 2022. 23. Radiologyinfo.org [Internet]. 2022. https://www.radiologyinfo.org/en. Accessed 10 Nov 2021. 24. Bange M, Huh E, Novin SA, Hui FK.  Readability of patient education materials from RadiologyInfo.org: has there been progress over the past 5 years? AJR Am J Roentgenol. 2019;213:875–9. 25. Hansberry DR, John A, John E, Agarwal N, Gonzales SF, Baker SR.  A critical review of the readability of online patient education resources from RadiologyInfo.Org. AJR Am J Roentgenol. 2014;202:566–75. 26. ACR Patient & Family-Centered Care Toolkit [Internet]. Reston, VA: American College of Radiology; 2022. https://www.acr.org/Practice-­Management-­Quality-­Informatics/Patient-­ Family-­Centered-­Care/PFCC-­Toolkit. Accessed 1 Dec 2021. 27. Radiology cares. Oak Book (IL): Radiologic Society of North America. 2022. https://www. rsna.org/practice-­tools/patient-­centered-­care. Accessed 1 Dec 2021. 28. Cowan N. The magical number 4 in short-term memory: a reconsideration of mental storage capacity. Behav Brain Sci. 2001;24:87–114. 29. Gobet F, Clarkson G. Chunks in expert memory: evidence for the magical number four…or is it two? Memory. 2004;12(6):732–47. https://doi.org/10.1080/09658210344000530. 30. Bennett I, Switzer J, Aguirre A, Evans K, Barg F. ‘Breaking it down’: patient-clinician communication and prenatal care among African American women of low and higher literacy. Ann Fam Med. 2006;4(4):334–40. https://doi.org/10.1370/afm.548. 31. Coulehan JL, Block MR. The medical interview: mastering skills for clinical practice. 5th ed. Philadelphia: F. A. Davis; 2006. 32. Kirmayer LJ.  Rethinking cultural competence. Transcult Psychiatry. 2012;49(2):149–64. https://doi.org/10.1177/1363461512444673. 33. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O 2nd. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118(4):293–302. https://doi.org/10.1093/phr/118.4.293. 34. Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–25. https://doi.org/10.1353/hpu.2010.0233. 35. Roberts DE. Shattered bonds: the color of child welfare. New York: Civitas Books; 2002. 36. Movement for Black Lives. End the war on Black Health and Black Disabled People [Internet]. M4BL. 2020. https://m4bl.org/policy-­platforms/end-­the-­war-­black-­health/. Accessed 11 Feb 2022. 37. Nelson A. Body and soul: the black panther party and the fight against medical discrimination. Minneapolis, MN: University of Minnesota Press; 2013. 38. Black Panther Party. The Black Panthers: Ten Point Program [Internet]. Catalyst Project: Anti-­ Racism for Collective Liberation. 2022. https://www.collectiveliberation.org/wp-­content/ uploads/2015/01/BPP_Ten_Point_Program.pdf. Accessed 11 Feb 2022.

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39. Black Women Birthing Justice. Home [Internet]. Black Women Birthing Justice. Black Women Birthing Justice. https://www.blackwomenbirthingjustice.com/. Accessed 11 Feb 2022. 40. Uzazi Village. About [Internet]. Uzazi Village. https://uzazivillage.org/about/. Accessed 11 Feb 2022.

Chapter 6

Art and Drawing in Radiology Education Kitt Shaffer and Nicholas Spittler

Abbreviation VTS Visual thinking strategies

Introduction There are at least three ways to think about the potential role of art in radiology education—as a method of honing observational skills, as a way to foster creativity and maintain resilience, and as a way of illustrating findings in an educational setting. Much has been published regarding the first two topics, but not as much about the third. In fact, there is a well-described framework called visual thinking strategies (VTS) that has been used as a method of making visual assumptions transparent as well as fostering teamwork, active listening skills, and validating multiple viewpoints. In Part I of this chapter, details about VTS are presented with evidence for its potential role in enhancing visual reasoning, which is particularly important in radiology due to the visual nature of the specialty. In Part II, information is provided regarding the possible value of art, observational, and participatory, in fostering creativity and preventing burn-out through enhanced resilience. In Part III, the role of real-time drawing by an instructor as a tool for illustrating imaging findings in educational settings is explored, including information on technical aspects of live drawing in various common teaching venues. K. Shaffer (*) Department of Radiology, Boston Medical Center, Boston, MA, USA N. Spittler Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_6

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 art I: Structured Observation of Art to Enhance P Visual Reasoning Visual thinking strategies (VTS) was initially developed by Abigail Housen, a cognitive psychologist, and Philip Yenawine, an art educator [1, 2]. The basic technique is deceptively simple. A group observes a piece of art, which can be two-­dimensional, three-dimensional, video or any other visual medium. One person in the group acts as the facilitator. The facilitator uses a limited number of well-defined steps to guide the discussion. These steps begin with an initial question to the group (“What is going on in this work?”), with follow-up of each response in a carefully structured way. For each observation, the facilitator probes the assumptions of the observer by paraphrasing what has been said (requesting confirmation for accuracy from the initial observer), and then asks “What is it in this work that you are seeing that makes you say that?”. The cycle is repeated by asking “What more can we find?”, with the same paraphrasing and probing for each subsequent response. Participants are encouraged to offer alternative interpretations for what is being seen. No one viewpoint is considered as the truth. The role of facilitator can rotate among group members for different works, giving each member a chance to develop robust active listening skills. The discussion in a VTS session often goes in unexpected directions. New participants may start by thinking “I am not sure I like this work, or will have anything to say about it,” but once the conversation begins, and observers make comments or offer alternative explanations for what they are seeing, the richness of different viewpoints becomes evident. One of the major benefits of this experience is to demonstrate the range of perspectives that are possible and to become more comfortable with uncertainty. The role of facilitator is particularly challenging, which is counter-­intuitive given the proscribed nature of the leading questions that are used. It is in the paraphrasing and confirmation of what has been said that the vital role of active listening becomes compellingly evident. The entire group interaction is greatly enhanced by asking each member to rotate as facilitator, as this fosters active listening by all participants, even when they are not acting in the facilitator role. Many papers have been published on the value of VTS in medical and allied health fields [3–5]. In addition to obvious potential benefits in terms of accurate and logical interpretation of visual cues, which could have pertinence in physical diagnosis [6], other benefits have been shown. The active listening and sharing of views lead to enhanced communication skills, enhanced humanism and more acceptance of uncertainty, particularly when contemporary art is used [7]. With particular reference to radiology, VTS sessions have been shown to increase the vocabulary used to describe imaging findings, the amount of time spent studying the images, and the number of clinically relevant observations made [8]. The use of VTS directed toward social determinants of health in a resource poor setting led to better understanding of these issues by medical students [9].

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 art II: Art Appreciation and Participation to Foster P Creativity and Prevent Burn-Out Engagement with visual art is another way to avoid burn-out and has been demonstrated to foster creative thinking and perspectives that can take observers out of themselves and into a larger realm [10]. Active participation in a creative task has been shown to increase neural connections, and may work against aging changes in the brain [11]. Creating art seems to make more new connections than observing and thinking about art, as shown in one study of retirement-age subjects with fMRI [12]. The group that actively made art developed significantly more new neural connections and scored better on a test of resilience that the group that engaged only in observation and discussion of art. One method that can stimulate creative thinking as well as teamwork is to divide participants into groups of 8–10, and provide each group with the same inexpensive raw materials—pipe-cleaners, cardboard, markers, wire, crayons, tubing, scissors, glue, tape, for example. Then ask the groups to construct something to illustrate a topic or a concept. The value of forced teamwork in a low risk environment has been demonstrated using foam board or spaghetti for construction materials [13]. Groups can compete for a prize, with each group demonstrating their product to the entire room of participants, introducing a gaming aspect that can also enhance engagement [14]. Such an experience can quickly break down barriers in a new group and foster more open communication. Another method of participatory art is a drawing exercise that can be used prior to an interactive learning session (for example, on mediastinal contours on radiography). In order to attune the group to the visual importance of attention to contour details, and the effect of slight changes in perspective on the appearance of complex shapes, participants are arranged in rings around any three-dimensional sculpture. If not conducted in a museum setting, small figurative sculptures or any objects with complex contours can be used. In a classroom, sculptures may be placed on tables, with participants seated around the objects. Participants are each given a drawing support (a firm cardboard square is fine for this), a piece of drawing paper (white or colored, smooth or textured paper, clipped to the support), and a drawing implement (colored crayons or charcoal in dark colors work well). Participants draw the object for about 3–4 min for the first round, and then each participant lays down their drawing (on its support) and drawing tool, and moves in a clockwise fashion to the next perspective on the object. After the first round only 1 min per view is allowed before the next shift to a new drawing spot. Collaboration in creation of art can help those who feel uncomfortable with the medium to feel more free and willing to participate, allowing each to make a contribution to the drawing in whatever way they choose. In this exercise, each drawing becomes a team project and participants find themselves freed from concern about their own perceived drawing skill. With about eight participants in a group, a completed drawing takes about 15–20  min (allowing time for shifting position). The results are often astounding and the debrief at completion of the exercise is always

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interesting. As a facilitator, it is helpful to circulate during the actual drawing portion of the session to encourage participants to focus on the contour of the object. Such collaborative group art activities have been shown to help participants to overcome reluctance or feelings of inadequacy [15, 16]. A group drawing exercise with a focus on contour and perspective can then be reinforced in a teaching session on an anatomic region where contour is important, such as the mediastinum. For the mediastinal session, each participant is initially given two printed pages that each show a modified chest radiograph image with the mediastinum removed (Fig. 6.1), and a white crayon. Participants are asked at the start of the session to draw the normal contour of the mediastinum on the image with the white crayon. Next, a series of cases demonstrating normal and abnormal mediastinal examples (using a website with built-in drawing features, Fig. 6.2). Web images include photographs of a three-dimensional model of the heart (constructed from CT data using inexpensive materials such as foamboard, Fig. 6.3). Cases are presented using socratic methodology, calling on individuals to discuss cases. Participants are then asked to use the second printed image to draw the mediastinum again. Virtually all participants feel more confident in their second contour drawing, and can easily assess how much they have learned about components that make up the mediastinum through comparison of the two drawings (Fig. 6.4). During the pandemic, when group activities were curtailed, a version of this teaching session was developed using a free open-source virtual whiteboard program (SketchPadPro, timescraper.com) for the drawing exercise, and the same teaching website (Fig. 6.5). Fig. 6.1  Digital chest radiograph with mediastinum removed using photo processing software

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Fig. 6.2  Website showing thumbnails of images used in the interactive session on mediastinal contours

Fig. 6.3  Heart model constructed from CT data: enlarged CT slices were placed on foamboard, cut to size, glued, and stacked, then painted. The image on the right is a photograph of the model, altered with a photo-processing program to emphasize contours of structures

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Fig. 6.4  Example of initial mediastinal contour drawing (prior to the interactive case discussions), and final mediastinal contour drawing, showing more important anatomic details

Fig. 6.5  Initial webpage for the drawing exercise. Students were divided into breakout rooms with no more than six participants per room. Each room started their drawing from a different perspective, but then “passed” their drawings on so that each breakout group produced six total drawings, with each participant contributing to each drawing

The drawing exercise link displays images of a figurative sculpture from different perspectives to be used for the initial collaborative drawing part of the exercise (Fig. 6.6).

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Fig. 6.6  Top image shows one perspective on the sculpture and an adjacent area for drawing. Bottom images are examples of other perspectives on the same sculpture

Participants were able to “pass” their drawings to each other, contributing to sketches from many different angles, with a facilitator keeping track of time on Zoom, sending out chat messages when it was time to move on to the next drawing. In this way, the collaborative drawing experience could be simulated via distance-­ learning methods, with results similar to the in-person event. The drawings possible with this program are every bit as interesting as those obtained in person (Fig. 6.7). The remainder of the mediastinal exercise was conducted using Zoom (Zoom Video Communications, Inc.). The empty mediastinum images were transmitted digitally to participants, who could either annotate online or print and draw on, followed by the interactive tutorial reviewing contour abnormalities of the mediastinum. A link to the collaborative whiteboard program was given to participants a week before the actual teaching session, along with a list of tasks to complete, so

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Fig. 6.7  Example of drawing that can be produced using the collaborative whiteboard program

Fig. 6.8  Webpage for participants to practice use of the whiteboard program prior to the teaching session

that participants could become familiar with the drawing tools before the teaching session (Fig. 6.8).

Part III: Art and Active Drawing as a Teaching Tool Studies have shown that drawing as an instructional technique has unique value, particularly in visually oriented topic areas, such as anatomy and histology. Having students draw histology slides increases their retention of learning [17]. Live drawing

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during anatomy instruction was preferred by students compared to slideshows, and students who were taught in this manner had better immediate and late retention of material [18]. Other papers advocate drawing as a learning tool in biology [19], in surgery education with inclusion of sculpture for 3D visualization [20], and in anatomy [21]. Modeling with play dough has been described to better visualize relationships in cerebral aneurysms [22]. A guide has been published on best practices for use of modeling in classrooms to dynamically translate 2D into 3D [23]. A simplified drawing method, cartooning, has been shown to be an effective tool for teaching health professionals about hepatitis B [24], and to teach pediatric and adult patients and hospital personnel about many medical and health issues in an approachable and humorous way [25]. In the early days of radiology education, teaching was often performed at a viewbox with films and was most often case-based [26]. Emphasis was placed on appropriate and supportive question formulation to optimize assessment of problem-solving approaches as well as recognition of findings. Clinical information was given as needed to tailor the discussion, with alternatives offered to broaden the differential. Images could be annotated on the fly using dry-erase markers to outline complex shapes and subtle findings. Alcohol wipes allowed removal of marks for the next session. With the shift to digital imaging, this same teaching method could be adapted for use with digital images [27]. A photo editing program (Photoshop, Adobe Systems) can be used to open full resolution images in DICOM, or convert files to other formats including native PSD files. For complex structures, the layer feature in Photoshop can be used to pre-draw structures that would be too difficult or time-consuming to draw on the fly (Fig. 6.9). Layers can easily be made visible or invisible during a teaching session. In order to have more control of the actual drawing process, a digital drawing table connected to a laptop with a USB, and a pressure-sensitive stylus allow more motor control of the drawing process than is feasible with a trackpad or mouse. Fig. 6.9  Example of image with complex drawing on a separate layer, that can be made visible during teaching with a single click

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Fig. 6.10  Teaching website, with a limited palate of drawing tools allowing free-hand annotation of images in real time. Tools include image inversion, adjustment of brightness and contrast, typing of text, erasing, selection of color, filling of areas, a pointer, and magnification

However, photoshop is a complex program and has many features not necessary or designed for presentation and teaching. Digital drawing tablets suffer from interface issues and are not compatible with all operating systems. Another option is to design a website with a limited set of necessary drawing tools, and to upload images for teaching sessions (Fig. 6.10). The use of the website also allows more portable access to teaching files and fewer interface challenges, as the site can be accessed from any computer with an internet connection. With this website model, an iPad and Apple Pencil (Apple, Inc) can be used to draw on images instead of using a digital drawing tablet. A smartboard with stylus also works well. Movies can be uploaded providing a feature that is not possible with Photoshop—drawing on movie images. After converting to a web-based format, movies can be scrolled with drawing possible on each individual movie frame in real time (Fig. 6.11). Case-based hot-seat teaching remains the gold standard in radiology education, providing the most realistic simulation of the actual work done by a radiologist [28, 29]. Case-based teaching can work well, regardless of the venue. Live drawing with case images has been successful in settings ranging from auditoriums filled with 200+ students, to 10 students in a small group session. Granted, the larger formats are more stressful for students, but an explanation of the educational value of

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Fig. 6.11  Example of display of a movie file with scrollable cross-sectional images that can be moved using the scrubber bar at the bottom of the page. The same drawing tools and text tools can be used on each movie frame

case-­based and interactive teaching goes a long way toward convincing learners of the value of this activity, despite the stress involved. Intense vicarious learning [30] offers value to all in the room, not only the student actively discussing the case. With careful attention to non-judgmental question formulation, and supportive flexibility to allow each participant to experience satisfaction of correct answers, this method can be adapted to virtually any teaching setting. A free PACS emulator, such as Horus (Horus Project) can be used to provide an accurate example of actual radiology image presentation and workflow [31]. To encourage participation from all students, a flipped classroom approach is advantageous [32], allowing students to preview images and formulate theories regarding cases prior to the in-class sessions, giving them more confidence to be take part in classroom discussions. The ability to randomly access images, either on a laptop using file folders or on a website, also allows non-linear discussions to unfold based on learner goals and questions rather than instructor pre-planned organization.

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Conclusion The relationship between art and medicine has a long and rich history, beginning with anatomic drawing [33]. In recent years, better understanding has been gained of the potential for appreciation and creation of art as a remedy for burnout and a way to foster flexible, creative thinking [34]. Collaborative exercises can be an effective way to make those without personal experience in drawing more comfortable with this learning method. And live drawing by an instructor is a particularly effective way to provide interactive teaching of visually-based topics, such as radiology. As visual thinkers, radiologists are naturally drawn to many of these teaching methods as well as to art as a way to experience beauty and to provide a source of fulfillment, which is vital to ongoing success in the stressful world of medicine.

References 1. Housen A. Aesthetic thought, critical thinking and transfer. Arts Learn J. 2002;18:1. 2. Yenawine P.  Thoughts on visual literacy. In: Handbook of research on teaching literaciy through the communicative visual arts. MacMillan Library Reference; 1997. 3. Klugman CM, Peel J, Beckmann-Mendez D. Art Rounds: teaching inerprofessional students visual thinking strategies at one school. Acad Med. 2011;86(10):1266–71. 4. Bentwich ME, Gilbey P. More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy. BMC Med Educ. 2017;17:200–9. 5. Chisolm MS, Kelly-Hendrick M, Wright SM. How visual arts-based education can promote clinical excellence. Acad Med. 2021;96(8):1100–4. 6. Naghshineh S, Hafler JP, Miller AR, Blanco MA, Lipsitz SR, Dubroff RP, Khoshbin S, Katz JT. Formal art observation training improves medical students’ visual diagnostic skills. J Gen Intern Med. 2008;23(7):991–7. 7. Schaff PB, Isken S, Tager RM. From contemporary art to core clinical skills: observation, interpretation, and meaning-making in a complex environment. Acad Med. 2011;86(10):172–6. (comfort with ambiguity). 8. Agarwal GG, McNulty M, Santiago KM, Torrents H, Caban-Martinez AJ. Impact of Visual Thinking Strategies (VTS) on the analysis of clinical images: a pre-post study of VTS in first-­ year medical students. J Med Humanit. 2020;41(4):561–72. 9. Allison J, Mulay S, Kidd M. Life in unexpected places: employing visual thinking strategies in global health setting. Educ Health (Abington). 2017;30(1):64–7. 10. Mangione S, Chakraborti C, Staltari G, Harrison R, Tunkel AR, Liou KT, Cerceo E, Voeller M, Bedwell WL, Keaton Fletcher BS, Kahn MJ. Medical students’ exposure to the humanities correlates with positive personal qualities and reduced burnout: a multi-institutional US survey. J Gen Intern Med. 2018;33:628–34. 11. McFadden SH, Basting AD.  Healthy aging persons and their brains: promoting resilience through creative engagement. Clin Geriatr Med. 2010;26(1):149–61. 12. Bolwerk A, Mack-Andrick J, Lang FR, Dorfler A, Mainhofner C. How art changes your brain: differential effects of visual art production and cognitive art evaluation on functional brain connectivity. PLoS One. 2014;9(7):e101035. 13. Somerville M, Horton A, Frey D. Breaking the ice with prospective students: a team-based design activity to introduce active learning. In: Proceedings of Conference on Frontiers in Education, Boston, MA, USA; 2002. p. T1A1–6.

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14. Verzat C, Byrne J, Fayolle A. Tangling with spaghetti: pedagogical lessons from games. Acad Manag Learn Edu. 2009;8(3):356–69. 15. Nimmer D. Art from intuition: overcoming your fears and obstacles to making art. 2014. 16. Park J, Kang JR. Assessing the six-member collaborative drawing technique with the collaborative art elements scale. Arts Psychother. 2017;59:75–82. 17. Balemans MCM, Kooloos JGM, Donders RT, Van der Zee CEEM. Actual drawing of histological images improved knowledge retention. Anat Sci Educ. 2015;9:60–70. 18. Alsaid B.  Slide shows vs graphic tablet live drawing for anatomy teaching. Morphologie. 2016;100(331):210–5. 19. Quillin K, Thomas S. Drawing-to-Learn: A framework for using drawings to promote model-­ based reasoning in biology. CBE-Life Sci Educ. 2015;14:1–6. 20. Card EB, Mauch JT, Lin IC. Learner drawing and sculpting in surgical education: a systematic review. J Surg Res. 2021;267:577–85. 21. Amin A. ‘Drawing’ to learn anatomy: exploring the theoretical underpinning and conditions favouring drawing based learning. J Pak Med Assoc. 2020;70(11):2017–22. 22. Eftekhar B, Ghodsi M, Ketabchi E, Ghazvini AR. Play dough as an educational tool for visualization of complicated cerebral aneurysm anatomy. BMC Med Educ. 2005;5(15):1–4. 23. Wilson KJ, Long TM, Momsen JL, Speth EB. Modeling in the classroom: making relationships and systems visible. CME Life Sci Educ. 2020;19:fe1. 24. Sim MG, McEvoy AC, Wain TD, Khong EL. Improving health professionals’s knowledge of hepatitis B using cartoon based learning tools: a retrospective analysis of pre and post-tests. BMC Med Educ. 2014;14:244–52. 25. McDermott TJ.  Cartooning: a humorous approach to medical and health education. J Biocommun. 1989;16(4):20–7. 26. Miller RE, Andrew BJ.  View box exercises for teaching problem solving in Radiology. AJR. 1976;128:271–2. 27. Su TJ, Shaffer K. Reinventing the apprenticeship: the hot seat in the digital era. Acad Radiol. 2004;11(11):1300–7. 28. Phelps A, Fritchle A, Hoffman H.  Passive vs. active virtual reality learning: the effects on short- and long-term memory of anatomical structures. Stud Health Technol Inform. 2004;98:298–300. 29. Bucklin BA, Asdigian NL, Hawkins JL, Klein U. Making it stick: use of active learning strategies in continuing medical education. BMC Med Educ. 2021;21(1):44. 30. Roberts D. Vicarious learning: a review of the literature. Nurse Educ Pract. 2010;10:13–6. 31. Sugi MD, Kennedy TA, Shah V, Hartung MP. Bridging the gap: interactive, case-based learning in radiology education. Abdom Rad (NY). 2021;46:5503–8. 32. Riddell J, Jhun P, Fung CC, Comes J, Sawtelle S, Tabatabai R, Joseph D, Shoenberger J, Chen E, Fee C, Swadron SP. Does the flipped classroom improve learning in graduate medical education? J Grad Med Educ. 2017;9(4):491–6. 33. Dahan S, Shoenfeld Y. A picture is worth a thousand words: art and medicine. Isr Med Assoc J. 2017;19(12):772–6. 34. Reed K, Cochran KL, Edelblute A, Manzanares D, Sinn H, Henry M, Moss M. Creative arts therapy as a potential intervention to prevent burnout and build resilience in health care professionals. AACN Adv Crit Care. 2020;31(2):179–90.

Chapter 7

Workstation Teaching Susan Hobbs

A Definition Radiology trainees learn by interpreting imaging cases at the workstation. This is our predominant clinical patient environment. Traditional learning is when the trainee reviews the case and creates a report to be reviewed with a faculty member. The faculty member and the trainee then review the case together, the report is edited by the trainee or faculty member, and subsequently the faculty member attests to reviewing the study and final signs the report. Not so long ago this term consisted of view-box or alternator teaching. Evolving language includes newer modes of reviewing cases such as remote, asynchronous, and virtual readout session. Regardless of the term, trainees learn by initially reviewing cases at the workstation and subsequently receiving feedback on their interpretation of each case. The expected end of residency result is a colleague competent in the radiology subspecialties and with the ability to seek out new information, review information that they may no longer recall, and the skills for continued education in their daily practice.

An Evolution The transformation from view-box teaching to workstation teaching represents a shift in pace. There has been continual increase in speed of imaging from the modalities of CT, MRI, and US. In addition, there is increasing data arising from each S. Hobbs (*) Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_7

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exam. These factors have been indelibly involved in this shift to the current workstation-­based teaching experience. Radiology is a visual specialty and relies on identification and synthesis of large datasets to create a description of the findings or a diagnosis. For example, in the 1990s a chest CT may have been reconstructed at 10  mm slice increments; now standard of care is to display the data at 1.5 mm slice increments or thinner. In addition, the datasets can be displayed in the coronal or sagittal imaging plane, soft tissue and lung window algorithms, and MIP or MinIP reconstructions may transmitted to the PACS system for review, depending on institutional protocols. Thus, at a minimum the data submitted for interpretation is significantly increased as compared to that submitted 30 years ago. The technology has advanced in additional ways as new MRI sequences are added, new contrast agents have been developed and brought to clinical practice, and new CT technology such as dual energy CT has become available. These new technologies are often additive to the existing sequences/images rather than replacing parts of the exam. The cost is increased time of interpretation for each study, with a concomitant increased risk of image fatigue, particularly at the trainee level. The increased data available in a study is accompanied by increased speed of the technology. A CT scan can be acquired in seconds. Depending on the exam; the entire patient interaction in the modality is 10 min. This has led to increased patient throughput. It is not unusual for there to be 50 or greater CT exams placed on a subspecialty workstation list from a single imaging site. Thus, there has been a concomitant increase in volume of studies to interpret. In addition to the fast-paced evolution of technology and associated increase in caseload, the landscape of healthcare systems has changed over the past 30–40 years. Academic/Teaching hospitals may have associated centers of excellence, Level I trauma centers, transplant centers, cancer centers, and children’s hospitals to name a few specialty options. This often means that patients presenting for imaging evaluation at these sites are complex and may have incomplete histories. Many hospitals are merging and becoming “enterprises”; thus, leading to complexity in patient imaging distribution with patients preferably imaged where they live. This leads to increasing volumes and increasing complexity of the cases at the regional sites, which in turn may lead to increasing volumes of cases presented to the academic subspecialist. Academic radiology departments like many academic departments have by necessity become more productivity based. This leads to a conflict between patient care, teaching, and research obligations in radiology departments. Turn-around times have become important as quality measures for the hospital, however the cost of a resident-driven workflow is often not included in the metrics. It is estimated that resident driven workflows slow turn-around times [1]. This leads to decreased productivity by supervising faculty members, estimated at a 50% reduction in output [2]. This may adversely impact teaching faculty salaries or incentives depending on the compensation structure of the academic institution. Further complicating matters is the fact that the direct and indirect cost of teaching residents is not often included in physician compensation schemes [3]. Finally, COVID-19 has accelerated a change in the landscape of academic centers. Whereas previously, remote or teleradiology practice was primarily located in

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private practice settings, now the opportunity for remote educators in radiology exists. Historically, readouts occurred with the faculty radiologists at the workstation. As a result of COVID-19, per necessity these readouts ceased in many locations during the height of the pandemic and faculty began to work at home. This remote work changed the quality of life metrics for faculty, and many decided to leave the field. This may have a profound impact on training residents in the future [4]. In summary, a partial list of challenges for the radiology educator includes: • • • • • • • • •

Increased volume of cases due to increasing image utilization and regionalization; Increased complexity of cases if at a tertiary or quaternary care setting; New and continually advancing imaging technology; New and continually advancing treatment options with variable imaging patterns; Lack of incentive or reward for teaching/value placed on RVU productivity; Unpredictable or inconsistent types of cases available during a rotation; Faculty interests or focus outside of teaching, i.e. research or administration; Difficulty engaging in the different levels of residents at the workstation; Remote faculty, either by design or for other reasons.

Reframing the Workstation Teaching Mission In this chaotic and everchanging landscape, how do we maintain the daily educational mission of the radiology department? A broad amount of medical knowledge and pattern recognition must be quickly recalled with every study interpreted. Increasing discussions related to best imaging modality for different disease must be had. Increasingly, radiologists are expected to suggest next steps in the management of disease. In essence, the workstation curriculum is vast and critically important to successful radiology careers. The trainee must learn to incorporate large or small amounts of clinical information, anatomic and/or pathologic findings, and management and distill this into a concise reported impression. The success of the radiology field relies on educators and academic departments being innovative, engaged, and prioritizing the learning environments of the trainees. It is not enough to model ourselves after our past experiences as the current technological and imaging utilization explosion is not the same as prior view-box teaching. Radiologists are innovative and we can be innovative in the clinical education world. The aim of this chapter is to provide a foundation or launch-pad for the academic radiologist to create the learning environment that works best at their institution.

Changed Role of Faculty at the Workstation In order to become board certified radiologists, all trainees must pass the American Board of Radiology Core Exam, which is an image rich multichoice question (MCQ) exam. This multiple-choice format has replaced the traditional oral board

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examination that view-box teaching lent itself to extremely well. Efficient and effective teaching should take into account the cognitive skill levels to succeed as a radiologist which will help the trainee as it comes to this first exam and subsequent exams. Details about the sequence of exams is found at https://www.theabr.org/ diagnostic-­radiology and https://www.theabr.org/interventional-­radiology.

Creating a Positive Clinical Learning Environment It is important for each faculty member or faculty group to set a consistent and positive learning environment for themselves and the trainee. This encompasses the ACGME acknowledgement that the learning and working environment has a significant role in the education of trainees [5]. A review of the Common Program Requirements in regard to the Clinical Experience in Radiology is reviewed in the article by Olivera [6]. The faculty model the expectations of their trainees. This begins by setting the tone at the beginning of the day with introductions and expectation setting. An example of how this could look is modeled in Table 7.1. This can be done in both the in-person and remote environment [7]. In addition, it is important that feedback on resident performance at the workstation be timely, specific, and actionable. It is also important that as we consider how busy we become at the workstation that we do not inadvertently set a negative implicit curriculum that is not helpful to the profession. It is important to ensure that the unwritten curriculum regarding the everyday environment is positively modeled [8].

Understanding the Curriculum It is imperative that each teaching faculty member understand their rotational expectations. This information should come from the subspecialty core faculty member (educational director) and/or a program director. This rotational expectation should be discussed among members of the subspecialty or practice. The faculty should Table 7.1  Positive clinical learning environment Method Introduce yourself Informal interaction to get to know the trainee Your working style Assess their comfort level for the day

Rationale This is particularly important for the first-year residents This should be nonintrusive but should establish some rapport May not be needed every day Everyone works differently

Milestone category Interprofessional and team communication

Professionalism Professionalism

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feel competent to teach this material, which goes hand in hand with faculty participation in continuing medical education and maintenance of their certification in the field. This models the life-long learning aspect of the ACGME curriculum and is an unwritten part of residency education. The first step in any rotation/curriculum should be to develop the basic information regarding exams, anatomy, physiology, and pathology. However, this is not always applicable, and it is difficult to retain this vast amount of material without experiential context. Developing critical thinking skills at higher levels of competency is the overall goal of radiology education. There are plenty of books, journals, and video media available for radiology residents to learn material, all of which serve to build foundational medical knowledge. It is the synthesis of the physics, pathology, physiology, that is critical to the success of a rotational experience. Clinical cases seen on any given day may derive from different modalities (X-ray, US, CT, and MRI) or body part (thoracic, musculoskeletal, or neuroradiology) and even ages from newborn to adult depending on the rotation and institution. A busy general  clinical service, or a service such as pediatric imaging  that encompasses multiple ages and modalities make it difficult to coherently teach. This disruptive and sometimes inconsistent pattern in disease encounter is clearly different from a didactic teaching session. In addition, faculty schedules are variable. It may be the case that the number of service sites and rotation schedules mean that a faculty member teaches a resident on 1 day and does not see them again for a week. Teaching at the workstation is variable due to differing teaching styles, differing emphasis on “important” findings, different data collection, and different perception and interpretation amongst the teachers. Thus, there is no continuity in educational material or assessment when relying on workstation teaching, making it difficult to ensure that the depth and breadth of required curricular teaching occurs.

Bloom’s Taxonomy Utilization at the Workstation Given the above challenges, each moment with a trainee becomes critical. Workstation education is important as this is the place where residents consolidate all the information received regarding patient history, past medical knowledge, radiology findings, technological information, and practice. It is not as important to review each and every ICU chest film a resident interprets as it is to ensure the trainee is aware of anatomy, can identify lines and tubes and their purposes, and can identify and problem-solve unexpected findings or significant change [9]. In addition, the faculty will model the expected practice should they encounter an object or surgical procedure not previously encountered or need to communicate directly with the primary provider. Bloom’s taxonomy was originally developed for comprehensive examination development, but the principles can be applied to radiology education. A rudimentary understanding of cognitive learner levels in the revised Bloom’s taxonomy can

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Table 7.2  Abdominal imaging application of Bloom’s taxonomy Level I: Knowledge/recall II: Comprehension

III: Application IV: Analysis V: Synthesis VI: Evaluation

Example Anatomy: Appendix is located in the right lower quadrant History given is right lower quadrant pain. The trainee will understand the appropriate use of US, CT, and MRI in the diagnosis of right lower quadrant pain The trainee will look for appendicular pathology in addition to other potential abnormalities in the right lower quadrant Does this look like appendicitis, ruptured appendicitis, cancer, or other pathology? Do the findings on the exam explain the patients right lower quadrant pain and/or the clinical concern for appendicitis? Create the appropriate imaging algorithm for right lower quadrant pain based on patient age, symptoms

be helpful in framing the individualized educational mission at the workstation. An example of learner levels for a radiology resident is included in Table 7.2. The first two levels in Table  7.2 involve foundational knowledge and pattern recognition of pathognomonic imaging appearance or expected imaging appearance. This is an expectation that the resident has achieved these levels prior to starting the rotation and there may be educational material or didactic content available to the trainee prior to the start of the rotation. Thus, the faculty may expect that an R1 resident on their first thoracic rotation be able to identify lobar pneumonia rather than having to teach the appearance at the workstation. Depending on the level of the resident, a faculty member should have a clear expectation of the learning experience on the case. For example, the abdominal imaging division may expect that the R4 resident identifies the presence of the appendix in the right lower quadrant, identifies that it has ruptured with an abscess on the CT and has put in a call to the emergency medicine team caring for the patient. The next step is then to investigate the rest of the exam. Is there an incidental ovarian cyst or renal lesion that may need follow-up management or imaging? However, when reviewing a similar case with an R2 resident the teaching points may center on the different potential locations of the appendix and what the alternative pathology might look like and be located [9]. It should be acknowledged that for a visual clinical specialty like Diagnostic Radiology the perceptual skills and the integrative or interpretation skills will not develop synchronously. In the first year, the time spent on anatomy and expected physiology or pathology should be emphasized. In the last 2 years, these should be mastered, and the emphasis should be on proposing a differential diagnosis and the synthesizing the amount of data acquired in an image. In other words, the trainee should create a concise and clear impression based on all the information provided rather than recapitulating the findings. Each rotation should have clear learning objectives and these learning objectives should be level-based. These objectives should be those that will best be assessed at

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Table 7.3  Pediatric Radiology objective example After the first rotation in pediatric radiology the trainee will be able to Identify normal anatomic structures on radiographs

Identify the expected course of support devices in the abdomen or chest X-ray Identify when normal anatomy and expected positioning of devices is violated and list potential etiologies on radiographs Review the electronic medical record to identify support for their differential diagnosis in regards to abnormalities in anatomy or device placement on radiographs

After the third rotation in pediatric radiology the trainee will be able to Identify the complications that result from the most common congenital heart diseases on chest X-ray, CT, and MRI Describe the surgical procedures to repair the defect and their appearance chest MRI, CT, X-ray Understand the reason for the cardiac MRI in the setting of heart failure in congenital heart disease status post repair Create a detailed report to convey findings, interpretations, and management options to the consulting specialist

the reading station: i.e., is that patient in appropriate position, is the acquisition of the Doppler wave form appropriate? In effect, what we want is that  the resident acquiring knowledge from a book, lecture, webinar or a YouTube video apply that knowledge to the case in front of them. An example of an objective is given in Table 7.3. It is not possible or feasible to create these granular rotational objectives for each rotation. Nor is it feasible for faculty or residents to recall such granular expectations daily. However, this granularity may be important in the first year of residency for clarity of expectations and to set a solid base for future resident learning. Having an understanding of the general cognitive learner level expectation for a type of exam or pathology commonly seen in the subspecialty can level-set for the assessment of the residents ACGME milestones. Radiologists’ curriculum is usually set yearly and in 1-month blocks. One may have musculoskeletal radiology at the beginning of R1 year and then not return to that experiential rotation for 10–12  months. However, there are usually spaced lecture/ didactics throughout the academic year as well and general call shifts which will lead to repetitive variable spacing of exposure to the subspecialty. Retrieval-­based learning should be emphasized in the R1 year as the residents are establishing their basic knowledge and search patterns. How can the faculty best support this learning method? If the resident reads 10 wrist X-rays in their R1 rotation, focus on the learning objectives for that year. Emphasize that this is the expectation for and of themselves as they move forward in training. Obviously, if they have mastered those objectives before the end of the first rotation; move to the next rotational objectives in a similar pattern. One does not need to review every item on every film but there should be enough random repetition that the residents are held accountable for that competency. The faculty are held accountable for educating to the objective. If they are an R2 or above, utilize the study to review with you the abnormal findings, next steps, additional imaging expectations. The normal exams with clear, concise, correct results, and interpretation may not need direct resident feedback other than a final signed report.

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Efficient and Effective Workstation Teaching Every faculty member should develop their own teaching style and many are familiar with the traditional precepting model which focuses on closely reviewing each patient. In radiology, this typically involves the faculty siting side-by-side with the trainee, reviewing the images while the resident is either quiet or pointing out their findings. The faculty asks questions about the patient and there is a final discussion regarding the impression and management. This is repeated for a series of cases depending on the number of cases previewed by the resident. The resident may be correcting the report during this readout but often continues to correct after the readout. The completed report is then sent to the faculty member to final sign and attest to review of the case with the trainee. Some faculty, edit the case during the readout and final sign at the time of the review. This removes the resident from a portion of the educational process as they may not have an opportunity to review the case for the discrepancies in read. This is a time-consuming method and much of the time devoted to the case is not spent in education. Busy clinical practices and remote learning in combination with competence-­ based education requires more trainee assessment. The above education scheme may lead to shortcuts where the faculty quickly reviews cases with trainees and makes changes to reports without exploring why the resident erred, providing more information on the importance of the correction, or providing resources for the trainee. Radiology educators can learn skills that may make them more efficient at the workstation and allow them to assess the understanding of the trainee. Two examples of time-efficient teaching strategies are described in this section. In the One Minute Preceptor (OMP) method [10]; the educator obtains a diagnostic or management commitment from the trainee and then provides feedback and correction. This is an accepted tool in the ambulatory clinical setting [11]. The five steps in the OMP method are outlined in Table 7.4. The first step in the OMP model is often the hardest to master; however, this commitment step harkens back to “hot-­ seat” case conferences. The clinical learning environment should foster the trainee to offer their interpretation of the case whether it be right or wrong. The educator Table 7.4  One Minute Preceptor Microskills 1 Commitment 2 Supporting evidence 3 Reinforce the general teaching point 4 Positive reinforcement 5 Correct mistakes

Ask the resident to provide their impression or next steps in management of the case Ask them to provide their reasoning for this impression, their evidence, and/or their thought-process Summarize the take-away points from the case and reinforce the application to subsequent cases Let trainee know if it was a good synthesis of the case Don’t avoid this step. If you need to point out mistakes make them specific, timely, relevant and provide learning resources

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should refrain from seeking additional information about the case prior to obtaining the commitment. This additional information may be an important part of the feedback or teaching moment. The second step in the OMP model is to ask the resident to reflect on what supported their final diagnosis. This step could include a request for differential diagnosis, a discussion of the findings, and/or a request for medical record review. This step should seek information from the trainee that is pertinent and specific to the case. The third step of this method is to teach the general concept of the case. This should be factual and avoid individual idiosyncratic preferences. It has been proposed that this step should be thought of as imparting a “general rule.” The trainee should not be learning that with Radiologist A they follow rule A and with Radiologist B, they follow rule B. There are acknowledged disagreements in management plans but these differences should be evidence-based. If there is no new information to impart; then this part may be skipped. Finally, it is important to provide both positive and negative feedback. This feedback can and should include suggestions for reference articles or texts to review. It is important to provide the positive feedback to reinforce the competency. This should focus on behaviors that the resident should be able to repeat consciously. The generic “good job” does not inform the resident what specifically was the good job. Likewise, mistake correction should be specific to the case. The feedback; both positive and negative, should be specific and/or interactive. This OMP has been utilized in radiology departments with a sample study published in India [12]. Utilizing the OMP tool; the educator will avoid lecturing and encourage independent thinking and the ability to assess the learner’s competence in a short span of time. As the trainee progresses through their residency, the efficiencies become more apparent as the educator will spend less time trying to clarify the data and give minilectures. The approach aims to foster discussion regarding the general concept of the case and to provide feedback to the trainee that they can use in the future when faced with a similar problem. However, it should be noted that for some cases and dependent on resident level, this model may not be appropriate. For more complex cases or teaching a new modality, the radiologic adaptation of the 5-min moment may be more appropriate. The 5-min moment is a tool used to teach physical examination skills to trainees [13]. The framework for this type of session is outlined in Table 7.5. This can be used in radiology to explain the context and usefulness of pattern recognition, chart review, or other basic competency that is needed to review a study. The second part of this method is to demonstrate the competency. This can be done utilizing the current case or prior saved teaching cases. Many PACS systems have teaching case capability and thus companion cases can be pulled up rapidly. Finally, this technique involves returning to review the relevant history needed, patterns of disease, and differential diagnosis. This model may also be useful in the group readout situation.

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Table 7.5  The 5-min moment Narrative: This is the story of why being able to identify the _____ sign Historical Previously only X-ray If possible bring in examples from perspective the PACS teaching files Clinical vignette Personal experience or a compelling Discuss the bad outcome or the case. Bring in the missed case or the great outcome great call case Discuss the importance of the radiologist correlating the patient signs and symptoms to the findings Expected Review the expected findings for the disease entity and why the DDX from examination the resident might not have been inclusive. Or was spot on and just findings reviewing. Or the prior impression was incorrect Interpretations Describe the next steps Management recommendations. Incidental findings. If need to call or not Caveats and errors

Individual Vs. Group Readout Group readout can be a beneficial collaborative learning tool and if facilitated by the educator can introduce the trainees to specific pathology or exam types that they might have limited exposure to. In this setting, the faculty would review the service residents’ cases prior to the readout session. They would set aside cases with teaching points, common misses, or good discussion cases. The trainees are asked to designate exams about  which they have specific questions. At a designated time, the trainees and faculty spend an agreed upon amount of time reviewing the selected cases. It is important to be efficient and focused in this teaching session.

Peer-to-Peer Teaching Resident to resident teaching or collaborative learning occurs at the workstation if more than one trainee is within the same workspace. Peer collaborative learning has been shown to be an effective method to share experiences, knowledge, and improve communication skills. This type of peer learning is gaining traction in radiology practice performance reviews [14]. However, it is a natural way for the trainees to communicate at the workstation as it is less stressful to request a consultation from a fellow trainee than it is from a faculty member. Therefore, an educational goal for trainee education could be to review some basic tenets of education pedagogy.

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Trainee Assessment In a busy practice it may seem difficult to provide feedback during the day. However, end of rotation feedback may be too late. Feedback to the learners is often forgotten at the end of a busy day. In addition, the faculty may have asynchronous contact with the trainee or infrequent contact with the trainee during the rotation. The feedback needs to be built into the day, timely, and pertinent to the patient cases reviewed. Feedback is an important part of the trainee-faculty encounter. Specific negative and positive feedback is critical for resident goal-setting and self-assessment [15]. The OMP and the 5-min moment have built in assessment loops and feedback structure. Utilizing these throughout the day will be useful to the trainee. It is important that this feedback be directed at specific aspects of the resident’s performance which will allow them to identify their deficiencies and create an individual learning plan to address these deficiencies [16]. Sharing this constructive feedback with the residency program on the end of rotation assessment is a useful tool for the program’s clinical competency committee.

Conclusion Experiential learning is a key component of current radiology education. While there is clear need for didactic teaching and independent work to build foundational knowledge, workstation teaching is essential in application of this knowledge. Workstation teaching uses a higher-level Blooms taxonomy as it forces the trainee to understand and synthesize the imaging findings and to generate an appropriate differential diagnosis for a case. Summary Table •  Create a positive work environment •  Understand the curriculum • Allow residents to apply learned knowledge (higher level blooms) • Assess the performance of the trainee and provide immediate feedback

References 1. Heilbrun ME, Poss B, Boi L, Anzai Y, Hu N, Kaplan RS. Assessing the training costs and work of diagnostic radiology residents using key performance indicators—an observational study. Acad Radiol. 2020;27:1025–32. 2. Jamadar DA, Carlos R, Caoili EM, Pernicano PG, Jacobson JA, Patel S, Noroozian M, Dong Q, Bailey JE, Patterson SK, Klein KA, Good JD, Kazerooni EA, Dunnick NR. Estimating the effects of informal radiology resident teaching on radiologist productivity: what is the cost of teaching? Acad Radiol. 2005;12:123–8.

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3. Cohen MD, Gunderman RB, Frank MS, Williamson KB. Challenges facing radiology educators. J Am Coll Radiol. 2005;2:681–7. 4. Poyiadji N, Klochko C, LaForce J, Brown ML, Griffith B. COVID-19 and radiology resident imaging volumes–differential impact by resident training year and imaging modality. Acad Radiol. 2021;28:106–11. 5. ACGME.  Program requirements for graduate medical education in diagnostic radiology. https://www.acgme.org/globalassets/pfassets/programrequirements/420_ diagnosticradiology_2021v2.pdf. Accessed 1 Feb 2022. 6. Oliveira A, Slanetz PJ, Catanzano TM, Sarkany D, Siddall K, Johnson K, Jordan SJ. Strengthening the clinical learning environment by mandate-implementing the ACGME common program requirements. Acad Radiol. 2020;27:1–5. 7. Nadgir R. Teaching remotely: educating radiology trainees at the workstation in the COVID-19 era. Acad Radiol. 2020;27:1291–3. 8. Herr KD, George E, Akarwal V, McKnight CD, Jiang L, Jawahar A, Pakkal M, Ulano A, Ganeshan D. Aligning the implicit curriculum with the explicit curriculum in radiology. Acad Radiol. 2020;27:1268–73. 9. Smith E, Gellatly M, Schwartz CJ, Jordan S. Acad Radiol. 2021;28:1626–30. 10. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “Microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5:419–24. 11. Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnositing the patient and the learner: proof of concept. Acad Med. 2004;79(1):42–9. 12. Kachewar SG. Implementing one minute preceptor for effective teaching and learning among radiology residents. Indian J Appl Radiol. 2015;1(1):104. 13. Chi J, Artandi M, Kugler J, Ozdalga E, Hosamani P, Koehler E, et al. The five-minute moment. Am J Med. 2016;129(8):792–5. 14. Chetlen AL, Petscavage-Thomas J, Cherian RA, Ulano A, Nandwana SB, Curci NE, Swanson RT, Artrip R, Bathala TK, Mankowski Gettle L, Frigini LA. Collaborative learning in radiology: from peer review to peer learning and peer coaching. Acad Radiol. 2020;27:1261–7. 15. Ramani S, Leinster S. AMEE Guide no. 34: teaching in the clinical environment. Med Teach. 2008;30(4):347–64. 16. Burns J, Chetlen A, Morgan DE, Catanzano TM, McLoud TM, Slanetz PJ, Jay AK. Affecting change: enhancing feedback interactions with radiology trainees. Acad Radiol. 2021;2021(28):1–5.

Chapter 8

Effective Feedback in Radiology Education Smyrna Tuburan

Introduction Avery is a radiology resident, and it is the end of the last day of their resident rotation. Having been the primary attending for today’s case review with Avery, they ask you for feedback on their performance. For some readers, this scenario would be a simple relatively easy task. However, likely for most readers, this scenario can be anxiety provoking and at times inwardly produce a flight-or-fight response. Of the different types of communication, feedback can be the hardest to give and receive. Hopefully, after reading this chapter, you will be more comfortable to engage with learners in effective feedback conversations.

Feedback: Essential for Growth In a communication process, the core element of feedback is the step the receiver takes by relaying decoded received communication back to the sender. The receiver takes a message from the sender, decodes the message, and feeds back a

S. Tuburan (*) Department of Radiology and Imaging Sciences, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_8

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message - “feedback”—to the sender. For better or worse, the term “feedback” has morphed from a neutral communication process term to imply a judgment or criticism of a behavior or performance. Keeping this in mind, it is no wonder that terms that inherently are feedback such as “performance reviews,” “scorecards,” “semi-annual review,” etc. invoke a sense of dread or fear. Ultimately, these benchmarks are a form of judgment, and in the field of medicine these standards are necessary and set for patient safety and care. In education and other fields like business, after decades of focusing on feedback and most recently on feedback culture, a re-centering on why feedback is essential in the first place. So why feedback? To improve performance? To change behavior? Specifically, in a medical education environment, feedback for radiology trainees is essential for their development into independent radiologists. Simply, the why of feedback for a radiology trainee is growth. At the core of Avery’s request for feedback is fostering an opportunity of growth. How you proceed depends on what type of feedback is warranted.

Feedback Defined There are two main types of feedback—formative and summative. As someone interested in teaching, you are likely most familiar with formative feedback. This type of feedback is commonly seen in the daily setting of case reviews or observing procedural skills. The goal of formative feedback is to stimulate a learning process to improve performance. Formative feedback interactions are low-stake, regular in occurrence, and specific. In Avery’s scenario, clearly defined feedback to how their performance was during the day or in regards to a specific case would be classified as formative feedback. Summative feedback on the other hand is performed at the end of an evaluation cycle. Examples of summative feedback include resident semi-annual review, end of rotation evaluations, USMLE, and ABR core and certifying examinations. In other words, summative feedback is high stakes and infrequent with comparison of performance to set standards. Responding to Avery’s request for feedback with an end-of-rotation evaluation would be an example of summative feedback. A comparison of feedback types is provided in Table 8.1.

Table 8.1  Formative vs. Summative feedback Formative Frequent Throughout time Low stakes

Summative Infrequent End of evaluation cycle High stakes

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Check the Settings In every communication cycle, there is the setting or environment that surrounds the process. Intrinsic elements are also involved that are unique to the individuals including emotions, biases, and mindsets. As feedback is one of the most difficult communication types, it is most imperative to recognize the different factors involved. So now that you know the type of feedback to give, take a moment to observe and take mental inventory of the settings on the entire feedback interaction. This includes your own emotional and physical states as well as the other individual’s. What about the physical environment? Is the immediate environment conducive to giving or receiving feedback? In the educator–learner relationship, the expected hierarchical differential inherently impacts the environment. Are there options to decrease the hierarchical differential? In addition, the social elements of the interaction can also make a difference in the approach to feedback delivery. For example, the interactions would differ if Avery was a first-year resident and you worked with Avery for only one shift versus if Avery was a senior resident that you worked with for several months and additionally was your research mentee.

Barriers to Effective Feedback There are three main categories of barriers to effective feedback. The first is the system surrounding the overall learning environment. Included in the systemic barriers is the setting as discussed previously, time, and expectations of each of the individuals involved. Time is the precious resource that affects the overall effectiveness of the feedback. Examples of how time is a barrier include from the overall time spent with or observing the trainee to time available to engage in the feedback encounter. Another major barrier is expectations. This barrier includes the varying cognitive biases of both the trainee and the educator. Managing expectations is no easy task. However, individual and institutional efforts can be performed such as implementing training to mitigate unconscious bias. Additionally, negativity bias strongly affects what we hear. In other words, we dwell on the negative and brush over the positive. A helpful setup is to ensure that mutually agreed upon goals are set at the start of the learning encounter and that these goals include setting the expectation of feedback interactions to occur at a regular basis.

Implementing Effective Feedback You have decided what type of feedback to give, you performed a settings check, considered and mitigated as best as possible the barriers to feedback. You are ready to embark on the feedback interaction. How can you ensure that the feedback is

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implemented effectively? Whether the type of feedback is formative or summative, remember at the core of the conversation is growth. Consider this as an opportunity for partnering with your trainee in a two-way conversation with the focus on advancing development of the trainee. With the why of feedback established, you can move on to breaking down the feedback into two main elements—content and delivery.

Feedback Content 1. Specific Your observations in the content of feedback should be specific, focused, and descriptive of the individual’s actions and behaviors. The discussion is about performance, not the person. However, a distinction is made with praise. Praise, for example, is communicating you are happy with a performance such as “Nice job.” “Good reports.” While praise feels good, it often does not provide enough information to understand what is being done effectively to repeat an action or behavior. The feedback content should be relevant to timely specific behaviors or incidents. 2. Candid Whether negative or positive, the feedback should be fair and honest. Particularly with negative feedback, an explanation of the impact of the behavior and what is at stake should be included in the discussion. 3. Actionable Feedback should be able to tie into the individual’s or program’s goal. Focus on the future beyond the feedback in the interaction, while having the trainee articulate what it is they are trying to achieve for themselves. Curate precise actionable specifics to take forward.

Feedback Delivery 1. Allyship In the approach to the feedback interaction, shift from being a critic to an ally. As someone’s ally you are supportive, caring, and genuinely confident in them. To express that you are an ally, empathize by acknowledging how difficult their situation is when receiving feedback. At the same time, you are confident in their ability to tackle the challenge of growth from the feedback. Lastly, to clearly communicate that you are an ally, ask to work together rather than in isolation. 2. Timing Timing is critical in the delivery of feedback. Allow for sufficient time for the conversation to occur, as well as an allotment of reflection time for the trainee to engage and discuss the feedback. Consideration should also be made for when the feedback is performed, as giving feedback when either individual is fatigued

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or distracted (i.e., post-call, following a significant life or clinical event) is not a setup for success. 3. Plan Your role in this wrap-up stage of the feedback interaction is to facilitate the learner’s development of strategies to enable their improvement to occur. An action plan is developed that is specific, measurable, achievable, relevant, and time-based.

The Educator’s Reflection Take a moment to think back to a time when someone gave you feedback. How did you initially feel? Did you feel respected during the encounter? How, or did, you grow from the experience? To further the ability to deliver effective feedback, managing your own mindset and identity is likely to have a profound effect on your success. Our past experiences of receiving feedback as trainees undoubtedly play into how we deliver feedback as educators. Promoting and modeling your learning and growth to trainees will foster a collective environment that encourages self-development.

What Would You Do? Role Playing Feedback Scenarios The following are scenarios that you may or have encountered a variation of as an educator or former trainee. Consider what you would do in each of the settings. There are no “correct” answers to address each scenario, albeit there are more ideal responses. The goal of these scenarios is to bring awareness to your thoughts and reactions to each of the following. Ask yourself how you would respond in each scenario recalling that the goal of feedback is growth. Remind yourself to check the settings, decide what type of feedback to provide, address any barriers, and formulate your delivery before engaging in each of the following learning opportunities. 1. Unsafe Trainee—You are the attending in the morning and are reviewing the prior overnight cases reported by a second-year resident who is halfway into a rotation of overnight shifts. You have reviewed this resident’s reports on multiple mornings in the past few days and critical interpretative errors were made every night. No in-person review is performed as the resident leaves promptly at the end of the shift as expected for the rotation and due to duty hour restrictions.

(a) Destructive feedback—An example would be to stop the resident prior to the resident’s departure from the workplace, and giving vague comments such as “you had some big misses this last week, did you see the changes I made to your reports?” or “rough couple days? You made several significant

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mistakes. Please review my report revisions when you have time. Hope you can get some rest.” (b) Constructive feedback—In this scenario, it is important to recognize the timing of feedback delivery is critical and a barrier. Without in-person review of cases and considering the trainee’s significant fatigue, the environment and timing are beyond the timely immediate feedback following the shift. One option is to set an assigned time with the trainee soon following the overnight shifts rotation, and to review the specific cases with errors. The review could be followed by working together on an action plan to address any specific deficiencies in the trainee’s performance. 2. Unprofessional Trainee—You are the attending on service, and you overhear a trainee on the service speaking loudly on the phone to a clinician who called in to request assistance for the next best steps and type of study to order regarding their patient. The trainee’s tone of voice is curt and loud when they say “that is a ridiculous request and is not clinically warranted. Goodbye.” Later in the day, you receive a phone call in the reading room directly from the clinician who was on the phone earlier with the resident to discuss their encounter. The clinician reports to you that they felt the radiology trainee was unprofessional and rude.

(a) Destructive feedback—It is natural for some to want to avoid this feedback situation entirely and move on with the day’s work. Not addressing the encounter directly with the trainee and commenting on unprofessional behavior indirectly such as on a rotation evaluation, does not create an environment for allyship or growth. In addition to avoidance, another less helpful response would be that while on the call with the clinician dive into taking either side between the trainee and clinician. (b) Constructive feedback—Consider pausing after the conversation with the clinician to set for yourself as the educator the goals of the feedback discussion with the trainee. An opening open-ended question is often helpful to initiate discussion, “how do you think your phone conversation went with the clinician? Can you tell me more about what was discussed?” Another question is “how do you think you were perceived and heard by the clinician?” Maintaining a nonjudgmental mindset in this feedback scenario is important to be able to accurately tune into what the trainee offers as their perspective of the conversation. 3. Underperforming Trainee—A senior level resident who has recently passed their ABR CORE exam is on your busy service. You quickly become aware that this resident consistently reports half of the volume that an average junior level resident performs on the rotation with expected duties being equal. You have worked with the senior level resident previously when they were a junior resident and they had performed previously as expected compared with their junior peers. (a) Destructive feedback—Jumping to conclusions here would not be ideal. Assumptions that the resident is slacking off or is not interested in perform-

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ing expected duties secondary to the recent passing of the exam can create a resentful environment or distrust. (b) Constructive feedback—As mentioned previously, the ABR CORE exam is a form of summative feedback, and the feeling of relief is a natural consequence of having completed and passed the exam. However, expectations of clinical service performance are still warranted. If a feedback mechanism is in place, consider opening the feedback conversation with “how do you think you are performing on this rotation for your expected level?” Consider modeling by discussing the career-long expectations of continued growth and professional development while celebrating the achievement of significant milestones.

4. Trainee to Faculty—You are a junior resident and the faculty attending you have worked with several days on the rotation has consistently kept you past the shift end time. This attending will typically start the day by letting you know that they will be in their office if you need anything, leave the reading room, occasionally check-in to perform case reviews and then will return at approximately 30 minutes prior to the end of the shift. The final case reviews sessions of the day will often extend beyond one hour past the shift end time.



(a) Destructive feedback—Due to hierarchal differences, from a trainee’s perspective avoidance or delayed feedback on the end of rotation anonymous evaluation can be the easy path. However, this would not be beneficial of the learning experience of the trainee nor the faculty’s professional behavior in clear need of address. (b) Constructive feedback At the beginning of the shift consider discussing with the faculty a specific detailed schedule for the day. If a huddle type check-in at the start of the shift is present with other trainees and faculty, discuss expected work times and ask what is expected to allow enough time for case review. Hierarchal differences are a barrier of effective feedback that are unfortunately inherent in the trainee and faculty relationship. If the trainee is uncomfortable beyond the ability to initiate the discussion with the attending, the trainee is encouraged to, in a timely manner, seek out allies in the immediate learning environment such as other residents including chief residents, faculty, or if needed the program director to address the behavior with the attending.

Tips on Giving Feedback Remotely As if giving effective feedback is not difficult enough, recent changes in some clinical practices have warranted providing feedback in a remote setting. Reading non-­ verbal full body clues is limited or eliminated if video conferencing is unavailable. A mutual experience of the physical setting is lost. Giving feedback remotely is simply not ideal. However, as work models are shifting, remote feedback at times

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may be the only option. It is more imperative to be strategic in the feedback delivery with the added barrier of a remote setting. One strategy that is helpful both remotely and in-person is to start by asking questions and follow with clearly stating the good intentions of the encounter. Precise language becomes more important to the feedback conversation when remote and the wrap-up next steps stage is vital to clarify any misunderstandings. Additionally, while the full body clues can be limited by the field of view on camera, facial expressions can become accentuated as the main focal point in virtual meetings. Becoming conscious of any facial mannerisms that may be misread can help to ensure the receiver focuses on the reality of your message.

Gathering or Receiving Feedback While most of this chapter is largely focused on giving feedback, as an educator reading this book, you are also inherently interested in furthering your skills. Receiving feedback is necessary to improve your role as an educator. The first step is to ask for feedback, both positive and negative, from your learners. When receiving feedback, eliminate distractions, give the encounter your full focus, and listen carefully. Particularly when receiving negative feedback, it is natural to respond into fight or flight. Own your feelings and the subsequent reactions to those feelings. In the same manner that you ask your trainees to reflect and evaluate the feedback, do so as well, including the next steps of planning and taking action for your progress. Just as educators hope their learners reach their full potential and grow through feedback, so do educators become learners themselves from feedback given to them.

Conclusion From consumer purchase surveys, social media engagement icons, platforms dedicated to providing feedback to businesses, to mobile applications ratings, the concept of engaging in feedback is ever present and constant in our everyday life. We live in a culture of instant feedback both requested for and received. As an educator living within this permeating culture, it is important to create a safe environment, with timely encounters and strategic delivery of feedback. Remembering that the reason for the feedback, while at times challenging for both the educator and trainee, is to enrich and foster the growth of the trainee. In doing so, our trainees become fuller independent radiologists and further the care of patients.

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Key Points • There are two types of feedback, low-stakes formative and high-stakes summative. • Providing a safe environment and establishing trust are important first steps in the feedback process. • Feedback must be immediate and specific, with clear indication of what was done well and what must be worked on as an area of improvement.

Suggested Reading https://hbr.org/2019/01/how-­leaders-­can-­get-­honest-­productive-­feedback. Providing feedback: practical skills and strategies. https://doi.org/10.1016/j.acra.2016.11.023. https://hbr.org/2021/12/feedback-­isnt-­enough-­to-­help-­your-­employees-­grow. https://hbr.org/2020/06/good-­feedback-­is-­a-­two-­way-­conversation. https://hbr.org/2019/05/what-­good-­feedback-­really-­looks-­like. https://hbr.org/2019/03/the-­feedback-­fallacy. https://hbr.org/2021/01/giving-­critical-­feedback-­is-­even-­harder-­remotely. https://hbr.org/2021/02/stop-­softening-­tough-­feedback. Feedback: a key feature of medical training. https://doi.org/10.1148/radiology.215.1.r00ap5917. Affecting change: enhancing feedback interactions with radiology trainees. https://doi. org/10.1016/j.acra.2021.05.018. Teaching radiology trainees from the perspective of a millennial. https://doi.org/10.1016/j. acra.2018.02.008. A guide to midrotation feedback. https://doi.org/10.1016/j.jacr.2018.08.004.

Chapter 9

Writing High-Quality Multiple-Choice Questions Georgios A. Sideris, Amninder Singh, and Tara Catanzano

Introduction Examinations are an essential component of the career of every medical professional, as they can monitor progress and ascertain competence at multiple milestones during the long pathway of training. Formative assessments are low-stakes evaluations that monitor the progress of a student or a trainee, such as subject examinations during medical school (Shelf exams), and in-training examinations (end-­ of-­rotation or in-service exams) during radiology residency. Self-assessment items for continued medical education (CME) after board certification also belong to this category. Formative assessments are beneficial in various ways. They can highlight areas of weakness, motivate trainees, and promote further learning. They also provide feedback to faculty and aid in addressing instructional gaps in the curriculum that may require improvement. Summative assessments, on the other hand, are usually high-stakes evaluations that evaluate the cumulative knowledge of a student or trainee at the end of an instructional unit. Examples include medical licensing and board examinations. They provide evidence of the overall competence of the test-­ taker and ascertain that they meet the standards to proceed to the next level of training [1]. Radiology encompasses complex cognitive functions that are difficult to assess on a single examination. Being a competent radiologist requires a unique skill set that is more effectively applied in daily practice  rather than in written or oral examinations with hypothetical clinical scenarios and limited interaction. This has

G. A. Sideris (*) · A. Singh · T. Catanzano Department of Radiology, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 T. Catanzano (ed.), Image-Based Teaching, https://doi.org/10.1007/978-3-031-11890-6_9

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been particularly evident in the last decade as high stakes examinations including the American Board of Radiology’s examinations have transitioned from a traditional oral examination to a multiple-choice format. Developing a consistent search pattern, comparing to prior studies, crafting concise reports, correlating with clinical information, and communicating imaging findings are only some of the higher order skills that are less effectively assessed by single-best-answer written examinations. However, despite the inherent limitations, written examinations remain an efficient way to estimate the degree of candidate knowledge and therefore every effort must be made to maintain a high quality in tested items. In 1956, Benjamin Bloom and his colleagues created the Taxonomy of Educational Objectives [2]. It is a hierarchy of cognitive skills in order of increasing complexity that has been applied as a roadmap in defining learning objectives both for lectures and assessments. The Taxonomy consists of six pillars: lower cognitive skills (“Knowledge,” “Comprehension”) and higher cognitive skills (“Application,” “Analysis,” “Synthesis,” and “Evaluation”) (Fig. 9.1). A revision of the original taxonomy was published by Anderson et al. in 2001, which turned the static classification of learning objectives  into a dynamic, two-dimensional table [3]. The two axes of the table are the cognitive and the knowledge domains (Fig. 9.2). The cognitive domain includes the same concepts as the ones originally introduced by Bloom, with the exception that the nouns were replaced with verbs: “Remember,” “Understand,” “Apply,” “Analyze,” “Evaluate,” and “Create.” Additional words describing specific actions are attached to each verb in order to make the objectives clearer (Table 9.1) [4]. The revision also introduced the dimension of knowledge, which comprises four subdivisions representing the types of knowledge that learners are expected to acquire. These range from concrete to abstract and are classified as: factual, conceptual, procedural, and meta-cognitive [3]. Factual knowledge refers to knowledge of terms, elements, and details. Conceptual knowledge refers to awareness of classifications, generalizations, principles, models, and theories. Procedural knowledge includes subject-specific skills, algorithms, techniques, methods, and knowledge of procedural indications. Meta-cognitive knowledge requires familiarization with cognitive tasks and self-cognition. Each knowledge type is matched with each of the cognitive processes to form a 24-cell grid of learning outcomes (Fig. 9.2). Bloom’s taxonomy has been increasingly utilized to guide test development and to provide a theoretical measure of the cognitive skills that each testing item assesses. Although lower taxonomy levels are more easily targeted in examinations, well-rounded examinations need to include questions that span multiple cognitive levels. Assigning questions to a specific taxonomy level, however, is challenging and oftentimes subjective. Items testing higher order skills may also require basic cognitive skills in order to be answered. The addition of clinical vignettes and radiological images enables the assessment of higher order skills rather than simple factual recall. The spectrum of the examinee’s cognitive levels should always be driven by the learning objectives of the examination [5]. Higher order skills may not be relevant in a clerkship assessment for medical students, whereas too many lower-­ level items in a high-stakes examination may not provide adequate assessment of competency.

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Evaluation Synthesis

Analysis

Application

Comprehension

Knowledge

Fig. 9.1  Hierarchy of cognitive skills based on the original taxonomy by B. Bloom

Fig. 9.2  Graphic representation of the 2001 revision of Bloom’s Taxonomy

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Table 9.1  Description of the cognitive skills from lower to higher order as presented in the 2001 revision of Bloom’s Taxonomy “Remember” Recalling facts, recognizing patterns, structures, and processes Recalling, Recognizing “Understand” Demonstrating comprehension through interpreting, exemplifying, classifying, summarizing, inferring, comparing, explaining Interpreting, Exemplifying, Classifying, Summarizing, Inferring, Comparing, Explaining “Apply” Implementing acquired knowledge, carrying out a procedure Executing, Implementing “Analyze” Deconstructing material, organizing and differentiating components Differentiating, Organizing, Attributing “Evaluate” Making judgments based on criteria and standards Checking, Critiquing “Create” Putting elements together to construct something novel Generating, Planning, Producing Cognitive processes further clarifying each category are shown in italics

The present chapter provides insight into the challenges of creating multiple-­ choice questions (MCQs)  for radiology assessments and discusses their quality assessment.

Assessment Modalities Closed-format questions have been commonplace in undergraduate and postgraduate medical examinations, with MCQs being the gold standard in most high-stakes assessments [6]. MCQs have been a validated testing tool since the early twentieth century, with high reliability and discriminatory capacity [7]. In the current era, this question type can be readily administered either in a computerized fashion or in paper format and can test a broad range of topics within a short period of time. These characteristics are ideally suited for summative examinations. Depending on their quality, they can target a wide spectrum of cognitive functions, ranging from simple recall to higher order learning. They are also easily reproducible and can be readministered to test the progress of examinees over time. Scoring is objective without the risk of inter-examiner variability, with reliable results provided instantaneously for computer-based examinations [8]. MCQ item performance can be rigorously tested with psychometric analysis, which in turn can be used in an examination audit process, with iterative improvements in the quality of the examination [9, 10]. There are numerous types of MCQs, some of which have been abandoned due to their confusing structure and poor statistical performance [11, 12]. MCQs can be divided into two broad categories based on the number of correct answers: single best answer and multiple correct answers. Items with more than one correct response essentially turn the question into a true/false format which comes

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with several limitations. These items are usually more prone to guessing and ask the examinee to decide whether an option is absolutely true or absolutely false, which may sometimes be ambiguous. The typical single best answer format contains a stand-alone item with a stem followed by a variable number of options, only one of which is correct (A-type) (Example 1). There may also be multiple stems with the same option set (also known as “extended matching items” or R-type)  (Example 2). Occasionally, more than one item pertaining to the same clinical scenario are grouped into a sequential set of questions called a “case cluster.” Each item provides additional information and can assess varying levels of cognitive skills. Item writers can choose whether the examinees can return to the previously seen items (G-type) (Example 3). If a response is implied with the subsequent item, examinees should not be able to return to the previously seen item (F-type) (Example 4). Despite their well-established role in medical knowledge assessment, MCQs have been criticized for their limitations. Constructing a high-quality MCQ is very labor-intensive and requires formal training [13]. Poorly constructed items may provide cues and allow for guessing. Less sophisticated items test only primarily test recognition and factual recall rather than higher order cognitive skills such as problem-­solving and critical thinking. Moreover, choosing an answer from a brief list of options does not represent a real-life clinical situation, especially when some of the distractors are unlikely or clearly incorrect [14]. Open-ended questions are an alternative assessment modality that is less frequently used currently in medical education settings. In this testing model, the examinee is presented with a clinical scenario, followed by an open-ended question requiring a brief response. When there are multiple sequential questions instead of a single question, the format is called “modified essay question” [15, 16]. Open-­ ended questions provide a better insight into the reasoning of the test-taker, allowing for the assessment of higher-level cognitive skills. If the stem is appropriately written, the risk for cueing can be eliminated. Although they are much easier to construct than MCQs, their grading is a lot more challenging, time-consuming, and may be plagued by inter-scorer discrepancies. There is currently no evidence to suggest that open-ended questions are superior in assessing higher levels of knowledge than MCQs [17].

Guidelines for MCQ Construction Although MCQs have been used as an educational tool for almost a century, the first official guidelines were established in the late 1980s by the seminal work of Haladyna et al. [18]. This publication was a taxonomy of recommendations for the construction of MCQs based on previously published reports dating back to 1935. It was an empiric list of suggestions that was subsequently amended by the same authors [19], and served as the roadmap for future studies.

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The first step in creating a high-quality MCQ item is to clarify the objectives [13, 20]. A question should reflect the level of training and test knowledge or skills that the examinees are reasonably expected to have at their training level. The tested concepts should pertain to clinically relevant concepts rather than trivial knowledge. Items must address non-controversial topics that are supported by current, evidence-­ based literature. Controversial or emerging topics and concepts should be avoided. The number of questions on one particular topic throughout the examination should reflect the topic’s relative importance. Examples of flawed questions are presented in Appendix 2.

The Stem The stem of an MCQ contains the clinical vignette based on which the test-taker will answer the question. The clinical scenario should describe a clear problem presented in a linear fashion (linearity) (Table 9.2). The structure of the stem should typically follow a consistent pattern with a logical flow. The vignette usually starts with demographic information (age and gender) followed by pertinent past medical history and presenting symptoms. Subsequently, physical exam findings and relevant laboratory results may be presented. When the item contains an image, the imaging modality may be implied and the item may proceed directly to the lead-in. Additional details regarding the imaging that was performed can be provided at the discretion of the item writer. Alternatively, when the item does not provide an image, the radiological findings may be described verbally before proceeding to the question. Occasionally, stems can be abbreviated so as to contain only the absolutely necessary clinical information, omitting some of the other components that are not essential for the interpretation of the image or do not significantly alter the differential diagnosis. In addition to linearity, the stem must be able to pass the so-called cover test. For a stem to pass the cover test, the test-taker must still be able to answer the question even after “covering” the available answer options. Passing the cover test indicates Table 9.2  Linear structure of the stem of a MCQ item MCQ stem component Demographic data Pertinent history Presenting symptoms Work-up Lead-in Key

Example A 30-year-old female… … with no significant past medical history… …presented with nausea, vomiting and a positive home pregnancy test. Her LMP was 4 weeks ago Serum hCG was 115. Pelvic US was only notable for a corpus luteum What is the most likely diagnosis? Pregnancy of unknown location

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that the stem provides sufficient information to answer the question (Example 5). Stems should be focused and kept as short as possible. When the application of knowledge is tested rather than simple recall, stems tend to be longer. Even for application questions, stems should only include the clinical information that is necessary to answer the question. A stem should not be used as an opportunity to provide informative statements or teaching points. Stems must remain independent from one another and not provide information that can be used to answer another item, which would reduce the validity of the test. The amount of information within the stem should be kept as short as possible. Any extraneous material, also known as “window dressing,” adds construct-irrelevant difficulty and should be omitted. It has been shown that the presence of redundant information can increase the time to answer a question by 20% [21]. Wording should be simplified as much as possible, with low reading difficulty and no misleading phrasing (“red herrings”). Any eponym or abbreviation should be defined.

The Lead-In The lead-in is the specific question that the examinees are being asked to answer. The question can be delivered either as a complete sentence or as a sentence that requires completion. A full sentence question is preferred as it is clearer and more direct. The sentence-completion format is thought to be more difficult, as it requires holding the unfinished question in working memory while reading the options, thus increasing the cognitive burden. The question should be delivered in a simple and straightforward way to avoid confusing the examinee. Long sentences with complicated syntax and vague terms increase the difficulty of the item. Third-person construction is preferred over second-person. Negatively posed questions are questions containing negative constructions (such as “not”, “except”). They require reverse thinking as the examinee tries to identify the wrong answer instead of the correct one, which is not typically in a real-life clinical context and should thus be avoided. Occasionally, they may be appropriate, for example, in instances where the examinee is asked to exclude something from the differential. In these cases, the negative term should be capitalized or underlined to ensure that it is not overlooked by the test-taker.

The Images Although images are an indispensable part of any radiology examination, there are no established guidelines regarding their optimal use in tests. The addition of an image markedly expands the spectrum of cognitive skills that can be tested by an

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MCQ, thus increasing the value of the item and the overall reliability of the examination. The skills that can be tested span across multiple Bloom’s taxonomy levels, such as simple recall, pattern recognition, lesion detection, identification and mitigation of an artifact, formulation of a diagnosis, comparison to prior studies (if provided), and recommendation for the appropriate next step in management [22]. MCQ items containing images typically ask the examinee to review the stem and image and reach a conclusion based on these. Alternatively, the item may have a “hot-spot” format, whereby the examinee is asked to mark a structure by selecting a specific area on the image (Example 6). This applies to items where the perception of an abnormality is the tested skill [23]. When images are added in an MCQ item, they need to be essential to correctly answer the question. If the question can be answered without the need to review the image, it most likely represents a redundant feature, and the item should be revised (Example 7). A test similar to the cover test can be applied by covering the image and ensuring that the question is not answerable without looking at the image. Test developers can decide how many images will be presented to the examinee. There may be a single image, more than one image of a single modality, or images of various modalities. It should be kept in mind that having more images usually increases the time required to answer a question [24]. Part of the tested skills may be to identify the imaging modality that is presented, especially in high-stakes examinations. In this case, a description of the modality or of the projection that is shown may not be necessary. A stem should never describe in words findings that are present in the image. Any image that is presented in an examination must be technically perfect and meet certain quality standards. Examinees rarely have access to diagnostic monitors when taking tests, therefore every effort must be made to make the findings readily recognizable. Item writers should present the image in the appropriate display window for the desired finding. Alternatively, a brightness feature may be provided to the examinee that will enable them to alternate between windows. A zooming feature should also be available to enhance the visibility of findings. The inverting feature may be useful when plain films are presented. If more than one image is provided, they must be clearly visible as clickable thumbnails, to ensure that they will not be overlooked by the testtaker. All images need to be devoid of any patient identifier or metadata that could breach patient confidentiality. Cross-sectional images can either be presented as a scrollable set of images or as independent still images. If a scrollable series is used, it should only include the area of interest rather than the entire scanned body part. Scrollable series might take more time to load but may make it easier to review compared to separated slices. When still images of any modality are presented, they may be cropped to include just the finding of interest. Images should preferably not include any incidental findings that may distract the examinee (Table 9.3).

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Table 9.3  Considerations for images included in MCQ items •  •  •  •  •  •  •  •  •  • 

Images must be technically perfect and appropriately windowed Images may be cropped to only include the finding of interest Images with distracting incidental findings should be avoided Patient identifiers must be removed Editing tools (brightness, inversion, zooming) are recommended The question should not be answerable without reviewing the images The stem does not need to mention the modality of the presented study The stem should not describe in words findings present on the images All image sets need to be readily seen as thumbnails Adding more images increases the time needed to answer the question

The Key The key is the option that unequivocally answers the question. It should indisputably be the most correct option, and it should ideally be backed up by a reference from a credible source. The key should be approximately equal in length to the remaining options. Savvy test-takers are aware that the longest answer choice (at least two times longer than the rest) is usually the correct one. This occurs as item writers try to ascertain that the phrase is indisputably correct and therefore feel the need to add additional words (Example 8). Wording must be carefully selected in order to avoid clueing. An option that shares common words with the stem is also more likely to be the correct one. This subtle pitfall is called “convergence” and is well-known among test-wise examinees [11]. Moreover, vague quantifiers (such as usually, rarely, may, can, etc.) may clue to the correct answer as they include anything within the realm of possibility. The position of the key may also provide inadvertent clueing. The habit of “burying” the key within the options has led to the overuse of position B or C as the spot for the correct answer. Therefore, the key should ideally be randomly positioned.

The Distractors The selection of distractors is the most vital part of the construction of an MCQ item, but also the hardest and most time-consuming one. Since questions usually ask the examinee to identify the response that is the “most likely” to be correct, all answers need to have some element of truth, otherwise they would not be realistic or plausible. Incorrect options may still be possible but are much less likely than the key, or may contain information that is partially or fully wrong  (Example 9). Distractors should ideally include common misconceptions and errors made by

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trainees. Distractors are usually selected by content experts by inferring possible misconceptions based on their judgment and experience. An alternative and markedly more arduous process of selecting distractors is to isolate common errors from open-answer versions of the items. Latent Dirichlet Allocation is a machine learning language processing model that has been used by several studies in order to generate plausible distractors based on the written responses of students [25]. It has been shown that items targeting higher levels of Bloom’s taxonomy allow the formulation of a higher number of efficient distractors [26]. The ideal number of options has been a long-standing debate among test developers [27]. There is a common belief that the presence of more options decreases the likelihood of correct guessing. Item writers are often reluctant to reduce the number of options, fearing that it would lead to inappropriate passing. However, there is evidence showing that it is the quality, not the quantity, of the distractors that impacts the value of the item. Although it may be tempting to add an increased number of options, it has been shown that there is a natural limit in the number of plausible distractors [27]. Adding more non-functioning distractors does not alter the discriminatory capacity of the item, as the additional responses are implausible and therefore rarely chosen [28]. Multiple studies have compared the performance of MCQ items based on their number of options. A UK study examined the statistical performance of distractors in 480 5-option MCQ items in undergraduate medical examinations answered by 269 students [29]. Only 7% of questions were found to have four functioning distractors. Reduced-option models were created by eliminating the least functioning distractors. The frequency of students who picked those options was randomly assigned to the remaining choices, with the assumption that they were guessing. The pass rate was increased by 1–3% resulting in a marginally easier exam. However, changes in reliability and discrimination were negligible [29]. These results were corroborated by a metanalysis also showing negligible changes in reliability, difficulty, or discrimination in 3-option items [30]. Three-option items are associated with faster responses by up to 8 s, allowing for the inclusion of 16% additional MCQ items within a 1-h testing period. This could allow the examination to cover a broader content and increase its validity [31]. Having 3–5 options has been considered the standard amount, with 4 being the typical number. The American Board of Radiology (ABR) supports the use of 4-option items and allows the use of three options only when a fourth option is not logical or reasonable [32]. There is no evidence suggesting that the number of options needs to be uniform throughout the test [33]. Distractors should be phrased very clearly and should describe a single concept. Options must be mutually exclusive and independent of one another in order to avoid overlap. They should be homogeneous and belong to the same category. For example, they should all involve a disease, a number, or an imaging study (Example 5). For questions with numerical responses, the available options must

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share the same measurement unit and should not have overlapping values. Definite modifiers (such as “always”, “never”) should be avoided as savvy test-takers are aware that there are very few concepts that are universally true or false. The use of phrases such as “All of the above” and “None of the above” is generally discouraged as they do not require a full understanding of the material. “All of the above” should be avoided because the examinee needs to only recognize two correct answers in order to conclude that all options are correct. “None of the above” technically asks the examinee to identify an unlisted option as correct, without indicating that they actually know which that option is. Both of these constructs have a low ability to discriminate high from low-functioning examinees. Distractors need to be grammatically correct and their phrasing needs to match the one in the stem. Options with grammatical errors are universally recognized as incorrect. The presence of two mutually exclusive options or of two options that share similar features (single pairing) should be avoided as it increases the odds of guessing (Example 10). Two or three mutually exclusive pairs are acceptable. Distractors should be arranged in a numerical, alphabetical, or logical order whenever possible. Random allocation is also acceptable.

Post-hoc Analysis MCQs undergo extensive scrutiny after their use in examinations in order to verify their structural soundness. The phase of the post-hoc analysis is based on several key parameters that provide insight into the overall quality of each item and of the examination as a whole. Each parameter is evaluated by a multitude of instruments and statistical tests (Table 9.4). The results of these tests can help identify problematic aspects of the examination and lead to important edits [9].

Table 9.4  Pillars of post-hoc analysis of MCQ items Validity  •  Does the test measure what it is supposed to measure? Reliability  •  How consistently does the test measure the skill/knowledge of interest? Item difficulty  •  What percentage of examinees answered the item correctly? Item discrimination  •  Does the performance on the item correlate with the performance on the overall exam? Distractor efficiency  •  Are the distractors selected by a reasonable number of examinees?

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Validity The validity of an examination is considered the most important psychometric parameter in educational testing. It reflects the extent to which the test measures what it is intended to measure, and it indicates how well the test is assessing the traits of interest. Validity offers a pragmatic meaning to the test scores and provides a linkage between test performance and real-life performance. Examinees who score high on an exam with high validity have a higher likelihood of performing well in a real-life scenario. Validity is tightly related to reliability. Although reliability is necessary to accomplish validity, it is not sufficient [34]. Validity is divided into several subtypes [35]. Content validity assesses whether the examination is testing all aspects of a topic. It is a measure of the adequacy of coverage of the contents that it is supposed to assess. For example, a board examination that has no questions referring to breast imaging lacks content validity. Content validity is usually assessed by expert judgment. A way to increase content validity is to increase the number of items within a test, which allows broader coverage of material [36]. Criterion-related validity estimates how well the test can predict a specific outcome compared to an established and valid external criterion (gold standard). Based on the timing of measurement, it can be divided into two categories: concurrent validity (when the predictor and the criterion are obtained concurrently) and predictive validity (when the criterion is obtained at a later time). An example of predictive validity would be a comparison of scores at in-service examinations with board scores. Construct validity examines the ability of a test to measure an abstract (non-measurable) trait. Although it is predominantly relevant for surveys and questionnaires, it also applies to MCQs. For example, a radiology test may contain items with complex phrasing and thus inadvertently assess the reading skills of an examinee. In order to ascertain construct validity, there should be evidence that the test measures what it is meant to measure rather than irrelevant attributes. A way to demonstrate this is to compare the exam with a different test that is meant to assess similar traits and prove that there is a strong correlation (convergent validity). Alternatively, it can be compared to a test that assesses dissimilar characteristics and prove that there is no strong correlation (discriminant validity).

Reliability Reliability is a measure of the internal consistency or reproducibility of a test. In all exams, the performance of items pertaining to the same topic should be concordant. Performance on any single item should be indicative of the performance on any

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other item testing the same body of knowledge. In other words, reliability represents the correlation of the test with itself and demonstrates the degree to which a test consistently measures a learning outcome. Cronbach’s alpha is one of the most commonly used reliability coefficients [37]. The prerequisite for its use is the assumption that all items are unidimensional (test the same trait). Alpha values range between 0 and 1. The higher the value, the greater the reliability of the test. A value of 0.8 is acceptable in high-stakes examinations. Cronbach’s alpha increases as the number of related items within a test increases. Values that are too high (>0.90) indicate that some items are redundant. Cronbach’s alpha only applies when the test has been taken by a cohort of examinees rather than an individual. Based on the classical test theory, the observed score is the sum of the true score and the measurement (or random) error. Cronbach’s alpha can demonstrate the concordance between the true and observed scores by providing an estimate of the measurement error. High alpha values are associated with lower measurement errors and therefore indicate that the proportion of the score that is attributed to random error is low.

Item Difficulty The difficulty of an item is reflected by the number of correct responses. The difficulty index (p-value) is the proportion of the examinees that responded correctly and, as such, always has positive values. The optimal difficulty index should be aligned with the objectives of the examination. It is generally preferred to have a range of difficulties within an exam. Very difficult (75%) and bottom (