HUEH March 2016 Radiology-ENT Faculty Visit
Last month, Mary Beth Cunnane, M.D., a Radiologist specializing in Head and Neck at Massachusetts Eye and Ear, spent a week working with ENT residents at Hôpital de l’Université d’Etat d’Haïti (HUEH) to improve their skills in CT scan-based interpretation for pathologies of the head and neck. In addition to group lectures shared with HUEH’s Radiology residents, Dr. Cunnane focused on one-on-one case-based teaching sessions, reinforcing a systematic approach to interpretation. In the complicated anatomical landscape of the head and neck, CT imaging is critical not only to diagnosis but operative planning. An advanced understanding CT anatomy and CT appearance of pathology facilitates improved surgical decision-making and is necessary for more complex surgical interventions.
Surgical residents in Haiti’s only ENT Residency Program have limited access to radiology expertise, receiving only a brief introduction during their first year of medical school. During their residency, trainees have limited opportunities to gain familiarity with CT anatomy and CT appearance of pathology since few patients have the funds to pay for scans. HUEH, Haiti’s primary public training hospital does not currently have a CT scanner, forcing patients to obtain their scans from nearby private hospitals or imaging centers. This functional separation of clinician from radiologist generally prohibits the dialogue necessary for comprehensive interpretation, putting the onus on the clinician to become independently proficient at CT interpretation. Plans for the rebuilding and modernizing of the HUEH facility, intended to replace the loss of infrastructure caused by the 2010 earthquake, include a CT scanner. In anticipation of this expansion of radiology service offerings, the HUEH Radiology residents are eager to expand their program’s curriculum.
“Watching an individual work through a scan allows the instructor to appreciate that person’s level of skill and adjust instruction accordingly.” Dr. Mary Beth Cunnane
During the week, Dr. Cunnane’s target skill set for transfer was the use of a standard checklist for CT interpretation. Dr. Cunnane developed the checklist, featuring all structures a clinician should examine when interpreting a neck CT, based upon the probability of disease in a given anatomic location given a presumed history of ear, nose, or throat disorders. A checklist has the advantage of:
- Structuring an otherwise potentially confused exam
- Exposing the clinician to multiple examples of normal anatomy, allowing the construction of a visual database of normal and normal variants over time
- Reducing the chance that findings most important to an ENT physician will be missed
- Preventing a “blinders” effect causing the clinician to focus on the area of interest to the exclusion of other potential abnormalities
In addition to general lectures, Dr. Cunnane focused on 20-30 minute individual tutoring sessions, encouraging residents to “think out loud” as they processed CT scans and describe each structure they were examining. These one-on-one sessions allowed Dr. Cunnane to meet with the eight ENT residents even during their busy clinical schedules and gain rapid feedback on shared and individual challenges. For example, multiple residents had difficulties differentiating sphenoid sinus from the nasopharynx on soft tissue windows, prompting the use of alternative strategies for identification. Residents were assessed and scored on a checklist at the beginning and end of the week while examining a CT scan presented without clinical history, and showed significant improvements.
While interpretation of radiographic images is a complex skill that takes many years to master, a great deal of progress may be made via deliberate practice and feedback. For radiology and ENT residents in the United States, such feedback is provided by a radiology attending during training and a combination of pathology results, surgical findings, and clinical follow-up over the course of their careers. Continued medical education for radiology lends itself well to distance learning and utilizing case consultations as further educational opportunities.
Dr. Cunnane ran a similar course in Mbarara Uganda for ENT residents at Mbarara University of Science and Technology in 2015.
Our continued thanks to Dr. Patrick Jean-Gilles and the ENT residents at HUEH and Dr. Mary Beth Cunnane for her contributions.