PGY3 Breast Imaging rotation

Supervisor: Dr. Connie Hapgood, St. Clare’s

Overall educational goals for the program:
Residents will spend a total of 4 months throughout their rotation working in breast imaging and will be expected to develop general competency in all aspects of breast screening and diagnosis. General competency is defined as the ability to interpret screening and diagnostic mammography, breast ultrasound, and breast MRI; to guide clinical colleagues in the correct imaging evaluation of screening patients as well as diagnostic patients with various clinical breast problems; and to have a working knowledge of breast interventional procedures and breast pathologies. The goal of residency training in breast imaging is to be proficient at screening and diagnostic mammography, breast ultrasound, needle localization procedures, and core biopsy techniques. As well as to develop a working knowledge of breast MRI.
Residents rotate through breast imaging at St. Clare’s hospital. Duties will involve screening and diagnostic mammography/ultrasound, as well as breast MRI and interventional procedures. Trainees will function as a daily member of the breast imaging service while rotating through the various breast imaging duties that comprise the section’s work, including participating in weekly Radiology Pathology rounds. Currently, residents rotate through breast imaging in their third, fourth and fifth year of residency.
The assessment tools utilized during each rotation include an end of rotation exam and ITER. For all breast imaging blocks, a score of 70% must be achieved on the exam.  If not, the exam must be repeated until a score of 70% has been achieved. There will be a mid rotation progress discussion to help guide the resident as needed.
The resident is asked to contribute one interesting case per rotation to the Radiology Breast Imaging teaching file. Review such case with one of the breast Radiologists and then present the case at weekly interesting case rounds. The case is then to be emailed to Dr. Hapgood.
A minimum of 8 daily performance assessment (DPA) cards must be submitted to complete this rotation. This enhances feedback throughout the rotation and comments from the cards will be used on the final ITER for the rotation.
Suggested reading list;
YouTube link for a module on mammographic positioning.

ACR BI-RADS® Atlas Fifth Edition Quick Reference Guide. Available at:
Fundamentals of Diagnostic Radiology by Brant and Helms (Breast chapter).
Clinical breast imaging by Gilda Cardenosa
Breast MRI Diagnosis and Intervention by Morris and Liberman
Breast Imaging: The requisites.
Breast Imaging: Case review series.

Goals and objectives: 
PGY3 breast imaging rotation (1 month):
Medical Expert
Develop an organized approach to dictating a mammographic/breast ultrasound study.
Know the anatomy of the female breast including lymphatic drainage routes and physiologic changes that occur with age, pregnancy and hormone replacement therapy (HRT).
Know the anatomy of the male breast and how it differs from a female. Become familiar with the appearance of gynecomastia on breast imaging.
Understand the difference between and role of screening mammography and diagnostic mammography.
Recognize the commonly used mammographic projections and what constitutes proper
positioning and technique. Observe at least one mammogram being performed by the technologists during the first week of the rotation.
Recognize common mammographic artifacts.
Be able to appraise breast density and describe the risks associated with dense breast tissue.
Be able to localize a lesion within the breast given standard (MLO, CC) and problem solving mammographic views (spot views, true lateral, exaggerated CC).
Identify and classify breast masses, calcifications, architectural
distortions and other abnormalities on mammographic images using the Birads Lexicon.
Develop an understanding of Birads classification with regards to mammography. Distinguish benign features from malignant ones.

Understand the indications, correlation and complications of breast
interventional procedures initially observing and then performing under
supervision of a radiologist. Procedures include:

1. Needle localization with stereotactic or ultrasound
2. Cyst/abscess aspiration
3. Core needle biopsy of a breast mass with stereotactic or
ultrasound guidance
4. Fine needle aspiration biopsy of an axillary lymph node
Be able to localize pathology in a breast lumpectomy specimen.
Develop an understanding of the indications for breast ultrasound.
Develop an understanding of what constitutes adequate sonographic technique with regards to breast imaging.
Be able to correlate mammography and breast ultrasound with regards to lesion localization.
Perform and interpret breast ultrasound examinations under the supervision of a radiologist.
Identify and classify breast masses and other abnormalities on ultrasound using Birads Lexicon.
Recognize common artifacts often encountered in the assessment of a lesion using ultrasound.
Develop an understanding of Birads classification with regards to breast ultrasound. Distinguish benign features from malignant ones.
Introduction to breast MRI imaging.
Introduction to the physics of breast imaging (dedicated teaching in Physics curriculum). 
a) Mechanism of obtaining and optimizing digital mammograms
i) Target/filter combinations
ii) Use of a grid
iii) Reduction of scatter
iv) Radiation dose
b) Adjustment of mammography techniques for special cases, including thin breasts
c) Mechanism of obtaining and optimizing breast US images
d) Mechanism of obtaining and optimizing breast MR images
e) Recognizing, understanding, and correcting artifacts in breast imaging, including mammography, US, and MR imaging
f) Workstation display of digital mammograms
i) Required equipment parameters
ii) Image processing
Computer-assisted display software for breast MRI, including the role of dynamic enhancement characteristics
Know the indications for, perform and interpret galactograms under the supervision of a radiologist.
Develop an organized approach to dictating a mammographic study, breast ultrasound and breast MRI study.
Establish good relationships with other health professionals.
Actively take part in discussions at weekly Radiology Pathology rounds, first week observing then leading rounds under the supervision of a radiologist.
Establish good relationships with the patient and their families. Obtain informed consent for all interventional procedures. Address concerns of the patient and their family members. 

Become an effective consultant of radiology.
Work effectively with other members of the health care team. Interact with house staff, nurses, technologists, booking staff, and other physicians as “first contact” to streamline requests. Staff radiologist always available for consult.
When needed, discuss with booking staff and referring physician the need for additional studies/biopsy and corresponding booking dates.
Help promote patient centered care. Effectively involve the patient in the decision making process whether it be additional radiographic studies, biopsy or consultation with other health professionals i.e. surgery.
Set realistic priorities and use time effectively to optimize professional performance.
Understand the principles of practice management and quality assurance.
Demonstrate effective use, allocation and utilization of health care resources with specific attention to radiology.
Demonstrate competency in ensuring patient safety.
Health Advocate:
Understand the role of breast imaging in screening.
Recognize the radiologist’s role in ensuring all patients receive the appropriate radiological investigation.
Understand and communicate the benefits and risks of radiological intervention and treatment, including screening.
Recognize the effect of over calling findings on the patient’s mental health.
Demonstrate an understanding and a commitment to the need for continuous learning.
Be aware of up to date literature concerning the current staging and Birads classification of breast carcinoma.
 Be up to date on current surgical and medical management techniques with regards to breast pathologies both benign and malignant.
Develop and implement an ongoing and effective personal learning strategy.
Critically appraise medical information and demonstrate basic knowledge in biostatistics and experimental design with respect to breast radiology.
Demonstrate an ability to be an effective teacher of breast radiology. Actively contribute to weekly Rad Path rounds.
Contribute one interesting case per rotation to the Radiology Breast Imaging teaching file. Review such case with one of the breast Radiologists and then present the case at weekly interesting case rounds. Then email the case to Dr. Hapgood.
Practice radiology in an ethical, honest and compassionate manner maintaining the highest quality of care and professionalism to all colleges and patients.
Demonstrate integrity, honesty, compassion and respect for diversity.
Demonstrate reliability and conscientiousness.
Demonstrate an awareness of personal limitations, seeking advice when necessary.
Be committed to the health and well being of all patients, however also understand the importance of one’s own health and well being.
Accept advice graciously.
Fulfill medical, legal and professional obligations of a radiologist.