Diagnostic Radiology Residency Program

Goals & Objectives

PGY 2-5 Rotations

Department of Medical Imaging

University of Toronto

Last updated: March 2013

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Table of Contents • General Program Objectives of Training 2

• Specific Rotation Supervisors 6

• Specific Rotation Objectives:

Introductory PGY-2 Rotation 8

Introductory Ultrasound Course 13

Breast Imaging 14

Chest Radiology 19

Cardiac 23

CT 27

GI/GU 31

MRI 36

Musculoskeletal 40

Neuroradiology 45

Head & Neck 49

Nuclear Medicine 52

Pediatrics 56

Ultrasound 61

Obstetrical Ultrasound 66

Vascular Interventional Radiology 70

General/ER Imaging 74

Community Rotation 77

Research Rotation 80

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OVERALL PROGRAM OBJECTIVES OF TRAINING DIAGNOSTIC RADIOLOGY

RESIDENCY TRAINING PROGRAM OVERALL GOALS The overall goals of the University of Toronto Diagnostic Radiology Program are to train physicians to be competent in the basic knowledge, technical skills and attitudes necessary to function as consultants in Diagnostic Radiology. Graduates will have the ability to supervise, advise on and perform imaging procedures to such a level of competence and across a broad range of medical practice, as to function as a consultant to referring family physicians and specialists. The graduate will have a foundation for a career built on continuous learning and recognition of the importance of communication, interdisciplinary collaboration, research and professional attitudes and respect. The program is designed to meet the specifications of the Royal College of Physicians and Surgeons of Canada, as well as address the CanMEDS objectives. Our objectives below have been adopted from those outlined by the Royal College. GENERAL OBJECTIVES - Diagnostic Radiology On completion of the educational program, the graduate physician will be competent to function as a consultant in Diagnostic Radiology. Communication skills, knowledge and technical skills are the three pillars on which a radiological career is built. All three depend on the acquisition of an attitude to the practice of medicine which recognizes both the need to establish a habit of continual learning and recognition of the importance of promoting a team approach to the provision of imaging services. Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to Diagnostic Radiology. In addition, all residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis. SPECIFIC OBJECTIVES - Diagnostic Radiology MEDICAL EXPERT General Requirements Demonstrate diagnostic and therapeutic skills for ethical and effective patient care. Access and apply relevant information to clinical practice so as to have competence in

clinical radiological skills. Demonstrate effective consultation services with respect to patient care, education and

legal opinions. Specific Requirements Demonstrate knowledge of human anatomy at all ages, both conventional and multi-

planar, with emphasis on radiological applications. Demonstrate knowledge of all aspects of clinical radiology, including understanding of

disease, appropriate application of imaging to patients, importance of informed consent, complications such as contrast media reactions, and factors affecting interpretation and differential diagnosis.

Show competence in manual and procedural skills and in diagnostic and interpretive skills.

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Demonstrate the ability to manage the patient independently during a procedure, in close association with a specialist or other physician who has referred the patient. The radiologist should know when the patient's best interests are served by discontinuing a procedure, or referring the patient to another physician.

Demonstrate knowledge regarding the acceptable and expected results of investigations and/or interventional therapy as well as unacceptable and unexpected results. This must include knowledge of and ability to manage radiological complications effectively.

Demonstrate the appropriate follow-up care of patients who have received investigations and/or interventional therapy.

Competence in effective consultation, conduct of clinico-radiological conferences, and the ability to present scholarly material and lead case discussions

COMMUNICATOR General Requirements Establish appropriate therapeutic relationships with patients/families. Demonstrate ability to listen effectively. Obtain the appropriate information during consultation with referring physicians in order

to be able to make recommendations regarding the most appropriate testing and/or management of patients.

Discuss appropriate information with patients/families and the health care team, and be able to obtain informed consent for tests and procedures when this is needed.

Specific Requirements Produce a radiology report describing the imaging findings, most likely differential

diagnoses and, when indicated, recommend further testing and/or management. Demonstrate appropriate communication with referring physicians, including an

understanding of when the results of an investigation or procedure should be urgently communicated.

Communicate effectively with patients and their families and have a compassionate interest in them.

Recognize the physical and psychological needs of the patient and their families undergoing radiological investigations and/or treatment, including the needs of culture, race and gender.

COLLABORATOR General Requirements Demonstrate effective consultation skills when working with other physicians and health

care professionals. Demonstrate effective contributions to other interdisciplinary team activities.

Specific Requirements Competent in functioning as a member of a multi-disciplinary health care team in the

optimal practice of radiology. MANAGER General Requirements Demonstrate effective resource utilization to balance patient care, learning needs and

other activities.

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Competent at allocating finite health care resources wisely. Work effectively and efficiently in a health care organization. Utilize information technology to optimize patient care, life-long learning and other

activities. Specific Requirements Be competent in conducting or supervising quality assurance including an understanding

of safety issues and economic considerations. Be competent in computer science as it pertains to the practice of radiology.

HEALTH ADVOCATE General Requirements Identify the important determinants of health affecting patients. Contribute effectively to improve the health of patients and communities. Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements Explain the benefits and risks of radiological investigation and treatment including

population screening. Recognize when radiological investigation or treatment would be detrimental to the

health of a patient. Educate and advise on the use and misuse of radiological imaging. Demonstrate an understanding of the fundamentals of quality assurance in radiology.

SCHOLAR General Requirements Develop, implement and monitor a personal continuing education strategy. Critically appraise sources of medical information. Facilitate learning of patients, house staff, students and other health professionals. Contribute to development of new knowledge.

Specific Requirements Competent in evaluation of the medical literature. Demonstrate the ability to teach radiology to medical students, residents, technologists

and clinical colleagues. Complete a radiology research project, which may include quality assurance. Demonstrate an appreciation for the important role that basic and clinical research plays

in the critical analysis of current scientific developments related to radiology. Demonstrate an understanding of the fundamentals of epidemiology, biostatistics and

decision analysis. PROFESSIONAL General Requirements Deliver highest quality care with integrity, honesty and compassion. Exhibit appropriate personal and interpersonal professional behaviors. Practice medicine ethically consistent with the obligations of a physician respecting the

needs of culture, race and gender.

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Specific Requirements Assess one's own performance, strengths and weaknesses. Demonstrate an understanding of the ethical and medical-legal requirements of

radiologists. Training in Canada The foregoing represents the general and specific objectives that all candidates for the Royal College examinations in Diagnostic Radiology are expected to meet. For those training in Canadian programs, these objectives will be accomplished in a staged manner. Residents in Canadian programs may obtain the document describing this approach from their program directors.

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Specific Rotation Supervisors

Site Rotation Supervisor Sick Kids General Cathy Macdonald MSH Breast Imaging Supriya Kulkarni Chest Radiology TaeBong Chung Computed Tomography Nasir Jaffer Emergency Robert Bleakney Gastrointestinal Imaging Nasir Jaffer Muculoskeletal Robert Bleakney Neuroradiology Edward Kassel Nuclear Medicine Aaron Hendler Obstetrical Ultrasound Katherine Fong Ultrasound Myles Margolis Vascular/Interventional Radiology John Kachura

PMH Body MR Imaging Kartik Jhaveri Breast Imaging Supriya Kulkarni Computed Tomography Martin O’Malley Head & Neck Imaging Eugene Yu SHSC Body CT/MRI Caitlin McGregor Breast Imaging Belinda Curpen Cardiac Imaging Anna Zavodni Chest Imaging Patricia Dunlop Computed Tomography Caitlin McGregor Emergency Imaging Linda Probyn Gastrointestinal Imaging Jane Wall Introductory PGY-2 Mia Skarpathiotakis Neuroradiology Sean Symons Nuclear Medicine Lisa Ehrlich Musculoskeletal Joel Rubenstein Obstetrical Ultrasound Phyllis Glanc Ultrasound Caitlin McGregor Vascular/Interventional Radiology Chris Dey SMH Breast Imaging Franklin Goldberg Chest Imaging William Weiser Computed Tomography Errol Colak Emergency Imaging William Weiser Gastrointestinal Imaging Arthur Zalev Introductory PGY-2 Walter Mak MR Imaging Anish Kirplani Musculoskeletal Imaging Dawn Pearce Neuroradiology Dipanka Sarma Nuclear Medicine Gilbert Hurwitz Vascular/Interventional Radiology Vik Prabhudesai Ultrasound Derek Muradali

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Specific Rotation Supervisors Cont’d Site Rotation Supervisor TGH Cardiac Imaging Elsie Nguyen Chest Imaging TaeBong Chung Computed Tomography Martin O`Malley Introductory PGY-2 Bob Bleakney Nuclear Medicine Aaron Hendler Ultrasound Mostafa Atri Vascular Interventional Radiology Chia Sing Ho TWH Computed Tomography Anthony Hanbidge Musculoskeletal Imaging David Salonen Neuroradiology Richard Farb Ultrasound Anthony Hanbidge Vascular Interventional Radiology Martin Simons MSH/UHN Introductory PGY-2 Robert Bleakney WCH Breast Imaging Supriya Kulkarni

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Last updated: September 2012 INTRODUCTORY PGY-2 ROTATION Hospital: MSH/UHN, SHSC, SMH PGY 2 – First 11 weeks Supervisor: MSH/UHN: Dr. E. Bartlett Dr. E. Yu SHSC: Dr. R. Pugash SMH: Dr. W. Mak ROTATION DESCRIPTION: The Introductory rotation introduces the PGY-2 residents to the basics of radiology practice and guides them in their study and preparation for their upcoming on-call duties that begin with backup-call at the end of this rotation. The PGY-2 residents rotate through the core radiology subspecialties most relevant to their on-call responsibilities and within these rotations; there will be an emphasis on the clinical scenarios and skills most relevant to after-hours radiology. These “mini-rotations” range from 1 to 3 weeks long (depending on the hospital site) for a total of 11 weeks and will occur at the residents’ base hospitals. Over the course of this rotation, the residents will become familiar with the different resources and functionality of each section of the department. The rotations include exposure to neuroradiology, thoracic imaging, musculoskeletal imaging, and abdominal imaging (radiography, CT and ultrasound) and can be adjusted at the discretion of the Site Coordinator and/or Program Director to best meet the needs of the residents at that site. Residents may be given an opportunity to spend time with the technologists in CT and MRI to enhance their understanding of scanning techniques and protocols. During their mini-rotations, the PGY-2 resident will initially be given responsibilities appropriate to their level of training, and later commensurate with the degree of progress made. They will be expected to perform preliminary assessment of imaging studies, review these studies with their supervisors and dictate final reports. In each rotation, the focus of the resident should be on review of imaging studies performed on patients from the Emergency Room and from the inpatient units. During this rotation, the resident will have exposure to the on-call service as a “shadow” or “buddy” to the senior resident covering the on-call duties. The PGY-2 residents will be exposed to the common pathologies and scenarios that are experienced on-call as well as observe how these situations are handled by the more senior resident. GOALS & OBJECTIVES: By the end this rotation, the resident will develop a basic skill set required for emergency

radiology interpretation and management of common on-call scenarios Basic approach to plain film interpretation of bones, joints, CXR and abdomen Basic emergency CT indications, the use of contrast materials, and the basic

interpretation of these CT exams (including neuro, chest, body, MSK) Develop knowledge of important trauma/emergency diagnoses as outlined below Basic ultrasound principles including indication, common surgical/obstetrical/emergency

problems Develop and improve knowledge of radiological anatomy

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MEDICAL EXPERT/CLINICAL DECISION MAKER: Thoracic Imaging During this rotation, the resident will become familiar with basic chest radiologic examinations (including plain radiographs and CT studies), and demonstrate the following knowledge:

Anatomy: • Chest X-ray - mediastinal border-forming structures on frontal CXR, major

airways, major and minor fissures , AP window • CT - anatomy of major arteries and veins (aorta and its branches, pulmonary

arteries, central veins); cardiac chambers, pericardium; trachea and major bronchi

Important Diagnoses:

• Pneumonia • Pleural effusion • Atelectasis • Congestive heart failure • Pulmonary embolus • Pneumothorax - be able to recognize on CXR and CT, identify tension • Aortic injury - dissection and transection , CXR and CT features of both • Aortic aneurysm

Musculoskeletal Imaging During this rotation, the resident will become familiar with basic musculoskeletal radiologic examinations (including plain radiographs and CT studies). Residents will learn standard views for assessing joints and basic CT protocols for spine and extremity evaluation. The residents are expected to demonstrate the following knowledge:

Anatomy: • Radiographs - Basic anatomy of axial and appendicular skeleton and major

joints • CT – cross sectional anatomy of spine and major joints

Important Diagnoses:

• Develop an approach to cervical spine trauma • Review common cervical spine, thoracic and lumbar spine injuries • Recognize and describe common fractures and dislocations of the

appendicular skeleton

Abdominal imaging During the abdominal radiography and abdominal CT section of the rotation, the resident will become familiar with standard abdominal radiographs and CT studies. During the ultrasound component of this rotation, the resident will work with an experienced sonographer and ultrasound teacher in order to obtain hands-on experience performing ultrasound studies for common pathologies encountered on-call. The focus of this training will be to learn the basic operation of the ultrasound machine and develop an ability to perform focused ultrasound for specific clinical problems. The resident will review studies with supervising staff and may perform some dictation. In addition, an ultrasound course will also be given in the fall of the

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PGY-2 year to improve hands-on ultrasound training (given by an experienced ultrasonographer). During these rotations, the resident should demonstrate the following knowledge:

Anatomy (radiographic, CT and ultrasound):

• Recognize normal appearance of kidneys, adrenals, pancreas, liver, spleen, bowel, gallbladder, biliary tree, IVC, aorta, bladder, uterus, ovaries, prostate, seminal vesicles

• Peritoneal and retroperitoneal spaces and ligaments • Vascular structures: Aorta, celiac axis, SMA, SMV, IVC, iliac arteries and

veins, splenic vein, portal vein, hepatic veins.

Important Diagnoses • Pneumoperitoneum: radiographs and CT • Free intraperitoneal fluid: radiographs and CT • Bowel obstruction: radiographic and CT features of large and small bowel

obstruction and their causes • Acute appendicitis: appendicolith on X-ray, US and CT appearance • Cholecysititis • Bile duct dilatation • Pancreatitis • Renal colic • Abscess • Retroperitoneal hemorrhage • Traumatic injuries: liver, spleen, kidney, urethra, bladder • Abdominal aortic aneurysm plus features of leak/rupture • Ectopic pregnancy • Tubo-ovarian abscess • Normal early gestation • Complications of pregnancy - early pregnancy loss, retained products of

conception, endometritis • Testicular torsion • Epididymitis/orchitis

Neuroradiology During the neuroradiology section, the resident will focus on CT scans of the brain and spine with some limited exposure to MR, with the goal of demonstrating the following knowledge:

Anatomy: Basic understanding of neuroanatomy in the axial plane on CT including: • Skull • Dura • Sinuses • Ventricular system • Basal cisterns • arterial supply to brain/Circle of Willis • venous drainage/dural sinuses • brainstem, cerebral hemispheres, cerebellum • basal ganglia • major white matter tracts • sella, pituitary gland

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• physiologic calcifications Important Diagnoses:

• Infarction: early signs, assessment of age Cerebral Hemorrhage: location (SAH, SDH, EDH, intraparenchymal, interventricular), differentiating features, etiologies

• Signs of mass effect • Hydrocephalus • Differential diagnosis of ring enhancing lesions • Cerebral Edema: vasogenic versus cytotoxic • Role of IV contrast • Cauda equina syndrome/acute compressive myelopathy

Contrast agents: • Basic types of contrast • Contrast reactions: diagnosis and management

COMMUNICATOR: Demonstrate ability to dictate a radiologic report. Demonstrate satisfactory communication skills when interacting with supervising staff,

support staff, colleagues and referring physicians. COLLABORATOR: Demonstrate good developing consulting skills when interacting with other physicians

and health team members. Exhibit ability to interact appropriately with other radiology department staff,

demonstrating a team approach to patient care. Exhibit ability to interact appropriately with other residents in both radiology and

referring services

MANAGER: Demonstrate understanding of the basic indications for urgent or emergent imaging. Demonstrate understanding of the basics of which imaging modality is appropriate for

common clinical scenarios. Exhibit ability to consider advantages and disadvantages of available imaging modalities. Exhibit ability to consider available imaging resources when planning and recommending

patient care, using them effectively and efficiently. Display ability to protocol imaging studies appropriately considering the clinical

indication. Demonstrate ability to prioritize requests for urgent imaging examinations.

HEALTH ADVOCATE: Demonstrate an understanding of the basic principles of radiation safety and to recognize

and consider radiation doses when recommending, approving and protocoling cases. Demonstrate an understanding of the importance of timely imaging studies.

PROFESSIONAL: Demonstrate integrity, honesty and compassion. Display ability to understand and practice ethical and medical-legal requirements of

radiologists.

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Demonstrate awareness of own limitations. Demonstrate punctuality and attendance at all teaching sessions, rounds, lectures, etc.

SCHOLAR: Exhibit ability to set personal learning goals and reading plan during rotation. Exhibit ability to progress critical appraisal skills for literature reviews.

References: Brant & Helms: Fundamentals of Diagnostic Radiology Weir & Abrahams: Imaging Atlas of Human Anatomy Harris: The Radiology of Acute Cervical Spine Trauma **highly recommend!** Harris: The Radiology of Emergency Medicine Webb, Brant & Helms: Fundamentals of Body CT Sanders: Clinical Sonography: A Practical Guide Cwinn, Grahovac: Emergency CT scans of the Head: A Practical Atlas ** see additional information and comments on section: recommended reading list

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Last updated: August 2012 INTRODUCTORY Ultrasound Course Hospital: SHSC Course Outline: This course consists of 4 sessions (each session is 2 hours in length) and is mandatory for

PGY2 Residents. The Goals of the course are to give the PGY2 Residents exposure to basic ultrasounds

skills to assist with on-call and rotation preparation. Staff Radiologists and Technologists will assist the Residents (in small groups of 2 to 3

Residents) to learn how to use the ultrasound machines and to identify anatomy. The last session will include Standardized Patients to learn transvaginal scanning.

At the end of the 4 sessions, PGY2 Residents will be able to:

1. DEMONSTRATE ABILITY TO RECOGNIZE THE NORMAL APPEARANCE OF THE FOLLOWING ANATOMICAL STRUCTURES:

Kidneys, adrenals, pancreas, liver, spleen, bowel, GB, biliary tree bladder, uterus, ovaries, cul-de-sac Vascular structures: aorta, celiac, splenic, SMA, IVC, iliac arteries and veins,

SMV, splenic vein, portal vein, hepatic veins.

2. DEMONSTRATE BEGINNER SKILL FOR SCANNING TECHNIQUE - ABDOMINAL AND PELVIC ULTRASOUND

3. DEMONSTRATE TECHNIQUE FOR AND RECOGNIZE ULTRASOUND

APPEARANCE OF FREE INTRAPERITONEAL FLUID

“3-point” check: RUQ, LUQ, Pelvis

4. RESIDENT READING: DEMONSTRATE UNDRSTANDING OF FEATURES OF SOME IMPORTANT CLINICAL DIAGNOSES FREQUENTLY INVESTIGATED WITH ULTRASOUND:

Acute appendicitis, cholelithiasis and cholecystitis, pancreatitis, abnormal bile

duct dilatation Feature of a simple cyst Features of an abscess Aortic aneurysm Complex adnexal cyst or mass Ectopic pregnancy Complications of pregnancy: missed abortion, placenta previa, placental

abruption, retained products of conception, endometritis Residents are given feedback during the course and may be asked to do an informal exam at the end of the course.

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Last Updated: October 2012 BREAST IMAGING Hospital: MSH, SHSC, SMH, PMH Supervisor: MSH: Dr. S. Kulkarni SHSC: Dr. R. Jong SMH: Dr. F. Goldberg PMH: Dr. S. Kulkarni WCH: Dr. S. Kulkarni Mandatory: 3 rotations which may be taken in any training year Elective: 1 – 6 months elective option in PGY-5 with approval of the Program Director Breast Imaging is offered at 4 hospitals (MSH, PMH, SMH, SHSC) where full training in all modalities and exposure to all procedures is provided. Residents must complete 3 rotations in Breast Imaging, which may be done at separate times or in blocks, but preferably experiencing 2 or possibly 3 hospitals. Participation in pertinent imaging and interdisciplinary clinical rounds at each hospital is expected. The resident should take an active and progressive role in case presentation. Access to teaching material is provided at all 4 hospitals. PROGRAM GOALS: By the end of mandatory training, the residents must demonstrate basic knowledge, technical skills and attitudes necessary for the competent performance of all aspects of Breast imaging including: 1) Supervision and interpretation of mammograms, including screening, diagnostic and post-surgical populations. 2) Diagnostic breast ultrasound 3) Breast interventional procedures with minimal supervision: core biopsy (stereotactic and US-guided), aspirations, galactography, needle localization. 4) Basic understanding of breast MRI 5) Function as a junior consultant for breast imaging with independence and minimal supervision. In addition, the resident may have acquired knowledge and skills in MRI guided imaging procedures. ROTATION OBJECTIVES: Rotation objectives will be the same at all rotation sites. MEDICAL EXPERT/CLINICAL DECISION-MAKER: Demonstrate understanding of quality assurance, proper positioning and basic

mammographic techniques. Demonstrate ability to identify normal and abnormal anatomical appearances on

mammography. Demonstrate ability to discuss the technical and physical factors important for obtaining

an optimal mammographic study. Demonstrate ability to make a preliminary assessment of mammographic images,

advising the technologist on the need for additional views, as necessary. Demonstrate ability to identify features of malignant and benign disease.

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Demonstrate ability to develop an approach to the assessment of breast calcifications and breast masses.

Demonstrate ability to establish a plan for management or follow-up of probably benign disease/lesions.

Demonstrate ability to learn the role of ultrasound in breast imaging. Demonstrate ability to identify normal and abnormal breast anatomy on ultrasound. Display ability to perform needle localization techniques. Demonstrate understanding of the indications and techniques for stereotactic biopsy, US-

guided core biopsy, cyst aspiration. Demonstrate understanding of the techniques and indications for galactography. Demonstrate familiarity with the evaluation of the male breast. Demonstrate familiarity with the evaluation of the post-surgical breast (including

complications, post-surgical and post-radiation appearances). Demonstrate understanding of the radiology - pathology correlation and understand

patient management when there is variance with the mammographic study. Participate in Radiology-Pathology conference and present cases as requested Demonstrate basic understanding of the indications for and interpretations of breast MRI

studies. Rotation 1 The first rotation will provide an introduction to basic breast anatomy, epidemiology and risk factors for breast cancer, the routine views, technique and basic physics, the viewing format, an introduction to the evaluation of calcifications and masses, the classic features of malignancy, post-operative and post-radiation changes and gynecomastia. Instructions on the format of the mammogram report and integrating the ACR lexicon will be provided. The complementary role of ultrasound, the technique and indications will be introduced. The resident will learn the classic features of a cyst, carcinoma, implants and potential pitfalls. The resident will be directed to key articles and be able to undertake literature searches where indicated. Procedures may begin on this rotation and the resident is expected to follow-up each with radiologic-pathologic correlation. Rotation 2 The resident continues to develop background knowledge of breast cancer; the resident will develop an understanding of the staging TNM system for breast cancer and the principles of treatment and be aware of the psycho-social issues of breast cancer. The differential diagnoses of mammographic and sonographic lesions are expanded. The resident should know the common supplementary views and how to use them to problem solve. The elements of a QC program and an awareness of elements of the CAR accreditation program are expected. The resident should develop sensitivity to bioethical and medical-legal issues and maintain consideration for the patient's needs. Teaching technologists and medical students is expected. Consent-taking and procedural skills are consolidated. The resident will be trained in both stereotactic and US-guided biopsies and by the end of rotation the resident should be able to perform breast ultrasound, and both stereotactic and US-guided biopsies independently while under supervision, for uncomplicated patients. Rotation 3 Procedural skills are enhanced with further experience. Greater independent consulting skills, problem-solving skills and the ability to detect subtle cancers will be developed. Sequencing of tests and appropriateness criteria are emphasized. The resident is expected to independently

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manage an increasing volume of diagnostic cases. The resident is expected to demonstrate progressive independence in management of procedures, including US and stereotactic and US-guided biopsies. For difficult interpretations or procedures, the resident should recognize the limits of their personal expertise and request help from the staff as required. More in depth understanding of the QC program and the physicist's report will be achieved. The resident will be expected to develop a basic understanding of the indications for and interpretation of breast MRI. Experience with the OBSP would have to be made by special arrangement. COMMUNICATOR: Demonstrate ability to dictate well-organized succinct reports, describing relevant

findings, diagnosis and recommendations with appropriate report format and use of ACR lexicon.

Demonstrate effective communication skills when dealing with patients, during consent or procedures, as well as with support staff, colleagues and consulting clinicians.

COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate ability to interact appropriately with other radiology department staff with a

team approach to patient care. MANAGER: Demonstrate awareness of the indications for various breast imaging modalities. Demonstrate ability to consider appropriateness of requested examinations and patient

referrals. Demonstrate ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. HEALTH ADVOCATE: Demonstrate awareness and understanding of breast imaging recommendations, screening

recommendations and optimal patient work-up for various breast problems. Demonstrate an understanding of the importance of advocacy with patients, with primary

care physicians and with the community for the role of breast screening. PROFESSIONAL: Demonstrate awareness of own limitations Demonstrate integrity, honesty and compassion. Demonstrate ability to practice patient centered care accepting responsibility for duties,

respect for confidentiality and sensitivity to cultural, age, gender and disability issues of patients

Demonstrate ability to practice understanding of ethical and medical-legal requirements of radiologists.

Demonstrate professional appearance and communication. Demonstrate good work ethic with enthusiasm and motivation. Demonstrate professional work habits with punctuality, dependability, organization and

efficiency, including attendance at clinical duties, teaching sessions, rounds, lectures, etc.. Demonstrate ability to incorporate feedback into improved personal performance.

SCHOLAR: Demonstrate ability to set personal learning goals and objectives during rotation.

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Demonstrate commitment to self-education through attendance at and participation in team rounds, and through appropriate use of resources.

Demonstrate ability to take a leadership role in the learning of others, with teaching/supervision of junior residents on rotation, elective students, off-service residents.

Rotation Responsibilities: Clinical: The resident and supervising staff must review and discuss at the start of the rotation, the

mandatory goals and objectives for the resident’s rotation. The resident is responsible for knowing and attaining all of the stated goals for successful completion of the rotation.

Where there are other residents or fellows on service, diagnostic and procedural cases will be shared, based on the expected goals as stated for each resident rotation level, and as discussed with the supervisor.

The resident must show progression of abilities over the time of the rotation, by increasing efficiency and volume of case management, both diagnostic and procedural, and must show an ability to prioritize activities while on service

The resident should be familiar with all the pertinent medical history of all patients undergoing mammograms or breast interventional techniques.

The resident is responsible for knowing the indication for further mammographic views, ultrasound and needle biopsies of breast imaging abnormalities.

The resident is responsible for reporting all mammograms, reviewed under direct supervision of the staff radiologists. All mammograms must be reviewed with a radiologist! The resident should be aware of the importance of timely reporting and report verification and indications for verbal communication with referring physicians.

The resident is responsible for breast US performed for further assessment of a palpable lump or mammographic abnormality.

The resident should perform, under appropriate supervision, all assigned needle localization procedures, galactograms and biopsies. The resident should check daily the list of cases in US, and identify the biopsy cases. Please let the staff radiologist or technologist in US know that you are available for participation in the procedure.

Teaching: The resident is encouraged to bring interesting cases to noon rounds or resident half-days. The resident is expected to attend and participate in relevant clinical rounds such as

Radiology-Pathology review rounds. Supervision/teaching of elective medical students or off-service residents, along with

assigned staff radiologist. Rounds: Hospital based

Evaluation: Each individual resident is responsible for meeting the stated goals and objectives for

successful evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisors and to

ensure that the ITER is reviewed before leaving the rotation. Daily performance evaluation and observation of interpretation and interventional skills Rounds performance – including collaboration, communication and scholarly ability.

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Resident should have mid-rotation discussion with supervisor – please remind the supervisor at this point in time!

Formal ITER at end rotation OSCE and oral examination

Diagnostic and Procedural Skills to log and requirements for residency:

1. Mammographic interpretation - 700 2. Ultrasounds - 80 3. MRI - 15 4. Ultrasound core biopsies - 10 5. Stereotactic biopsies - 10 6. Galactograms - 1 7. Fine needle aspiration - 5 8. Needle localization - 3

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Last updated: April 2012 CHEST RADIOLOGY Hospital: SHSC, SMH, TGH PGY- 2: 1-2 months, Supervisor: SHSC: Dr. H. Shulman PGY- 3/PGY-4: 1-2 months SMH: Dr. W. Weiser PGY- 4/PGY-5: 1 or 2 months TGH: Dr. T. Chung PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in the basic skill set required for pulmonary imaging, including: 1) Plain film assessment of the thorax 2) CT protocoling and interpretation of the thorax 3) Interventional techniques including needle biopsy (CT and/or fluoroscopic guidance) and

thoracentesis (in some sites, will be covered on the interventional radiology rotation) ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: Demonstrate an understanding of the anatomy of the thorax, including the chest wall,

pleura, mediastinum and lungs. Demonstrate an understanding of pulmonary physiology relevant to imaging

interpretation. Demonstrate knowledge of how a chest radiograph and CT is obtained, and the physics

governing the acquisition of a satisfactory image. Demonstrate an organized approach to interpretation of chest radiography and CT. Demonstrate an understanding of the commoner chest pathologies and their radiographic

signs, including: cardiogenic and non-cardiogenic pulmonary edema, collapse and atelectasis, infection, neoplastic disease, interstitial lung disease, organic and inorganic lung diseases, mediastinal masses, diseases and abnormalities of the pleura and diaphragm, pneumothorax, pulmonary vascular patterns and vascular lesions.

Demonstrate ability to recognize patterns of diseases of the chest and their differential diagnoses

COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings

with appropriate terminology, differential diagnosis and recommendations. Demonstrate effective communication skills when dealing with patients and families

including consent for procedures Demonstrate timely and appropriate communication of findings with consulting clinician

COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians and health

team members. Demonstrate the ability to interact appropriately with other radiology department staff

with a team approach to patient care. MANAGER: Demonstrate an understanding of the indications for CXR versus CT and MRI for

thoracic investigation

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Demonstrate an understanding of the indications for thoracic procedures. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. Demonstrate ability to triage physician requests regarding urgency of imaging study Demonstrate ability to monitor and protocol CT and MRI

HEALTH ADVOCATE: Demonstrate ability to recognize and consider radiation doses when recommending,

approving and protocoling cases. Demonstrate understanding of benefits and risks of medical imaging investigations Demonstrate ability to recognize situations where imaging and treatment would be

detrimental to the health/safety of patient PROFESSIONAL: Demonstrate ethical practice Demonstrate integrity, honesty and compassion and respect for others. Demonstrate professional behavior, appearance and communication Demonstrate professional work habits with punctuality, work ethic, organization and

efficiency Demonstrate ability to self assess and an awareness of strengths and weaknesses

including limitations and acceptance of constructive criticism. SCHOLAR: Demonstrate ability to read and review material appropriate to meet rotation objectives

including critical appraisal of literature. Demonstrate ability to contribute to the learning of others, with teaching/supervision of

junior residents on rotation, elective students, off-service residents. ROTATION GOALS: ORIENTATION (2 weeks) PGY-2 Goals:

1. Ability to determine if a chest radiograph is technically adequate. 2. Development of general approach to chest radiograph. 3. Ability to recognize major emergency cardiothoracic problems on CXR, including

pneumonia, CHF, lobar atelectasis, pneumothorax and aortic rupture/dissection. 4. Introduction to basic CT findings.

1st/2nd MONTH PGY-2 Goals:

1. Ability to direct technologist to correct technical problems with CXR and CT. 2. Learn how the various cardiothoracic imaging procedures are performed. 3. Knowledge of anatomy of cardiothoracic structures on CXR and CT. 4. Ability to recognize and give basic differential diagnosis of major patterns of

cardiothoracic diseases. 2nd/3rd MONTH PGY-3/PGY-4 Goals:

1. Learn the clinical and radiographic manifestations of all major cardiothoracic diseases.

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2. Gain knowledge of the indications and contraindications of the various cardiothoracic imaging methods and procedures.

3. CT protocoling, customizing study technique, monitoring studies, contrast contraindication, and treatment of complications.

4. Ability to recognize disease on CT and MRI and to give a differential diagnosis based on the pattern(s) seen.

5. Become comfortable with interpretation of ICU CXR’s. 6. Develop consultative skills. 7. Develop skills in percutaneous biopsy of the lung and mediastinum including

pneumothorax assessment and treatment. 4th/5th MONTH PGY-4/PGY-5 Goals:

1. Consolidate the above and improve on all weaknesses. 2. Become comfortable with discussing cases at clinical rounds. 3. Develop ability to teach cardiothoracic imaging to clinical as well as more junior

radiology residents. 4. Become competent with biopsies (lung, med) and complications. 5. Consolidate interpretative skills in thoracic CT. 6. MRI contraindications, customizing study technique, monitor studies, contrast-

contraindications and treatment of complications. Rounds: Hospital based. Evaluation: Rounds performance Resident should have mid-unit discussion with supervisor Formal ITER at end rotation OSCE and oral examination

Suggested Resources: CD-ROMs are available for any Resident in the University of Toronto Department to borrow. Availability of these CD-ROMs to medical students, fellows, faculty and non U of T trainees will be limited and only with permission of the Program Director. All CD-ROMs will be kept by the Program Director's secretary who will control all loan transactions. Guidelines 1. Please notify the secretary three days in advance of loan requests. Phone Kathryn, 340-

3372, voice mail after 4p.m. is preferred or you may also fax your request to the attention of Kathryn to 593-0502. Leave phone number where you can receive a message that your request will be available. Advance reservations will be accepted also.

2. CD-ROMs will be available for pick-up from Kathryn, Monday to Friday 9 to 4 p.m.,

The Toronto Hospital, NCSB 1C-571 All loans must be secured by signing an agreement that if lost or damaged, the

borrower will agree to pay the replacement cost. This cost will be provided on request.

Residents will also sign an understanding that CD-ROMs under copyright restrictions may not be copied and that to do so is notifiable to the holder of the

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copyright and to do so is in violation of University policy. Please note ACR policy on pirating of the Learning File.

3. CD-ROMs should be returned promptly to Kathryn who will 'sign-in' the return. The loan is for one week with the option for one week renewal if not otherwise reserved. Please phone your renewal request via Kathryn voice mail. 4. Please notify Kathryn promptly if there is any problem with a CD. Available to Borrow 1. Radiology of Pneumonia, W. Weiser, U of T. 2. ACR Learning Files. Reading List:

1. Hansell DM, Armstrong, Lynch DA, McAdams HP: Imaging of Diseases of the Chest 4th edition. Year Book Medical Publishers, Chicago, 2005.

2. Felson, B., Chest Roentgenology. W.B. Saunders Co., Philadelphia, 1973. 3. Felson, B., Weinstein, A.S., Spitz, H.B. Principles of Chest Roentgenology: A

Programmed Text. W.B. Saunders Co., Philadelphia, 1965. 4. Fraser, RS, Muller NL, Colman NC, Pare, P.D: Diagnosis of Diseases of the Chest, 4th

edition. Vol. 1-4. W.B. Saunders Company, Philadelphia, 1999. 5. Fraser, R.S., Pare, J.A.P., Fraser, R.G., Pare, P.D. Chapter 4 Roentgenologic Signs in the

Diagnosis of Chest Disease. In: Synopsis of Diseases of the Chest, 2nd ed. W.B. Saunders Co., Philadelphia, 1994, pp. 165 – 255.

6. Fraser, R.S., Colman NC, Muller NL, Pare, P.D., Synopsis of Diseases of the Chest. 3rd ed. W.B. Saunders Company, Philadelphia, 2005.

7. Heitzman, E.R. The Lung. Radiologic-pathologic correlations. 3rd ed. C.V. Mosby Co., St. Louis, 1994.

8. Miller, S.W., Cardiac Radiology: The Requisites. Mosby-Year Book Inc., St. Louis, 1996.

9. Naidich, DP., Webb WR, Muller NL, et al. Computed Tomography and Magnetic Resonance of the Thorax. 4th ed. Raven Press, New York, 2007.

10. Reed, J.C. Chest Radiology. Plain Film Patterns and Differential Diagnosis 5th edition. Mosby-YearBook Inc. St. Louis, 2003.

11. Soto, B., Kassner, K.G., Baxley, W.A. Imaging of Cardiac Disorders. Lippincott, Philadelphia, 1992.

12. Thurlbeck W.M., Churg, A.M., ed. Pathology of the Lung. Theime, New York, 1995. 13. Webb, W.R., Brant., W.E., Helms, C.A. Fundamentals of Body CT 3rd edition. W.B.

Saunders Co., Philadelphia, 2005. 14. Webb, W.R., Muller, N.L, Naidich, D.P. High-Resolution CT of the Lung 4th edition.

Raven Press, New York, 2008.

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Last updated: April 2012 CARDIAC RADIOLOGY Hospital: SHSC, TGH PGY-3/PGY-4: 1 month Supervisor: SHSC: Dr. A. Zavodni PGY- 4/PGY-5: 1 month TGH: Dr. E. Nguyen PROGRAM GOALS: By the end of residency training, the resident should demonstrate competence in the basic skill set required for cardiovascular imaging, including: 1) Plain film assessment of the heart and its great vessels 2) Common indications and imaging techniques for imaging the heart and its great vessels with

CT and MRI 3) Common diseases that are seen when imaging the heart with CT and MRI 4) To become familiar with MRI and CT physics as it relates to the cardiovascular system 5) To understand the post processing used to analyze a coronary CTA, gated aortic CTA or

cardiac MRI ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: Demonstrate an understanding of basic anatomy of the heart, pericardium and its great

vessels including the coronary arteries. Demonstrate an understanding of basic cardiovascular physiology such as systolic and

diastolic dysfunction, ways to detect volume and pressure overload of the ventricles. Demonstrate knowledge of how a cardiac gated CT coronary angiogram is obtained and the

concepts of prospective versus retrospective cardiac gating and impact on radiation dose to the patient. Demonstrate ability to protocol CT and MRI studies related to cardiovascular imaging. Demonstrate understanding of the ways to reduce the radiation dose to the patient.

Demonstrate familiarity with MRI and CT physics as it relates to the cardiovascular system.

Demonstrate an understanding of post processing techniques used in reporting cardiac CTA and MRI.

Demonstrate an organized approach to interpretation of the chest radiograph relevant to assessing cardiac chamber enlargement, aortic disease, pulmonary edema, and pulmonary arterial hypertension.

Demonstrate an understanding of the common disease entities imaged with chest radiographs, CT and MRI to include but not limited to:

Chest radiographs: cardiac chamber enlargement, pericardial effusion, pulmonary edema, pulmonary arterial hypertension, aortic disease (including traumatic causes) CT: CT calcium score, coronary artery disease, coronary artery bypass grafts pre or post-operative assessment, traumatic cardiovascular lesions, pericardial disease as a complementary study to MRI, assessment of the invasion of the cardiac great arteries by tumor, congenital heart disease when MRI contraindicated (For example: Fontan with pacemaker or too many pulmonary AVM coils or fenestration coils, Tetralogy of Fallot with pacemaker to assess RV function or eligibility for endovascular pulmonary valve replacement)

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MRI: distinguishing thrombus from tumor (metastases, primary benign such as myxoma or primary malignant such as angiosarcoma) Ischemic Cardiomyopathy- Viability Study, know vascular territories of the left ventricle using American Heart Association (AHA) 17 segment model Non-Ischemic Cardiomyopathy- acute myocarditis, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia/cardiomyopathy, sarcoidosis, amyloidosis, Anderson-Fabry Disease, iron overload states (chronically transfused patients such as beta-Thalassemia major) Congenital Heart Disease- ASD, VSD, PDA, bicuspid aortic valve, anomalous pulmonary venous return, Tetralogy of Fallot, Fontan circuits in single ventricles, transposition of the great arteries (complete type and congenitally corrected), coarctation, Marfan syndrome, Ebstein’s anomaly, Takayasu’s arteritis OBJECTIVES: THE GOAL IS TO COMPLETE YOUR ONE MONTH CARDIAC IMAGING ROTATION IN PGY-3 OR PGY-4 YEAR FIRST MONTH PGY-3/GPY-4 Goals:

1. Demonstrate an understanding of the basic techniques of cardiac gating used in imaging the coronary arteries.

2. Demonstrate an understanding of why beta blockers and sublingual nitroglycerin are used, their doses and contraindications.

3. Demonstrate an understanding of the methods of radiation dose reduction in cardiac CTA.

4. Demonstrate an understanding of the role of the calcium score and when to do calcium score CT versus coronary CTA.

5. Demonstrate an understanding of the most common indications for coronary CTA and gated CTA.

6. Demonstrate an understanding of when to use gated technique versus non-gated technique when assessing aortic disease.

7. Demonstrate a familiarity with MRI and CT physics as it relates to the cardiovascular system.

8. Demonstrate an introductory understanding of cardiac MRI: common techniques (steady state free precession sequences for function, phase contrast imaging to assess flow, MR angiograms, double inversion recovery sequences and delayed enhancement inversion recovery prepared gradient sequences, adenosine perfusion); advantages over CT; limitations of cardiac MRI (know which has better temporal versus spatial resolution between CT and MRI).

9. Demonstrate the ability to view some of the common disease entities imaged with cardiac MRI listed above.

10. Demonstrate the ability to independently process a coronary CTA case and a cardiac MRI for assessment of ventricular function and flow with phase contrast imaging.

Volume requirements: During the cardiac rotation, the goal is to review and complete the post processing for 2 coronary CTA cases per day, review with the cardiac imaging staff and dictate the cases. Enter your cases in the Excel database at TGH and SHSC when you are finished dictating the case.

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If doing cardiac MRI, the goal is to complete 2 cardiac MRI cases per day including the ventricular functional analysis and phase contrast analysis if relevant. Try to select a sample of cases so that your exposure is broad. During the first few days of the rotation you may only complete one case as you are learning but your goal should be to complete 2 cases per day whether it is CT or MRI. The cardiac imaging staff, fellows and 3D lab CT and MRI technologists are always available if you need help. There is also a teaching module assembled by Ivonna Verschuur to guide you through the CTA post processing and this is available on most cardiac CTA reporting workstations at TGH. As with any rotation, the more you see, the more you learn and you always remember a case better having seen a live case compared to reading about it in a book or on a website.

FIRST OR SECOND MONTH PGY-4/PGY-5 Goals: 1. Build on the knowledge from the first rotation. If only doing one cardiac rotation, the objectives are as outlined above. COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate effective communication skills when dealing with patients, during consent or

procedures, as well as with consulting clinicians. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate ability to interact appropriately with other radiology department staff with a

team approach to patient care. MANAGER: Demonstrate an understanding of the indications for CT versus MRI for cardiac imaging

and the advantages and disadvantages for each investigation. Participate in protocoling and monitoring cardiovascular studies. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses when recommending,

approving and protocoling cases (i.e. understands ways to reduce radiation dose to the patient for CT coronary angiogram studies) and why this is important.

Demonstrate an understanding of the benefits and risks of medical imaging investigations. Demonstrate ability to recognize situations in which imaging or treatment would be

detrimental to the health/safety of a patient. PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate ability to understand and practice ethical and medical-legal requirements of

radiologists. Demonstrate awareness of own limitations.

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SCHOLAR: Demonstrate ability to set personal learning goals and reading plan during rotation. Demonstrate ability to contribute to the learning of others, with teaching/supervision of

junior residents on rotation, elective students, off-service residents. Rounds: There are Adult Congenital Heart Disease Rounds every Monday at noon. There is teaching for cardiology and radiology residents on Wednesdays at noon. There is an echo conference on Thursdays at noon and Surgical/Pathology conference at 8 am on Fridays. All conferences are held in the Bayer Conference Room 12 Floor Eaton South at TGH. At SHSC, there are Arrhythmia Rounds every Wednesday at 7 am, combined Cardiology and Cardiovascular Surgery Rounds every Friday at 7 am and Trauma Rounds every Tuesday at 430 pm. Evaluation: Rounds performance Resident should have mid-rotation discussion with supervisor Formal ITER at end rotation OSCE and oral examination

Suggested Resources: We keep an Excel database of all cases (CT and MRI) of every cardiac case reported. You can search using “FIND” tool in Excel to search for particular disease entities to view. The Excel database is found on all the computers in the cardiac reporting area at TGH. There is a teaching module for post processing of the coronary CTA which explains how to create volume rendered reconstructions, multi planar and curved planar reconstructions, maximum intensity projection images etc. The ACR has a website for cardiac imaging cases. UCSF has a CD with good cardiac cases. Evaluation: Rounds performance Resident should have mid-rotation discussion with supervisor Formal ITER at end rotation OSCE and oral examination

Reading List: Gatzoulis Adult Congenital Heart Disease Lee, Vivian Cardiovascular MRI Physics Webb and Higgins Thoracic Imaging: Pulmonary And Cardiovascular Radiology

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Last updated: October 2011 CT Hospital: All sites PGY 2: 2 months Supervisor: MSH: Dr. M. Margolis PGY 3: 1 month PMH: Dr. M. Haider PGY 5: 1 month SHSC: Dr. C. McGregor SMH: Dr. A. Lata TGH: Dr. M. O’Malley TWH: Dr. A. Hanbidge All Residents receive 4 months' training in Computed Tomography (CT). Two months of training occurs in the PGY2 year, one month in the PGY3 year with a further month in the PGY5 year. Residents also have the opportunity for further electives in PGY5 PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in skills required for CT imaging and interpretation including: 1) CT of abdomen & pelvis (male and female) 2) Competence in protocoling CT examinations. Able to advise technologist regarding any special imaging or additional techniques required for case. 3) Competent and comfortable supervising CT cases. 4) increasing workload/volume as they progress through residency ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: PGY2/PGY3: Duration of training - 3 months. The PGY2/PGY3 Resident should demonstrate a familiarity with CT protocols, and progressively, protocol studies over the course of their rotation. The Resident should also demonstrate an understanding of the indications, contraindications and potential side effects of giving oral, intravenous and rectal contrast. The Resident should demonstrate the ability to recognize mild, moderate and severe reactions to intravenous contrast and should exhibit competency in the treatment of these reactions. The Resident should demonstrate an understanding of prophylactic regimens for potential allergy. The PGY2/PGY3 Residents should: Demonstrate familiarity with the principles of Computed Tomography Demonstrate an understanding of the effect of altering imaging parameters such as slice

thickness, kV and MAS, Demonstrate an understanding of the technical aspects of CT scanning, effects of altering

“window” and “level”, common CT artifacts. Demonstrate an understanding of cross sectional anatomy of the abdomen and pelvis (male

and female) Demonstrate a familiarity with the appearance of a normal CT scan of the chest, abdomen,

pelvis (male and female). Demonstrate an understanding of common indications for CT scans with emphasis on

Emergency scans

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Demonstrate the ability to recognize common abnormalities on CT scans (including artifacts) and describe these abnormalities and begin to formulate reasonable differential diagnosis and recommendations for further investigations, if appropriate.

Demonstrate the technique of CT reporting with emphasis on study technique, quality of the scan and confidence level of the diagnosis.

PGY5: Duration of training - 1 month. The PGY5 Resident should: Demonstrate familiarity with and understand CT protocols for investigating a wide variety

of disease processes. Demonstrate an understanding of the uses/role of various contrast agents: Oral, Rectal,

Vaginal, Intravenous – When and why? Demonstrate competency in interpreting scans of the abdomen and pelvis. Demonstrate a familiarity with the technique of CT angiography as it applies to the

abdomen and pelvis. Demonstrate knowledge of common pathologies and their associated CT findings, with

particular reference to oncology. Demonstrate the ability to develop appropriate differential diagnosis based on CT findings.

Demonstrate the ability to correlate CT findings with other imaging modalities (US, Plain films…)

Demonstrate an understanding of the technique and gain experience performing CT-guided biopsy and interventional procedures: indications, contraindications, technique, potential complications.

COMMUNICATOR: Demonstrate an understanding of the technique of CT reporting with emphasis on study

technique, quality of the scan and confidence level of the diagnosis. Demonstrate the ability to comfortably discuss findings with referring clinicians and

display competency for issuing reports. Demonstrate ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate effective communication skills when dealing with patients, during consent or

procedures, as well as with consulting clinicians. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care. MANAGER: Demonstrate an understanding of the indications for CT, with particular reference to

oncologic investigation. Demonstrate the ability to consider advantages and disadvantages of CT relative to other

imaging modalities. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently.

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HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses when approving and

protocoling cases. Demonstrate an understanding of the benefits and risks of radiological investigations and

treatment to optimize the health of patient and communities.

PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Demonstrate professional work habits including punctuality, organization and efficiency Demonstrate good work ethic and enthusiasm Demonstrate awareness of own limitations.

SCHOLAR: Demonstrate the ability to develop a self-directed ongoing learning progress (goals and

objectives) during rotation. Demonstrate the ability to contribute to the learning of others, with teaching/supervision of

junior residents on CT rotation, elective students, off-service residents.

Rotation Responsibilities: Clinical: Review all requisitions to be approved, with the staff radiologist. Protocol all requisitions under the supervision of the staff radiologist. Review the cases with the staff radiologist prior to reporting. Perform as many CT guided biopsies as possible. Act as a consultant for housestaff who wish to review cases or requests for CT for

ER/Inpatients. Act as resource for CT nurses and technologists

Teaching: Supervision/teaching of elective students, junior residents or off-service residents, as

appropriate Rounds: Daily resident rounds Informal daily viewbox teaching

Evaluation: Assessed on daily basis by staff assigned to CT rotation as well as staff at daily rounds. Resident should have mid-rotation discussion with supervisor Formal ITER at end of rotation. Abdominal oral exam and OSCE

Resources: Department Library with specific CT books and cross-sectional anatomy texts Department Journals Internet Resources ** Discuss with rotation supervisor**

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Recommended texts: Webb, Brant et al: Fundamentals of Body CT Lee, Segal & Stanley: Computed Body Tomography with MRI Correlation Atlas of CT Variants Reading/Reference List:

1. Atlas of Human Anatomy, Netter FM. CIBA Geigy 1989. 2. An Atlas of Anatomy, Grant JCB. Williams & Wilkins Co., Baltimore 1962. 3. Fundamentals of Body CT. Webb, Brant, Mevis. WB Saunders. 4. Computed Tomography of the Body with MRI. Moss AA, et al. WB Saunders 1991. 5. Christensen's Physics of Diagnostic Radiology. Fourth Edition. Lea & Febiger 1990. 6. Body CT, Categorical Course Syllabus. American Roentgen Ray Society 1994. 7. Computed Tomography of the Body. Moss, Gamsu, Genant. Saunders.

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Last updated: September 2012 GI/GU Imaging Hospital: MSH, SHSC, SMH PGY- 2: 1 month Supervisor: MSH: Dr. N. Jaffer PGY-3/PGY-4: 2 months SHSC: Dr. J. Wall PGY- 5: Electives SMH: Dr. A. Zalev All residents receive 3 months' training in Gastrointestinal Radiology - 1 months in the PGY-2 year, two months in the PGY-3 or PGY-4 year and, if desired, one elective month in the PGY-5 year. PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in the basic skill set required for gastrointestinal imaging. Knowledge of GI imaging will be obtained during dedicated PGY-2 rotation, general rotations with GI/fluoroscopy assignments, pediatric rotation, on-call experience and senior PGY 5 rotation. As well, by the end of residency training, the resident should be able to demonstrate the skills required for interpretation of GU procedures and demonstrate competency in the approach and interpretation of CT examinations. General Guidelines: 1. Demonstrate an understanding of the indications, limitations of, and become proficient in

performing an adequate number of GI examinations along with the interpretation of abdominal radiographs, CT scans and contrast GI examinations

2. Demonstrate competency in the operation of fluoroscopic equipment and demonstrate a good understanding of radiation safety

3. Complete the required reading of recommended gastrointestinal references (provided on University of Toronto Residency Web site and from rotation supervisors)

4. Complete a required number of University of Toronto On-Line Tests (pre- and post -GI rotation) cases on GI imaging and contribute teaching cases (Under construction)

ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: PGY-2: Duration of training – 1 month The PGY-2 resident should demonstrate the ability to perform, under close supervision, common GI procedures including deglutition studies, upper GI series (double contrast), small bowel follow through, small bowel enema and barium enema (single contrast) and CT enterography/enteroclysis, pouchograms and where applicable, CT colonography studies. The resident should also demonstrate an understanding of the common GU procedures, including cystography, voiding cystourethrography and retrograde urethrography. The PGY-2 resident should also demonstrate the ability to interpret plain films of the abdomen as part of the rotation and there should be an emphasis on plain film interpretation throughout the residency.

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The PGY-2 resident should: Demonstrate a familiarity with the standard fluoroscopy unit and its operation. Demonstrate a familiarity with the principles of radiation safety and protection, particularly

minimizing radiation dose to the patient, their co-workers and themselves. Demonstrate a familiarity with the various GI contrast agents (barium, water soluble) and

pharmacologic agents (anticholinergic agents etc) used in GI examinations along with their indications, contraindications and side effects

Demonstrate an understanding of the anatomy, pathology and treatment of diseases affecting the GI tract.

Demonstrate the ability to interpret various imaging modalities including plain films, contrast GI studies and CT scans of the abdomen

Demonstrate an understanding of the indications and contraindications to cystography, voiding cystourethrography, retrograde urethrography and retrograde pyelography.

Demonstrate an understanding of the anatomy and embryology of the GU tract. Demonstrate a familiarity with the appearance of normal, plain X-rays, contrast studies of

the GU tract and CT studies. Demonstrate a familiarity with common abnormalities of the GU tract and how they appear

on plain radiographs, contrast studies and CT studies. Demonstrate the ability to formulate differential diagnosis, depending on the radiographic

appearances. Demonstrate an understanding of the techniques of reporting GI and GU examinations with

emphasis on technique, quality of the study and confidence level of the diagnosis. PGY-3/PGY-4: Duration of rotation - 1 month The PGY-3/PGY-4 resident should build on the knowledge and expertise gained in the PGY-2 year. Common GI and GU examinations can be performed with more independence. The PGY-3/PGY-4 resident should: Demonstrate competency in performing the common GI and GU procedures including,

contrast examinations of the upper GI tract, small bowel follow through and small bowel enemas, contrast examinations of the lower GI tract and CT enterography/enteroclysis and CT colonography (where available).

Demonstrate familiarity with less common procedures such as pouchograms, ostomy studies, fistulograms, sinograms, nephrostomy tube changes, transrectal ultrasound, conduit/reservoir studies and hysterosalpingography (some of these may be learned on the VIR rotations).

Demonstrate familiarity with ERCP studies (where available) Demonstrate familiarity with the role of sectional imaging (ultrasound, CT, and MRI) and

functional imaging (nuclear medicine) in imaging the GI and GU tract. Demonstrate competence in interpreting and reporting GI and GU studies.

PGY-5: Duration of rotation - 1 month (Elective) The senior resident should demonstrate competence at performing most GI and GU studies with little supervision. The resident should complement areas of weakness identified in earlier rotations.

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The PGY-5 Resident should: Demonstrate competence in the interpretation of GI and GU studies independently. Demonstrate competence at issuing reports with reasonable differential diagnosis and

appropriate recommendations for further investigations where appropriate. Demonstrate ability to lead discussion with clinical colleagues relating to particular cases

and problems. Where available, demonstrate competence, in performing, and reporting CT colonography

studies according to the Canadian Association of Radiologists and American College of Radiology CTC Standards of Practice Guidelines (reference).

Demonstrate the ability to perform, under supervision, transrectal ultrasound and transrectal ultrasound-guided biopsy of the prostate gland and other common interventional procedures such as nephrostomy in a dilated system. The resident should demonstrate knowledge of the indications, contraindications and complications of these procedures and display the ability to obtain informed consent.

All studies should be reviewed with a staff radiologist. COMMUNICATOR: Demonstrate ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate effective communication skills when dealing with patients, during consent or

procedures, as well as with consulting clinicians. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians and health team

members. Demonstrate ability to interact appropriately with other radiology department staff with a

team approach to patient care. MANAGER: Demonstrate an understanding of the indications for various imaging tools for GI and GU

investigation. Demonstrate ability to consider advantages and disadvantages available imaging

modalities. Demonstrate ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. HEALTH ADVOCATE: Demonstrate ability to recognize and consider radiation doses when recommending and

approving GI and GU examinations on patients (CT and contrast studies) Demonstrate satisfactory knowledge of radiation safety and developing/maintaining low

radiation dose techniques to minimize radiation to patients, technologists, residents/radiologists

PROFESSIONAL: Demonstrate integrity, honesty and compassion with patients, health team members

especially medical technologists and colleagues Demonstrate an understanding and practice radiology under the strict ethical and medical-

legal requirements of radiologists. Demonstrate an awareness of own limitations, seek advice and learn methods to improve.

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SCHOLAR: Demonstrate ability to set personal learning goals and reading plan during rotation. Demonstrate ability to complete reading the most relevant literature in GI and GU diseases

(textbooks and reference articles provided (references 2, 3). Demonstrate ability to contribute to the learning of others, with teaching/supervision of

junior residents on rotation, elective students, off-service residents. Demonstrate ability to audit abnormal GI and GU examinations with referring physicians

for effective learning. Review the Standards of Practice guidelines for various GI and GU examinations set by

American College of Radiology and the Canadian Association of Radiologists (references).

RESIDENT RESPONSIBILITIES: Clinical Perform, interpret and report cases (plain films, contrast studies, and CT scans where applicable) in the GI and GU area, assuming increasing responsibility and caseload with, increasing level of skill demonstrated, reviewing all cases with supervising staff. Teaching: Teach medical students, elective students, junior resident staff as appropriate, the algorithm of imaging studies for various diseases/symptoms on their patients, the value of interdisciplinary consultation and basic interpretation of imaging studies Rounds: Residents should attend all Abdominal Imaging Teaching Rounds and where possible any

relevant clinical rounds at their respective institution Volunteer to present imaging studies at these clinical rounds (to gain knowledge of patient

management issues) Evaluation: ITER: Mid–rotation discussions with supervisor Formal ITER at end rotation (to include the type and number of GI fluoroscopic

examination and average fluoroscopic times for those studies) Performance at Resident Rounds (hospital based or view box teaching files) OSCE and abdominal oral examination (university based)

RECOMMENDED READING LIST:

1. Web-based teaching tools at the University of Toronto a. Techniques of Gastrointestinal Imaging web site:

http://individual.utoronto.ca/ecolak/ b. Post graduate web site (UME) with teaching files (under construction)

2. Residents Manual of Techniques of Gastrointestinal Examinations (MSH by Dr Nasir

Jaffer, SMH by Dr. Arthur Zalev) a. GI Radiology Procedures (Updated 2011) b. Small Bowel Disease Made Easy (Updated 2011)

3. Text books

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a. Alimentary Tract Radiology. Margulis, Burhenne. Most recent edition. b. Clinical Radiology of Abdomen. Herlinger H, et al. Saunders. Most recent

edition. c. Dynamic Radiology of the Abdomen. Myers M. Most recent edition. d. Radiology of Inflammatory Bowel Disease. Radiological Clinics of North

America. January 1987. e. Advances in Intestinal Imaging. Radiologic Clinics of North America. March

2003. f. Gastrointestinal Radiology. A Pattern Approach. Eisenberg RL & JB

Lippincott. Most recent edition. g. Textbook of Gastrointestinal Radiology. Richard M. Gore & Marc S. Levine.

Most recent edition. h. The Requisites: Gastrointestinal. Halpert R. Most recent edition. i. The Developing Human. Moore KL. WB Saunders Co. j. The CIBA Collection of Medical Illustrations. The Reproductive System &

Kidneys Ureter & Urinary Bladder. Netter FM. CIBA 1965. k. An Atlas of Anatomy. Grant JCB. Williams & Wilkins Co. Baltimore. 1962. l. Radiology of the Kidney. Davidson AJ. WB Saunders Co. 1985. m. Radiology of the Urinary System. Elkin M. Little, Brown and Co. 1980. n. Textbook of Uroradiology. Dunnick NR, et al. Williams & Wilkins. o. Urologic Radiology of the Adult Male Lower Urinary Tract. McCallum RW, p. Colapinto V, Thomas CC. 1976. q. Diagnostic Ultrasound, Vol 1. Rumack CM, Wilson SR, Charboneau JW.

Mosby 1991. r. Computed Tomography of the Body with MRI. Moss AA, et al. WB Saunders.

1991.\ s. Clinical Urography: Pollack. Saunders

4. Reference Review Articles (Posted on U of T Medical Imaging Web Site) a. Radiographics Review articles b. Radiology and AJR: Resident Review articles c. Radiologic Clinics of North America. Multiple other issues with GI subjects

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Last Updated: October 2012 MRI Hospital: PMH, SHSC PGY-4 or PGY-5: 1 month Supervisor: PMH: Dr. K. Jhaveri SHSC: Dr. C. McGregor Body MRI is offered at PMH as an elective 1 month rotation to PGY-5 trainees. Additional Body MRI experience is obtained during general MRI elective rotations at SMH and SHSC. Participation in pertinent imaging and interdisciplinary clinical rounds is expected. PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in skills required for basic MRI imaging and interpretation. Exposure includes dedicated MRI rotations, as well as organ-based or body-system rotations (eg. Body). The rotation at Sunnybrook HSC is a combined Body CT/MRI rotation and includes 2 to 3 days per week of Body MRI. ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: The Resident should: Demonstrate familiarity with the principles of Magnetic Resonance Imaging. Demonstrate familiarity with techniques and protocols of MRI, in particular as they apply

to the abdomen and pelvis. Demonstrate knowledge of the indications and contraindications for a patient having an

MRI scan. Demonstrate knowledge of the indications, contraindications and possible side effects to

the use of gadolinium. Demonstrate knowledge of sectional anatomy of the abdomen and pelvis. Demonstrate familiarity with the appearance of a normal MRI scan of the abdomen and

pelvis, male and female. Demonstrate familiarity with the appearance of common abnormalities including artifacts. Demonstrate familiarity with the technique of reporting MRI scans with emphasis on image

sequences, quality of the scan and confidence level of the diagnosis.

All MRI scans should be reviewed with a Staff Radiologist. Additional for Sunnybrook HSC rotation: Demonstrate an understanding of the principles of CT (including effect of altering imaging

parameters (slice thickness, kV, MAS), window and level, common artifacts). Demonstrate the ability to recognize common abnormalities on CT scans. Demonstrate an understanding of various CT protocols for investigating a wide variety of

disease processes Demonstrate an understanding of the use of contrast agents (oral, rectal, intravenous).

COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations.

37

Demonstrate effective communication skills when dealing with patients, during consent and sedation, as well as with consulting clinicians.

Demonstrate timely/appropriate communication of findings with the responsible physician. Demonstrate the ability to obtain and synthesize relevant history and information from

referring physicians, patients and families. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians and health team

members. Demonstrate the ability to interact appropriately with other MRI (and CT) department staff

with a team approach to patient care. MANAGER: Demonstrate awareness of the indications for MRI . Demonstrate the ability to consider the advantages and disadvantages of MRI versus other

imaging modalities. Demonstrate the ability to consider available imaging resources when approving cases,

protocoling and making recommendations for further imaging, using them efficiently and effectively.

Demonstrate the ability to triage physician requests regarding the urgency of an imaging study.

Demonstrate appropriate time management skills when completing assigned rotation duties. Demonstrate the ability to monitor MRI (and CT imaging) studies and appropriately

modify the protocol based on the findings. HEALTH ADVOCATE: Demonstrate a complete understanding of the indications, contraindications and biological

safety issues of MRI imaging. PROFESSIONAL: Demonstrate the ability to develop professional attitudes to deliver highest quality care

showing integrity, honesty, compassion and respect for all persons. Demonstrate the ability to understand and practice the ethical and medical-legal

requirements of radiologists. Demonstrate a good work ethic with enthusiasm and motivation for learning. Demonstrate professional work habits with punctuality, organization and efficiency Demonstrate awareness of own limitations. Demonstrate the ability to accept constructive criticism

SCHOLAR: Demonstrate the ability to set personal learning goals and objectives during rotation for the

development of a personal continuing education strategy. Demonstrate the ability to take a leadership role in the learning of others, with

teaching/supervision of junior residents on rotation, elective students, off-service residents. Demonstrate the ability to critically appraise the literature.

Rotation Responsibilities: Clinical: The rotation will focus on the basics of MRI including time spent observing and assisting the technologist with patient positioning, selection of coils and imaging.

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As rotations progress, the resident will become increasingly involved with: Reviewing all available MRI scans with supervising staff person. Dictating reports, if so desired or requested by MRI radiologist. Performing patient sedation and Gadolinium injection (if competent venipuncture skills) Reviewing and assisting with assessment of additional sequences or imaging required. As senior, assist with protocoling

The resident should develop a study schedule including: Basic MRI: physics, safety, contrast, sedation MRI brain, spine, musculoskeletal and body

The Sunnybrook HSC rotations will have 2 to 3 days on MRI and the remainder on CT.

Teaching: Supervision/teaching of elective students, junior residents or off-service residents, as

appropriate Rounds: Hospital based.

Evaluation: Assessed on daily basis by staff assigned to MRI rotation as well as staff at resident rounds. Formal ITER at end of rotation. In-training OSCE and abdominal oral examination

Recommended texts: There are many excellent MRI texts. Many are large reference volumes – select chapters of interest. There are also a number of excellent “case series” type books available. Physics: MRI Principles. D.G. Mitchell, W.B. Saunders, 1999. MRI: The Basics,Ray H. Hashemi,William G. Bradley, Christopher J. Lisanti All major MRI textbooks include chapters on physics of MRI

Brain and Spine: Magnetic Resonance Imaging of the Brain and Spine. Scott Atlas, Raven Press. Cranial MRI Imaging. Kucharczyk MRI: Central Nervous System. Kucharczyk MR and CT Imaging of the Head, Neck and Spine. Latchaw

MSK: Musculoskeletal MRI. Kaplan, Helms, Dussault MRI of the Musculoskeletal System. D. Stoller Internal Derangement of Joints. Resnick MRI of the Musculoskeletal System. A Teaching File. Deutsch & Mink Magnetic Resonance Imaging of the Musculoskeletal System. Berquist Abdominal-Pelvic MRI, Richard C. Semelka Primer on MR Imaging of the Abdomen and Pelvis, Diego R. Martin, Michele A. Brown,

Richard C. Semelka

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General: Magnetic Resonance Imaging. Stark & Bradley Magnetic Resonance Imaging of the Body. Higgins, Hricak, Helms.

Reading List:

1. Atlas of Human Anatomy. Netter FM. CIBA Geigy 1989. 2. An Atlas of Anatomy. Grant JCB. Williams & Wilkins Co. Baltimore 1962. 3. Computed Tomography of the Body with MRI. Moss AA, et al. WB Saunders 1991. 4. Christensen's Physics of Diagnostic Radiology. Fourth Edition. Lea & Febiger 1990. 5. Syllabus. Special Course: MR 1990. Radiological Society of North America. - old 6. Magnetic Resonance Imaging. Volume Two. Stark, Bradley. Mosby. 7. Body MRI: Siegelman, E., Body MRI, Elsevier 2005 8. Cardiac MRI: Higgins and De Roos, MRI and CT of the Cardiovascular System,

Lippincott 2006

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Last updated: October 2011 MUSCULOSKELETAL Hospital: MSH, SHSC, SMH, TWH PGY 2: 1 months PGY 3/4: 2 months PGY 5: 1 required plus elective opportunities Location Supervisor Site MSK focus Mount Sinai Hospital Dr. Robert Bleakney Sports, Tumour, Arthroplasty, Arthritis St. Michael’s Hospital Dr. Dawn Pearce Trauma, Sports, Foot & Ankle Sunnybrook HSC Dr. Joel Rubenstein Trauma, Sports, Arthritis Toronto Western Hospital Dr. David Salonen Spine intervention, Sports, Arthritis, Hand and Wrist, Foot and Ankle PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in the basic skill set required for musculoskeletal imaging. Pediatric topics will be further supplemented by the Sick Kids Pediatric rotation.

1) Plain film interpretation of bones, joints, soft tissues 2) CT - indication, protocoling, basic interpretation of bones, joints and soft tissues. 3) MRI - indication, protocoling, interpretation of basic bone, joint and soft tissues. 4) Arthrography (standard, CT, MRI) and joint injections - indications, potential

complications, basic procedural skills, basic interpretation 5) Musculoskeletal ultrasound - indication, developing interpretation 6) Interventional - indications, potential complications and basic technique for

a. Fluoroscopic, CT guided bone biopsies b. US or CT guided soft tissue biopsies c. Fluoroscopic or US-guided joint injections/aspirations d. Facet joint injections e. Bursal or tendon sheath injections

ROTATION OBJECTIVES: Rotation objectives may vary at each site depending on the site MSK focus. All residents will rotate to the MSH/TWH sites during their residency training in order to gain exposure to bone tumours and spine intervention.

MEDICAL EXPERT/CLINICAL DECISION-MAKER: To acquire and demonstrate knowledge of radiological anatomy of peripheral and axial

skeleton, including the relevant soft tissues. Demonstrate the ability to recognize, name and describe common fractures and dislocations

(resident need not be familiar with all the eponyms).

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Demonstrate the ability to develop an approach to joint disorders, including knowledge of clinical and imaging features differentiating various forms of arthritis.

Demonstrate the ability to develop an approach to assessment and diagnosis of tumours and tumour-like conditions, in particular the radiographic features discriminating non-aggressive from aggressive bone lesions.

Demonstrate the ability to describe features of the common bone tumours: metastases, multiple myeloma, lymphoma, osteosarcoma, Ewing’s sarcoma, osteoid osteoma, giant cell tumours, chondroid lesions, etc.

Demonstrate the ability to develop an understanding of infection and how it affects the musculoskeletal system (osteomyelitis, septic arthritis, discitis).

Demonstrate the ability to recognize and describe complications of orthopedic devices including fracture fixation and spine and arthroplasty hardware

Demonstrate the ability to recognize and describe features of metabolic bone disease: Renal osteodystrophy, rickets, scurvy, osteomalacia, osteoporosis, hyperparathyroidism, congenital syphilis.

Demonstrate the ability to describe the major features of the more common skeletal dysplasias: osteogenesis imperfecta, mucopolysaccharide disorders, Down’s syndrome, achondroplasia, epiphyseal and metaphyseal dysplasias.

PGY2 (1 or 2 months): The resident is introduced to basic anatomy, joint structure and plain film radiographic

techniques. The resident is expected to demonstrate an understanding of basic trauma, normal variants,

a basic approach to interpretation of joint disease, an approach to the diagnosis of tumors and tumor-like lesions and to have a basic understanding of infection involving bones and joints. Emphasis is on plain film radiography.

The resident should demonstrate a basic understanding of the relevant clinical management of common musculoskeletal disorders.

The resident should demonstrate an introductory understanding of CT techniques and protocoling and the appearance of some pathologies on CT.

The resident may have the opportunity to be involved with MRI case review. The resident will be directed to maximize their understanding and knowledge in the area of

specialty focus at the hospital. The resident will be expected to participate in any procedural activities during their rotation

time, demonstrating an understanding of technical skills and also demonstrating familiarity with indications, patient preparation and management of potential complications. In particular, the resident should demonstrate familiarity with the technique of joint aspiration / injection e.g. shoulder, hip.

The resident will be expected to prepare cases for rounds and will demonstrate appropriate use of computer and library resources to enhance their knowledge.

PGY3/4 (1 or 2 months): The resident will continue to expand and demonstrate their knowledge of bone, joint and

soft tissue diseases. The resident should demonstrate greater efficiency in dealing with plain film examinations

and diagnoses and in their experience with CT and MR interpretations and case management.

The resident should demonstrate the ability to direct basic CT protocols with limited supervision.

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The resident should demonstrate familiarity with the appearance of common pathologies on MRI examinations.

There should demonstrate increased experience in performing arthrograms and the resident should take advantage of any opportunity to learn MSK ultrasound.

PGY5 (elective): The resident should: Demonstrate efficiency in interpretation of plain film and assist junior residents in film

review or case management. Demonstrate the ability to direct consultations regarding MSK cases with increasing

independence. Demonstrate an understanding about the various imaging modalities for different clinical

situations and should demonstrate the ability to assist support staff in technical issues required to obtain optimal studies.

Demonstrate the ability to perform some procedures, such as arthrograms with minimal supervision.

Demonstrate the ability to protocol and interpret basic MSK CT cases. Demonstrate familiarity with the appearance and interpretation of basic MSK MRI studies

and common pathologies and demonstrate the ability to protocol basic MRI examinations. Demonstrate an understanding of the role of MSK US. Demonstrate and develop basic knowledge base of ultrasound appearance of normal

structures (tendons, ligaments, muscles) as well as common pathologies (e.g. rotator cuff tear, Achilles tendon tear).

COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations, in a timely manner. Demonstrate effective communication skills when dealing with patients, during consent or

procedures, as well as with consulting clinicians. Demonstrate an understanding of when it is necessary to contact a referring

clinician/service with an urgent/unexpected finding. Demonstrate the ability to obtain and synthesize relevant history and information from

referring physicians, patients, and families. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care. MANAGER: Develop and demonstrate an understanding of indication for plain film assessment, nuclear

medicine, CT and MRI, considering advantages and disadvantages of available imaging modalities related to musculoskeletal imaging.

Demonstrate the ability to consider available imaging resources when planning and recommending patient care, using them effectively and efficiently.

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Demonstrate the ability to triage physician requests regarding the urgency of an imaging study.

Demonstrate appropriate time management skills when completing assigned rotation duties. Demonstrate the ability to monitor imaging studies and appropriately modify the protocol

based on the findings. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses when recommending,

approving and protocoling cases. Demonstrate an understanding of indications, contraindications, patient preparation, needle

path, risks and post procedural management of CT and US guided procedures including management of complications.

PROFESSIONAL: Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Exhibit appropriate personal and interpersonal professional behaviors. Demonstrate integrity, honesty and compassion and respect for others. Demonstrate professional appearance and communication. Demonstrate good work ethic, with enthusiasm and motivation for learning. Demonstrate professional work habits with punctuality, organization and efficiency. Demonstrate the ability to incorporate feedback into improved personal performance. Demonstrate awareness of own limitations. Demonstrate the ability to appraise one’s own professional performance.

SCHOLAR: Demonstrate the ability to set personal learning goals and reading plan during rotation. Demonstrate the ability to contribute to the learning of others, with teaching/supervision of

junior residents on rotation, elective students, off-service residents. Demonstrate the ability to critically appraise the literature as needed. Residents on rotation at Sunnybrook may be expected to give a short presentation on an

MSK arthritis topic at combined Radiology/Rheumatology rounds and will give a brief (15 to 20 minute) presentation at rounds during the final week of the rotation (a teaching evaluation will be completed) – please speak with rotation supervisor for details.

Evaluation: Each individual resident is responsible for meeting the stated goals and objectives for

successful evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisors and to

ensure that the ITER is reviewed before leaving the rotation. Daily performance evaluation and observation of interpretation & interventional skills Rounds performance – including collaboration, communication and scholarly ability. Resident should have mid-rotation discussion with supervisor – please remind the

supervisor at this point in time! Formal ITER at end rotation

Diagnostic and Procedural Skills to log: Joint injections/aspirations (fluoroscopy, ultrasound, CT)

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Biopsies (bone, soft tissue) Spine procedures MSK ultrasound

Reading/Reference List: Anatomy and Radiography Meschan I. An atlas of normal radiographic anatomy. W. B. Saunders & Co.,

Philadelphia, 1959. Weir J, Abrahams P. Imaging Atlas of Human Anatomy. 3rd ed. Mosby 2003.

Normal Variants Keats T, Anderson M. Atlas of Normal Roentgen Variants that may Simulate Disease. 8th

ed. Mosby. 2007

General Texts Helms CA. Fundamentals of skeletal radiology. 2nd ed. W.B. Saunders & Co., 1994

[Quick Introductory Text] Resnick D. Bone and joint imaging. 2nd ed. W.B. Saunders Co., Philadelphia, 1996.

[“Baby Resnick”] Resnick D. Diagnosis of bone and joint disorders. 4rd ed. W. B. Saunders, Philadelphia,

2002. [6 Volume Ref TeI] Weissrnan BNW, Sledge CB. Orthopedic radiology. W. B. Saulders Co., Philadelphia,

1986. [Excellent text, unfortunately out of print. May be available as reference at hospital or in library].

Arthrography/Procedures Freiberger RH, Kaye JJ. Arthrography. Appleton-Century-Crofts, New York, 1979.

Neoplasms Levesque J, Marx R, Bell RS, Wunder JS, Kandel R . A clinical guide to primary bone

tumors. Lippincott-Williams & Wilkins, 1998. Articular Diseases Brower AC, Flemming DJ. Arthritis in black and white. 2nd ed. W. B. Saunders, 1997.

MRI and CT Berquist TH, ED. MRT of the musculoskeletal system. 3rd ed. Lippincott-Raven

Publishers, New York, 1995. Resnick 11, Kang 1-1s. Internal derangement of joints. W.B. Saunders. 1994.

Ultrasound Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences.

2007. Trauma Rogers LF. Radiology of skeletal trauma. 2nd ed. Churchill Livingston Inc. New York,

1992.

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Last updated: September 2011 NEURORADIOLOGY Hospital: MSH, SHSC, SMH, TWH Neuroradiology Rotation PGY 3-5: 4 months Supervisor: MSH: Dr. E. Kassel SHSC: Dr. S. Symons SMH: Dr. D. Sarma TWH: Dr. R. Farb PROGRAM GOALS: To train Radiologists in the basic knowledge, technical skills and attitudes necessary for the competent performance of diagnostic neuroradiology including:

a) CT of the brain, head and neck, and spine b) MRI of the brain, head and neck, and spine c) CT and MR angiography of the brain, head and neck, and spine. d) Technique of fluoroscopically guided procedures including lumbar puncture and

lumbar myelography. ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: Neuroradiology is offered at three hospitals, St. Michael's Hospital, University Health Network (UHN) and Sunnybrook Health Sciences Centre (SHSC) where full training in all modalities and exposure to all procedures is provided. Residents do a minimum of four months of neuroradiology training. Participation in pertinent imaging and interdisciplinary clinical rounds at each hospital is expected. The resident should take an active and progressive role in case presentation. Access to teaching material is provided at all three sites. This rotation will be channeled in such a manner as to achieve the following goals: Demonstrate competency and a three-dimensional perceptual understanding of the normal

anatomy of the brain, skull, paranasal sinuses, facial bones and spine. Demonstrate an understanding of the basics of computerized tomography and exhibit

competency in prioritizing, protocolling and the interpretation of normal and abnormal head and spinal CT studies.

Demonstrate an understanding of the basics of MRI and exhibit competency in the interpretation of normal and abnormal brain, head and neck, and spinal MRI studies.

Demonstrate a competent approach to fluoroscopically guided lumbar puncture, lumbar myelography and interpretation of CT myelographic examinations.

Demonstrate an understanding of normal cerebrovascular anatomy and common pathologies through the study and interpretation of CT and MR angiography.

Demonstrate a basic understanding of the indications, technique and risks of cerebral and spinal angiography, and the differences with cross sectional techniques.

Observe cerebral catheterization procedures. Demonstrate an understanding of carotid ultrasound, duplex US studies.

Rotation specific goals Rotation 1 - PGY2

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Demonstrate an understanding of different CT protocols for CT brain, head and neck, and spine including appropriate use of contrast, and exhibit an understanding of the importance of prioritizing and reporting studies according to clinical needs.

Demonstrate a familiarity with anatomy and common pathology of the brain, head and neck, and spine

Demonstrate the ability to review and report CT examinations of the brain, head and neck, and spine

Demonstrate the ability to perform fluoroscopically guided procedures, particularly lumbar punctures and myelography technique & interpretation.

Rotation 2 - PGY3-4 Residents will rotate for a minimum of three months and during this time will: Demonstrate an expansion of knowledge and experience with plain film, CT, MRI and

fluoroscopic procedures Demonstrate an understanding of the managerial aspect of neuroradiology (under

supervision) by prioritizing, protocolling and facilitating studies, and learning to respond promptly to clinical needs

Demonstrate an understanding of the indications, and the relative advantages and disadvantages of each imaging modality in patient assessment

Demonstrate an understanding of the basic principles of CT and MR, including protocols and limitations

Demonstrate familiarity with MR appearances of common pathologies Observe catheter angiography and neurointerventional procedures Demonstrate the ability to assume increasing independence and responsibility under

supervision. Rotation 3 – PGY5 PGY5 additional rotations in neuroradiology will allow the resident to Demonstrate an increase in responsibility and efficiency of daily work Demonstrate an expansion knowledge through more complex cases and greater technical

understanding Exhibit a greater involvement with interdisciplinary team activities.

Guidelines for Daily Procedural Volumes PGY Level Procedure

PGY 2 PGY 3/4 PGY 5

CT Brain, facial bones, sinuses, orbits

10 14 14

CTA 2 2 2 CT Spine 3 4 5 MRBrain 0 4 5 MR Spine 0 4 5 (Numbers may vary at each site – Please check with your rotation supervisor)

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COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate the ability to address the clinical question first and incidental findings later.

Demonstrate effective communication skills when dealing with patients, staff and referring clinical services.

COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care, including interactions with trauma team, emergency room staff & neurosciences team members.

MANAGER: Demonstrate an awareness of the indications for various neurological imaging modalities. Demonstrate the ability to consider advantages and disadvantages for each available

imaging modality. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. Demonstrate the ability to quickly grasp and respond to clinical needs in emergent and

urgent situations. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses and consent issues, when

recommending, approving and protocoling cases, as well as biological issues for MRI imaging.

PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Demonstrate an awareness of one’s own limitations.

SCHOLAR: Demonstrate the ability to set personal learning goals & objectives during rotation. Demonstrate the ability to take a leadership role in the learning of others, with

teaching/supervision of junior residents on rotation, elective students, off-service residents. Participate in a research project, whenever possible.

Teaching:

1) Present one formal round at the Regional Neurosciences Conference. 2) Supervision/teaching of elective medical students or off-service residents, along

with assigned staff radiologist. 3) Act as a consultant to residents in other disciplines in the planning and

interpretation of neuroradiological procedures. 4) Bring interesting cases to show your co-residents.

Rounds: Hospital based.

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Evaluation: Assessed on daily basis by staff assigned to neuro rotation Rounds performance Resident should have mid-unit discussion with supervisor Formal evaluation (ITER) and discussion (on resident performance) will be held at the end

of the rotation. Residents can then comment on the rotation value.

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Last updated: September 2011 Head & Neck Hospital: PMH Head & Neck Rotation PGY 5: 1 month Supervisor: Dr. E. Yu PROGRAM GOALS: To train Radiologists in the basic knowledge, technical skills and attitudes necessary for the competent performance of diagnostic head and neck / ENT imaging. ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: Dedicated Head and Neck / ENT training is offered at Princess Margaret Hospital (PMH). All residents will have a 1-month rotation at PMH for Head and Neck / ENT during the last 18 months of their training. The Head and Neck / ENT service at PMH is predominantly dedicated to oncologic imaging of the head and neck. In addition, we provide the general head and neck / ENT services for the remainder of the University Health Network (UHN) sites. Residents will be exposed to all modalities and exposure to all procedures is provided. Participation in pertinent imaging and interdisciplinary clinical rounds at each hospital is expected, with multi-disciplinary tumor board rounds occurring every Tuesday AM at 0800. Access to teaching material is provided, including a dedicated head and neck imaging website (www.headandneckrad.com) that includes lectures, anatomy modules, case presentations and quizzes, and links to other Internet-based resources. This rotation will be channeled in such a manner as to achieve the following goals: Demonstrate a working knowledge of normal head and neck anatomy including vascular

anatomy; Demonstrate an understanding of the relative advantages and disadvantages of CT vs. MRI,

as well as the use of IV contrast agents, as it applies to the imaging of head and neck cancer and general ENT imaging;

Demonstrate the ability to apply a systematic approach to CT and MR imaging of complex head and neck cases, including pre-treatment and post-treatment oncology cases;

Demonstrate a basic understanding of the natural history of head and neck cancers, especially of SCCa;

Demonstrate a basic understanding of lymph node pathology and classification; Demonstrate the ability to apply a systematic approach towards non-oncologic pathologies,

such as trauma, infection/inflammatory, congenital and general ENT pathologies. Guidelines for Daily Procedural Volumes PGY Level Procedure

PGY 4/5

CT Head and Neck 7-10

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MRI Head and Neck 3-5

COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate the ability to address the clinical question first and incidental findings later.

Demonstrate effective communication skills when dealing with patients, staff and referring clinical services.

COLLABORATOR: Demonstrate an understanding of the radiologist’s role within the team of oncology heath

care providers: head and neck surgeons, radiation oncologists and medical oncologists; Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care, including interactions with trauma team, emergency room staff & neurosciences team members.

MANAGER: Demonstrate an awareness of the indications for various head and neck / ENT imaging

modalities. Demonstrate the ability to consider advantages and disadvantages of available imaging

modalities. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. Demonstrate appropriate time management skills when completing assigned rotation duties. Demonstrate the ability to quickly grasp and respond to clinical needs in emergent and

urgent situations. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses and consent issues, when

recommending, approving and protocoling cases, as well as biological issues for MRI imaging.

Demonstrate the ability to recognize situations in which imaging or treatment would be detrimental to the health/safety of a patient.

PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Demonstrate an awareness of one’s own limitations (aware of strengths and weaknesses). Exhibit appropriate personal and interpersonal professional behaviors Demonstrate good work ethic, with enthusiasm and motivation for learning Demonstrate professional work habits with punctuality, organization and efficiency Demonstrate the ability to incorporate feedback into improved personal performance

51

SCHOLAR: Demonstrate the ability to set personal learning goals & objectives during rotation. Demonstrate the ability to take a leadership role in the learning of others, with

teaching/supervision of junior residents on rotation, elective students, off-service residents. Demonstrate the ability to critically appraise the literature relevant to head and neck

imaging. Teaching: Supervision/teaching of elective medical students or off-service residents, along with

assigned staff radiologist. Act as a consultant to residents in other disciplines in the planning and interpretation of

head and neck / ENT studies. Bring interesting cases to show your co-residents.

Rounds: Hospital-based Multi-disciplinary Tumor Boards [Tuesdays 0800-0900, 6th floor auditorium, PMH; no rounds on 3rd Tuesday of each month]. Evaluation: Assessed on daily basis by head and neck / ENT imaging staff Resident should have mid-unit discussion with supervisor Formal evaluation (ITER) and discussion (on resident performance) will be held at the end

of the rotation. Residents can then comment on the rotation value. OSCE and oral examination

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Last updated: February 2013 NUCLEAR MEDICINE Hospital: UHN, SHSC, SMH, HSC PGY-3: 1 or 2 months PGY-4: 1 or 2 months PGY-5: 1 month elective Location Supervisor Site focus UHN Aaron Hendler General Nuclear Medicine,

SPECT, CT, PET SHSC Lisa Ehrlich General Nuclear Medicine,

PET, therapy, DXA SMH Gilbert Hurwitz General Nuclear Medicine,

Cardiac HSC Amer Shammas Pediatric Nuclear Medicine PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in the basic skill set required for nuclear medicine.

1. Nuclear Medicine physics - radioactive decay, radiobiological, introduction to dosimetry and regulations

2. Instrumentation – Anger camera, SPECT, probes, dose calibrators, probes, instrumentation QC

3. Radiopharmacy –introduction to generators, preparation, administration, quality control 4. Radiation safety – safe handling of radiopharmaceuticals, radiation monitoring, 5. Diagnostic nuclear medicine – indications, patient preparation and interpretation

a. Bone scans b. Lung scans c. Infection imaging –WBC, gallium d. Renal scans imaging and quantitation of function e. Endocrine imaging – thyroid, parathyroid, neuroendocrine tumor imaging (MIBG, octreotide) f. Cardiac Imaging – myocardial perfusion, MUGA g. CNS -brain, CSF h. Tumor imaging- sentinel node procedures i. GI – Liver, spleen, GI bleeds, Meckel’s, gastric emptying

6. Therapeutic nuclear medicine a. Hyperthyroidism b. Thyroid cancer c. Radioimmunotherapy d. Palliation of bone pain

7. PET interpretation – indications, pitfalls

ROTATION OBJECTIVES: Rotation objectives may vary at each site depending on the site Nuclear Medicine focus. All residents will rotate to either UHN or SBHSC sites during their residency training in order to gain exposure to PET.

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MEDICAL EXPERT/CLINICAL DECISION-MAKER: To acquire and demonstrate knowledge of basic nuclear medicine radiation safety To acquire and demonstrate knowledge of basic instrumentation To acquire and demonstrate knowledge of basic radiopharmacy To acquire and demonstrate knowledge of normal biodistribution of the most commonly

used radiopharmaceuticals To acquire and demonstrate knowledge of image interpretation in pathologic states. To acquire and demonstrate knowledge of basic principles of radioisotope therapy To demonstrate an understanding of PET CT principles and image interpretation

PGY-3/PGY-4 (1 or 2 months, first rotation): Demonstrate an introductory understanding of basic instrumentation, radiopharmacy,

radiation safety and QC Demonstrate a basic understanding of scan patterns in normal and disease states Demonstrate an introductory understanding of protocoling requisitions Demonstrate an introductory understanding of scan interpretation and reporting Demonstrate an understanding of the basic principles of computer analysis in nuclear

medicine Demonstrate an introductory understanding of informed consent before thyroid therapy for

cancer and hyperthyroidism Demonstrate an introductory understanding of pharmacologic and exercise stress

testing/EKG interpretation Demonstrate the ability to perform sentinel node procedures and CSF flow studies

PGY-3/PGY-4 (1 or 2 months, second rotation): Demonstrate an expansion of knowledge of instrumentation, radiopharmacy, radiation

safety and QC Demonstrate a more advanced understanding of scan patterns in normal and disease states Demonstrate the ability to review, and if necessary, modify all studies before the patient

leaves the department Develop and demonstrate a more advanced skill level in image interpretation Demonstrate the ability to help protocol requisitions Demonstrate the ability to perform computer analysis in nuclear medicine independently Demonstrate the ability to obtain informed consent before thyroid therapy Demonstrate an introductory understanding of basic PET CT scan interpretation Demonstrate the ability to perform sentinel node procedures and CSF flow studies Demonstrate the ability to obtain informed consent for I131 therapy for thyroid cancer or

hyperthyroidism PGY-5 (elective): Demonstrate efficiency in the interpretation of routine nuclear medicine studies and assist

junior residents in film review or case management Demonstrate the ability to direct consultations regarding nuclear medicine cases with

increasing independence Demonstrate the ability to perform some procedures, such as CSF flow studies and sentinel

node procedures with minimal supervision Demonstrate the ability to protocol nuclear medicine requisitions cases independently Demonstrate familiarity with the appearance and interpretation of basic PET CT Demonstrate an understanding of radioimmunotherapy and radionuclide bone palliation. Demonstrate an understanding of nuclear medicine QC and exhibit the ability to

troubleshoot basic QC problems

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COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations, in a timely manner. Demonstrate effective communication skills when dealing with patients, during consent or

procedures, as well as with consulting clinicians. Demonstrate an understanding of when it is necessary to contact a referring

clinician/service with an urgent/unexpected finding. Demonstrate the ability to obtain and synthesize relevant history and information from

referring physicians, patients, and families. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians and health team

members. Demonstrate the ability to interact appropriately with other imaging department staff with a

team approach to patient care. MANAGER: Develop and demonstrate an understanding of the indications for nuclear medicine studies

and exhibit the ability to consider how it fits in with other imaging modalities. Demonstrate the ability to consider available imaging resources when planning and

recommending nuclear medicine studies. Demonstrate the ability to triage physician requests regarding the urgency of an imaging

study. Demonstrate appropriate time management skills when completing assigned rotation duties. Demonstrate the ability to monitor imaging studies and appropriately modify the protocol

based on the findings. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses when recommending,

approving and protocoling cases. Demonstrate an understanding of indications, contraindications, patient preparation and

radiation risks of nuclear medicine procedures

PROFESSIONAL: Demonstrate an understanding of the ethical and medical-legal issues of nuclear medicine. Exhibit appropriate personal and interpersonal professional behaviors. Demonstrate integrity, honesty and compassion and respect for others. Demonstrate professional appearance and communication. Demonstrate good work ethic, with enthusiasm and motivation for learning. Demonstrate professional work habits with punctuality, organization and efficiency. Demonstrate the ability to incorporate feedback into improved personal performance. Demonstrate awareness of own limitations. Demonstrate the ability to appraise one’s own professional performance.

SCHOLAR: Demonstrate the ability to set personal learning goals and reading plan during rotation. Demonstrate the ability to contribute to the learning of others, with teaching/supervision of

junior residents on rotation, elective students, off-service residents. Demonstrate the ability to critically appraise the literature as needed. Residents on rotation at Sunnybrook may be expected to give a short presentation on a

nuclear medicine topic

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Evaluation: Each individual resident is responsible for meeting the stated goals and objectives for

successful evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisors and to

ensure that the ITER is reviewed before leaving the rotation. Daily performance evaluation and observation of interpretation and interventional skills Rounds performance – including collaboration, communication and scholarly ability. Resident should have mid-rotation discussion with supervisor – please remind the

supervisor at this point in time! Formal ITER at end rotation OSCE and/or oral examination

Diagnostic and Procedural Skills to Log: Sentinel node injection CSF flow studies Therapy informed consent

Reading/Reference List:

General Nuclear Medicine Textbooks

1. Essentials of Nuclear Medicine Imaging. Fifth Edition Mettler & Guiberteau. 2. Nuclear Medicine: The Requisites. Third Edition Ziessman and Thrall 3. Practical Nuclear Medicine. Palmer, Scott & Strauss. 4. Case Review: Nuclear Medicine. Ziessman & Rehm. 5. Nuclear Medicine Manual. Aunt Minnie

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Last updated: May 2012

PEDIATRICS Hospital: HSC PGY-4: 4 months Supervisor: Dr. C. McDonald PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in imaging and interpretation skills required for general pediatric studies including: 1) Knowledge of common pediatric disorders and diagnoses. 2) Awareness of common normal variants. 3) Knowledge of urgent pediatric abnormalities and emergencies. 4) Ability to perform general pediatric fluoroscopic procedures. 5) Supervision/performance of common pediatric CT and US examinations. 6) Awareness of role of pediatric MR and nuclear medicine examinations. ROTATION OBJECTIVES: The pediatric radiology rotation is an introduction covering a broad scope of imaging exams. The intent of the residency rotation is not to achieve subspecialty expertise but to emphasize the imaging studies and imaging algorithms of the more common and emergent disease processes unique to the pediatric population. At the end of the rotation the major objective is for the resident to demonstrate the ability to

recognize and interpret common pediatric abnormalities and normal variants which most practicing radiologists experience in a contemporary practice. As well, residents must demonstrate an awareness of less common but clinically critical abnormalities. The breadth and scope of these findings, the relatively short rotation time and the varied levels of experience of the residents dictate a significantly different approach to teaching and resident responsibility than most adult rotations.

Residents should demonstrate competency in performing and interpreting common fluoroscopic examinations in gastrointestinal and genitourinary imaging.

Residents should demonstrate the ability to competently protocol, perform and interpret common examinations in cross sectional US and CT imaging.

Residents should demonstrate the ability to diagnose and act appropriately on radiologic emergencies as they pertain to pediatrics.

Residents will acquire a knowledge base sufficient to pass the Pediatric sections of both the American and Canadian certification examinations in Diagnostic Radiology.

MEDICAL EXPERT/CLINICAL DECISION-MAKER: Develop and demonstrate a basic level of knowledge and a systematic approach in reading

pediatric imaging studies for evaluation of various common and emergent diseases Demonstrate the ability to decide what radiographic studies are needed to clarify common

and emergent clinical problems Demonstrate the ability to know the appropriate use and limitations of radiographic studies

as they pertain to pediatrics COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations.

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Demonstrate effective communication skills when dealing with pediatric patients, families, staff and referring clinical services

Demonstrate an understanding of when it is necessary to contact staff and referring clinical services with an urgent finding.

COLLABORATOR: Demonstrate good consulting skills when interacting with other pediatric physicians and

health team members. Demonstrate the ability to interact appropriately with other radiology department staff,

referring clinical services and support staff, demonstrating a team approach to the care of the pediatric patient.

MANAGER: Demonstrate an awareness of the indications for various imaging modalities for the

pediatric patient. Demonstrate the ability to consider the advantages and disadvantages of available imaging

modalities for care of the pediatric patient. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses and consent issues, when

recommending, approving and protocoling cases involving pediatric patients. PROFESSIONAL: Demonstrate the ability to consistently act in the best interest of the patient and family. Demonstrate integrity, honesty and compassion maintaining patient/family confidentiality. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Demonstrate an awareness of one’s own limitations.

SCHOLAR: Demonstrate the ability to set personal learning goals and objectives during rotation. Demonstrate the ability to take a leadership role in the learning of others, with

teaching/supervision of junior residents on rotation, elective students, off-service residents. Demonstrate the ability to participate in quality assurance with a presentation or project

during the rotation. Rotation Responsibilities: Clinical: There will be structured system and modality-based rotations as well as elective time with the focus on using the appropriate imaging modality to diagnose and manage pediatric patients and on interpreting features of commonly obtained imaging studies and on urgent pediatric diseases. Pediatric Radiology is a four-month rotation, usually taken as a block rotation, during the PGY-4 year. A graded level of responsibility is given to each resident, according to their individual capabilities, keeping in mind the short time spent in experiencing pediatric imaging. Rotations for residents include imaging of emergency room patients, outpatient clinic patients, and inpatients, including patients in the neonatal, pediatric and cardiac intensive care units. In all rotations the resident is expected to independently review each case in an effort to observe the appropriate findings, formulate a diagnosis or differential diagnosis and plan/suggest further

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imaging examinations or patient management. They are then to review each case with a staff radiologist. In areas where a contrast examination is required, the case is reviewed with a staff radiologist and depending on the resident’s knowledge and experience, the resident is expected to perform the examinations (with ‘hands-on’ guidance if necessary). Clinical responsibilities include ‘in house’ on call on a rotation basis with other residents. In this capacity, they are expected to act as consultants to clinicians for all emergency room plain images and for all inpatient examinations for which they are consulted. As well, they are to organize and execute, depending on the resident’s experience and knowledge base, any procedures or cross sectional imaging studies to be done, under the supervision of a fellow/staff radiologist. They also carry a ‘Trauma Team’ pager and are expected to review all images on trauma patients and co-ordinate any further imaging examinations required under supervision of the fellow/staff radiologist, and to carry out those examinations if they are capable. Skills: Pediatric Radiology, integrates training in both imaging modality and organ systems encompassing all aspects of Radiology only applied to a different patient population. Residents will be evaluated on their technical skills at radiologic procedures as a component in their overall evaluation. The clinical state of the patient must be evaluated by the resident and reviewed with the fellow/staff before each procedure. Fellow or staff supervision is always present, be it “hands-on” initially, or more consultative as the resident demonstrates increasing competence during their rotation. The residents’ technical skills are usually limited to fluoroscopic and ultrasound procedures. Teaching: The residents are encouraged to review studies with medical students, rotating residents in pediatric and other subspecialties, and foreign observers who frequently are present in the department. Attitude: The pediatric population is intrinsically unique. Medical and radiologic patient care necessitates an appropriate attitude towards children and their families. The resident must be able to demonstrate an appreciation for this unique circumstance in order to relate appropriately with the child, the family and the differing clinical services involved. Rounds: Rounds are a mixture of didactic teaching and problem-based or case-oriented film review, depending on the topic presented. Didactic rounds are performed by fellows/staff radiologists. Residents are expected to participate in Quality Assurance Rounds where a topic is assigned and during their rotation present an Interesting Case Rounds topic. Residents are encouraged to attend the many clinical rounds held with the hospital clinicians. Evaluation: Evaluation is performed on a continuing day-to-day basis, during case-review rounds, as well as at the end of each section. Residents are responsible for meeting the outlined goals and objectives and are encouraged to seek feedback from supervisors during each section of their rotation, particularly at the mid-point of the rotation. Problematic residents are approached when necessary during their rotation, to encourage improvement during the remainder of the rotation. The final

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evaluation for the formal ITER is a composite report from fellows and staff Radiologists and is discussed with the resident at the end of the rotation with the Program Site Coordinator. Rotations: The following is an outline and an approximate list of relative time spent by each resident in each of the various areas of the department, during their rotation in Pediatric Radiology. Cardiovascular System Imaging modalities: The focus is on interpreting chest radiographs and to have a limited experience with CT studies. There will be no direct time spent interpreting cardiac MR studies however, the resident should become familiar with the indications and limitations of the examination. The emphasis is on identifying abnormalities associated with congenital heart disease on the chest radiograph of the infant and older child. Develop a systematic and comprehensive approach in interpretation of the chest radiograph emphasizing a useful and limited differential diagnosis based on the findings with an emphasis on pulmonary blood flow patterns. Understand the basic pathophysiology producing the various imaging patterns and know the basic interventional and surgical treatments and expected post-operative findings and complications. Gastrointestinal System Imaging modalities: There will be exposure to abdominal radiographs, contrast UGI and LGI studies, air enema for intussusception reduction, US, CT and limited exposure to MR and nuclear medicine. Identify common and life threatening congenital anomalies emphasizing congenital and acquired intestinal obstructions, necrotizing enterocolitis with free intraperitoneal air, ileus and pneumatosis intestinalis, inherited and acquired infectious/inflammatory lesions and neoplasms involving the bowel, biliary system and solid viscera. Genitourinary System Imaging modalities: There will be exposure to plain radiographs, VCUG, US, CT and limited exposure to MR and nuclear medicine . Identify congenital anomalies and inflammatory and infectious conditions of the kidneys and urinary tracts and demonstrate the appropriate work-up for urinary tract infections, neoplasms and ischemic injuries involving kidneys, adrenal glands and genital tracts. Neuroradiology Imaging modalities: There will be exposure to plain radiographs, CT, MR and ultrasonography. Identify congenital anomalies of the skull, spine, brain and spinal cord, demonstrate the ability to interpret full spine radiographs for scoliosis, inflammatory/infectious conditions, neoplasms and trauma. Chest and Airway

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Imaging modalities: There will be exposure to plain radiographs, CT (including high resolution), ultrasonography and limited MR. Identify congenital anomalies of the lungs, airspace and interstitial pulmonary disease, foreign bodies, abnormalities of lung volume, neoplasms and trauma. Lateral neck radiographs for adenoidal and tonsillar hypertrophy, limitations for epiglottic and glottic edema, foreign body, retropharyngeal abscess and congenital and acquired subglottic narrowing. Musculoskeletal System Imaging modalities: There will be exposure to plain radiographs, CT, MR and ultrasonography Identify common skeletal dysplasias, osteomyelitis, arthritis, benign and malignant bone tumors, cysts, bone destruction, common and unique fractures in the immature skeleton emphasizing the Salter-Harris classification, common dislocations, metabolic and osteochondroses, demonstrate the ability to read hip radiographs and sonograms for developmental hip dysplasia. Emergency Room/OPD Clinic (plain films) 2-3 weeks Inpatient (plain films) 2-3 weeks GI/GU 2-3 weeks Cardiac 1week Neuroradiology 1-2 weeks Ultrasound 2 weeks CT/MRI 2-3 weeks Elective 1 week

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Last updated: October 2012 ULTRASOUND Hospital: MSH, SHSC, SMH, TGH, TWH PGY-2: 2 months Supervisor: MSH: Dr. M. Margolis PGY-3: 1 month SHSC: Dr. C. McGregor PGY-5: Elective (1 to 2 months) SMH: Dr. D. Muradali (2 months of OB Ultrasound TGH: Dr. M. Atri (PGY 3 and 5) described in a separate document) TWH: Dr. A. Hanbidge All Residents receive at least 5 months' training in Ultrasound (2 months of OB Ultrasound are described in a separate document). Two months of training occur during the PGY-2 year, one month in the PGY-3 year and one month of OB Ultrasound in each of the PGY3 and 5 years with the option elective months in the PGY-5 year. Residents are encouraged to select at least one of these months in the PGY-5. PROGRAM GOALS: By the end of residency training, the resident should demonstrate competency in ultrasound skills required for general ultrasound including:

1) The ability to perform and interpret ultrasound of abdomen, pelvis, small parts, peripheral vascular system

2) The ability to advise technologist regarding special views or parameters required for cases

3) An understanding of the strengths and limitations of ultrasound as compared to the other cross-sectional modalities

4) An understanding that US is a real-time examination and that decisions regarding the final diagnosis is made while the patient is in the department.

ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: PGY-2: Duration of Training - 2 months The PGY-2 resident will not be responsible for performing any complete examinations before reviewing with the staff radiologist during this month. They will gradually increase responsibility to fully scan a patient during this month as follows: During the first week, they should primarily observe the technologist or responsible radiologist while performing a scan. During this week, they should demonstrate the ability to perform brief focused examinations of the abdomen, pelvis (male, female), thyroid and peripheral veins after each scan. During week 2-4, the residents demonstrate the ability to do a complete examination, which will then be fully rescanned by a designated technologist.

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The PGY-2 Resident should demonstrate familiarity with: The knowledge of the operation of a standard ultrasound machine. Different approaches to examination of different organs (learn the proper approach to scan

different organs i.e. liver, kidney etc.) Normal sectional anatomy of abdomen, pelvis - male and female (including transvaginal

US), small parts - thyroid and scrotum, and peripheral veins. The appearance of a normal ultrasound scan of abdomen, pelvis - male and female

(including transvaginal US), scrotum, neck, leg veins, and prostate. Normal Doppler examination of abdomen, pelvis - male and female (including transvaginal

US), first trimester pregnancy (normal and abnormal), scrotum, leg veins. Common indications for ultrasound scans with emphasis on emergency procedures. Patient preparation for ultrasound scans. Techniques of ultrasound reporting with emphasis on the quality of the ultrasound scan. Strength of the use of ultrasound comparison with other imaging. Limitations of the use of ultrasound.

PGY-3: Duration of Training – 1 month Residents should demonstrate more independence and gradually move from having their examinations reviewed by the technologists to being checked by the attending staff. The PGY-3 Resident should demonstrate competency with regards to: All of the above (PGY-2 goals) as well as: The ability to scan more complex cases and technically more challenging patients, and 2nd

and 3rd. trimester pregnancy. The US appearance of more complex pathologies. The ability to interpret and report complete ultrasound examinations. The technique of ultrasound guidance for interventional procedures.

PGY-4 and PGY-5 A PGY-4 and PGY-5 may perform and/or check complete cases under the guidance of a supervisor. Senior residents should demonstrate: The ability to conduct ultrasound examinations on their own including: a) machine turn-

on, machine set-up; b) transducer selection; c) exam performance. The ability to review basic US examinations performed by the technologists. The ability to interpret sonograms of abdomen, pelvis - male and female, scrotum, neck, leg

veins, transplant ultrasound, and second and third trimester obstetrics A familiarity with a) ultrasound guided interventional procedures; b) transrectal ultrasound

prostate and c) carotid ultrasound. Senior residents should review scans with staff radiologist depending on the complexity of the scan. COMMUNICATOR: Demonstrate the ability to obtain and synthesize relevant history and information from

referring physicians, patients, and families. Demonstrate the ability to review previous relevant imaging.

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Demonstrate the ability to dictate well-organized reports, describing relevant findings in the findings section, and diagnosis and recommendations in the impression in a timely manner.

Demonstrate effective communication skills when dealing with patients, technologists/clerical staff and referring clinical services.

Demonstrate the ability to obtain consent if needed (for example an US-guided procedure). Demonstrate an understanding of when it is necessary to contact a referring

clinician/service with an urgent/unexpected finding. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care. MANAGER: Demonstrate an awareness of the indications for various ultrasound examinations. Demonstrate the ability to consider the advantages and disadvantages of ultrasound versus

other imaging modalities. Demonstrate the ability to consider available imaging resources when planning and

recommending patient care, using them effectively and efficiently. Demonstrate the ability to triage physician requests regarding the urgency of an imaging

study. Demonstrate appropriate time management skills when completing assigned rotation duties.

HEALTH ADVOCATE: Demonstrate the ability to recognize and consider the strength of US as an imaging study

that does not involve radiation, especially in the children and younger patients. Demonstrate the ability to recognize and consider consent issues, patient comfort and other

patient-related issues, when participating or performing ultrasound/ultrasound guided procedures.

For male residents to always have a female staff in attendance when performing transvaginal US examination.

PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Demonstrate awareness of own limitations. Exhibit appropriate personal and interpersonal professional behaviors. Demonstrate professional appearance and communication. Demonstrate good work ethic, with enthusiasm and motivation for learning. Demonstrate professional work habits with punctuality, organization and efficiency. Demonstrate the ability to incorporate feedback into improved personal performance. Demonstrate the ability to appraise one’s own professional performance.

SCHOLAR: Demonstrate the ability to set personal learning goals and objectives during rotation. Demonstrate the ability to take a leadership role in the learning of others, with

teaching/supervision of junior residents on rotation, elective students, off-service residents, and technologists.

Demonstrate the ability to critically appraise the literature as needed.

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Evaluation: Each individual resident is responsible for meeting the stated goals and objectives for

successful evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisors and to

ensure that the ITER is reviewed before leaving the rotation. Daily performance evaluation and observation of interpretation and interventional skills Rounds performance – including collaboration, communication and scholarly ability. Resident should have mid-rotation discussion with supervisor – please remind the

supervisor at this point in time! Residents are expected to do the appropriate volume of cases for their level of training Formal ITER at end of rotation OSCE and oral examination (In-training exams arranged by the Program)

Diagnostic and Procedural Skills to Log: Log the number of scans in each category; abdomen, pelvis, transvaginal US, prostate,

neck, peripheral veins, carotid arteries as appropriate to the level of training. Number of US-guided procedures, if exposed to US guided-procedure.

Rotation responsibilities: In first 1-2 weeks: Focus on learning basic US scanning techniques. May review interesting cases that have occurred during the day with assigned radiologist. Subsequent weeks resident responsibilities include: Review patient charts, lab data, previous imaging, in order to provide appropriate

information for the involved technologist and study interpretation. Provide supervision/guidance to the technologist for cases requiring consultation &/or

scanning. Report all cases he/she has been involved with (scanning or reviewing). All cases to be

reviewed by supervising radiologist. Teaching: The resident is encouraged to bring interesting cases to noon rounds or resident half-days. Supervision/teaching of elective medical students or off-service residents, along with

assigned radiologist. Teaching of technologist and ultrasound students, as appropriate.

Rounds: Hospital based.

Reading List: PGY-2 Sanders R: Clinical Sonography: A Practical Guide. Little, Brown & Company. Sauerbrei E: A Practical Guide to Ultrasound in Obstetrics and Gynecology. Raven Press. Kurtz AB, Middleton WD: Ultrasound - The Requisites. Mosby - Yearbook Inc. PGY-3 - PGY-4 Rumack C, et al (eds.): Diagnostic Ultrasound (pediatrics are an option). Mosby - Yearbook. Mittelsteadt C: Abdominal Ultrasound. Churchill Livingstone.

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PGY-5 Nyberg D: Transvaginal Ultrasound. Mosby - Yearbook. Nyberg D: Diagnostic Ultrasound of Fetal Anomalies: Text and Atlas. Mosby - Yearbook. Burns P, Taylor K: Clinical Applications of Doppler Ultrasound. Raven Press. Zwiebel WJ: Introduction to Vascular Ultrasonography. WB Saunders Company. Sauerbrei E, Nguyen K, Nolan R: Abdominal Sonography. Raven Press. Syllabus. Special Course: Ultrasound Radiological Society of North America. Syllabus. Special Course: Ultrasound Radiological Society of North America.

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Last updated: February 2013 OBSTETRICAL ULTRASOUND Hospital: MSH and SHSC PGY-3: 1 month Supervisor: MSH: Dr. Fong PGY-5: 1 month SHSC: Dr. Glanc PROGRAM GOALS: Upon completion of the rotation, the resident should demonstrate competency in the basic skill set required for obstetrical ultrasound including: 1) An understanding of the role of ultrasound as a screening and diagnostic tool in the management of pregnancy 2) The ability to identify normal pregnancy and fetal anatomy 3) The ability to recognize common fetal structural abnormalities and pregnancy complications 4) An understanding of the use of biophysical profile scoring and Doppler to evaluate fetal well-being ROTATION OBJECTIVES: MEDICAL EXPERT/CLINICAL DECISION-MAKER: Demonstrate knowledge of the basics of ultrasound physics, machine operation,

bioeffects and safety issues as they relate to pregnancy and the fetus. Develop and demonstrate an understanding of sonoembryology and the ability to

recognize normal fetal anatomy and gross fetal structural abnormalities in the first trimester of pregnancy.

Demonstrate an understanding of prenatal screening for chromosomal abnormalities and nuchal translucency measurement

Demonstrate the ability to recognize normal fetal anatomy and fetal structural abnormalities at the 18-22 week anatomic scan.

Demonstrate an understanding of the use of biophysical profile scoring and Doppler to evaluate fetal well-being and fetoplacental dysfunction.

Demonstrate the ability to integrate clinical findings with ultrasound interpretation in order to make diagnoses and contribute to patient management.

FIRST TRIMESTER Ultrasound features of normal early pregnancy, including multiple pregnancy (determination of chorionicity and amnionicity), failed early pregnancy, spontaneous complete/incomplete abortion, subchorionic hematoma, gestational trophoblastic disease, gross fetal structural abnormalities (such as acrania/anencephaly, holoprosencephaly, abdominal wall defect). Fetal biometry: crown rump length, nuchal translucency SECOND AND THIRD TRIMESTER Normal findings: normal fetal anatomy/situs/development, placenta, amniotic fluid volume, multiple gestations, cervical appearance and length.

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Fetal biometry: • Measurements to assess gestational age (biparietal diameter, head circumference,

abdominal circumference, femur length) • Measurements to aid in the diagnosis of fetal anomalies: nuchal skin fold, cerebral

ventricular atrial width • Assessment of fetal growth and fetal weight estimation: interpretation and understanding

the limitations of standard measurements singly or serially Recognition of soft markers: nuchal thickening, choroid plexus cyst, echogenic cardiac focus, echogenic bowel, mild ventriculomegaly, mild pelviectasis. Recognition of fetal abnormalities that require high risk obstetrics referral, including chromosomal abnormalities such as Down's syndrome and Turner's syndrome, congenital malformations (neural tube defects, chest masses, abnormal heart, abdominal wall defects, renal, gastrointestinal tract and hepatic abnormalities, skeletal dysplasias, cleft lip/palate), intrauterine growth restriction, hydrops, congenital infections, complications of twin pregnancy (including twin to twin transfusion sequence). Recognition of pregnancy complications: Oligohydramnios and polyhydramnios, placental abnormalities (including placenta previa, abruption, adherent placentas, vasa previa), cord abnormalities (including cord prolapse, two-vessel umbilical cord, cord masses), abnormal cervix (including short cervix, funneling, bulging amnion), fibroids, ovarian cysts. Assessment of fetal well-being:

Biophysical profile scoring: interpretation and understanding the limitations Evaluation of fetal blood flow: umbilical cord Doppler, fetal cranial Doppler:

waveform analysis in normal and complicated pregnancies. COMMUNICATOR: Demonstrate the ability to dictate well-organized reports, describing relevant findings,

diagnosis and recommendations. Demonstrate effective communication skills when dealing with patients and their families

and also with ultrasound technologists, referring physicians, midwives, genetic counselors and other members of the health care team.

Demonstrate an understanding of when it is necessary to contact a referring clinician/service with an urgent/unexpected finding.

COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health care

team members. Demonstrate the ability to interact appropriately with ultrasound technologists and other

radiology department staff with a team approach to patient care. Demonstrate the ability to interact with area co-ordinator and ultrasound technologists

regarding scanning opportunities. MANAGER: Demonstrate awareness of the indications for various types of ultrasound examinations

during pregnancy, including the use of Doppler. Demonstrate the ability to consider advantages and disadvantages of obstetrical

ultrasound versus fetal MRI.

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Demonstrate the ability to consider available imaging resources when planning and recommending patient care, using them effectively and efficiently.

HEALTH ADVOCATE: Demonstrate the ability to recognize and consider ultrasound bioeffects and safety,

patient comfort, consent issues and other patient-related issues, when participating or performing obstetric ultrasound.

PROFESSIONAL: Demonstrate the ability to provide high quality care with integrity, honesty, respect and

compassion. Demonstrate an understanding and practice the ethical and medical-legal requirements of

radiologists. Exhibit appropriate personal and interpersonal professional behaviors. Demonstrate professional appearance and communication. Demonstrate good work ethic, with enthusiasm and motivation for learning. Demonstrate professional work habits with punctuality, organization and efficiency. Demonstrate an awareness of one’s own limitations. Demonstrate the ability to incorporate feedback into improved personal performance.

SCHOLAR: Demonstrate the ability to set personal learning goals and reading plan during rotation. Demonstrate the ability to contribute to the learning of others, with teaching/supervision

of elective medical students, off-service residents. Demonstrate the ability to critically appraise the literature as needed. Residents may be expected to give a short presentation of cases to be discussed at weekly

Fetal Medicine Rounds, monthly Fetal Pathology Rounds (combined Radiology, Genetics, Obstetrics and Pathology), sonographers and resident rounds.

EVALUATION: Each resident is responsible for meeting the stated goals and objectives for successful

evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisor. Resident should be able to generate standard views of the fetus including the head, face,

heart, spine and abdomen (stomach, bladder, kidneys and cord insertion). Resident should have mid-rotation discussion with supervisor – please remind the

supervisor at this point in time! Formal ITER at the end of rotation

Reading/Reference List: AIUM practice guidelines for the practice of obstetric ultrasound examinations – published in conjunction with ACR and ACOG, 2007. www.aium.org SOGC clinical practice guideline. Content of a complete routine second trimester obstetrical ultrasound examination and report, 2009. J Obstet Gynaecol Can 2009;31(3):272-275 Saunders RC, Blackman LR, Hogge WA, et al. Structural fetal abnormalities, the total picture. 2nd edition, Elsevier, 2002

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Kurtz AB, Middleton WD. Ultrasound: The Requisites (Requisites in Radiology). Mosby, St. Louis, 2003. Stat Diagnosis – Obstetric Ultrasound. Amirsys. www.statdx.com (OB Imaging section) Callen PW. Ultrasonography in Obstetrics & Gynecology. 5th edition. W.B. Saunders Company, Philadelphia, 2008 Rumack, Wilson, Charboneau, Johnson. Diagnostic Ultrasound, volume 2, 3rd edition. Elsevier Mosby, St. Louis, 2005 Nyberg DA, McGahan JP, Pretorius DH, Pilu G. Diagnostic imaging of fetal anomalies. Lippincott Williams & Wilkins, Philadelphia, 2003 Teaching file of interesting cases in CEOU – RadFiler, powerpoint presentations of previous "OB rounds" Internet sites: OMIM, thefetus.net

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Last Updated: February 2013 VASCULAR/INTERVENTIONAL RADIOLOGY Hospitals: MSH, SHSC, SMH, TGH, TWH PGY 2/3/4: 12 weeks Supervisors: MSH: Dr. J. Kachura SHSC: Dr. C. Dey PGY 5 (elective): 4 weeks SMH: Dr. V. Prabhudesai TGH: Dr. C. Ho TWH: Dr. M. Simons All Residents will have three months of Vascular and Interventional Radiology, which will include 12 weeks in the PGY-2/3/4 year. There will be an option for a 4 week elective in the PGY-4 or PGY-5 year. PROGRAM GOALS: By the end of residency the resident should demonstrate a good knowledge of vascular anatomy (cross sectional and angiographic) and a good knowledge of non-vascular anatomy as it pertains to planning and performing vascular and non-vascular interventions. Residents should demonstrate a basic understanding of common interventional techniques such as vascular access, seldinger and trochar techniques, catheter and wire exchanges, drainage catheter placement with tract dilation and loop formation. Residents should have an understanding of common procedures including biopsies, abscess drainages, nephrostomy tube placement, biliary drainage, vascular access, angiography, IVC filter insertion, angioplasty and embolization. The emphasis of training will be on common basic procedures with a focus on clinical assessment of patients, indications and appropriateness of procedures, interpretation of intraprocedural images, potential complications of procedures and their immediate management as well as post procedure care. At the end of the residency, the resident should demonstrate the ability to communicate with referring clinicians to determine if a clinical problem can appropriately be managed by interventional radiology. They should demonstrate an adequate ability to interpret routine CTA and MRA studies. They should demonstrate the ability to communicate findings of an invasive procedure including appropriate steps in post-procedure care. Residents demonstrate the technical skills necessary to perform basic biopsies and drainages and basic vascular access procedures. They should demonstrate adequate technical skill to continue in fellowship training in angiography and interventional radiology. The spectrum of procedural opportunity can vary at each training site and even within the same site from month to month.

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ROTATION OBJECTIVES: Angiography and Interventional Radiology can be thought of as vascular and non-vascular "Invasive" Radiology. The vascular section includes all types of vascular imaging modalities, including those that are not invasive, such as vascular sonography, IVDSA, CTA, and MRA. The vascular radiology service is a synergistic complement to the other vascular related services. The most important of these services include vascular surgery, the "Thrombosis Team", and Cardiology. Vascular radiology also plays a key role in providing long-term venous access, which is an important service to the entire hospital. The non-vascular section of invasive radiology includes mostly biopsies, primary tumor treatments, drainages, and enteric feeding tubes. The most important services to which the non-vascular invasive radiology service supports include general surgery, gastroenterology, urology, intensive care unit and general medicine. A common misconception of this rotation is that the emphasis is on the resident's ability to perform procedures. Instead, the resident's procedural ability will not be evaluated by the Royal College at all. However, residents will be expected to develop and demonstrate proficiency in basic procedures. Residents with an aspiration to obtain advanced skills are encouraged to continue on to a VIR fellowship. The resident objective for both the vascular and non-vascular sections of invasive radiology is to demonstrate competence in knowledge and the application of knowledge in the following categories: The following lists are not intended to be comprehensive. They are intended to point to areas of emphasis. MEDICAL EXPERT/CLINICAL DECISION-MAKER: Anatomy (relevance to image guided interventions):

a) Vascular: axial and appendicular arterial and venous anatomy b) Mediastinum and Lung c) Abdomen: in particular hepatobiliary, pancreatic, digestive system and

urinary tract d) Male and female pelvis

Physiology and pathophysiology:

a) Arterial: occlusive, aneurysm, traumatic, vasculitic b) Venous: thrombosis, valvular incompetence c) Hemostasis and thrombosis d) Hepatobiliary disease e) Pancreatitis and pancreatic masses f) Digestive system g) Urinary tract h) Malignancies and mode of dissemination

Clinical skills:

Demonstrate an understanding of the indications, contraindications and therapeutic or management alternatives to invasive radiologic procedures.

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Pre-procedural work-up: - Review of clinical history and previous imaging studies - Preliminary blood work - Determining what premedications and/or blood products may be required

Patient management:

- Obtaining informed consent - Sedation and pain control dosing and reversal - Patient monitoring and management of unfavourable developments

such as: contrast allergy, hypoxia, hypotension, etc. - Post procedure care including medications, monitoring and management of

complications

Procedural Skills: - Be able to perform PICC’s, paracenteses, thoracenteses, uncomplicated abscess drainages and biopsies - Basic catheter and guidewire manipulations - Real time ultrasound guidance

Vascular Imaging: - Interpret and report vascular CTA and MRA studies - Recognize findings relevant to future intervention

Technical skills:

The most important skill to acquire during residency is to demonstrate the ability to know

what not to do and when to call for help. Even so-called “simpler” procedures such as biopsies and abscess drainages can result in complications. Competence in technical skills requires extensive training. Do only what you have been asked to do by your procedural supervisor. If you do not feel comfortable doing what is asked, please let your procedural supervisor know immediately.

The resident is encouraged to maintain a record of procedures performed during the

rotation. The degree of supervision on each procedure will depend on the case and the resident’s ability.

COMMUNICATOR: Demonstrate the ability to collect and synthesize information related to common clinical

VIR scenarios and communicate that information to the VIR team Demonstrate the ability to communicate with referring physicians in obtaining relevant

clinical history, and the ability to identify the key clinical question or issue. Demonstrate the ability to provide an organized, succinct, but thorough report to the VIR

team. Demonstrate the ability to communicate relevant information to the patient/family members

and obtain informed consent for procedures. COLLABORATOR: Demonstrate good consulting skills when interacting with other physicians & health team

members. Demonstrate the ability to interact appropriately with other radiology department staff with

a team approach to patient care.

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MANAGER: Demonstrate awareness of the indications for various interventional modalities. Demonstrate the ability to consider the advantages and disadvantages of available operative

and interventional procedures. Demonstrate the ability to consider available VIR resources when planning, recommending

and prioritizing patient care, using them effectively and efficiently. HEALTH ADVOCATE: Demonstrate the ability to recognize and consider radiation doses when recommending,

approving and performing cases. PROFESSIONAL: Demonstrate integrity, honesty and compassion. Demonstrate the ability to show sensitivity and care to the patient and the patient’s family. Demonstrate an understanding of and practice the ethical and medical-legal requirements of

radiologists. Demonstrate an awareness of one’s own limitations.

SCHOLAR: Demonstrate the ability to set personal learning goals & objectives during rotation.

Procedural Log: **Residents are required to complete the procedure log available on the Radiology Residency Website (under “Forms”) and present to the rotation supervisor at the end of the rotation prior to ITER completion.** All vascular and non-vascular procedures which the resident has been involved in should be included. Note level of involvement and interesting points of educational value. Suggested Reading List:

1. Valji, K. Vascular and Interventional Radiology. W. B Saunders, Philadelphia, 1999. 2. Kaufman, J.A. and Lee, M.J. Vascular and Interventional Radiology: The Requisites.

Mosby, 2004. 3. Kandarpa, K. Handbook of Interventional Radiologic Procedures, 3rd Edition, Lippincott

Williams and Wilkens, 2001.

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Last Updated: September 2012 EMERGENCY Imaging Hospital: MSH, SHSC, SMH, TGH, TWH PGY-2: 1 month Supervisor: MSH: Dr. R. Bleakney PGY-3/PGY-4: 1-2 month SHSC: Dr. L. Probyn PGY-5: Elective (1 month) SMH: Dr. W. Weiser TWH: Dr. R. Bleakney Introduction: All residents receive 2-4 months training in Emergency Radiology, divided in 1 month rotations in the PGY-2 to PGY-5 years. The main emphasis of the rotation is plain film interpretation (although residents are encouraged to interpret associated CT studies when applicable). Objectives: MEDICAL EXPERT By completion of the rotation, the PGY-2 resident should demonstrate the ability to: Interpret plain radiographs performed in the ER department and communicate discrepancy

between preliminary (emergency physician) and final (radiology staff) interpretations according to department protocol.

Describe the standard views obtained and patient positioning for plain film examinations of the spine, ribs, pelvis, extremities, joints

Describe fracture patterns. Appreciate the normal appearance of a chest radiograph, recognize abnormalities

(pneumothorax, fractures, pneumonia, pulmonary edema, diaphragmatic herniation), evaluate aortic trauma, dissection and pulmonary thromboembolic disease (with corresponding CT imaging where applicable).

Recognize the appearance of normal 3 view abdominal radiographs and abnormalities (free air, bowel obstruction, abnormal calcification)

Understand and have knowledge of trauma imaging protocols including CT and MRI. Act as a liaison between the trauma team and the radiology department by arranging

imaging studies (CT, MRI); facilitate interpretation of emergency radiographs and when applicable, imaging from an outside institution.

Understand and have knowledge of normal anatomy and recognize of abnormal imaging findings in acute conditions including:

• MSK: o Fractures: spine, chest, pelvis and extremities (including descriptions of

fractures) o Fracture mechanics, pathology, and classifications including: Salter-Harris,

pelvic fractures, Garden classification of femoral neck fractures, ankle fractures, hand/wrist fractures, etc.

o Common treatments for fractures and knowledge of complications o Infection (septic joint, osteomyelitis) o Avascular necrosis

• Chest:

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o Pneumothorax, pneumomediastinum, pneumopericardium, o Pneumonia. aspiration o Lung collapse, atelectasis, lung contusion, hemmorhage o Pulmonary edema o Diaphragmatic injury/herniation o Aortic injury, aortic dissection and pulmonary thromboembolic disease

• Abdomen: o Free air, intramural air, pneumobilia, abnormal collections/abscess, ascites o Bowel obstruction o Malrotation o Abnormal calcifications

In addition to the above, the PGY-3- PGY 4 resident should have developed an increasing knowledge of medicine, surgery and imaging allowing him/her to demonstrate the ability to: Integrate clinical history and imaging findings to provide a diagnosis or an appropriate

differential diagnosis. Develop a more advanced approach to patient management, taking into account patient age,

risk of contrast nephropathy, radiation exposure, and risk and cost of therapeutic interventions.

Assess the risk benefit ratio for imaging, especially considering radiation and its consequences.

The PGY-5 resident should be able to demonstrate the ability to:

Act as a junior staff by interpreting plain radiographs independently and reviewing select cases with the staff radiologist.

Interpret a large volume of plain radiographs including ER, ICU, inpatient and outpatient department and associated CT studies, ultrasounds, GI studies, angiography and imaging intervention procedures if applicable.

COMMUNICATOR All residents (PGY-2-PGY-5) should develop skills to demonstrate the ability to: Facilitate transfer of care between the post-call resident and the arriving radiology team in

order to provide continuity of care, including scheduling studies requested overnight and alerting the radiology staff to prompt review of complex cases where final interpretation would alter immediate patient management.

Formulate concise and clear written and verbal reports for the referring clinician. Communicate effectively and respectively with patients and their family, medical

colleagues and all members of the health care team. COLLABORATOR All residents (PGY2-PGY5) should develop skills to demonstrate the ability to: Teach medical students and resident colleagues at a level appropriate to their education

level and competence. Act as an educator to referring physicians, health professionals and patients.

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Increase knowledge of clinical medicine and surgery, and gain competence in appropriately choosing imaging workup of plain film abnormalities and facilitate in arranging additional studies/interventional treatment.

MANAGER All residents (PGY-2-PGY-5) should develop skills to demonstrate the ability to: Prioritize imaging requests from the emergency physicians considering patient acuity,

available imaging modalities and resources. Assist the referring clinician in selecting the most appropriate imaging study utilizing

patient information (age, body habitus, renal function). Appreciate the importance of a team approach in patient care and facilitate communication

between clinicians, radiologists, radiology residents, radiology technologists and nurses. Have appropriate time management skills when completing assigned rotation duties Monitor imaging studies and appropriately modify the protocol based on the findings.

HEALTH ADVOCATE All residents (PGY-2-PGY-5) should demonstrate the ability to: Develop an approach to select appropriate radiology examination based on risk versus

benefit for individual patients pertaining to emergency situations. Be aware of radiation and contrast risk for various radiologic examinations, particularly in

the setting of a pediatric, pregnant or breast feeding patient and develop skills to educate and counsel patients.

SCHOLAR All residents (PGY2-PGY5) should demonstrate the ability to: Develop self-directed learning by developing personal learning goals and objectives, and

seek out learning resources. Present at departmental rounds and/or teach (resident colleagues, medical students and

allied health workers) on a topic subject related to emergency radiology, preferably with an emphasis on plain film interpretation.

PROFESSIONAL All residents (PGY-2-PGY-5) should demonstrate the ability: Recognize personal limitations of competence, knowledge and skill. Respect the clinical opinion of referring clinicians., and demonstrate the ability to suggest

and promote alternative, more appropriate or safer imaging modalities tailored to the clinical situation

Be aware of ethical issues related to emergency radiology, including consent, truth telling, disclosure of error, misdiagnosis, and resource allocation.

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Last updated: September 2011 Community Hospitals: CVH, THC, Etobicoke, Scarborough GH, Lakeridge PGY 4: 1 month (mandatory rotation) PGY 5: 1 month (elective) Location Supervisor Credit Valley Hospital Dr. Kelly Wong Trillium Health Centre Dr. Bill Magnuson Etobicoke Dr. Marc Ossip Scarborough General Hospital Dr. Veera Bharatwal Lakeridge Hospital Dr. Louis Wu ROTATION DESCRIPTION: Goals:

1) Gain exposure to radiology as practiced in a community hospital setting. a. Experience the volume and pace of work b. Experience the case mix and types of pathology c. Observe the structure of community radiology practice

2) Complement learning in areas with decreased volume in the teaching hospitals a. exposure to fluoroscopy studies and interventions (GI, GU, MSK) b. exposure to conventional radiographs c. the resident should be encouraged to work independently once he/she has demonstrated competence to the supervising radiologist. Reports should always be reviewed by the supervising radiologist.

Duty hours: 1) The resident will match his/her regular duty hours on elective to those of the community

staff physicians. Residents are expected to be present at the elective site Monday to Friday inclusively.

2) The resident is not required to participate in their academic half-day for the duration of the elective to facilitate continuity and lack of disruption of elective time (unless videoconferencing is available).

On-Call:

1) PGY4 mandatory rotation Residents are required to be on-call at the community hospital site as directed by the rotation supervisor 2) PGY5 elective Residents Residents do 50% of normal on-call requirement (based on points) up to a total of 3.5 points. On-call duties will be at the resident’s “base hospital” and will preferably be scheduled on weekends (ie. Friday or Saturday) to limit disruption of the elective due to post-call days.

a. If a resident is at the same hospital before and after this elective, on-call duties will take place at that hospital

b. If a resident is returning to a different hospital than the one from which they came, they will do call at the hospital from which they came

c. If a resident is scheduled at AFIP or Sick Kids Hospital before or after this elective, the resident will perform on-call duties at a hospital to be designated by

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the program chief resident based on the hospital that most requires an extra resident in the on-call pool.

d. The 50% of call that is missed does not need to be made up at an earlier or later date.

e. There can be optional call at the elective site (coordinated by the rotation supervisor)

Evaluation:

1) Resident evaluation a. The resident and the supervising staff at the site will meet during the last week of

the rotation to give face to fact feedback by reviewing the resident’s performance, including specific strengths and weaknesses. The rotation supervisor will complete an online evaluation form using the POWER system. The resident and supervisor should also meet at the midterm of the rotation to review the resident’s performance.

2) Rotation evaluation a. The resident will evaluate the rotation experience and/or specific supervisors

either by completing an online evaluation form GOALS & OBJECTIVES:

1) Exhibit gains in exposure to radiology as practiced in a community hospital setting. a. Experience the volume and pace of work b. Experience the case mix and types of pathology c. Observe the structure of community radiology practice

2) Demonstrate the complementation of learning in areas with decreased volume in the teaching hospitals

a. exposure to fluoroscopy studies and interventions (GI, GI, MSK) b. exposure to conventional radiographs c. the resident should be encouraged to work independently once he/she has

demonstrated competence to the supervising radiologist. Reports will, however, be reviewed by the supervising radiologist.

MEDICAL EXPERT Demonstrate knowledge of human anatomy and basic sciences Demonstrate knowledge of clinical medicine and medical imaging Demonstrate appropriate diagnostic and interpretive skills Demonstrate competence in the imaging work-up of common medical problems in the

community setting Demonstrate understanding of the standard imaging modalities and use in the community

setting - radiography, fluoroscopy, CT, ultrasound and MRI and their uses in the community setting

Demonstrate an understanding of indications for common interventional radiology procedures and how to perform them

Demonstrate ability to perform common fluoroscopic studies/procedures (including upper GI series, small bowel follow-through, single and double contrast barium enema, lumbar puncture, MSK procedures) and intravenous urograms where available

Demonstrate an understanding of the risks and benefits of the use of iodinated contrast as well as management of contrast reactions

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COMMUNICATOR Demonstrate the ability to communicate effectively with referring physicians with patients

and their families in the community setting Demonstrate the ability to provide timely/appropriate communication of findings with

responsible physician Demonstrate the ability to produce quality written reports and records Demonstrate the ability to obtain informed consent

COLLABORATOR Demonstrate the ability to work with physician colleagues and other health care

professionals in the community setting Demonstrate the ability to contribute to interdisciplinary team activities Demonstrate the ability to function as a member of a multi-disciplinary health care team

MANAGER Demonstrate an understanding of the effective resource utilization in medical imaging as it

pertains to the community setting Demonstrate an understanding of the fundamentals of quality assurance in medical imaging Demonstrate an understanding of safety issues and economic consideration in medical

imaging in the community setting Demonstrate an understanding of the utilization of information technology resources

HEALTH ADVOCATE Demonstrate an understanding of radiation safety including the risks of ionizing radiation

and the ALARA principle with appropriate use of alternative imaging modalities that do not use ionizing radiation

Demonstrate the ability to act as an advocate for the individual patient and affected populations in the community setting (i.e. recognizes situations in which imaging or treatment would be detrimental to the health/safety of a patient)

Demonstrate an understanding of the determinants of health affecting patients and the role of population screening

SCHOLAR Demonstrate the ability to critically evaluate the literature as it pertains to radiology Demonstrate inquisitiveness around interesting cases Demonstrate the ability to apply the principles of evidence-based medicine Demonstrate the ability to teach (colleagues, medical students, allied health care workers)

PROFESSIONAL Demonstrate an understanding of the ethical and medical-legal requirements of radiologists Demonstrate appropriate personal and interpersonal professional behaviors Demonstrate integrity, honesty and compassion and respect for others Demonstrate professional appearance and communication Demonstrate a good work ethic, with enthusiasm and motivation for learning (punctual,

organized, efficient, responsible) Demonstrate an awareness of one’s own strengths, weaknesses Demonstrate the ability to accept constructive criticism

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Last updated: August 2012 Research Hospital: Sick Kids, MSH, PMH, SHSC, SMH, TGH, TWH, WCH Elective: 1 – 3 months elective option in PGY 2-5 with approval of the Program Director PROGRAM GOALS: The fundamental goal of the Research rotation is to provide trainees with the knowledge, skills and attitudes necessary for a successful career in health research. The requisite knowledge, skills and attitudes are conceptualized within the CanMEDS framework, and are attained via mentored research. ROTATION OBJECTIVES: Rotation objectives will be the same at all rotation sites. MEDICAL EXPERT: Demonstrates knowledge of material relevant to the research project or course material Demonstrates knowledge of clinical medicine and medical imaging as it pertains to the

research project Demonstrates a basic understanding of the relevant clinical management as it pertains to the

research project

COMMUNICATOR: Demonstrates ability to produce good quality written material (i.e. research papers,

abstracts, grants, REB requests, etc.) Demonstrates ability to effectively communicate with the research supervisor, committee

and other collaborators Demonstrates an understanding and practices informed consent regarding research project

if applicable

COLLABORATOR: Demonstrates ability to work with the research supervisor, other physicians, health team

members, statisticians, etc. Demonstrates appropriate research collaborations within the Department of Medical

Imaging, and within the University (i.e. interdisciplinary research)

MANAGER: Demonstrates appropriate time management skills when completing research activities

HEALTH ADVOCATE: Demonstrate ability to appropriately obtain research ethics to complete research activities

PROFESSIONAL: Demonstrates an ethical practice of medicine Exhibits appropriate personal and interpersonal professional behaviours

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Demonstrates integrity, honesty, compassion, and respect for others Demonstrates professional appearance and communication Demonstrates good work ethic, with enthusiasm and motivation for learning Demonstrates professional work habits with punctuality, organization, and efficiency Demonstrates ability to incorporate feedback into improved personal performance Demonstrates an awareness of own limitations Demonstrates ability to self-assess (aware of strengths and weaknesses) Demonstrates ability to accept constructive criticism

SCHOLAR: Demonstrates the ability to critically appraise relevant literature Demonstrates the ability to develop a personal continuing education strategy Demonstrates teaching abilities (medical students, residents, allied health workers) Demonstrates the development of a plan for publications and other research output Submission of a manuscript to a scientific journal Presentation of a paper or poster at a scientific meeting Manuscript accepted for publication in a scientific journal Submission of an application for external funding (salary award) Successful funding (salary award) granted National recognition (paper or poster award at scientific meeting) International recognition (paper or poster award at a scientific meeting) Collaborative activities (interdisciplinary collaborations)

Rotation Responsibilities: Publication and other research output: While publications in peer-reviewed journals are the generally recognized for of expected output, it is recognized that in certain areas of research, other outputs are also important. These would include major forms of clinical trial development, implementation of practice guidelines, development of an international database, patenting and licensing a drug, etc. Funding: Major consistent funding for salary award or for research grants from national and international peer-reviewed funding agencies. National and international recognition: In the form of major national or international prizes, local prizes, presentation of scientific work at major conferences, local seminars/research presentations, and presented posters at institutional meetings Evaluation: Each individual resident is responsible for meeting the stated goals and objectives for

successful evaluation and completion of the rotation. Each resident is responsible to regularly seek evaluation feedback from supervisors and to

ensure that the ITER is reviewed before leaving the rotation. Rounds performance – including collaboration, communication and scholarly ability. Resident should have mid-rotation discussion with supervisor – please remind the

supervisor at this point in time! Formal ITER at end rotation