Residency does little to improve appropriate imaging selection in emergency medicine

Emergency medicine residents need more stringent, focused instruction in order to be familiarized with appropriateness guidelines for diagnostic imaging selection, according to a study published in the October issue of the American Journal of Roentgenology.

As knowledge of the risks associated with medical radiation increases, the need for making informed decisions about the most appropriate imaging examination in emergency department settings is growing as well, wrote R. Joshua Dym, MD, of the Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, N.Y., and colleagues. 

Researchers in the study created an online multiple-choice survey based on 10 clinical scenarios from the American College of Radiology (ACR) Appropriateness Criteria guidelines in order to determine the adeptness of residents from American Council for Graduate Medical Education-accredited emergency medicine residency training programs in selecting appropriate radiologic exams for specific clinical scenarios. The authors additionally aimed to ascertain whether training improves this decision-making ability over the length of these residencies. A total of 583 residents from at least 77 different emergency medicine residency training programs completed the survey, whose correct answers were derived from the ACR Appropriateness Criteria guidelines.

Results indicated that the overall average number of questions answered correctly was 7.1 out of 10, with no significant difference between the scores of the residency class years. While eight of the 10 common clinical scenarios were correctly answered by most participants, two were distinct outliers. The first, which was properly answered by 20.9 percent of the population, was suspected pulmonary embolism. While the most appropriate initial imaging examination is a chest x-ray, most selected CT angiography. The second scenario, which was identified rightly by 28.5 percent of respondents, was recurrent sinusitis, of which most thought no imaging was required. In actuality, CT is the appropriate imaging decision to effectively evaluate the extent of disease and assess for underlying abnormalities that may be surgically correctible.

Overall, the study’s findings indicated there was no marked improvement in ability to select appropriate imaging studies over the course of residency.

“Greater engagement with clinicians by radiology organizations and departments may help promote the use of mutually accepted guidelines, such as the ACR Appropriateness Criteria,” wrote Dym and colleagues. “Increased education and adoption of these guidelines, along with personal and automated assistance by radiologists, should lead to better utilization of radiology resources and improve interdepartmental communication and patient care.”