Current Status of Radiology Training in Otolaryngology Residency Programs

Key Points

Question  What is the current state of radiology training in otolaryngology residency programs?

Findings  In this survey of the responding US otolaryngology residency programs, directors reported having a radiology curriculum, and half also have a dedicated radiology rotation. Program directors reported different views on the optimal time in training for the radiology rotation.

Meaning  Despite most US otolaryngology programs having a radiology curriculum, the variation in frequency, setting, and format highlight an opportunity for formal guidelines from the Accreditation Council for Graduate Medical Education to standardize radiology education.

Importance  Otolaryngologists use head and neck imaging on a daily basis. However, little is known about the training residents receive on the subject. Understanding the current training environment is important to identify areas of improvement for resident education.

Objective  To assess the current state of radiology training in otolaryngology residency programs.

Design, Setting, and Participants  This was a cross-sectional survey of 106 otolaryngology residency program directors involving multiple academic institutions.

Main Outcomes and Measures  The main outcome of this study is the number of US otolaryngology residency programs that have a radiology curriculum. Measured outcomes were obtained from an anonymous online survey and reported as a percent of total respondents.

Results  Program directors from 39 of 106 (37%) US otolaryngology residency training programs responded to the survey. Twenty-eight of 39 (71%) have a focused radiology curriculum; 18 of 28 (64%) conduct sessions on a monthly basis, 8 of 28 (29%) on a quarterly basis, and 2 of 28 (7%) on a weekly basis. The predominant format (20 of 27 programs [74%]) is a mix of case-based review of inpatient studies and standard lectures. The largest proportion of sessions were run by radiologists (13 of 28 [46%]), with a mix of radiology and otolaryngologists close behind (11 of 28 [39%]). Twenty-two of 39 residency programs (56%) have a dedicated radiology rotation within their educational curriculum, of which 17 of 22 (77%) occur in postgraduate year 1 (PGY-1) of training, 3 of 22 (14%) in PGY-3, and 2 of 22 (9%) in PGY-4. Rotation lengths range from 1 week to 3 months, with most running 1 to 4 weeks. Thirty-two of 38 of US program directors (84%) believe that a formal radiology curriculum would benefit their residents. Thirty-five of 39 believe that this should be a case-based review of images. Twenty-four of 38 believe this should be done on a monthly basis. Fifteen of 39 responding program directors (39%) believe the optimal time is during the PGY-3 of training, 36% (14 of 38) favor the PGY-2, and 23% (9 of 38) in PGY-1.

Conclusions and Relevance  Despite no standardized requirements from the Accreditation Council for Graduate Medical Education (ACGME), 71% of US otolaryngology residency program directors who responded to our survey have a radiology curriculum. Most run didactics sessions at the desired frequency, setting, and format preferred by responding program directors. More than half of programs provide a dedicated radiology rotation, mostly during PGY-1, while identifying PGY-2 and PGY-3 as the optimal time for such an experience. These results highlight the need for a more thorough review of radiology education requirements from the ACGME to improve the training of otolaryngology residents across the country.

Otolaryngologists rely on various head and neck imaging modalities on a daily basis. Experience with ordering and interpreting radiologic studies is an important competency for all graduating residents of otolaryngology programs. However, little is known how residency programs structure training in head and neck imaging throughout the 5 years. The Accreditation Council for Graduate Medical Education (ACGME) does not have formal written guidelines outlining standards that all programs must meet. Therefore, it is up to each program to determine the format and amount of time this topic should be given during educational didactics. Other than research on allergy training in otolaryngology programs, studies addressing exposure and education in specific subspecialties are lacking.^1,2 Franzese¹ found that the ACGME and American Board of Otolaryngology have attempted to increase and define requirements in allergy training in residency programs, but little has been published regarding how the residents are trained, what they do in allergy clinics, and how competency is measured in this area. Competency in head and neck radiology is critical to practicing otolaryngologists, yet little is known about how programs prepare their residents in this competency. This article sheds light on the variability of the head and neck radiology educational component across ACGME-accredited otolaryngology residency programs.

Institutional review board approval was waived for this study. The ACGME establishes requirements, evaluates, and authorizes residency programs with the overall goal to continually improve resident education and training.³ This body is divided into different residency review committees (RRCs) that are specialty specific. They are tasked with establishing training requirements and assessing individual programs’ compliance with them. The most recent program requirements were revised in July 2016 and do not mention specific radiology training requirements. Programs are required to provide hospital-based resources stating “there should be clinical services in the related fields of anesthesiology, emergency medicine, neurological surgery, neurology, ophthalmology, pathology, pediatrics, and radiology.”^3(p8) The only other mention of radiology is within the options for the postgraduate year 1 (PGY-1) structured education on nonotolaryngology rotations as “anesthesia, emergency medicine, general surgery, neurological surgery, neuroradiology, ophthalmology, oral-maxillofacial surgery, pediatric surgery, plastic surgery, radiation oncology, and vascular surgery.”^3(p18) To summarize, at this time residency, programs are required to have radiology resources available and may have a PGY-1 neuroradiology rotation. There is no required radiology rotation or curriculum that exists within the current RRC program requirements.

A 12-question survey was crafted on the topic of current radiology training-in-residency programs (Table). Core issues of training format, content, frequency, and timing were included in the survey. This was sent electronically to the 106 program directors from US otolaryngology programs and anonymous responses were collected from February to May 2017.

Program directors from 39 of 106 US otolaryngology residency training programs (37%) responded to the survey. Twenty-eight of 39 of the programs that responded (71%) have a focused radiology curriculum during residency. Twenty-four of 28 (64%) conduct sessions on a monthly basis, 8 of 28 (29%) on a quarterly basis, and 2 of 28 (7%) on a weekly basis. The predominant format (20 of 27 programs [74%]) is a mix of case-based review of inpatient studies and standard lectures. Five of 27 (19%) reviewed inpatient radiologic studies and 2 of 27 (7%) had a standard lecture format (Figure). The largest proportion of sessions were run by radiologists (13 of 28 [46%]), with a mix of radiologists and otolaryngologists close behind (11 of 28 [39%]). Only 4 of 28 programs [14%] had sessions run solely by otolaryngologists. Twenty-two of 39 residency programs (56%) have a dedicated radiology rotation within their educational curriculum, of which 17 of 22 (77%) occur in PGY-1 of training, 3 of 22 (14%) in PGY-3 and 2 of 22 (9%) in PGY-4. Rotation lengths range from 1 week to 3 months, with most running 1 to 4 weeks. Thirty-two of 38 US program directors (84%) believe a formal radiology curriculum would benefit their residents. Thirty-five of 39 believe that this should be a case-based review of images. Twenty-four of 38 believe this should be done on a monthly basis. Fifteen of 39 responding program directors (39%) believe the optimal time is during the PGY-3 of training, 14 of 39 (36%) favor PGY-2, and 9 of 39 (23%) PGY-1.

Radiology education in otolaryngology has not been standardized by the ACGME. Formalized curricula are not established, and little literature exists on the topic. The field of general surgery (GS) has discussed the importance of radiology in practice and the need for resident education. The American Board of Surgery has emphasized the importance of clinical radiologic training, but variable results have been published when investigators assessed trainees’ proficiency in diagnostic imaging evaluation.⁴ Similar variability has been reported in other specialties regarding radiology training.^5,6 To our knowledge, there are no studies discussing resident accuracy and confidence in interpretation of imaging in otolaryngology. However, from the realm of GS, we can extrapolate that similar rates of variability exist.

The ACGME presently mandates a minimum of 1900 chest films, 600 abdominal or pelvic computed tomographic scans, and 350 abdominal or pelvic ultrasonographic images to achieve competency in a diagnostic radiology residency.⁷ The ACGME requirements for surgical residents, however, make no mention of training requirements in diagnostic radiology. Therefore, any competency GS residents achieve in radiology is without explicit guideline or curriculum. Butler et al⁸ conducted a survey of GS 125 attending and 155 resident physicians investigating the use of radiologic interpretation in their practice. They also assessed the perceived need for a standardized radiology curriculum in GS training, with 69% of faculty and 74% of residents answering “yes.” Of the respondents who answered “yes,” faculty and residents felt the sessions should occur monthly (44% and 49%, respectively) and that both attending radiologists and surgeons should lead teaching sessions (85% and 78%, respectively). Data on desired timing, frequency, and setting of radiology didactic sessions are scant in the surgical literature. To our knowledge, no study has investigated this topic in the subspecialty of otolaryngology.

As stated previously, there are no requirements from the RRC for a standardized radiology curriculum in otolaryngology. However, our study reports that 71% of programs have a focused curriculum. This is a much higher number than anticipated and overall shows the emphasis programs place on radiology education. From our survey, we see that most radiology education occurs during monthly sessions, run by radiologists and otolaryngologists, and is a mix of lecture- and case-based review of images. Weekly protected academic time allows every program to craft an educational curriculum for residents. However, very few programs discuss radiology on a weekly basis. Most (64%) allot time once a month for this endeavor. When US program directors were asked to choose their ideal educational format and timing, most chose monthly sessions discussing case-based review of images. Therefore, most programs are likely holding sessions at the desired frequency and with the desired format.

More than half of the programs (56%) have a dedicated radiology rotation within their curriculum. A focused rotation allows residents to explore the topics of head and neck radiology beyond a monthly lecture. Given no requirement for such a rotation, having more than 50% of programs with this type of experience is very encouraging. However, a deeper look at the numbers highlights an interesting trend. In the 2016-2017 academic year, the RRC revised the requirements for the PGY-1, increasing the amount of otolaryngology training to 6 months and allowing more flexibility for nonotolaryngology rotations. Programs have 3 months to choose nonotolaryngology experiences that include neuroradiology as one rotation option. Our survey indicates that of the 56% of programs that have a radiology rotation, 77% of them occur during PGY-1. We do not know how many rotations were established before the 2016-2017 academic year, but it is likely many programs used this increased flexibility to provide this radiology experience. Furthermore, when program directors were asked when the optimum time for a dedicated radiology rotation should occur, 39% responded for PGY-3, 36% for PGY-2, and only 23% for PGY-1. Therefore, while more than half of programs have a radiology rotation, 75% of program directors think this experience should occur at a different time in training than is currently the most common.

The ACGME program requirements introduction^3(p1) states that “supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth.” This ACGME statement makes clear the need for supervision throughout medical education to ensure that every resident is competent to practice unsupervised after completing their training. In programs without standardized curricula, much of a resident’s knowledge may be self-taught. Given the importance of head and neck radiology in modern-day otolaryngology, the addition of radiology-specific program requirements would be consistent with the ACGME’s goal of supervision and direction to ensure clinical competency. Interestingly, our study shows that this lack of standardized requirements has not created barriers to programs having radiology curricula. However, there is considerable variance in terms of timing, frequency, and setting for didactic sessions. In addition, programs that offer dedicated rotations are not doing so in the perceived optimal time for maximal resident benefit.

Finally, the goal for radiology education is comfort and competency with the available imaging modalities. The goal is not to have otolaryngologists relying on their own “reads.” For practical as well as medicolegal reasons, the radiologist’s report will not be replaced. It is interesting that while we as otolaryngologists may not have a basic understanding of radiology, we expect our radiologists to have a fundamental understanding of our surgical procedures and postoperative course. The more the surgeon understands about radiology, the more fruitful the surgeon-radiologist relationship becomes. Therefore, there is a tremendous opportunity to further the interdisciplinary relationship between our 2 specialties.

A limitation of this study is its low response rate. While we contacted all 106 programs, only 37% responded. Our results show a high percentage of programs with radiology curricula. However, it is difficult to generalize this conclusion to all otolaryngology programs across the country when more than half the programs did not respond.

Despite the lack of standardized requirements from the ACGME, 71% of US otolaryngology residency programs that responded to our survey have a radiology curriculum. Most conduct monthly didactic sessions, run by both radiologists and otolaryngologists, and are a mix of lecture- and case-based review. This format is the desired frequency, setting, and format by most responding program directors. More than half of the programs provide a dedicated radiology rotation, three-quarters of which occur in PGY-1. Most responding program directors believe a rotation is beneficial but see PGY-3 and PGY-2 as the optimal time. The ACGME program requirements seek to standardize the resident experience across the country. Given the considerable variability encountered in radiology education, we believe standardized program requirements will improve education across all programs, enhance the level of patient care, and further the interdisciplinary teamwork of otolaryngologists and radiologists.

Corresponding Author: Kirkland N. Lozada, MD, Department of Otolaryngology, New York Eye & Ear Infirmary of Mount Sinai, 310 E 14th St, Sixth Floor, New York, NY 10003 (kirkland.lozada@gmail.com).

Accepted for Publication: October 24, 2017.

Published Online: January 18, 2018. doi:10.1001/jamaoto.2017.2881

Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Lozada.

Drafting of the manuscript: Lozada.

Critical revision of the manuscript for important intellectual content: Both authors.

Administrative, technical, or material support: Both authors.

Study supervision: Both authors.

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.