•
•
Education
Viewbox Seminar: A New Method for Teaching Roentgenology 1 Benjamin Felson, M.D.,2 George Jacobson, M.D.,3 Eugene P. Pendergrass, M.D.,4 Leonard J. Bristol, M.D.,s Otha W. Linton, M.S.J., and Robert W. Harrington, Ph.D. The American College of Radiology designed a "crash" program to train radiologists to interpret and classify the radiological manifestations of coal workers' pneumoconiosis. This Viewbox Seminar combines two pedagogic techniques, group viewbox study, and a test-teach-test sequence of instruction that compels active participation in the learning process. Weekend scheduling and good location and transportation connections facilitate attendance, making this an excellent way to teach large groups of radiologists certain subtleties of radiology in a short time. INDEX TERMS:
Diagnostic Radiology • Education • Radiology and radiologists
Radiology 116:75-78, July 1975
•
• cians with the responsibility of making and interpreting chest roentgenograms on a large number of underground coal miners. The roentgenograms were to be classified by a revised and expanded, but largely unknown, classification of the pneumoconioses that had been developed by representatives of the International Labor Office (ILO), the Union Internationale Contre Ie Cancer (UICC), the British Pneumoconiosis Research Group, and the United States Public Health Service (USPHS) at a meeting held in Cincinnati in 1968. This revision became known as the ILO-UtC Classification. Since there were only four U. S. radiologists (present co-authors) intimately familiar with this classification, and an estimated 100,000 coal miners soon to be surveyed, it was obvious that a "crash" program would be needed to train a large group of physicians to interpret and classify the many anticipated roentgenograms. In response to a request from the National Institute of Occupational Safety and Health (NIOSH) of the USPHS, the ACR contracted to develop educational materials and teaching methods and to conduct seminars to acquaint physicians with the roentgen manifestations and classifications of CWP. Under supervision of a task force, consisting of representatives of NIOSH, the ACR, the American Medical Association, and the American College of Chest Physicians, the present authors were asked to prepare the program, conduct the seminars, and act as instructors. Under the rules set up by NIOSH, participation in a seminar qualified a physician to provide the first interpretation (A reading) of chest roentgenograms on coal workers. It was immediately apparent to us that there were
the past four years, the American College of Radiology (ACR) has presented more than twenty weekend teaching sessions, attended by several thousand physicians, dealing with a variety of problem areas in diagnostic roentgenology. Instead of using the conventional lecture-slide approach, a radically different method was devised. It was called Viewbox Seminar and combined in a unique manner two pedagogic techniques that compel the "student" to participate actively in the learning process. The first of these, simultaneous group viewbox study, was designed to teach the differences between the normal and abnormal roentgenogram and to facilitate the recognition and interpretation of subtle roentgen signs and patterns. The second, a test-teach-test sequence of instruction, was intended to enhance student involvement, motivation, and self-evaluation. The format was originally developed for seminars concerned with the roentgenology of coal workers' pneumoconiosis (CWP)-the Black Lung Seminars. The enthusiastic reception of the method led to its adaptation to seminars on skeletal, gastrointestinal, and pediatric radiology, and it has now become the standard format for many of the weekend teaching seminars conducted on still other topics by the ACR. The following discussion deals with our experience with these sessions, especially with the Black Lung Seminars.
O
VER
BACKGROUND The Coal Mine Health and Safety Act passed by Congress in 1969 presented radiologists and other physi-
1 From the American College of Radiology (B. F., G. J., E. P. P., Fellows; L. J. 8., Member; O. W. L., Director of Washington Office; R. W. H., Director of Education), 20 North Wacker Drive, Chicago, III. 60606. Accepted for publication in March 1975. 2 Present address: Department of ~adiology, Cincinnati General Hospital, Cincinnati, Ohio. 3 Present address: Department of Radiology, University of Southern California, Los Angeles, Calif. 4 Present address: Department of Radiology, University of Pennsylvania, Philadelphia, Penn. S Present address: Saranac Lake, New York. vb
75
76
BENJAMIN FELSON AND OTHERS
Fig. 1.
July 1975
The slide of the master radiograph is projected onto a large screen and specific features are pointed out as the students view a copy on individual viewboxes.
several problems unique to this situation that would require unorthodox solutions. These included (a) the low level of experience with the roentgen aspects of pneumoconiosis of many of the potential students; (b) the subtle nature of the roentgen manifestations of minimal CWP; (e) the absence of typical or "standard" roentgenograms to illustrate the categories of the new classification; and (d) the requirement that we train a large number of physicians rapidly. The need to perceive and study fine roentgenologic details in a setting consonant with normal standard viewing distance made the customary reliance on slide projection or photographs untenable. Yet, the number of people to be trained and the small number of teachers available to train them precluded one-to-one facultystudent consultation at the viewbox. Our dilemma was resolved by the timely development of inexpensive copying equipment and film capable of reproducing accurately and in quantity the fine roentgen detail of the original roentgenogram. Individual illuminators were purchased and master radiographs illustrating the various manifestations of pneumoconiosis were selected and copied in appropriate numbers. It now became possible for a group of 200 physicians to look simultaneously at an excellent copy of the same roentgenogram on a viewbox at the same time, and to be instructed in its interpretation and classification by a teacher on the podium. The next problem was how to proceed with the teaching itself. Since audience participation was already guaranteed by the method of viewing we had adopted, it seemed logical to emphasize self-learning which many educators now consider the best way to learn. To accomplish this, we decided to permit the student to work at his viewbox independently at intervals during the seminar.
A TYPICAL SEMINAR
As the seminars evolved, there were surprisingly'few departures from the original format. The current seminars are conducted as follows: 1. A faculty panel is organized to prepare teaching materials and provide instructors for the subject to be taught. Both faculty and subject are selected by the permanent task force of the AeR. 2. The first session of the seminar is held on a Friday evening, at which time didactic presentations are made by various members of the faculty to the entire student body. 3. On Saturday morning, the test-teach-test session begins. Two students are assigned to each of the 100 viewboxes and given a set of the test films to study and classify. They record their opinions on a worksheet. After the entire group finishes the test films, each radiograph is reviewed from the podium by a faculty member, who projects a slide of the master radiograph on a large screen, pointing out specific features as the student observes them on the copy on his own viewbox (Fig. 1). This preliminary test establishes for each student a baseline against which he can later measure his performance, after the practice and final test sessions. Teaching sessions now follow, utilizing a new set of films. Each student independently studies the same case on his viewbox, recording his findings on his worksheet. The instructor at the podium then discusses the details shown on the roentgenogram, emphasizes the principles illustrated, gives his conclusion, and answers questions. Case after case is studied in this manner for a period of about four hours. Several faculty members circulate among the students, clarifying, demonstrating, and discussing. Toward the end of the seminar, a final test is taken,
Vol. 116
VIEWBOX SEMINAR:
A NEW
METHOD FOR TEACHING ROENTGENOLOGY
using a third set of films in the same manner as on the preliminary test. 4. Interspersed throughout both days are short presentations on related aspects of the subject, e.g., its clinical and pathological features. 5. A brief questionnaire and critique sheet are distributed to the participants, to be completed before departure Sunday noon. 6. A home study syllabus is subsequently supplied to each participant, intended to provide him with material for future review. He is also given the option of purchasing miniature (10 X 13 cm or 4 X 5 in.) copies of the roentgenograms used at the seminar. 7. A follow-up questionnaire was sent to the participants of the first pneumoconiosis seminar approximately a year later to determine how often the information provided at the seminar had been used and how helpful it had been. RESULTS
It has been impossible to evaluate the actual value or impact of these seminars on the individual student. There is little doubt from the response to the questionnaires that the participants enjoyed them and considered them of great value. They generally rated the method superior to other methods used in similar courses and seminars attended in the past. A few expressed the opinion that the objectives could have been achieved with home-study materials alone. At the first pneumoconiosis seminar, a specific effort was made to measure the change in the level of performance of the participants, comparing statistically the results of the pre- and post-instruction tests. There appeared to be significant improvement in the ability of this group of 200 physicians to recognize the various stages of CWP and to accurately classify them. After instruction at the seminar, the participants raised their scores, on the average, about 20 %. The long term questionnaire provided only a subjective opinion as to improved performance following attendance at the pneumoconiosis course. Some of us were in a position to evaluate the subsequent performance in interpreting CWP chest films by some of the physicians who participated in these seminars, and we were usually disappointed in their performance. It seems naive that we should have expected high quality interpretations after only a two-day session on the subject. DISCUSSION
From the standpoint of interest and enthusiasm, the impact of the viewbox seminars on the participating students is strong, although the effect on their subsequent performance is unclear. Certain unsupported assumptions are probably valid:
77
Education
1. Active student participation, as in these seminars, is better for learning than passive participation, as in lectures. 2. Detailed roentgen patterns are better learned at the viewbox than from word descriptions, slides, or photographic prints. 3. The learning process is enhanced by concomitant close supervision by the instructor, even if he is at the podium. 4. Subjective evaluation of self-improvement is not necessarily accurate. 5. The student learns better if he likes the method of learning; or at least, he is more apt to stay alert. These assumptions, while not scientifically established, seem valid and make it likely that the Viewbox Seminar is a highly effective way to teach certain types of radiology. This is particularly true where subtle roentgen details of patterns must be studied. Weekend scheduling of the seminars is important for adequate attendance, as is the location of the city in which they are held. Many students commented that accessibility of good plane connections, the weekend schedule, and the short duration of the meeting facilitated their participation. In this regard, the ACR Task Force has made a special effort to recruit teachers of national repute with a penchant for excellent podium effectiveness. The participants were particularly pleased with the use of full-size top quality copies of the teaching radiographs. It seemed important that they were working with familiar materials in a familiar context, as well as at their own pace. The sharing of radiographs and illuminators ga,!e each pair of students some degree of helpful support, they claimed. They also agreed that the immediate confirmation of their interpretations provided reinforcement for their newly acquired information. Many felt it particularly important that we made them commit themselves in writing on each case before learning the faculty's opinion. The take-home written materials, especially the home study syllabus, was acclaimed by many, but how much use they made of it was not determined. Almost half the registrants purchased the miniaturized copies of the teaching sets. Except for the pneumoconiosis seminars, attendance was limited to radiologists. Radiology residents were generally excluded, but the few who managed to attend became enthusiastic proponents of the viewbox method. A number of general practitioners in mining communities attended the pneumoconiosis seminars. Their limited background in radiology slowed down the teaching pace. The logistics of an ACR seminar are relatively complex and costly. The reproduction of the sets of teaching radiographs and the purchase of a hundred illuminators with electrical attachments were a large one-time expense. The cost of transportation, handling, and storage
78
BENJAMIN FELSON AND OTHERS
of these materials is considerable. Setting up and breaking down the equipment, travel of the faculty, hotel space, etc., add significantly to the cost. The chest conferences were supported by NIOSH, and no tuition was charged. The seminars dealing with other subjects have not had such support, so that a substantial fee must be charged. Obviously the seminar format described here is not equally applicable to all topics in roentgenology. We do not consider the Viewbox Seminar the best way to learn
July 1975
radiology, but we do believe it to be an excellent way to teach a large group certain subtleties of our specialty. We strongly urge further testing and evaluation of this very promising system of learning.
Department of Radiology College of Medicine University of Cincinnati Medical Center Cincinnati, Ohio 45229
•
Education
Viewbox Seminar: A New Method for Teaching Roentgenology 1 Benjamin Felson, M.D.,2 George Jacobson, M.D.,3 Eugene P. Pendergrass, M.D.,4 Leonard J. Bristol, M.D.,s Otha W. Linton, M.S.J., and Robert W. Harrington, Ph.D. The American College of Radiology designed a "crash" program to train radiologists to interpret and classify the radiological manifestations of coal workers' pneumoconiosis. This Viewbox Seminar combines two pedagogic techniques, group viewbox study, and a test-teach-test sequence of instruction that compels active participation in the learning process. Weekend scheduling and good location and transportation connections facilitate attendance, making this an excellent way to teach large groups of radiologists certain subtleties of radiology in a short time. INDEX TERMS:
Diagnostic Radiology • Education • Radiology and radiologists
Radiology 116:75-78, July 1975
•
• cians with the responsibility of making and interpreting chest roentgenograms on a large number of underground coal miners. The roentgenograms were to be classified by a revised and expanded, but largely unknown, classification of the pneumoconioses that had been developed by representatives of the International Labor Office (ILO), the Union Internationale Contre Ie Cancer (UICC), the British Pneumoconiosis Research Group, and the United States Public Health Service (USPHS) at a meeting held in Cincinnati in 1968. This revision became known as the ILO-UtC Classification. Since there were only four U. S. radiologists (present co-authors) intimately familiar with this classification, and an estimated 100,000 coal miners soon to be surveyed, it was obvious that a "crash" program would be needed to train a large group of physicians to interpret and classify the many anticipated roentgenograms. In response to a request from the National Institute of Occupational Safety and Health (NIOSH) of the USPHS, the ACR contracted to develop educational materials and teaching methods and to conduct seminars to acquaint physicians with the roentgen manifestations and classifications of CWP. Under supervision of a task force, consisting of representatives of NIOSH, the ACR, the American Medical Association, and the American College of Chest Physicians, the present authors were asked to prepare the program, conduct the seminars, and act as instructors. Under the rules set up by NIOSH, participation in a seminar qualified a physician to provide the first interpretation (A reading) of chest roentgenograms on coal workers. It was immediately apparent to us that there were
the past four years, the American College of Radiology (ACR) has presented more than twenty weekend teaching sessions, attended by several thousand physicians, dealing with a variety of problem areas in diagnostic roentgenology. Instead of using the conventional lecture-slide approach, a radically different method was devised. It was called Viewbox Seminar and combined in a unique manner two pedagogic techniques that compel the "student" to participate actively in the learning process. The first of these, simultaneous group viewbox study, was designed to teach the differences between the normal and abnormal roentgenogram and to facilitate the recognition and interpretation of subtle roentgen signs and patterns. The second, a test-teach-test sequence of instruction, was intended to enhance student involvement, motivation, and self-evaluation. The format was originally developed for seminars concerned with the roentgenology of coal workers' pneumoconiosis (CWP)-the Black Lung Seminars. The enthusiastic reception of the method led to its adaptation to seminars on skeletal, gastrointestinal, and pediatric radiology, and it has now become the standard format for many of the weekend teaching seminars conducted on still other topics by the ACR. The following discussion deals with our experience with these sessions, especially with the Black Lung Seminars.
O
VER
BACKGROUND The Coal Mine Health and Safety Act passed by Congress in 1969 presented radiologists and other physi-
1 From the American College of Radiology (B. F., G. J., E. P. P., Fellows; L. J. 8., Member; O. W. L., Director of Washington Office; R. W. H., Director of Education), 20 North Wacker Drive, Chicago, III. 60606. Accepted for publication in March 1975. 2 Present address: Department of ~adiology, Cincinnati General Hospital, Cincinnati, Ohio. 3 Present address: Department of Radiology, University of Southern California, Los Angeles, Calif. 4 Present address: Department of Radiology, University of Pennsylvania, Philadelphia, Penn. S Present address: Saranac Lake, New York. vb
75
76
BENJAMIN FELSON AND OTHERS
Fig. 1.
July 1975
The slide of the master radiograph is projected onto a large screen and specific features are pointed out as the students view a copy on individual viewboxes.
several problems unique to this situation that would require unorthodox solutions. These included (a) the low level of experience with the roentgen aspects of pneumoconiosis of many of the potential students; (b) the subtle nature of the roentgen manifestations of minimal CWP; (e) the absence of typical or "standard" roentgenograms to illustrate the categories of the new classification; and (d) the requirement that we train a large number of physicians rapidly. The need to perceive and study fine roentgenologic details in a setting consonant with normal standard viewing distance made the customary reliance on slide projection or photographs untenable. Yet, the number of people to be trained and the small number of teachers available to train them precluded one-to-one facultystudent consultation at the viewbox. Our dilemma was resolved by the timely development of inexpensive copying equipment and film capable of reproducing accurately and in quantity the fine roentgen detail of the original roentgenogram. Individual illuminators were purchased and master radiographs illustrating the various manifestations of pneumoconiosis were selected and copied in appropriate numbers. It now became possible for a group of 200 physicians to look simultaneously at an excellent copy of the same roentgenogram on a viewbox at the same time, and to be instructed in its interpretation and classification by a teacher on the podium. The next problem was how to proceed with the teaching itself. Since audience participation was already guaranteed by the method of viewing we had adopted, it seemed logical to emphasize self-learning which many educators now consider the best way to learn. To accomplish this, we decided to permit the student to work at his viewbox independently at intervals during the seminar.
A TYPICAL SEMINAR
As the seminars evolved, there were surprisingly'few departures from the original format. The current seminars are conducted as follows: 1. A faculty panel is organized to prepare teaching materials and provide instructors for the subject to be taught. Both faculty and subject are selected by the permanent task force of the AeR. 2. The first session of the seminar is held on a Friday evening, at which time didactic presentations are made by various members of the faculty to the entire student body. 3. On Saturday morning, the test-teach-test session begins. Two students are assigned to each of the 100 viewboxes and given a set of the test films to study and classify. They record their opinions on a worksheet. After the entire group finishes the test films, each radiograph is reviewed from the podium by a faculty member, who projects a slide of the master radiograph on a large screen, pointing out specific features as the student observes them on the copy on his own viewbox (Fig. 1). This preliminary test establishes for each student a baseline against which he can later measure his performance, after the practice and final test sessions. Teaching sessions now follow, utilizing a new set of films. Each student independently studies the same case on his viewbox, recording his findings on his worksheet. The instructor at the podium then discusses the details shown on the roentgenogram, emphasizes the principles illustrated, gives his conclusion, and answers questions. Case after case is studied in this manner for a period of about four hours. Several faculty members circulate among the students, clarifying, demonstrating, and discussing. Toward the end of the seminar, a final test is taken,
Vol. 116
VIEWBOX SEMINAR:
A NEW
METHOD FOR TEACHING ROENTGENOLOGY
using a third set of films in the same manner as on the preliminary test. 4. Interspersed throughout both days are short presentations on related aspects of the subject, e.g., its clinical and pathological features. 5. A brief questionnaire and critique sheet are distributed to the participants, to be completed before departure Sunday noon. 6. A home study syllabus is subsequently supplied to each participant, intended to provide him with material for future review. He is also given the option of purchasing miniature (10 X 13 cm or 4 X 5 in.) copies of the roentgenograms used at the seminar. 7. A follow-up questionnaire was sent to the participants of the first pneumoconiosis seminar approximately a year later to determine how often the information provided at the seminar had been used and how helpful it had been. RESULTS
It has been impossible to evaluate the actual value or impact of these seminars on the individual student. There is little doubt from the response to the questionnaires that the participants enjoyed them and considered them of great value. They generally rated the method superior to other methods used in similar courses and seminars attended in the past. A few expressed the opinion that the objectives could have been achieved with home-study materials alone. At the first pneumoconiosis seminar, a specific effort was made to measure the change in the level of performance of the participants, comparing statistically the results of the pre- and post-instruction tests. There appeared to be significant improvement in the ability of this group of 200 physicians to recognize the various stages of CWP and to accurately classify them. After instruction at the seminar, the participants raised their scores, on the average, about 20 %. The long term questionnaire provided only a subjective opinion as to improved performance following attendance at the pneumoconiosis course. Some of us were in a position to evaluate the subsequent performance in interpreting CWP chest films by some of the physicians who participated in these seminars, and we were usually disappointed in their performance. It seems naive that we should have expected high quality interpretations after only a two-day session on the subject. DISCUSSION
From the standpoint of interest and enthusiasm, the impact of the viewbox seminars on the participating students is strong, although the effect on their subsequent performance is unclear. Certain unsupported assumptions are probably valid:
77
Education
1. Active student participation, as in these seminars, is better for learning than passive participation, as in lectures. 2. Detailed roentgen patterns are better learned at the viewbox than from word descriptions, slides, or photographic prints. 3. The learning process is enhanced by concomitant close supervision by the instructor, even if he is at the podium. 4. Subjective evaluation of self-improvement is not necessarily accurate. 5. The student learns better if he likes the method of learning; or at least, he is more apt to stay alert. These assumptions, while not scientifically established, seem valid and make it likely that the Viewbox Seminar is a highly effective way to teach certain types of radiology. This is particularly true where subtle roentgen details of patterns must be studied. Weekend scheduling of the seminars is important for adequate attendance, as is the location of the city in which they are held. Many students commented that accessibility of good plane connections, the weekend schedule, and the short duration of the meeting facilitated their participation. In this regard, the ACR Task Force has made a special effort to recruit teachers of national repute with a penchant for excellent podium effectiveness. The participants were particularly pleased with the use of full-size top quality copies of the teaching radiographs. It seemed important that they were working with familiar materials in a familiar context, as well as at their own pace. The sharing of radiographs and illuminators ga,!e each pair of students some degree of helpful support, they claimed. They also agreed that the immediate confirmation of their interpretations provided reinforcement for their newly acquired information. Many felt it particularly important that we made them commit themselves in writing on each case before learning the faculty's opinion. The take-home written materials, especially the home study syllabus, was acclaimed by many, but how much use they made of it was not determined. Almost half the registrants purchased the miniaturized copies of the teaching sets. Except for the pneumoconiosis seminars, attendance was limited to radiologists. Radiology residents were generally excluded, but the few who managed to attend became enthusiastic proponents of the viewbox method. A number of general practitioners in mining communities attended the pneumoconiosis seminars. Their limited background in radiology slowed down the teaching pace. The logistics of an ACR seminar are relatively complex and costly. The reproduction of the sets of teaching radiographs and the purchase of a hundred illuminators with electrical attachments were a large one-time expense. The cost of transportation, handling, and storage
78
BENJAMIN FELSON AND OTHERS
of these materials is considerable. Setting up and breaking down the equipment, travel of the faculty, hotel space, etc., add significantly to the cost. The chest conferences were supported by NIOSH, and no tuition was charged. The seminars dealing with other subjects have not had such support, so that a substantial fee must be charged. Obviously the seminar format described here is not equally applicable to all topics in roentgenology. We do not consider the Viewbox Seminar the best way to learn
July 1975
radiology, but we do believe it to be an excellent way to teach a large group certain subtleties of our specialty. We strongly urge further testing and evaluation of this very promising system of learning.
Department of Radiology College of Medicine University of Cincinnati Medical Center Cincinnati, Ohio 45229
