Using PACS for teaching radiology to undergraduate medical students | BMC Medical Education

Subjects

The research population was the medical students of the Islamic Azad University of Mashhad during the academic year 2021–2022. The entry criteria were: being a medical trainee student, consent to enter the study, and the exclusion criteria were: students who had previously graduated in radiology or other medical sciences and students who had renewed their course in radiology. participation in the study was voluntary, and students were informed that it would not impact their end-of-section evaluation After obtaining informed consent, they participated in the study. Ethical approval for this study was obtained from the Virtual University of medical sciences with the reference number [IR.VUMS.REC.1400.022]. This proposal was implemented after being approved by the ethics committee and obtaining the code of ethics.

Participants

The sample size was calculated using power analysis to ensure the study had sufficient power to detect a statistically significant difference between the control and intervention groups. Assuming an effect size of 0.5, a significance level (alpha) of 0.05, and a power of 0.80, it was determined that at least 50 participants were needed. To account for potential dropouts and ensure robustness, a total of 53 students were included in the study. According to the calculated sample size, four rotations of radiology internship students were included in the study for each of the control and intervention groups (each rotation is about 5–10 students). Due to the prevention of contamination, the first four rotations were assigned to the control group and the next four rotations to the intervention group.

The validity of the tools used in this study was established through expert review and pilot testing. Content validity was confirmed by 10 faculty members specializing in radiology. Reliability was assessed using Cronbach’s Alpha, yielding a coefficient of 0.91, indicating high internal consistency. In this study, three tools were used: measuring the level of knowledge, measuring the level of performance, and measuring the satisfaction of students in both groups (Appendix 1) and self-evaluation for PACS learning in the intervention group (Appendix 2). After one month of class, the final exam was taken which was a combination of 20 multiple choice questions and 5 short answer type questions (description and image recognition). The scores of the questions were collected as an objective assessment. To provide a subjective assessment of radiology learning, all students were invited to complete a satisfaction questionnaire on how radiology was taught. Also, the students of the intervention group were invited to complete a questionnaire for their self-evaluation of the amount of PACS learning. A 5-point Likert scale was used in both researcher-made questionnaires. The questionnaire used was created for this study. Informed consent was obtained from each patient whose data was used in the study, ensuring they were fully aware of how their medical images would be utilized for educational purposes.

Familiarization with PACS

Before starting the study with the PACS system, students were given an introductory session that covered the basics of PACS functionality, including how to navigate the software, view and manipulate images, and use the various tools available for image analysis.

Knowledge and performance measurement tools

In the knowledge section, questions evaluated theoretical content, and the performance section involved diagnosing radiographic image. Students described the type of radiography, pathological signs, and the final diagnosis. Multiple-choice questions and short answer questions were used to assess knowledge and performance The specific type of radiography used in this study included plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI). These imaging modalities were chosen to cover a broad spectrum of radiological techniques relevant to the medical curriculum. In the subject of knowledge, 20 multiple-choice questions were proposed based on the objectives of the lesson and the blueprint, which was approved by two colleagues of the radiology department, which must have been consistent with the objectives of the lesson. In the discussion of the performance of 5 of radiology images, which again corresponded to the objectives of the lesson and the blueprint, and it was approved by two colleagues of the radiology department that the objectives of the lesson were covered, they were provided to the students, and the students had to describe and diagnose the radiographies. The radiology images in both groups adequately covered the goals, but they were taught to the students in two different ways described.

Student satisfaction questionnaire

This questionnaire aimed to determine student’s satisfaction with the educational method. It consisted of ten questions graded on a 5-point Likert scale the range of scores was between 10 and 50 and higher scores indicating greater satisfaction. The content and form validity were confirmed by 10 faculty members and reliability was obtained by Cronbach’s Alpha test of 0.91.

Student self-assessment questionnaire

This questionnaire evaluated the learning rate of the PACS teaching method. It consisted of twelve questions graded on a 5-point Likert scale, and the range of scores was between 12 and 60, and higher scores indicate learning. Content and form validity were confirmed by 10 faculty members and reliability was assessed with a Cronbach’s Alpha of 0.91.

Implementation method in the control group

The teaching strategy involved traditional face-to-face interactive lectures using PowerPoint presentations. The practical part included demonstrating selected radiographic images on slides and discussing their interpretation.

This method aimed to develop the student’s ability to diagnose and interpret radiographs through structured lectures and guided discussions. A pre-test was conducted in the first session to determine the student’s initial knowledge and performance levels. The classes were held daily in person. After teaching the theoretical part with a PowerPoint presentation, radiographic images were shown to the control group for interpretation and discussion. This conventional method aimed to develop the ability to diagnose and interpret radiographs. The post-test to determine knowledge and performance was performed and the education satisfaction questionnaire was completed at the end of each rotation.

Bias caused by human factors during the teaching of the two groups was controlled by standardizing the teaching materials and methods across both groups. Additionally, the instructors were blinded to the group assignments to prevent any conscious or unconscious bias in teaching and assessment.

Implementation method in the intervention group

The stages of developing the training course using PACS software and DICOM were as follows: 1). Initial planning and curriculum alignment, 2) Selection of relevant radiographic cases, 3) Configuration of PACS workstations, 4) Training faculty on PACS software, and 5) Implementation of PACS-based learning sessions for students, followed by assessment and feedback.

After the control group, the rotations of the intervention group were included in the study, and the pre-test was administered to the students of the intervention group. Assessment of knowledge with multiple choice questions and performance with radiographic images was with short answer questions. The classes were held daily in person. In the intervention group, after participating in the theoretical part of the course, which was similar to the control group and was held face-to-face, for the practical part, they were trained in a virtual way with Adobe Connect software, and there was no face-to-face class for radiography images. In this way, students were given access to PACS Radiant software (installation on personal desktop). Following the teaching of the theoretical part, based on the goals of the radiology course for medical trainees, a number of images of the brain, lungs, bones, urinary tract, and digestive system (including radiography, CT and MRI) were assigned to the students of the intervention group, and the images of these patients were completely at their disposal.

The computers used were personal desktops with standardized configurations. Adjustments and calibrations were made to ensure all students could view images with consistent quality and brightness, replicating the clinical environment as closely as possible. This software enables students to perform basic operations with images, such as windowing, comparing different MRI sequences, and performing cross-sectional reconstruction (MPR) or 3D reconstruction, exactly as a radiologist does and has the facilities. After studying the material and checking the images, the students were required to announce the completion of their study to the teacher and they were given the opportunity to review the pictures, ask questions, and solve problems with the teacher in the virtual space.

The post-test to determine knowledge and performance was performed in the intervention group. The education satisfaction questionnaire was completed at the end of each rotation. The self-assessment questionnaire for PACS learning was completed at the end of each rotation.

Data analysis

The data was analyzed with SPSS-17 software, IBM, US. Central and dispersion indices were used in the descriptive statistics report, and a T-test was used in the analytical section, independent t-test, paired t-test and, chi-square test were used to compare the data. The confidence level was set at p < 0.05.