British Journal of Radiology (2005) 78, 483-484
© 2005 British Institute of Radiology
doi: 10.1259/bjr/82539295
Using PACS as a teaching resource
D Blunt, MRCP, FRCR and
D O'Regan, MRCP, FRCR
Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Introduction
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Digital storage has become the normal accepted method of collecting images, not only within radiology departments and hospitals but, with widely available digital cameras, to the general public; the term "pixel" has now entered common usage. This widespread acceptance of digital image storage has been mirrored in radiology departments with an ever-increasing number embracing PACS (Picture Archive and Communication System). This process has also proved highly acceptable to other clinical groups [1]. Within the National Health Service there is a proposed nationwide PACS roll out programme and most large hospital departments and training departments are either filmless or have plans to become so. The possibilities of PACS on improving and assisting many aspects of training in radiology has so far received relatively little attention [2–7].
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The requirements
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Most large departments worldwide have a training role, both for radiologists and non-radiologists. Within the UK the Royal College of Radiologists has a requirement, during training accreditation visits, that training departments have a film museum for teaching purposes [8]. The expansion in training numbers and increasing use of district general hospitals means that the majority of UK departments are involved to some extent in radiology training, and almost all will be involved in some form of teaching. Just as PACS has quickly become far more than an electronic viewing box, it has potential to be a huge extension to the concept of a simple collection of interesting cases. A PACS based film museum should be able to provide much more than a retrieval mechanism from stored lists.
The formats in which PACS can be used as a teaching resource should include the following:
- The ability for self directed study with retrieval of investigations in an anonymised, possibly randomised format, preferably on a topic or group of topics with hidden reports but available clinical details. This should include the complete DICOM data to simulate the real reporting experience. This will assist for preparation in examination technique and reporting and as importantly, simulate the day to day reporting experience.
- Studies should be retrievable by key word searching, as well as being retrievable by examination/modality type or pathology searching. Good examples of any condition which has been stored on PACS should be rapidly accessible. Key word searching is an accepted part of data retrieval and bypasses the need for strict coding [4].
- A mechanism for adding cases which does not require complex or lengthy case editing or authorship, nor coding procedures. Within a daily work pattern, the ability to highlight a case for teaching purposes needs to be rapid, easy and should not interrupt workflow significantly [6].
- Personal archive functionality. The best teaching cases are often those which the trainer has been involved in clinically rather than anonymous cases, however well validated, from another institution.
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Workflow planning
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Introducing PACS into a training department has implications for many facets of daily work. The ability to make cases available for viewing on multiple workstations simultaneously can allow a trainer to teach trainees of different levels of seniority on several cases almost simultaneously. The days of trainees competing for space around a viewing box are long gone but the new model poses challenges in organising rotas, staffing levels and uninterrupted teaching time as well as posing challenges for functionality. The functionality issues are crucial and encompass the ability to co-report an examination, referencing trainer and trainee within the report as well as allowing for checking of the final written report once this has been transcribed. This has medicolegal implications in the training environment, to ensure the appropriate accreditation of a report is given accurately.
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The survey
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We have been greatly surprised by the failure of PACS manufacturers to appreciate the demand for archiving and case retrieval functionality in PACS systems. In response to direct questioning we were surprised to learn that such functionality had rarely been mentioned in output based specification documents when developing PACS, or if mentioned, only as a possible future development (personal communication, GE Medical Systems, Slough, UK). We conducted a postal survey of the UK departments of radiology to assess the level of demand in the UK for PACS software that provides the capability to create integrated virtual film libraries and teaching resources. It asked each department to indicate if they had already installed or intended to install PACS within 5 years; whether the availability of software to provide an integrated virtual film library and training resource would be of interest to them; and how much it would determine their future choice of PACS provider. 237 questionnaires were posted and 144 responded (response rate 61%). 44 (31%) departments had already installed PACS and a further 97 (67%) intended to install it within 5 years. 95% of responders indicated that the availability of such software would be of interest to them. Of those intending to install PACS within 5 years 65 (67%) indicated that the availability of such a resource would be either a significant or decisive factor in their choice of PACS provider, if they were in a position to make the choice.
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Other approaches
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There have been various attempts to realise the potential teaching possibilities of PACS [9], but the solution must not simply aim at a validated collection of images in some digital film archive. The potential for digital film collections has been recognised by the RSNA MIRC project [10]. This allows for on-line access to a verified teaching archive of cases, accrued from a wide number of teaching centres. This project has not been without its difficulties. Many attempts to streamline the authoring process have been developed. This project provides a very useful archive and incorporates some self-directed learning opportunities but it does not incorporate full DICOM file retrieval and in its current format does not simulate the experience of reporting a case in daily work practice.
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The challenge
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PACS manufacturers have invested a huge amount in freeing radiology from the shackles of an analogue storage medium. There is a huge potential opportunity for training and teaching, in developing robust and searchable archiving facilities. Local or regional variants could allow for the retrieval of films to simulate local examination formats (for example randomise case mix of computed radiographic images, including normal studies, to simulate a rapid reporting packet for the British FRCR examination). In other countries the radiological higher specialist examinations are in part or completely digital, offering opportunities to set practice exams in formats very similar to the real exam. It is surprising that PACS manufacturers have not perceived the huge commercial advantage that a PACS system with these sorts of facilities would give them. Almost every large hospital in the UK will be a training department and it is almost inconceivable that any such department will wish to retain a conventional archive of analogue films. The same must be true around the world in large hospital departments. Failure to rise to this challenge and recognise the very widespread need will represent one of the greatest missed opportunities in radiology training in our conversion from analogue to digital storage.
Received for publication February 21, 2005.
Accepted for publication March 1, 2005.
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References
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Introduction
The requirements
