LAUSR

A skeletal survey for child abuse populates the worklist; to many radiology residents it seems the proverbial hot potato— perhaps because it has multiple images, it is perceived to be a tedious exam, or perhaps because it is a relatively uncommon and, at times, challenging study. Regardless, training programs are obliged to ensure residents are adequately trained to recognize and report findings of child abuse. Radiologists undoubtedly have a central role in identifying child abuse. Fractures are the second most common finding after bruising and, importantly, skeletal injuries can be identified on imaging studies obtained with no clinical suspicion for child abuse [1, 2]. Overlooking these fractures, many subtle even to the well-trained eye, could result in continued inflicted trauma and devastating outcomes for these children [3–6]. On the contrary, normal variations unique to young patients can be misinterpreted as injury with potentially — some might contend equally — disastrous results [7–9]. Some radiology practices, including our own, perform double reads of skeletal surveys for these reasons [10]. Given the complexities of such studies, it is of no surprise that non-pediatric radiologists fail to identify a significant number of fractures on skeletal surveys and misinterpret normal variations when compared to fellowship-trained pediatric radiologists [11]. To ensure that radiologists accurately interpret and report child abuse injuries, it is essential to improve not only our practice and research, but foremost our education. The essential role of educating primary care residents and the need to cultivate their skills for recognizing and reporting child abuse have long been established [12–14]. In this issue of Pediatric Radiology, Sharma and colleagues [15] shed light on deficiencies of radiology resident education in identifying child abuse injuries, with unacceptable misinterpretation rates reported irrespective of year of training. Startling findings indicate that only 10% (24/243) of residents suggested child abuse when provided an infant chest radiograph with posterior and lateral healing rib fractures [15]. This enlightening paper is a call to assess and further develop trainee education as well as ensure that graduating residents remain proficient in child abuse imaging. Case conferences, didactic lectures and textbooks are vital to the radiology resident training curricula; however, there is an essential role for interpreting cases at the workstation. Unlike other modalities and exams, the Accreditation Council for Graduate Medical Education (ACGME) does not require a resident to interpret a mandatory number of skeletal surveys or child abuse neuroimaging studies prior to graduation [16]. Our experience at a tertiary-care center with a busy child abuse prevention program revealed that a recent graduating class of 13 radiology residents dictated, on average, 40 skeletal surveys over their 4-year residency. This is likely inadequate experience, particularly because only approximately 20% of these studies are positive and, of those, only few have specific injuries for child abuse [17]. Other residency programs might provide even less experience. Given the variable numbers of these exams performed across institutions, shared teaching files of skeletal surveys and neuroimaging studies could easily be created to ensure all residents have access and opportunity to review a sufficient volume of child abuse cases and pathology. The use of simulated teaching files has already been established and was shown to improve the education of radiology residents in reading mammograms [18]. Residents would have the opportunity to “interpret” these studies over the course of their pediatric radiology rotations and review their findings with the attending radiologist. Following completion of the minimum cases over the course of the rotation or academic year, competency testing could be considered to assess deficiencies. In ensuring this dedicated training, we need to remain cautious so as not to dishearten or discourage residents from * Megan B. Marine [email protected]