Abstract
BACKGROUND: Accurate interpretation of chest radiographs (CXR) is essential as clinical decisions depend on readings.
OBJECTIVE: We sought to evaluate CXR interpretation ability at different levels of training and to determine factors associated with successful interpretation.
DESIGN: Ten CXR were selected from the teaching file of the internal medicine (IM) department. Participants were asked to record the most important diagnosis, their certainty in that diagnosis, interest in a pulmonary career and adequacy of CXR training. Two investigators independently scored each CXR on a scale of 0 to 2.
PARTICIPANTS: Participants (n=145) from a single teaching hospital were third year medical students (MS) (n=25), IM interns (n=44), IM residents (n=45), fellows from the divisions of cardiology and pulmonary/critical care (n=16), and radiology residents (n=15).
RESULTS: The median overall score was 11 of 20. An increased level of training was associated with overall score (MS 8, intern 10, IM resident 13, fellow 15, radiology resident 18, P<.001). Overall certainty was significantly correlated with overall score (r=.613, P<.001). Internal medicine interns and residents interested in a pulmonary career scored 14 of 20 while those not interested scored 11 (P=.027). Pneumothorax, misplaced central line, and pneumoperitoneum were diagnosed correctly 9%, 26%, and 46% of the time, respectively. Only 20 of 131 (15%) participants felt their CXR training sufficient.
CONCLUSION: We identified factors associated with successful CXR interpretation, including level of training, field of training, interest in a pulmonary career and overall certainty. Although interpretation improved with training, important diagnoses were missed.
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References
Liaison Committee on Medical Education. LCME accreditation standards. Liaison Committee on Medical Education web site. Available at: http://www.lcme.org. Accessed April 2005.
American Board of Internal Medicine. Internal medicine policies: requirements for certification in internal medicine. American Board of Internal Medicine website. Available at: http://www.abim.org. Accessed April 2005.
American Council of Graduate Medical Education. Internal medicine program requirements: internal medicine. July 2003. American Council of Graduate Medical Education website. Available at http://www.acgme.org. Accessed April 2005.
American Council of Graduate Medical Education. Internal medicine program requirements: pulmonary medicine. July 1999. American Council of Graduate Medical Education website. Available at http://www.acgme.org. Accessed April 2005.
American Council of Graduate Medical Education. Internal medicine program requirements: cardiovascular medicine. July 1999. American Council of Graduate Medical Education website. Available at http://www.acgme.org. Accessed April 2005.
American Council of Graduate Medical Education. Diagnostic radiology program requirements. December 2003. American Council of Graduate Medical Education website. Available at http://www.acgme.org. Accessed April 2005.
American Council of Graduate Medical Education. Internal medicine program requirements: critical care medicine. July 1999. American Council of Graduate Medical Education website. Available at http://www.acgme.org. Accessed April 2005.
Benger JR, Lyburn ID. What is the effect of reporting all emergency department radiographs? Emerg Med J. 2003;20:40–3.
Gatt ME, Spectre G, Paltiel O, et al. Chest radiographs in the emergency department: is the radiologist really necessary? Postgrad Med J. 2003;79:214–7.
Grosvenor LJ, Verma R, O’Brien R, et al. Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit? Clin Radiol. 2003;58:719–22.
Kuritzky L, Hardy RI, Curry RW. Interpretation of chest roentgeonograms by primary care physicians. South Med J. 1987;80:1347–51.
Kaufman B, Dhar P, O’Neill D, et al. Chest radiograph interpretation skills of anesthesiologists. J Cardiothorac Vasc Anesth. 2001;15:680–3.
Young M, Marrie TJ. Interobserver variability in the interpretation of chest roentgenograms of patients with possible pneumonia. Arch Intern Med. 1994;154:2729–32.
Herman PG, Hessel SJ. Accuracy and its relationship to experience in the interpretation of chest radiographs. Invest Radiol. 1975;10:63–7.
Eng J, Mysko WK, Weller GE, et al. Interpretation of emergency department radiographs: a comparison of emergency medicine physicians with radiologists, residents with faculty, and film with digital display. AJR. 2000;175:1233–99.
Monnier-Cholley L, Carrat F, Cholley BP, et al. Detection of lung cancer on radiographs: receiver operating characteristic analyses of radiologists’, pulmonologists’, and anesthesiologists’ performance. Radiology. 2004;233:799–805.
Walsh-Kelly CM, Melzer-Lange MD, Hennes HM, et al. Clinical impact of radiograph misinterpretation in pediatric ED and the effect of physician training level. Am J Emerg Med. 1995;13:262–4.
Potchen EJ, Cooper TG, Sierra AE, et al. Measuring performance in chest radiography. Radiology. 2000;217:456–9.
Quekel LG, Kessels AG, Goei R, et al. Detection of lung cancer on the chest radiograph: a study on observer performance. Eur J Radiol. 2001;39:111–6.
Jeffrey DR, Goddard PR, Callaway MP, et al. Chest radiograph interpretation by medical students. Clin Radiol. 2003;58:478–81.
Lave JR, Bankowitz RA, Hughes-Cromwick P, et al. Diagnostic certainty and hospital resource use. Cost Qual Q J. 1997;3:26–32.
Samuel S, Shaffer K. Profile of medical student teaching in radiology: teaching methods, staff participation and rewards. Acad Radiol. 2000;7:868–74.
Oldham SA. ICU chest radiographs—ICU calamities: evaluation of the portable chest radiograph. Emerg Radiol. 2002;9:43–54.
Shiraishi J, Hiroyuki A, Engelmann R. Computer-aided diagnosis to distinguish benign from malignant solitary pulmonary nodules on radiographs: ROC analysis of radiologists’ performance—initial experience. Radiology. 2003;227:469–74.
Mayhue FE, Rust DD, Aldag JC, et al. Accuracy of interpretation of emergency department radiographs: effect of confidence levels. Ann Emerg Med. 1989;18:826–30.
Lufkin KC, Smith SW, Matticks CA, et al. Radiologists’ review of radiographs interpreted confidently by emergency physicians infrequently lead to changes in patient management. Ann Emerg Med. 1998;31:202–7.
Pfeifer M. Nonradiologists reading radiographs: good medicine or stretching the scope of practice? J Cardiothorac Vasc Anesth. 2001;15:675–6.
Monnier-Cholley L, MacMahon H, Katsuragawa S. Computer-aided diagnosis for detection of interstitial opacities on chest radiographs. AJR. 1998;171:1651–6.
Kobayashi T, Xu XW, MacMahon H, et al. Effect of a computer-aided diagnosis scheme on radiologists’ performance in detection of lung nodules on radiographs. Radiology. 1996;199:843–8.
Weatherburn G., Bryan S, Nicholas A, et al. The affect of a picture archiving and communication system (PACS) on diagnostic performance in the accident and emergency department. Emerg Med J. 2000;17:180–4.
Dawes TJ, Vowler SL, Allen CM, et al. Training improves medical student interpretation in image interpretation. Br J Radiol. 2004;77:775–6.
Maleck M, Fischer MR, Kammer B, et al. Do computers teach better? A media comparison study for case-based teaching in radiology. Radiographics. 2001;21:1025–32.
Preston CA, Marr JJ, Amaraneni KK, et al. Reduction of “call-backs” to the emergency department due to discrepancies in the plain radiograph interpretation. Ann Emerg Med. 1988;17:1019–23.
Espinosa JA, Nolan TW. Reducing errors made by emergency physicians interpreting radiographs: longitudinal study. BMJ. 2000;320:737–40.
Schreiber MH. The clinical history as a factor in roentgenogram interpretation. JAMA. 1963;185:399–401.
Loy CT, Irwig L. Accuracy of diagnostic tests read with and without clinical information: a systematic review. JAMA. 2004;292:1602–9.
Herman PG, Gerson DE, Hessel SJ, et al. Disagreements in chest roentgen interpretation. Chest. 1975;68:278–2.
Robinson PJ, Wilson D, Coral A, et al. Variation between experienced observers in the interpretation of accident and emergency radiographs. Br J Radiol. 1999;72:323–30.
Albaum MN, Hill LC, Murphy M, et al. Interobserver reliability of the chest radiograph in community acquired pneumonia. Chest. 1996;110:343–50.
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The principal investigator had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Eisen, L.A., Berger, J.S., Hegde, A. et al. Competency in chest radiography. J GEN INTERN MED 21, 460–465 (2006). https://doi.org/10.1111/j.1525-1497.2006.00427.x
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DOI: https://doi.org/10.1111/j.1525-1497.2006.00427.x