In this bewildering COVID-19 era, physical distancing has created numerous pressures
and upended interpersonal relationships as we knew them, from the home front to the
grocery store to clinical practice. From the perspective of the academic radiology
educator, these new stresses have potential to compromise the valued experience of
active side-by-side teaching of trainees at the workstation, which arguably remains
the most critical component in the education of our future Radiologists 1-3.
As a remotely positioned academic teleradiologist, I have enjoyed the unique opportunity
to educate Radiology fellows and residents at the workstation from afar for over 7
years. While I do not intend to espouse exclusive authority on this topic, I can say
with confidence that it is feasible to maintain a constructive, mutually beneficial
relationship between attending and trainee despite the physical distance. Whether
your trainee is isolated to the office next door or miles away, currently available
tools are surprisingly simple to use and enormously helpful in making this experience
a positive one for both parties.
On any regular day our Radiology trainees (particularly our most junior residents)
are placed in challenging positions with the onus of tackling image interpretation,
accurate reporting, and communication, in many cases on a “trial by fire” basis. Certainly
the immediate availability of the on-site attending for questions and validation on
interpretation helps our trainees manage these challenges with greater confidence.
And of course, the benefit of the face-to-face encounter cannot be overstated3-4,
in which relationships develop and both parties engage not just with verbal communication
and tone of voice but also body language and facial expressions.
Now that we are intentionally physically distancing, it becomes even more incumbent
on us to recognize the difficulty of the trainees’ position and do our best to minimize
the negative impacts of this “new normal” on their education. In the remote setting,
without a direct visual on you as the educator, the trainee may feel abandoned, demoralized,
and less motivated to get the most out of the learning experience.
Fortunately, with modern technologies at our disposal, we can get fairly close to
the face-to-face encounter by taking greater efforts to communicate with alternate
means. Regardless of physical location, a successful interaction with the trainee
needs to be based on empathy and respect for the trainee's position and experience.
As with any relationship, the remote relationship with trainee can thrive when the
trainee feels acknowledged, heard, and valued.
Either the day before or at the start of the workday, provide your trainee with your
favored means of contact either by email or in-house messaging platform so you can
be reached easily when questions or concerns arise. Similarly, ask for the trainee's
best means of contact, be it by text, email, pager or phone.
Give the trainee a call and say hello at the start of the day. Keep in mind that your
voice provides the trainee with reassurance and comfort and so a phone conversation
at this point would be ideal. Just as you would do in person, ask how they've been,
what's new since you last chatted, if toilet paper has been restocked at your local
grocery store… normal conversational material like that. Formulate a plan and discuss
goals for the day, which will likely vary based on clinical rotation and trainee experience.
Most importantly, reassure your trainees that despite the distance, they are not alone
and that you are available whenever they need you, with no question too fundamental.
Most importantly, plan when the trainee will hear from you next for purposes of read
out. Again, this reinforces to trainees that they are on your radar and will not be
left stranded. At the time of this writing, we are well into the latter portion of
the academic year at most Radiology training programs, so by this point even first
years have gained some experience in the image review and dictation process and most
are able to function with some degree of independence. Come the start of the new academic
year however, brief discussions for each case reviewed and/or multiple abbreviated
read out sessions may be required, depending on experience and comfort level of the
trainee. This is something that can be gauged during that first conversation at the
start of the day and can be adjusted accordingly as the day progresses.
As you sign off on the trainee's preliminary reports, jot down specific small but
substantive as well as major changes in reports as well as any discrepancies in findings
and interpretations. In anticipation of a planned readout later in the day, keep these
comments on a post-it note or open a temporary word document at your workstation.
Look for any general trends that can benefit from improvement, for example inaccuracies
in reported techniques or word choices that can be improved. Provide specific comments
on individual cases, such as expanding a differential diagnosis or pointing out a
critical finding that can narrow a differential diagnosis.
Although every educator has different preferences, in general I find it more expeditious
to review cases reported by the trainee first, finalize the reports and then discuss
any changes and related teaching points later in the day at the pre-scheduled time.
The best way to replicate the side-by-side readout experience as much as possible
is to provide a context wherein you and the trainee are viewing the same images of
a case simultaneously. This can be accomplished through screen sharing technologies.
There are several platforms available for free or by monthly subscription that offer
HIPAA-compliant screen sharing technology that is easy to use with the ability to
point, annotate, and even share control of the mouse. Many typically allow for simultaneous
video feed from webcams to complement the screensharing experience, bringing us a
bit closer to the face-to-face encounter at the workstation. These platforms include
but are not limited to Zoom (San Jose, CA), Skype for Business (Redmond, Washington)
and Microsoft Teams (Redmond, Washington). Consider employing security options such
as using passwords to avoid disruption by uninvited attendees which plague larger
virtual meetings (so called “Zoom-bombing”). Using a per-meeting ID (rather than personal
meeting ID), using the waiting room feature before granting access to guests, disabling
the “join before host” function, and locking the meeting once all attendees are present
are other security measures that help to maintain the privacy of Zoom meetings. With
Microsoft Teams, unique login credentials, multi-factor authentication and encryption
are tools that can safeguard protected health information.
Video phone chat applications like FaceTime and WhatsApp might be tempting to use
but not all are necessarily HIPAA-compliant and therefore should be used with caution.
In house messaging platforms, texting and email are good ways to communicate provided
conversations maintain HIPAA compliance, but these don't afford the benefit of hearing
the voice of the other party or allow for the free conversational exchange of ideas
in an efficient manner.
At my institution, a screen sharing function is built into our PACS (Carestream, Rochester,
NY), allowing me to display images on my screen with the trainee viewing the same
screen concurrently. With both of us logged in the PACS, a click on the sharescreen
function prompts the pop-up of a unique code which I share with the trainee, granting
access of my screen to the trainee. Although the trainee does not have access to the
mouse to control the screen, the trainee can watch me scroll, point, measure and annotate
as we discuss individual cases over the phone (utilizing multi-way phone dialing if
more than one trainee is on the line). Not all PACS platforms allow for this function,
so it might be helpful to contact your IT department to find out if it is an option
Our division also utilizes Zoom which can replicate the common reading room experience
in the context of a daily meeting among all daytime faculty and trainees where attendees
can “call out” to other specific attendee(s) to discuss a case at any point during
the day. We also take advantage of “breakout room” options within that meeting, accommodating
smaller group read out sessions throughout the day.
The Read Out
At your pre-scheduled time, provide feedback constructively using appropriate word
choices and tone. If you are not utilizing video for a face to face engagement, the
trainee will not have your visual cues, facial expressions and body language to react
to, so it's even more important to use a voice with non-judgmental tone and word choices
without hurtful criticisms. Go over the individual cases you noted down earlier, and
discuss the specific changes you made in your reports. Emphasize teaching points and
discuss differential diagnoses on an as needed or case by case basis. I am a strong
believer in positive reinforcement, so during my readouts I don't limit discussions
to missed findings. I also make a point to emphasize the great calls made by trainees
The readout sessions don't have to be long, but they should be substantive. Session
lengths will vary based on the experience level of the trainee with more junior trainees
requiring a little bit more time than senior trainees. For first and second year residents,
before even making findings on a specific case, I like to discuss the reasoning behind
the imaging study in question, the technique involved in performing the study, and
what findings one might expect to see to confirm the suspected diagnosis. For third
and fourth year residents, a case review could include a discussion on a broader differential
diagnosis for a particular imaging finding and a best fit diagnosis based on the clinical
context of the study supported by a review of the patient's electronic medical record.
For fellows, a fruitful discussion could include a review of the benefits and limitations
of the imaging modality employed, alternative imaging strategies, and subtle anatomic
variations that might be evident on the study.
If workflow is slow, don't limit yourself only to cases on hand. Show cases from your
teaching file, share cases you saw the same day which you read independently of the
trainee, or have a brief discussion of regional anatomy using cases reviewed earlier.
Forward related supplementary educational materials to the trainee: on my desktop
I keep a folder of publications in PDF format, particularly review articles, that
come up frequently in case discussions which I can easily forward by email after the
At the end of the review session, give the trainees a sense of how they are doing,
and what they should work on in the future. For example, “You did a great job on these
cases, now moving forward let's try to get a few more cases done in the same amount
of time” or “Great job with making findings, now let's work on making your reports
Very importantly, ask the trainee if there are any unanswered questions or anything
else the trainee would like to discuss that did not come up earlier. This prompt is
often followed by a pause. Pauses often seem to take longer during virtual conversations,
so give the trainee a moment to think on it and don't rush this part of the conversation.
If you happen to be reviewing cases by an overnight or end-of-shift trainee with whom
you can't directly talk to, consider sending a brief email with feedback on specific
cases or just a general statement related to his or her performance. I find that trainees
are very happy to receive these communications and nearly always respond positively
to this feedback. With the innumerable issues that require attention on your plate,
feedback to the overnight trainee is easy to delay and ultimately forget about. Remind
yourself that sending an email doesn't take a whole lot of time, is best to send right
away after reviewing the case in question, and the trainees appreciate your feedback.
The Benefit to You
In light of the extra effort to reach out to and engage trainees, you may wonder what's
in it for you. Of course there's the gratification we all feel when we pass knowledge
onto others and inspire them to learn more. Our trainees help to keep us attendings
honest and on our toes on the basis of their inquisitive nature and eagerness to learn.
Keep in mind that during these difficult times of physical distancing, you are isolated
too. You will be lonely and maybe a little despondent yourself. Consider your time
with the trainee as your social engagement: if you're like me, you will find that
these interactions are the best part of your clinical workday and something to look
I recognize what I've put forth here isn't rocket science. Most Radiology educators
already follow many of the suggestions posited above in pre-COVID practice, but I
hope this serves as a reminder that with a little extra effort, we can continue to
do the same even with physical distancing measures in place. Hopefully, you will find
as I have that it is possible to engage remote trainees in a positive way, based on
a relationship anchored in mutual respect and empathy. Remember that hearing your
voice provides reassurance to the trainee that despite the distance, they are not
alone and that you are there to support them. Providing specific feedback shows you
care about their development as trainees. Just as importantly, in this strange time
of physical distancing, this educational interaction becomes a symbiotic relationship,
wherein you benefit from socialization as much as the trainee learns from you.
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