Emergency residents struggle to order appropriate imaging tests

Research published in the October issue of the American Journal of Roentgenology has found that over their course of residency, emergency medicine residents fail to show significant improvement in their ability to choose appropriate imaging studies.

For purposes of the study, researchers from the department of radiology at the Albert Einstein College of Medicine and Montefiore Medical Center created an online multiple-choice questionnaire that included 10 clinical scenarios taken from the American College of Radiology appropriateness guidelines. An invitation and link to the survey was sent to directors and coordinators of American Council for Graduate Medical Education-accredited emergency medicine residence training programs with the request that they forward the survey to their current residents.

The residents were asked to select the most appropriate imaging study for each of the ten scenarios. The scenarios included:

  • Acute onset flank pain and hematuria with otherwise normal laboratories and physical, suspected stone disease
  • Acute chest pain and shortness of breath, suspected pulmonary embolus
  • Acute right upper quadrant pain, fever, elevated WBC count and positive Murphy's sign, suspected acute cholecystitis
  • Acute respiratory illness (cough, dyspnea, chest pain and fever) in HIV-positive patient
  • Hemodynamically stable 25-year-old man after blunt abdominal trauma, moderate clinical suspicion of intra-abdominal injury, FAST scan (Focused Assessment with Sonography for Trauma) positive for intraperitoneal fluid
  • Acute low back pain in an otherwise healthy 18 year old with recent minor trauma
  • Soft tissue edema and ulcer of the foot in patient with diabetes-suspected osteomyelitis
  • Painful palpable mass in the breast of a 14-year-old girl
  • Febrile seizure (one episode lasting 10 minutes) in a previously healthy 2-year-old child, now with normal neurological examination
  • Clinical laboratory results and examination consistent with recurrent sinusitis

According to the researchers, 583 emergency residents participated in the survey. The overall number of questions answered correctly was 7.1 out of the 10. First-year through fourth-year residents respectively answered 6.9 , 7.1, 7.1, and 7.5 correctly.

"This finding suggests that there is a role for a more-rigorous focused instruction to better familiarize residents with appropriateness guidelines for diagnostic imaging selection," the researchers concluded.

Interestingly, the results of the study differed only slightly from similar research undertaken 10 years earlier and published in the journal Academic Radiology.

To learn more:
- see the study in the American Journal of Roentgenology
- check out the 2003 study in Academic Radiology

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