Is PACS to blame for more passive residents?

A chance discovery at the University of Pennsylvania Medical Center (UPMC) seems to implicate PACS in residents' reports of being less challenged by their training than they were in a film environment, said Dr. Steven C. Horii, a professor of radiology at Penn, during a session at the May Society for Computer Applications in Radiology meeting in Salt Lake City.

While conducting a time-and-motion study of the interpretation of emergency musculoskeletal examinations, UPMC researchers were surprised to find a major change in the way radiology residents in their department were being trained in musculoskeletal radiology.

"We believe a negative impact of this change is that the residents are less challenged," Horii said.

Prior to PACS implementation at UPMC, the role of the resident was to hang film for current unread studies on one of the film alternators, then review the examination and make notes of the findings. In this way, residents made the first interpretation of the study in about a third of the cases, all of which were subsequently reviewed by the attending radiologist before the resident dictated the report, Horii said.

After conversion to PACS and filmless operation in the musculoskeletal section, however, Horii noticed this pattern had changed.

Now the radiologist sits at the PACS workstation with the residents, and they review cases simultaneously. Although residents are routinely asked their opinion of the findings and are questioned on disease processes present, Horii noticed that residents were reviewing cases alone less often - the proportion of cases read first by residents decreased to about 14%. In addition, the attending radiologist now often dictates the report.

"This results in a fundamental change in the teaching process," Horii said. "As one of our researchers said, the residents changed from 'being' a radiologist to 'watching' a radiologist."

Whether this change adversely affects training is not yet known.

"Residents have not complained about this change, although some of them have never experienced the film-based manner in which training used to be accomplished," Horii said. "Many radiology residents understand that being required to provide an interpretation and then having that interpretation critiqued is one fundamental approach to learning to 'read' studies."

This decrease in 'first reading' has motivated some of the attending musculoskeletal radiologists to return to having the residents review cases first.