Radiology Education

The Value of a Medical Student

Radiology Triage Program in
Enhancing Clinical Education
and Skills
Jim Y. Chen, MD, Petra J. Lewis, MBBS
Rationale and Objectives: The Medical Student Radiology Triage Program (MSRTP) at Dartmouth-Hitchcock Medical Center recruits
third- and fourth-year medical students to streamline imaging workflow for on-call radiology residents. We sought to evaluate the benefit
of this program for improving medical student education.
Materials and Methods: Members of the program were surveyed anonymously from 2010 to 2012 using a web-based survey. The survey
asked the students to rate the program in several categories from 1 (very poor) to 5 (very good). Students also indicated if they are learning
any of the identified skills.
Results: Thirty of 54 (56%) former and current members responded to the survey. Support from on-call residents (mean rating 4.7) and
interactions with residents (mean rating 4.7) were rated the highest of the categories. Students ranked training provided (4.2), interactions
with technologists (4.2), and interactions with clinicians (4.1) the lowest. The medical training experience and overall experience were
graded with means of 4.4 and 4.5, respectively. Ninety-six percent of students felt they acquired triaging skills, whereas 92% of students
developed communication skills. Sixty-nine and sixty-two percent of students stated that they gained radiologic knowledge and general
medical knowledge, respectively. Sixty-five and fifty percent of students developed imaging appropriateness criteria and image interpretation skills, respectively. The most popular reason for joining the program was for financial compensation (number of students = 12), followed by exposure to radiology (n = 8), radiology education (n = 8), and clinical exposure (n = 7). Major strengths of the program included
interactions with residents, learning experience, and triaging of workflow. Students listed the top two problems with the program as
computed tomography technologists and clinicians not wanting to speak to them.
Conclusions: The MSRTP serves as a valuable clinical learning experience as well as being highly beneficial to resident workflows on call.
Participants of MSRTP gain clinical skills that they will use during residency.
Key Words: Medical Student Radiology Triage Program.
AUR, 2014

imilar to many other programs, medical students on

their radiology elective at our institution are required
to take evening call with the overnight resident on
one or two occasions. This experience can be useful for the
students, exposing them to a typical radiology residents
work pattern and enabling them to see a greater range of
emergency studies. It remains however a passive experience,
when the students shadow the residents while they perform
their duties. Students often wish to be more actively involved
in patient and study management. Naeger et al. (1) described

Acad Radiol 2014; 21:829833

From the Department of Medicine, University of Pittsburgh Medical Center
Presbyterian Shadyside, Pittsburgh, PA (J.Y.C.); Geisel School of Medicine
at Dartmouth, Hanover, NH (P.J.L.); and the Department of Radiology,
Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon,
NH 03756 (P.J.L.). Received September 16, 2013; accepted December 17,
2013. Grant Support: None. Address correspondence to: P.J.L. e-mail:
petra.j.lewis@hitchcock.org
AUR, 2014
http://dx.doi.org/10.1016/j.acra.2013.12.013

the radi-holiday stereotype and advocated for increased

responsibilities and expectations for students. Our residents,
although willing and enthusiastic to teach, are often overwhelmed with the volume of incoming studies and must
make this his or her priority.
In addition to interpreting studies, residents are constantly
paged by technicians, clinicians, and sometimes patients.
Answering these pages interrupts thought processes and delays
workflow and teaching. For example, a clinician might page
for the interpretation of a nonemergent computed tomography (CT) scan and wanted the resident to have a quick look
over the phone. The resident would have to close the current
study in midevaluation and then open the requested one.
Based on a presentation given at the Association of University Radiologist meeting in 2010 by Douglas Davis, MD, PhD
from the Department of Radiology at Yale, the Department of
Radiology at Dartmouth-Hitchcock Medical Center decided
to develop a program which would improve workflow
efficiency, de-stress on-call radiology residents and also provide
829

CHEN AND LEWIS

Academic Radiology, Vol 21, No 7, July 2014

TABLE 1. Potential Benefits of Medical Student Radiology Triage Program









Obtain an early, in-depth, and hands-on exposure to radiology in a dynamic and high-volume setting.
Develop consultant skills for working with clinicians from different backgrounds in high-acuity settings.
Develop knowledge of the appropriate indications for various imaging studies.
Foster multitasking and communication skills.
Networking opportunities within the department of radiology.
Extracurricular activity that serves as a point of conversation during residency interviews and an asset on curriculum vitae.
Financial compensation for a clinically educational experience.

TABLE 2. Medical Student Radiology Triage Program Member Responsibilities

 Answer the pager.
 Receive notifications from technicians regarding completion of Emergency Department (ED) and inpatient studies; validate that these
are available in the PACS.
 Take requests for ordering of studies; obtain protocol from resident and notify appropriate technician.
 Take requests for ultrasound and fluoroscopic examinations to be done by resident.
 Triaging of interventional radiology (IR) requests; contact IR resident when needed.
 Take requests for nuclear medicine examinations; notify technician.
 Take study interpretation requests from in-house clinicians; notify clinicians when interpretation is available and read interpretations
to clinicians if necessary.
 Take study interpretation requests from community and Veterans Administration (VA) hospital; confirm reception of study in Picture
Archiving and Communications System (PACS); fill out paperwork and fax it.
 Notify resident of incoming traumas.
 Sign out with resident regarding unfinished tasks at the end of the shift.

medical students with exposure to imaging. The implementation of this program did not imply that radiologists or residents
do not enjoy or wish to speak with clinicians. Members of this
program would gain clinical exposure to radiology as a field,
experience in imaging algorithms, and communication and
triage skills regardless of residency choice. Table 1 displays the
full list of proposed member benefits. In September 2010, the
department along with a fourth-year student implemented
the Medical Student Radiology Triage Program (MSRTP).
MATERIALS AND METHODS
The program has been virtually, entirely student-run since its
inception, with the corresponding author of this article
serving as faculty director. MSRTP recruited third- and
fourth-year medical students at the Geisel School of Medicine
(formerly Dartmouth Medical School) via email to take call
with radiology residents on weekdays (5 PM to 10 PM) and
weekends (2 PM to 9 PM), which were felt to be the times of
the greatest need for support by the residents. A yearly orientation session is given by the MSRTP student and faculty
directors with resident volunteers, which describes program
goals, student responsibilities, and workflow scenarios. The
MSRTP student director developed and sent out a PowerPoint manual to all students detailing many different situations
that they will encounter when on call. New members train
with the student director or another experienced student for
4 hours before starting their first shift. Students sign up for
shifts online, on a first come first serve basis. The department
provides a $10 hourly stipend.
830

Students have their own Picture Archiving and Communications System (PACS) logins with limited functionality; they
can access images but cannot annotate or read. At the beginning of the shift, students sign on to a PACS station in the same
reading room as the resident. Students carry the trauma pager
and answer calls from clinicians, radiology technicians, and
other hospital personnel. Students clearly state their role as
radiology triage when answering calls to avoid confusion
before establishing the nature and urgency of imaging requests
or inquiries. If the situation is emergent (i.e., cord compression, aortic dissection, and abdominal aortic aneurysm
rupture), requires resident expertise, or is simply requested
by the clinician, then the phone is promptly handed over to
the resident. The student generally gathers pertinent information (patient name, medical record number, location, study
type, indication, pertinent labs, and referrer name and pager
number) on a log sheet. If nonemergent, the student notifies
the resident of the requests in-between studies. The resident
then processes them in chronologic order. Students get results
to clinicians by phone or fax when they cannot be accessed
electronically. Table 2 displays a list of student responsibilities.
The student director is responsible for recruiting and
training new members: creating and updating manuals and
policy documents; maintaining work schedule and analyzing
program coverage statistics; updating the program according
to faculty, resident, and student feedback; and acting as a
correspondent between all involved. A new student director
is appointed by the MSRTP faculty director every year. He
or she receives the same stipend as other members for shifts
and does not receive any additional financial compensation.

Academic Radiology, Vol 21, No 7, July 2014

MEDICAL STUDENT RADIOLOGY TRIAGE PROGRAM

TABLE 3. Student Evaluations of the Program (n = 30).

Calculated Based on Likert Scale: (1) Very Poor; (2) Poor; (3)
Fair; (4) Good; (5) Very Good

TABLE 4. Skills Acquired by Students While Participating in

the Program. Twenty-six Total Responders

Category of Evaluation

Skill Learned

Support from on-call

residents
Interactions with
residents
Overall experience
Medical training
experience
Training provided
Interactions with
technologists
Interactions with
clinicians

Average Rating

Median Rating

4.7

4.7

4.5
4.4

5
5

4.2
4.2

4
4

4.1

Members of the program were surveyed online anonymously from 2010 to 2012 using SurveyMonkey (www.
SurveyMonkey.com, Palo Alto, CA). It asked the students
to rate the program in several categories (overall experience,
medical training experience, interactions with residents, support from on-call residents, training provided, interactions
with clinicians, and interactions with technologists) from 1
(very poor) to 5 (very good). Students answered if they acquired any of the selected skills: general radiologic knowledge,
general medical or surgical knowledge, triaging of tasks,
communication skills, multitasking, time management skills,
imaging appropriateness criteria, and image interpretation
skills. They also noted program strengths and how to improve
the program. Last, they were given the option of free texting
their reason for joining the program. The results were tallied
in Microsoft Excel. A similar survey was sent to radiology residents asking them to evaluate the program.
In addition, shift coverage was calculated (percentage of
available shifts covered by students) for individual days of
the week, months, quarters, and years.

RESULTS
Thirty of 54 (56%) former and current members responded to
the survey. Eight were third-year and 22 were fourth-year
medical students. The majority of students (n = 14) have
done six or more shifts. Nineteen students (63%) planned
on participating once every 2 weeks or more.
Generally, the program rated very high in all regards. Support
from on-call residents (mean rating 4.7) and interactions with
residents (4.7) were rated the highest of the categories
(Table 3). Students ranked training provided (4.2), interactions
with technologists (4.2), and interactions with clinicians (4.1)
the lowest. The medical training experience and overall experience were graded with means of 4.4 and 4.5, respectively.
Ninety-six percent of students felt they acquired triaging
skills whereas 92% responded to learning communication
skills (Table 4). Sixty-nine and sixty-two percent of students

Triaging of tasks
Communication skills
Multitasking
General radiologic knowledge
Imaging appropriateness criteria
General medical/surgical knowledge
Time management skills
Image interpretation skills

Number of Responses
[n (%)]
25 (96)
24 (92)
22 (85)
18 (69)
17 (65)
16 (62)
14 (54)
13 (50)

TABLE 5. Student-reported Reasons for Joining Medical

Student Radiology Triage Program. Number of Individual
Free Text Responses
Reason for Joining the Program
Financial compensation
Exposure to the field of radiology
Radiology education
Clinical exposure
Interest in radiology as a career
Interactions with radiologists
Experience answering a busy pager

Number of Responses
12
8
8
7
4
3
3

stated that they gained radiologic knowledge and general

medical knowledge, respectively. Sixty-five and fifty percent
of students responded to learning imaging appropriateness
criteria and image interpretation skills, respectively.
The most popular reason for joining the program was for
financial compensation, followed by exposure to radiology,
radiology education, and clinical exposure (Table 5). Students
listed financial compensation (n = 12) and learning experience
(n = 10) as the most popular reasons for continuing the program. Major strengths of the program included interactions
with residents, learning experience, and triaging of workflow.
Students listed the top two problems with the program as CT
technologists and clinicians not wanting to speak to them.
Most of the students felt that no additional training was needed.
MSRTP is continuing strong with 33 current members as
of April 2013. Students have covered 296 out of 312 (95%)
possible shifts in 2012, up from 84% in 2011 (its first full
year). Shift coverage was $94% for every month, except for
December (71%). Coverage for Saturdays (90%) and Sundays
(91%) were the lowest during the week.

DISCUSSION
More than 2 years into its inception, MSRTP has become a
popular program among students at the Geisel School of
Medicine. Participation increased, with 33 current members,
831

CHEN AND LEWIS

and attrition rates remained low. There have been remarkably

few issues with the program from within the department,
from clinicians or students. Students rated the overall experience very favorably. They appreciate the interaction
with, and support from, radiology residents. The lowest rated
aspects of the program were training provided, interactions
with clinicians, and interactions with technologists. To address
these issues, the following measures were taken.
To simplify the training process, the student director
created a step-by-step Microsoft PowerPoint manual that
highlighted most of encounters students would face during
a shift. The manual and documents related to the program
are shared online on Google Drive. The student director sends
the manual at least a week ahead of time and asks the trainee to
review it before training. On arrival, the trainee is given
responsibility for the pager. The student director then reviews
the manual again with the trainee to clarify any points.
The goal was to create a hands-on environment for the new
MSRTP member to become familiar with the tasks and responsibilities of the program. Assistance from the student
director was always available when issues arose.
At the beginning of the program, many clinicians were not
familiar with the students role. Sometimes this led to frustration and misunderstanding, especially from emergency
medicine physicians and surgeons. They frequently asked to
speak with the radiology resident right away for nonurgent issues. At house officer meetings, radiology residents explained
and clarified the role of MSRTP to other house staff. The goal
was to streamline after-hour workflow and create efficiency
for the radiology resident and to improve the speed (and
hopefully quality) of study interpretations. The students
were required to identify themselves as radiology triage.
Over time, these issues have decreased significantly. Currently,
the vast majority of clinicians are now willing to speak with
the student about nonurgent studies.
Radiology technicians had voiced concern about speaking
directly to the radiology resident for immediate questions.
Technicians were happy to communicate with students for
routine protocols, questions, and notifications of completed
studies that require interpretation. Previously, the student
would inquire about the details of the request. Now, the technicians state hot line, and they are transferred to the resident
immediately for urgent requests. If the resident is not in the
same room, the student finds the resident as soon as possible.
These solutions have been integrated into the training.
Students favorably rated the medical training provided
through the program. The overwhelming majority of students
reported that they have learned communication skills, multitasking, and triaging of tasks. These are skills that interns and
residents need regardless of specialty choice. Although we did
not expect medical students to interpret imaging studies on a
resident level, half of the participants reported an improvement in that area. About two-thirds of all participants added
to their general radiologic knowledge and gained awareness
of imaging appropriateness criteria, which we feel is a crucial
benefit. Prezzia et al. (2) surveyed 444 fourth-year medical
832

Academic Radiology, Vol 21, No 7, July 2014

students and found that 77% had never heard of the American
College of Radiology (ACR) Appropriateness Criteria. In
general, the medical students were also poorly informed
regarding radiation and magnetic resonance imaging safety.
In a survey of 175 postgraduate year1 residents, Saha et al.
(3) discovered that 81% had never used or heard of the
ACR Appropriateness Criteria. Only 33% of the residents
had high confidence in knowing when to order oral or intravenous contrast, and 36% had high confidence identifying and
premedicating contrast allergies. A disappointing 13% knew
the risk factors of nephrogenic systemic fibrosis. Hopefully,
this program will continue to educate students on imaging
appropriateness and risks even if they pursue other specialties.
Although financial compensation was the most popular
reason for joining MSRTP, several students pursued exposure
to the field of radiology and radiology education. Poot et al.
(4) surveyed students from 159 US medical schools and found
that 67% of them thought it was very or the most important to
have a basic fundamental knowledge of radiology to become a
competent doctor. Gunderman et al. (5) pointed out the
importance of medical students learning how radiologists
contribute to patient care. Gunderman and Hill (6) also highlighted 12 misconceptions about radiology and how radiologists should address them. With in-depth exposure to our field
from involvement in everyday tasks, these students at Geisel
School of Medicine gain a more accurate perception of
radiology that will help them with residency choice and in
their careers.
Preliminary results from resident surveys showed good
overall experience from their standpoint, very good interactions with students, and good contribution from students in
decompressing call. Residents highlighted the following
program strengths: the program allows them to finish reading
studies in an uninterrupted manner; it is less distracting not
answering the pager, especially when performing ultrasounds
and evaluating traumas; and it increases the time for them to
look at studies, allowing more work to be done in a timely
manner. Residents unanimously agree on continuation of
the program.
Similar triage programs or externships exist at the YaleNew Haven Hospital and the University of Iowa Hospitals
and Clinics (7,8). The Emergency Department Radiology
Triage Program at the Yale University School of Medicine
also surveyed 26 current and past participants. Students
reported that the most important factor for joining was
financial (9). Forty-two percent of the students stated that
their participation encouraged them to pursue a career in
radiology. Seventy-seven percent described the program as
being of at least moderate help to their medical careers. Students who participated in the radiology externship program
at the University of Iowa Carver College of Medicine
reported an overall positive experience (8). They achieved
better understanding of imaging indications, contraindications, risks, and benefits. We hope to see more radiology externships or triage programs starting to contribute to medical
student education.

Academic Radiology, Vol 21, No 7, July 2014

CONCLUSIONS
The MSRTP serves as a valuable clinical learning experience
for medical students, while streamlining off-hour workflow
for on-call radiology residents. Students reported an overall
positive experience. They develop communication, triaging,
and multitasking skills, acquire general radiologic knowledge,
and learn imaging appropriateness criteria. These are skills
they will need in residency, regardless of their specialty choice.

REFERENCES
1. Naeger DM, Phelps A, Kohi M, et al. Reading room electives: say goodbye
to the radi-holiday. J Am Coll Radiol 2013; 10:442448.
2. Prezzia C, Vorona G, Greenspan R. Fourth-year medical student opinions
and basic knowledge regarding the field of radiology. Acad Radiol 2013;
20:272283.

MEDICAL STUDENT RADIOLOGY TRIAGE PROGRAM

3. Saha A, Roland RA, Hartman MS, et al. Radiology medical student education: an outcome-based survey of PGY-1 residents. Acad Radiol 2013; 20:
284289.
4. Poot JD, Hartman MS, Daffner RH. Understanding the US medical school
requirements and medical students attitudes about radiology rotations.
Acad Radiol 2012; 19:369373.
5. Gunderman RB, Gasparis PT, Rahman T. Educating medical students
about radiologists contributions to patient care. Acad Radiol 2012; 19:
908909.
6. Gunderman RB, Hill DV. Students concerns and misconceptions about a
career in radiology. Acad Radiol 2012; 19:366368.
7. David DJ, Moon M, Kennedy S, et al. Introducing medical students to radiology as paid emergency department triage assistants. J Am Coll Radiol
2011; 8:710715.
8. Dobre MC, Maley J. Medical student radiology externs: increasing
exposure to radiology, improving education, and influencing career
choices. J Am Coll Radiol 2012; 9:506509.
9. Kennedy S, Knibutat DB, DelBasso SL, et al. The educational and career
impact of using medical students for triaging off-hour diagnostic imaging requests at a major academic medical center. AJR Am J Roentgenol 2010;
194:10271033.

833