Diagnostic Radiology

- This EPA focuses on accessing and using information systems to gather clinical data from the patient’s chart and the image storage system (e.g., PACS). - This includes summarizing the history, pertinent physical examination findings and results of relevant investigations from the clinical record and retrieving the imaging study and pertinent priors for review with a supervisor. - This EPA may be observed in patients undergoing any medical imaging study; the observation of this EPA is based on a single case. - This EPA does not include the use of advanced PACS functions—that is a Foundation stage activity.

Case review with staff radiologist, Core or TTP resident, or fellow Use Form 1 Collect 2 observations of achievement - At least 2 different assessors

Suggested observations: 2

- This EPA focuses on using a dictation system to record a simple or normal report. - At this stage, the resident is not expected to interpret an image; this EPA is limited to documenting the report as reviewed with a supervisor.

Review of report by staff radiologist Use Form 1 Collect 1 observation of achievement

Suggested observations: 1

- This EPA focuses on applying knowledge of anatomy and imaging technique to identify normal structures and landmarks.

Image review with staff radiologist, Core or TTP resident, or fellow Use Form 1. Form collects information on: - Modality: radiography; CT; other - Body region: abdomen/pelvis; cardiothoracic; head; MSK; spine Collect 7 observations of achievement - At least 1 abdomen/pelvis radiograph - At least 1 abdomen/pelvis CT - At least 1 chest radiograph (i.e., cardiothoracic) - At least 1 chest CT - At least 1 head CT - At least 1 MSK radiograph - At least 1 spine radiograph or CT

Suggested observations: 7

- This EPA includes recognizing serious, life-threatening, or critical illness and providing initial investigation and management. - An important aspect of this EPA is the timely recognition of the need for additional assistance and/or notification to the attending physician.

Direct observation and/or case review by supervisor (most responsible physician (MRP), other consulting staff , senior resident) Use Form 1. Form collects information on: - Presentation: acute respiratory distress; allergic reaction; altered level of consciousness; chest pain; hemodynamic instability; hypoglycemia; other Collect 5 observations of achievement - Any 4 different presentations

Suggested observations: 5

- This EPA includes performing a clinical assessment, including history and physical exam, developing a differential diagnosis, and selecting and prioritizing laboratory and imaging investigations. - This EPA will be observed in the ambulatory, emergency department or inpatient setting, with adult and pediatric patients, in a range of clinical conditions.

Case review with supervisor (staff or senior resident) Use Form 1. Form collects information on: - Setting: inpatient; outpatient; emergency department - Demographic: adult; pediatric; obstetric - Presentation: medical; surgical Collect 7 observations of achievement - At least 2 of each type of presentation - At least 1 pediatric case

Suggested observations: 7

- This EPA focuses on the role of the physician as a member of the interprofessional team. - This includes contributing to the work of the team, understanding and respecting the roles of other team members, and demonstrating appropriate professional behaviours. - This EPA will be observed in medical imaging as well as in clinical care settings. - The observation of this EPA is based on a period of time of at least one week.

Direct and indirect observation by supervisor, with input from other members of the interprofessional team Use Form 1. Form collects information on: - Setting: clinical rotation; medical imaging department - Includes input from (select all that apply): other supervisor(s); nurse(s); technologist(s); other physician/surgeon(s); other resident(s) or student(s); other Collect feedback during at least 3 rotations during Transition to Discipline - At least 1 observation in medical imaging department - At least 2 observations in clinical rotations - At least 2 observations that include input from nurses or other health professionals

- This EPA builds on the skills of the Transition to Discipline stage to include a variety of imaging modalities. - Examples of the radiological anatomy expected at this stage include cardiothoracic anatomy (lung segments, heart chambers, vessels and their branches), MSK anatomy (major tendons/ligaments; osseous anatomy and variants), neuro and head and neck anatomy (branches of carotid arteries and Circle of Willis; brain lobar anatomy; neck spaces; facial bones) and abdominal/pelvic anatomy (liver segments; vascular anatomy of liver; major branches of the abdominal aorta; abdominal spaces; female pelvis).

Image review with staff radiologist, Core or TTP resident, fellow, or by image quiz/OSCE Use Form 1. Form collects information on: - Modality: CT; radiography; ultrasound; other - Body region: abdomen/pelvis; cardiothoracic; MSK; neuro/head and neck - Observation: image review; quiz/OSCE Collect 12 observations of achievement - At least 3 from each body region - A variety of imaging modalities - At least 8 by image review - At least 5 different assessors - At least 3 staff radiologists

Suggested observations: 12

- This EPA includes attention to patient comfort, privacy and positioning, as well as applying knowledge of image generation and acquisition for ultrasound. - This EPA does not include image interpretation. - The observation of this EPA is based on a single US study.

Direct observation and/or review of generated images by staff radiologist or fellow, with input from the sonographer/technologist Use Form 1. Form collects information on: - Study: abdomen; testicle/scrotum; female pelvis; DVT; soft-tissue/surface; other - Doppler: no; yes - Transvaginal: no; yes - Findings (write in): Collect 10 observations of achievement - At least 3 abdominal - At least 1 testicular, including Doppler - At least 3 female pelvis; including at least 2 transvaginal and at least 1 with a finding of a first trimester embryo - At least 1 assessment for DVT - At least 1 soft-tissue/surface

Suggested observations: 10

- This EPA focuses on the work of a diagnostic radiologist to review, triage and plan for the delivery of medical imaging studies/procedures using different modalities. - This includes gathering information about the patient condition and purpose of the request, establishing the urgency, selecting the appropriate protocol and demonstrating stewardship of medical imaging resources. - This may include consideration of patient sedation or pre-treatment for prevention of contrast reactions. - It also includes communicating with technologists and documenting the plan for the imaging study or procedure. - The observation of this EPA is based on a batch of imaging requests. - At this stage, the batch should focus on requests for acute and common, inpatient or emergency department adult cases, primarily for CT and US imaging.

Review of a batch of requests with staff radiologist, which may include input from technologist Use Form 1. Form collects information on: - Number of requests in batch (write in): - Batch of inpatient or emergency adult cases: no; yes - Body region (select all that apply): abdomen/pelvis; cardiothoracic; head and neck; MSK; neuro; soft tissue; spine; vascular; other - Modality (select all that apply): CT; ultrasound; other Collect at least 5 observations of achievement - At least 5 different assessors

- This EPA focuses on an approach that ensures a comprehensive analysis of an imaging study, including an assessment of the quality of the generated image. - At this stage and for this EPA, it is not expected that the resident will identify or diagnose all relevant findings.

Image review, case discussion and/or review of report by staff radiologist, Core or TTP resident, or fellow Use Form 1. Form collects information on: - Body region: abdomen/pelvis; cardiothoracic; head; neck; MSK; spine; other - Modality: CT; radiography; ultrasound Collect 10 observations of achievement - At least 1 abdomen/pelvis CT - At least 1 abdomen/pelvis radiograph - At least 1 abdomen/pelvis ultrasound - At least 1 cardiothoracic CT - At least 1 cardiothoracic radiograph - At least 1 head CT - At least 1 neck CT - At least 1 MSK CT - At least 1 MSK radiograph - At least 1 spine radiograph

Suggested observations: 10

- This EPA focuses on the application of the knowledge of anatomy and imaging technique to address the clinical question. - This includes identification of acute and/or common findings significant to the patient’s care and recognition of critical findings that warrant communication with the referring physician. - This EPA does not include identification of all findings on the image – for example, in a CT performed for pulmonary embolism, it is not expected that a resident at this stage would necessarily identify findings consistent with interstitial lung disease.

Image review with staff radiologist, Core or TTP resident, or fellow, which may include input from technologists Use Form 1. Form collects information on: - Body region: abdomen/pelvis; cardiothoracic; MSK; neuro - Patient location: emergency department; inpatient; outpatient - Modality: CT; fluoroscopy; radiography; ultrasound - Finding (write in): Collect 20 observations of achievement - At least 5 of each body region - At least 1 emergency department case for each body region - At least 2 CTs - At least 2 radiographs - At least 2 ultrasounds - A variety of findings - At least 5 different assessors - At least 3 staff radiologists

Suggested observations: 20

- This EPA focuses on integrating the findings of an imaging study to generate a differential diagnosis. - Examples of acute or common findings include: pulmonary nodule/mass; consolidation; interstitial abnormalities; cardiomegaly; pneumomediastinum; pleural effusion; intra-axial intracranial hemorrhage; intra-axial mass; hydrocephalus; neck mass; bone lesion; soft tissue mass; joint effusion; arthritis; abdominal/pelvic solid organ lesion/mass; bowel wall thickening; dilated bowel; pneumoperitoneum; adnexal mass; hydronephrosis.

Image review and/or review of primary report by staff radiologist, Core or TTP resident, or fellow Use Form 1. Form collects information on: - Body region: abdomen/pelvis; cardiothoracic; MSK; neuro - Finding (write in): Collect 16 observations of achievement - At least 4 from each body region - A variety of findings - At least 5 different assessors - At least 3 different staff radiologists

Suggested observations: 16

- This EPA focuses on recognizing when a finding needs timely communication with the referring service and communicating effectively with that service. - This includes contacting the responsible clinician, clearly conveying the findings and their significance, answering questions, and providing recommendations. - It also includes documenting the interaction in the imaging report.

Direct observation by staff radiologist, with review of resident’s notation Use Form 1 Collect 3 observations of achievement - At least 2 different assessors

Suggested observations: 3

- This EPA focuses on the written communication skills of documenting the findings of imaging studies. - This includes generating an accurate and concise report, and recommending appropriate management, next steps and/or follow-up. - The observation of this EPA is based on the review of a single report, which must be solely the work of the resident.

Review of report by staff radiologist, Core or TTP resident, or fellow Use Form 1. Form collects information on: - Body region: abdomen/pelvis; chest/cardiac; MSK; neuro - Modality: CT; radiography; ultrasound; other - Diagnosis: infection; neoplasm; trauma; vascular; other Collect 12 observations of achievement - At least 3 of each body region (any modality) - At least 2 abdomen/pelvis CT - At least 2 chest/cardiac CT - At least 2 MSK CT - At least 2 neuro CT - At least 2 ultrasounds - A variety of diagnoses - At least 5 assessors - At least 3 staff radiologists

Suggested observations: 12

- The focus of this EPA is the detection and interpretation of major and minor findings in imaging of any body region using any imaging modality. - This includes assessing image quality, applying a systematic approach to image review, integrating findings with the clinical information and prior imaging studies, establishing a most likely diagnosis and a differential diagnosis, and providing recommendations for management. - The observation of this EPA is based on a batch of imaging studies; a batch being at least a half-day’s work. - As a whole, the observations for this EPA should document achievement in the full breadth of body regions and imaging modalities, in patients of all ages and with a variety of presentations and acuity of illness (i.e., inpatient, emergency, outpatient, follow-up).

Review of a batch of imaging studies with staff radiologist Use Form 1. Form collects information on: - Number in batch (write in): - Number of pediatric cases (write in): - Body region (select all that apply): abdomen/pelvis; breast; cardiac; chest; head and neck; MSK; neuro; spine; obstetrical; vascular - Modality (select all that apply): CT; fluoroscopy; mammography; MRI; nuclear medicine; radiography; ultrasound Collect 75 observations of achievement - At least 20 abdomen/pelvis batches - At least 6 breast batches - At least 2 cardiac batches - At least 8 chest batches - At least 10 MSK batches - At least 10 neuro batches - At least 3 batches that include head and neck imaging - At least 5 batches that include spine imaging - At least 3 batches that include vascular imaging - At least 2 nuclear medicine batches - At least 6 ultrasound batches - At least 2 ultrasound batches that include obstetrical ultrasound - At least 6 batches that include pediatric cases, across diverse modalities - At least 2 assessors for each body region and/or modality

Suggested observations: 75

- This EPA focuses on the communication skills of documenting the findings of imaging studies. - This includes generating an accurate concise report in a timely manner, with a focus on grammar and appropriate lexicon. - The achievement of this EPA requires competence across the breadth of imaging studies (i.e., all modalities, all body regions), including some cases with diagnostic uncertainty or complexity. - The observation of this EPA is based on the supervisor review of a batch of reports; a batch representing at least a half day’s work.

Review of a batch of reports by staff radiologist Use Form 1. Form collects information on: - Number in batch (write in): - Number of pediatric cases (write in): - Body region (select all that apply): abdomen/pelvis; breast; cardiac; chest; head and neck; MSK; neuro; obstetrical; spine; vascular - Modality (select all that apply): CT; fluoroscopy; mammography; MRI; nuclear medicine; radiography; ultrasound Collect 25 observations of achievement - At least 4 abdomen and pelvis batches - At least 2 breast batches - At least 2 cardiac batches - At least 2 chest batches - At least 3 MSK batches - At least 3 neuro batches - At least 2 batches that include head and neck imaging - At least 2 batches that include spine imaging - At least 3 batches that include vascular imaging - At least 2 nuclear medicine batches - At least 3 ultrasound batches - At least 2 ultrasound batches that include obstetrical ultrasound - At least 3 batches that include pediatric cases, across diverse modalities - At least 2 assessors for each body region and/or modality

Suggested observations: 25

- This EPA includes diagnostic and therapeutic image-guided procedures using any imaging modality and in any body region. - This includes reviewing the request and assessing patient suitability and eligibility for the procedure or alternative procedures and making a plan for the procedure, including the choice of imaging modality, approach to the procedure and choice of equipment. - It includes all aspects of performing the procedure: obtaining consent, providing patient sedation and pre-procedural care; performing the technical skills of the procedure; documenting the procedure; and providing post-procedural care. - It also includes providing management for any immediate reactions, adverse events or complications arising from the procedure.

Direct observation by staff radiologist, fellow, or TTP resident, with input from medical radiation technologist, sonographer and/or nurse Use Form 1. Form collects information on: - Procedure: aspiration - joint; aspiration – paracentesis; aspiration – thoracentesis; aspiration - other; biopsy; catheter manipulation; drainage tube insertion; enteric tube placement; lumbar puncture; vascular access; other - Body region: abdomen/pelvis; breast; chest/lung; other - Modality: CT; fluoroscopy; US - Demographic: adult; pediatric Collect 30 observation of achievement - At least 3 vascular access procedures - At least 5 fluoroscopic guided procedures, including at least 2 lumbar punctures - At least 5 image-guided aspiration procedures, including at least 1 paracentesis and at least 1 thoracentesis - At least 3 image-guided drainage tube insertions, including at least 1 abdominal/pelvic drainage tube insertion and 1 chest drainage tube insertion - At least 10 image-guided biopsies, including at least 2 CT-guided and at least 2 US guided biopsies, and at least 2 breast, at least 2 abdominal solid organ and at least 2 lung biopsies

Suggested observations: 30

- This EPA includes attention to patient comfort, privacy and positioning, and applying knowledge of image generation and acquisition for fluoroscopy. - This includes decisions about the use of contrast agent. - This EPA does not include image interpretation.

Direct observation and/or review of generated images by staff radiologist or fellow, with input from the technologist Use Form 1. Form collects information on: - Study: gastrointestinal; genitourinary; other - Demographic: adult; pediatric - Acuity: elective; urgent; emergent Collect 13 observations of achievement - At least 5 gastrointestinal studies - At least 5 genitourinary studies - At least 3 other fluoroscopic studies - At least 2 studies in the pediatric age group

Suggested observations: 13

- This EPA focuses on the radiologist’s role in ensuring the diagnostic quality of imaging studies in order to answer a clinical question, applying knowledge of image generation and acquisition for that modality. - This includes assessing the quality of images acquired and determining whether quality impacts diagnostic interpretation and/or patient safety, e.g., motion artefact, suboptimal contrast timing, misplaced markers. - It includes development of a plan to address the quality issue. - Examples include adjusting the process of the study (patient positioning, additional views, using contrast, using sedation), retaking certain images, acquiring supplemental images as necessary (e.g., acquiring US images, requesting thin reformats of CT), or recommending another diagnostic study. - This EPA does not include protocoling, image interpretation and reporting. - The observation of this EPA is based on an individual case with image quality concerns raised by the technologist or raised by the resident upon review of the image(s).

Review of imaging case with staff radiologist, may include input from technologist Use Form 1. Form collects information on: - Modality: CT; mammography; MRI; radiography; ultrasound - Issue identified by: technologist; resident; other Collect 15 observations of achievement - At least 3 CT studies - At least 3 mammography studies - At least 3 MRI studies - At least 3 radiography studies - At least 3 ultrasound studies - At least some issues that were identified by resident

Suggested observations: 15

- This EPA includes gathering the needed clinical information about the request and synthesizing clinical data with results of other investigations to develop an understanding of the clinical question and make recommendations about selection, sequence and/or timing of further investigation. - Examples include: recommending a follow-up study/procedure; altered renal function prohibiting the requested examination; incorrect or inappropriate study/procedure ordered based on clinical history; expediting the timing of a radiology study/procedure based on history or findings; conveying the urgency of the need for a radiology study/procedure; and working with the clinician to develop a management plan based on the imaging finding. - The observation of this EPA is based on the supervisor directly observing a single interaction between the resident and a referring physician/team - in person, via telephone or in a simulated scenario.

Direct observation by staff radiologist Use Form 1. Form collects information on: - Modality: CT; MRI; radiography; ultrasound - Body region: abdomen/pelvis; breast; chest; MSK; neuro - Setting: clinical; simulation Collect 3 observations of achievement - Different modalities and body regions - No more than 1 in simulation - At least 3 different assessors

Suggested observations: 3

- This EPA focuses on the work of a diagnostic radiologist to review imaging requests and plan imaging studies. - This includes gathering information about the patient condition and purpose of the request, triaging the urgency of the request, selecting the appropriate protocol and demonstrating attention to radiation, contrast and patient safety, as well as stewardship of imaging resources. - At this stage, this EPA includes adult and pediatric patients, in any clinical setting, and includes patient-specific factors that impact upon imaging such as impaired renal function, contrast allergy and pregnancy.

Review of a batch of requests by staff radiologist, fellow, or TTP resident, which may include input from technologist Use Form 1. Form collects information on: - Body region (select all that apply): abdomen/pelvis; cardiothoracic; head and neck; MSK; neuro; soft tissue; spine; vascular; other - Modality (select all that apply): CT; MRI; nuclear medicine; radiography; ultrasound; vascular; other - Number of requests in batch (write in): - Number of requests that need modifications (write in): Collect at least 12 observations of achievement - At least 3 batches of abdomen/pelvis requests - At least 3 batches of cardiothoracic requests - At least 3 batches of MSK requests - At least 3 batches of neuro requests - At least 3 batches with requests that needed modification - At least 4 batches that include CT requests - At least 4 batches that include MRI requests - At least 5 different assessors

- The focus of this EPA is the application of communication skills to clearly and compassionately convey imaging findings, including a diagnosis and the limits of the findings, to patients and families. - This EPA may be observed in any setting, including simulation, but is most likely to be relevant in breast imaging, fluoroscopy, obstetric, pediatric, interventional, and ultrasound settings.

Direct observation by radiologist, which may include input from other health professionals Use Form 1. Form collects information on: - Setting: clinical; simulation Collect 3 observations of achievement - No more than 1 in simulation setting - At least 3 different assessors

Suggested observations: 3

- This EPA focuses on the role of the diagnostic radiologist as a participant in and contributor to interdisciplinary clinical decision-making. - This EPA includes preparing and presenting cases, including a review of relevant literature, responding to questions from the interdisciplinary group and communicating effectively in this setting. - At this stage, the resident is not yet expected to be the sole source of Diagnostic Radiology expertise for the rounds. This is an expectation of the Transition to Practice stage.

Direct observation by staff radiologist, which may include input from other health professionals Use Form 1. Form collects information on: - Type of rounds (write in): Collect 2 observations of achievement

Suggested observations: 2

- This EPA focuses on the diagnostic radiologist’s role in the overall delivery of safe patient care in a medical imaging department, maintaining the volume and quality of the work. - This includes all aspects of the work of a diagnostic radiologist: interpreting and reporting a case load of imaging studies, providing consultation, performing/supervising procedures, triaging patients, protocolling requests, attending clinical rounds, etc. - This EPA also includes teaching and providing feedback to junior learners, as well as working effectively with the other health care professionals in the department as well as referring services. - Observation of this EPA should occur in at least two different medical imaging settings or services. - The observation of this EPA is based on a day of clinical activity, and may include daytime as well as after-hours work.

Direct and indirect observation by staff radiologist, with input from technologists Use Form 1. Form collects information on: - Complexity of day: low; medium; high - Includes after-hours call: no; yes - Body region (select all that apply): abdomen/pelvis; cardiothoracic; head and neck; MSK; neuro; soft tissue; spine; vascular; other - Modality (select all that apply): CT; MRI; nuclear medicine; radiography; ultrasound; vascular; other Collect 5 observations of achievement - At least 2 medium or high complexity days - At least 1 that includes after-hours call - At least 2 different modalities or body regions - At least 2 different assessors

Suggested observations: 5

- This EPA focuses on the investigation and/or management of patients for whom there is uncertainty in diagnosis and/or uncertainty in determining optimal treatment. - This EPA includes the interpretation of available imaging, synthesis with other clinical and laboratory information, integration of opinions from other radiologists and other physicians, as well as effective communication of uncertainty to the patient/family and/or the referring physician. - This EPA may require scholarly review of the literature and/or consultation with external experts.

Case discussion and/or review of images with staff radiologist Use Form 1. Form collects information on: - Description of case (write in): - Complexity of case: low; moderate; high Collect 3 observations of achievement - The cases for decisions regarding achievement must be moderate or high complexity - At least 2 assessors

Suggested observations: 3

- This EPA builds on the knowledge and skills demonstrated at the Core stage. - This EPA focuses on the role of the diagnostic radiologist as the authority providing radiologic expertise to the team discussion, advocating for the patient and demonstrating professional behaviour. - The observation of this EPA is based on one patient/case presentation (i.e., not on the entire meeting).

Direct observation by staff radiologist or another member of the interprofessional team Use Form 1. Form collects information on: - Type of rounds (write in): - Role of observer: diagnostic radiologist; treating physician/surgeon; other health care professional Collect 4 observations of achievement: - At least 2 different types of rounds

Suggested observations: 4

- This EPA includes using appropriate methods, analyzing results, critically reflecting on the findings and disseminating results. It may include obtaining grant funding and preparing a manuscript for publication. - This may include basic or clinical science related to diagnostic radiology, medical education research or quality improvement projects. - The achievement of this EPA may be based on preparation of a manuscript suitable for submission to a peer-reviewed journal, or presentation of the project at a peer- reviewed local, regional, provincial, national or international scientific meeting.

Review of submitted manuscript and/or direct observation of presentation by research supervisor Use Form 4 Collect 1 observation of achievement

Suggested observations: 1

- This EPA allows the resident to individualize training to prepare for fellowship training, prepare for practice in a specific setting and/or a setting requiring distinct skills, or act on performance gaps identified through self-assessment or by the competence committee. - This EPA may be used for any structured training experience: clinical or academic. Examples include: pursuing fellowship-specific clinical experiences; developing a scholarly focus. - The assessment of this EPA is based on the achievement of outcomes identified by the resident and approved by the program director/program committee. These outcomes must be SMART (specific, measurable, achievable, relevant, timely).

Review of resident’s plan and its outcome by supervisor, academic advisor or program director Use Form 4 Collect 1 observation of achievement

Suggested observations: 1