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2007 ACR Diagnostic Radiology In-Training Exam Rationales

Section VIII General Competency 162. As the prevalence of disease increases in a population, the sensitivity of a diagnostic test: A. increases. B. decreases. C. is unchanged. D. depends on the number of patients tested. RATIONALES: C. Correct. The sensitivity of a diagnostic test describes the test’s ability to detect disease in a population with the disease of interest. It is independent of prevalence, which describes the fraction of the population has the disease of interest. 163. As the prevalence of disease increases in a population, the positive predictive value of a diagnostic test: A. increases. B. decreases. C. is unchanged. D. depends on the number of patients tested. RATIONALES: A. Correct. Positive predictive value refers to the probability that a patient with a positive test result has the disease of interest. As the prevalence of disease increases, the more likely that a patient with a positive test result has the disease of interest.


164. The accuracy of interpretation of pre-operative chest radiographs in a Radiology Department is 98%. Which of the following statements is TRUE? A. The interpretive skills of the department radiologists are of high quality. B. The departmental imaging protocols are of high quality. C. The diagnostic training of residents in the department is of high quality. D. No meaningful inference can be made from the above statement. RATIONALES: D. Correct. Accuracy is defined as the total number of examinations with true positive and true negative test results, out of the entire number of examinations performed, and is influenced by both sensitivity and specificity. Without knowing the sensitivity and specificity of the diagnostic test, no meaningful inference can be made about the accuracy of the test. For example, if you had 100 chest x-rays, two of which demonstrated a lung cancer, but all 100 were read as negative, the sensitivity would be 0% (0 of 2), the specificity would be 100% (98 of 98), and the accuracy would be 98% Accuracy = TP + TN = 0 + 98 = 98% TP + FN + TN +FP 0 + 2 + 98 + 0 165. A study reports that a diagnostic test has a positive predictive value of 90%. What additional information is needed to determine whether a similar positive predictive value can be achieved in your clinical practice? A. Test sensitivity B. Test specificity C. Test accuracy D. Disease prevalence RATIONALES: D. Correct. Positive predictive value increases with disease prevalence. If the disease prevalence in your patient population is significantly lower than in the study population, the same positive predictive value cannot be achieved


166. What is the best ethical argument for full medical disclosure when patients have medical complications, which may have resulted from a physician’s mistake or judgment? A. To resolve patient concerns regarding the unknown etiology of a medical problem B. To avoid disciplinary action from the department chairperson C. To avoid retribution from angry patients or their family members D. To meet the requirements of the hospital/practice risk-management committee RATIONALES: A. Correct. “It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients…Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all of the facts necessary to ensure understanding of what has occurred.” While it may be prudent to inform a department chairperson and risk management committee/appointee of such information, this is not an ethical requirement of the physician. While honest communication with patient and family member often decreases legal liability, this is not an ethical requirement of the physician. References: www.acr.org Education portal, Nonclinical Skills Webcast, Module 5: Ethics section 8.12 “Patient Information,” AMA Council on Ethical and Judicial Affairs, Code of Medical Ethics, Current Opinions, 1998

http://www.acr.org/


167. An ethical commitment or motivation is defined as the: A. desire to comply with an ethical standard of care. B. ability to weigh competing values and motives and commit to a course of action. C. ability to interpret the situation and perceive that one is an ethical “agent” responsible for the welfare of others. D. ability to formulate an ethically ideal course of action and to articulate a well-formed line of reasoning for the position taken. RATIONALES (This Test Item Was Not Scored) A. While the desire to “comply with the ethical standard of care” may be admirable it is not the definition of ethical commitment/motivation. B. Ethical commitment/motivation is defined as “ability to weigh competing values and motives and to commit to what one will actually do; incorporates professional identity or role”. C. Ethical sensitivity is defined as “ability to interpret the situation and perceive that one is an ethical ‘agent’ capable of and responsible for impacting the welfare of others; incorporates identification of ethical issues”. D. Ethical reasoning is defined as “ability to formulate an ethically ideal course of action, to articulate a well-formed ‘justification’ or line of reasoning for the ethical position taken”.


168. The principles of medical ethics adopted by the American Medical Association (AMA) standards of conduct state that a physician shall: A. be obligated to provide care for all patients who seek it. B. be board eligible or certified in a specialty or disclose otherwise to patients. C. support access to medical care for all people. D. only participate in research for which approval has been granted from institutional IRB. RATIONALES: A. Incorrect. The sixth principle of medical ethics adopted by the American Medical Association states “a physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care”. B. Incorrect. The Principles of medical ethics adopted by the American Medical Association do not address board eligibility/certification or disclosure of such information. The fifth principle states “a physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated”. C. Correct. The nineteenth principle of medical ethics adopted by the American Medical Association is “a physician shall support access to medical care for all people”. D. Incorrect. The Principles of medical ethics adopted by the American Medical Association do not directly address research. However, the second principle states “a physician shall uphold the standards of professional interactions…”. The third principle states “a physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient”. References: www.acr.org Education portal, Nonclinical Skills Webcast, Module 5: Ethics

http://www.acr.org/


169. Which of the following statements accurately reflects the American College of Radiology Code of Ethics? A. The determination of whether or not to participate in quality assurance and utilization review is based on the discretion of the radiologist. B. With regard to expert medical testimony, members may accept compensation contingent upon the outcome of litigation. C. Prior to practicing in a hospital or other health-care entity, a radiologist must be board eligible or board certified. D. Members should not enter into an agreement that prohibits the provision of medically necessary care or that requires care at below acceptable standards. RATIONALES: A. Incorrect. The Rules of Ethics from the ACR Code of Ethics state “…A radiologist who regularly interprets radiographs and other images should reasonably participate in quality assurance, utilization review and other matters of policy that affect the quality of patient care…”. B. Incorrect.The Rules of Ethics from the ACR Code of Ethics state “In providing expert medical testimony, members should exercise extreme caution to ensure that the testimony provided is non-partisan, scientifically correct, and clinically accurate. The radiologist or radiation oncologist shall not accept compensation that is contingent upon the outcome of litigation”. C. Incorrect. The Rules of Ethics from the ACR Code of Ethics state “Prior to practicing in a hospital or other health care entity, a radiologist or radiation oncologist shall apply, and be accepted, as a member of that entity’s medical staff in accordance with the medical staff’s bylaws and in the same manner as all other physicians”. D. Correct. The Rules of Ethics from the ACR Code of Ethics state “Members should not enter into an agreement that prohibits the provision of medically necessary care or that requires care at below acceptable standards. Notwithstanding policies of a health plan, radiologists should advocate cost-effective appropriate studies or therapies that will benefit the patient, whose welfare is paramount”. References: www.acr.org, business practice issues, ethics, ACR Code of Ethics

http://www.acr.org/


170. Which of the following statements accurately describes the American College of Radiology Code of Ethics? A. It is a framework by which radiologists may determine the propriety of conduct in their relationship with patients, the public, colleagues, and members of allied professions. B. It is a set of laws that govern the methods by which radiology is practiced in the United States. C. It is composed of principles of ethics with no disciplinary procedures. D. It should be used as a set of guidelines for evaluating a radiologist’s eligibility for state licensure. RATIONALES: A. Correct. The Code of Ethics of the ACR states, “The Code of Ethics of the American College of Radiology is intended to aid the radiology community, individually and collectively, in maintaining a high level of ethical conduct. The code is not a set of laws but rather a framework by which radiologists may determine the propriety of conduct in their relationship with patients, with the public, with colleagues, and with members of allied professions.” The ACR Code of Ethics is composed of three sections, which include: Principles of Ethics, Rules of Ethics, and Disciplinary Procedures for Violation of Rules of Ethics. The ACR Code of Ethics is not intended to be used as criteria for a radiologist’s eligibility for state licensure. References: www.acr.org, business practice issues, ethics, ACR Code of Ethics

http://www.acr.org/


171. Which of the following is TRUE concerning the American College of Radiology practice guidelines on patient care and breast ultrasound? A. An appropriate indication for breast ultrasonography is radiation therapy planning. B. Breast ultrasonography should be performed by a board-certified radiologist only. C. Breast ultrasonography may be performed by a radiation technologist when the attending physician is present. D. Breast ultrasonography may be performed with a real-time scanner that operates at a center frequency of at least 5 MHz. RATIONALES: A. Correct. ACR Practice Guideline for Performing and Interpreting Diagnostic Ultrasound Examination states “Physicians who perform and/or interpret diagnostic ultrasound examinations should be licensed medical practitioners who have a thorough understanding of the indications for ultrasound examinations as well as a familiarity with the basic physical principles and limitations of the technology of ultrasound imaging.” Regarding studies performed by a diagnostic medical sonographer, it states “When a sonographer performs the examination, that person should be qualified by appropriate training to do so. This qualification can be demonstrated by certification or eligibility for same by a nationally recognized certifying body.” Therefore, distractors B and C are incorrect. ACR Guideline for the Performance of a Breast Ultrasound Examination states, “Breast ultrasound should be performed with a high-resolution and real-time linear array scanner operating at a center frequency of at least 7 MHz…” Therefore, answer D is incorrect. Per ACR Practice guidelines, “appropriate indications for breast sonography include: 1. Identification and characterization of palpable and nonpalpable abnormalities and further evaluation of clinical and mammographic findings. 2. Guidance of interventional procedures. 3. Evaluation of problems associated with breast implants. 4. Treatment planning for radiation therapy.” References: www.acr.org, Quality and Safety, Guidelines/Standards, Ultrasound, ACR Practice Guideline for Performing and Interpreting Diagnostic Ultrasound Examinations, ACR Practice Guideline for the Performance of a Breast Ultrasound Examination

http://www.acr.org/


172. Which of the following is TRUE concerning the American College of Radiology Practice Guidelines on patient care and pelvic ultrasound? A. The endometrium does not need to be evaluated in asymptomatic postmenopausal women. B. A transrectal or transperineal approach is useful in patients who cannot tolerate a vaginal probe. C. Transabdominal and transvaginal imaging must both be performed as patient’s initial evaluation at a hospital or health care facility. D. No recommendations specific to an examination performed by male physician or sonographer. RATIONALES: B. Correct. ACR Practice Guidelines for the Performance of Pelvic Ultrasound state “…The endometrium should be analyzed for thickness, focal abnormality, and the presence of fluid or mass in the endometrial cavity. Assessment of the endometrium should allow for variations expected with phases of the menstrual cycle and with hormonal supplementation. If the endometrial stripe is difficult to image or ill-defined, a comment should be added to the report.” Therefore, answer A is incorrect. While initial evaluation with both transabdominal and transvaginal approach is ideal, this is not a requirement of the ACR Practice Guidelines. The ACR Practice Guidelines state “All relevant structures should be identified by the transabdominal or transvaginal approach. In many cases, both will be needed…” Therefore C is incorrect. The ACR Practice Guidelines state “When possible, a female member of the physician or hospital’s staff should be present as a chaperone in the examining room if a male is performing the examination.” Therefore, answer D is incorrect. The ACR Practice Guidelines Specifications of the Examination state “…A Transrectal or transperineal approach is useful in patients who cannot tolerate a vaginal probe (e.g. virgins, postmenopausal women).” Therefore, answer B is correct. References: www.acr.org, Quality and Safety, Guidelines/Standards, Ultrasound, ACR Practice Guideline for the Performance of Pelvic Ultrasound in Females

http://www.acr.org/


173. In the US, the background radiation is approximately 3.6 mSv (360 mrem) per year. Which among the following contributes the MOST towards background radiation? A. Man-made radiation B. Radon exposure C. Cosmic radiation D. Terrestrial radiation RATIONALES: A. Incorrect. Man-made radiation includes medical x-rays, nuclear medicine procedures and others; however it contributes only 18% of the background radiation. B. Correct. Radon exposure accounts for nearly 55% and it arises from earth crust. C. Incorrect. It accounts to only 8% of the background radiation D. Incorrect. It accounts to only 8% of the background radiation References: The Essential Physics of Medical Imaging, 2nd edition. J.T. Bushberg, J.A. Seibert, E.M. Leidholdt, and J.M. Boone, Lippincott Williams & Wilkins (2002), Chap 23, p 748.


174. Which of the tissue is the least sensitive to damage from ionizing radiation? A. Breast tissue B. Skin C. GI tract D. Gonads RATIONALES: A. Incorrect. Breast tissues are highly sensitive to ionizing radiation. B. Correct. Among the tissues listed, skin is the least sensitive to damage. The radiation damage to skin is mostly due to deterministic effect. The skin damage occurs only if the skin receives greater than certain threshold dose (2 Gy) which can results from prolonged fluoroscopy exposure. C. Incorrect. GI tract are highly sensitive to ionizing radiation and is next only to gonadal tissues in terms of sensitivity. D. Incorrect. Gonads are the most sensitive tissues to damage from ionizing radiation References: Radiology Review - Radiologic Physics. Nickoloff EL & Ahmad N, Chapter 15.


175. According to HIPAA, the privacy rule gives patients the right to: A. refuse treatment by a health-care provider. B. refuse release of protected health information (PHI) to Health & Human Services when it is undertaking a compliance investigation or review of enforcement action. C. request disclosure of PHI for a spouse, parent, or child who is older than 18 years of age without requiring consent of said party. D. request that PHI in their records be corrected or changed. RATIONALES: D. Correct. A covered entity MUST disclose PHI (protected health information) in only two situations: a. to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their PHI; and b. to HHS (Health & Human Service) when it is undertaking a compliance investigation or review or enforcement action. Therefore, answer B is incorrect. The Privacy rule does not allow disclosure of PHI of a patient, aged 18 years or older, to a family member without the patient’s consent. Answer A is incorrect. The Privacy rule gives patients the right to: have their PHI protected, inspect and copy their records, request that PHI in their records be corrected or changed, ask for limits on how their PHI is used or shared, ask that they be contacted such as at work and not at home, and get a list of disclosures made of their PHI. The Privacy rule does not specifically address treatment issues or the right to refuse treatment. The Privacy rule sets “national standards for the protection of health information, as applied to the three types of covered entities: health plans, health care clearinghouses, and health care providers who conduct certain health care transactions electronically.” Therefore, answer A is incorrect. References: United States Department of Health & Human Services OCR Privacy summary www.hhs.gov/ocr/hipaaUniversity of Michigan Health Systems HIPAA Learning Module www.med.umich.edu/hipaa

http://www.hhs.gov/ocr/hipaa

http://www.med.umich.edu/hipaa


176. Concerning HIPAA, which of the following information is considered part of the Protected Health Information (PHI)? A. First names of patient’s children B. Photograph of extremity C. Name of employer D. Patient’s e-mail address RATIONALES: Protected Health Information (PHI) includes “individually identifiable health information” and “information that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual”. The first names of a patient’s children cannot be used to reliably identify a patient. Therefore, answer A is incorrect. A full face photograph is considered part of Protected Health Information (PHI). However, a photograph of an extremity cannot reasonably be used to identify an individual. Therefore, a photograph of an extremity is not part of PHI. Answer B is incorrect. The name of a patient’s employer is not part of PHI. Answer C is incorrect. The patient’s e-mail address can be used to identify an individual. E-mal address is part of PHI. Answer D is correct. References: United States Department of Health & Human Services OCR Privacy summary www.hhs.gov/ocr/hipaaUniversity of Michigan Health Systems HIPAA Learning Module www.med.umich.edu/hipaa

http://www.hhs.gov/ocr/hipaa

http://www.med.umich.edu/hipaa


177. The American College of Radiology Practice Guidelines for patient care and stereotactic breast biopsy state that: A. a radiopaque marker or clip must be placed at the time of biopsy. B. physicians participating in stereotactic biopsy of the breast should obtain 3 hours of Category 1 CMEs in stereotactically guided biopsy of the breast every 3 years. C. the referring physician is responsible for obtaining the results of cytopathologic or histopathologic sampling. D. no specific requirements are required for the radiologic technologist participating in stereotactic biopsy of the breast. RATIONALES: B. Correct. While many radiologists place a radiopaque marker/clip at the time of stereotactic breast biopsy, this is not a requirement per the ACR Practice guidelines. The ACR Practice guidelines do state that the physician’s report of the procedure should include “clip placement, if performed”. Therefore, answer A is incorrect. The ACR Practice guidelines state “…Initially, 3 hours of Category 1 CME didactic instruction in stereotactically guided biopsy and performance of at least three stereotactic breast biopsy procedures under the supervision of a qualified physician. Completion of a residency or fellowship program that includes instruction in stereotactic breast needle procedures is also acceptable…The physician should obtain 3 hours of Category 1 CME in stereotactically guided breast biopsy every 3 years…”. Answer B is correct. The ACR Practice guidelines state “…physician who performs the procedure is responsible for obtaining the results of the cytopathologic or histopathologic sampling to determine if the lesion has been adequately biopsied. These results should be communicated to the referring physician and/or to the patient…”. Therefore, answer C is incorrect. The ACR Practice guidelines state the radiologic technologist participating in stereotactic biopsy must have “…Initially, 3 hours of Category A continuing education units in stereotactically guided biopsy, plus documentation of five hands-on procedures under the guidance of a qualified technologist and/or the manufacturer’s application specialist. For maintenance of competence, participation in at least 12 stereotactically guided biopsies per year is recommended…”. Therefore, answer D is incorrect. References: www.acr.org, Quality and Safety, Guidelines/Standards, Breast Imaging and Intervention, ACR Practice Guideline for the Performance of Stereotactically Guided Breast Interventional Procedures

http://www.acr.org/


178. Using the following graph of test performance, which of the following statements is CORRECT? A. A positive test more reliably rules in the diagnosis than a negative test rules out the diagnosis. B. A negative test more reliably rules out the diagnosis than a positive test rules in the diagnosis. C. Test performance is dependent on the underlying population. D. Test performance can not be determined from the information provided. RATIONALES: A. Correct. When a test has a very high sensitivity, a negative result effectively rules out the diagnosis (SnNout). When a test has a very high specificity, a positive result effectively rules in the diagnosis (SpPin). References: Evidence-Based Medicine. Eds: Sackett et al. 2000. Churchill Livingstone.

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