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110. Concerning randomized controlled trials, which one is TRUE?

A. Randomized controlled trials are often performed to prove a hypothesis that one intervention isbetter than another.

B. Intention-to-treat analysis refers to analyzing groups of patients by the treatment they received.

C. Randomization reduces the risk of an imbalance in factors which could influence the clinicalcourse of the patients.

D. Most randomized controlled trials in radiology are double-blinded to reduce bias.

Question #110

Rationale:

Option A is false because equipoise is an ethical prerequisite to a randomized trial. Equipoise refers tothat state of knowledge in which no evidence exists that shows any intervention in the trial is better thananother. B is false because intention to treat analysis refers to analyzing groups of patients by how theyare randomized, regardless of whether or not they received treatment. D is false because most random-ized trials in radiology are open (no blinding) because blinding is usually not feasible or ethical.

Diagnostic In-Training Exam 2006 1

Section V – General CompetencySection V – General Competency

American College of Radiology2

Section V – General Competency

111. Federal policies and regulations regard which one of the following as patient-based(human subject) research?

A. Study comparing the methods and effectiveness of a non-ionic contrast medium in nine separateclinical trials, as reported in peer-reviewed journals

B. Tests from the effectiveness of a new compound for labeling human organs removed cadaversfor use in radiological anatomy classes

C. Study of the routine practices of a given radiology group in order to improve that group’s radio-pharmacy operations

D. Review of medical charts of patients who required emergency pulmonary angiography to see ifmedical outcome correlated with age

Question #111

Rationales:

A. Incorrect. The research uses aggregated and publicly available data, so this is not patient-basedresearch.

B Incorrect. The organs are from non-living individuals and while permission to use is required, theresearch to test the labeling agent is not human subject research.

C. Incorrect. The study methods may be systematic but the conclusions are intended to apply only tothe improvement of the organization’s radiopharmacy service and are not generalizable to other set-tings and so this is not patient-based research.

D. Correct. Systematic review of medical charts with the intent to produce generalizable conclusionsis human subjects research.


112. Which one of the following risk/benefit relationships must you discuss with a patient whenseeking consent for direct care or research intervention?

A. All those inherent in the intervention for society in general

B. Only those that may result directly from the intervention

C. Only those seen in previous administrations/studies with the intervention

D. Only those considered significant by physician or principal investigator

Question #112

Rationales:

A. Incorrect. You must assess only the impact of the specific intervention on subjects and others butnot for society in general.

B. Correct. You must assess only the direct impact of the specific intervention on subjects and others.

C. Incorrect. You must include risks and benefits that might appear for the first time.

D. Incorrect. You must think broadly about risks and benefits and not limit deliberations to those iden-tified by physician or principal investigator.





113. Concerning ethics and research, socioeconomically disadvantaged populations may be morevulnerable to coercion and, therefore,:

A. socioeconomically disadvantaged populations should be discouraged from participation.

B. the burden of research should not fall disproportionately upon such populations.

C. inclusion and exclusion research criteria should include specific socioeconomic criteria.

D. research participants may be included from other geographic areas to ensure specific socioecnomic criteria, regardless of study population.

Question #115

Rationale:

Ethical considerations in clinical research typically focus on the protection of research subjects.Subjects from socioeconomically disadvantaged populations may be more vulnerable to coercion.However, “the benefits from altruism that result from participation in research, particularly for severelychronically ill persons, may justify equitable consideration of historically disadvantaged populationssuch as the poor.” AMA guidelines on the subject selection for clinical trials are: “(1) Although theburdens of research should not fall disproportionately on socioeconomically disadvantaged populations,neither should such populations be categorically excluded, or discouraged, from research protocols. (2)Inclusion and exclusion criteria for a clinical study should be based on sound scientific principles.Conversely, participants in a clinical trial should be drawn from the qualifying population in the generalgeographic area of the trial without regard to race, ethnicity, economic status, or gender.”


114. In receiver operating characteristic (ROC) analysis, the area under the curve represents whatmeasure of diagnostic test performance?

A. Sensitivity

B. Specificity

C. Accuracy

D. Prevalence

Question #114

Rationale:

The area under the ROC curve represents the accuracy of the interpretation of a diagnostic test.





115. Concerning x-ray attenuation, the function of a beam filter is BEST for which reason?

A. Increases x-ray tube output

B. Decreases the heel effect

C. Decreases overall x-ray energy

D. Absorbs undesirable low energy (soft) x-rays

Question #115

Rationales:

A. Incorrect. A filter absorbs a fraction of the x-rays resulting in lower tube output

B. Incorrect. The beam filter in a typical radiography system is uniform in thickness and thus does notmodify the heel effect

C. Incorrect. A beam filter absorbs soft x-rays and hardens the beam, there by increasing the overallbeam energy

D. Correct. The main function of a beam filter is to absorb low energy x-rays (both bremsstrahlungand characteristic x-rays). This hardens the x-ray beam and reduces patient skin dose as low energyx-rays only get absorbed at the skin surface and do not assist in forming an image.


116. Concerning diagnostic tests, which is TRUE?

A. The optimal sensitivity and specificity of a diagnostic test are those values on the ROC curvethat are closest to the upper left hand corner (100% sensitivity and 100% specificity).

B. Specificity refers to the probability of a positive test result in a patient with disease.

C. Negative predictive value refers to the probability of a negative test result in a patient withoutdisease.

D. As the sensitivity threshold of a diagnostic test increases, the specificity of the diagnostic testdecreases.

Question #116

Rationale:

Option A is false because the optimal sensitivity and specificity of a diagnostic test is based on the dis-ease of interest and the consequences of a positive or negative test result. Option B is false becausespecificity refers to the probability of a negative test result in a patient without disease. Option C isfalse because Negative predictive value refers to the probability of not having the disease of interest in apatient with a negative test result.



117. Consider the following hypothetical 2 x 2 table generated from a study on diagnostic testperformance:

The _________________ is calculated as 40/100 or 40%

A. positive predictive value

B. negative predictive value

C. sensitivity

D. specificity

Question #117

Rationale:

When a 2 x 2 table, like the one above, is generated from a study of a disease specific risk factor, theupper left row percent (Yes & Disease Positive / All Yes = 50/100=50%) is called the ‘risk’ of disease.When the same table comes from the study of a diagnostic test, the upper left row percent is called the‘positive predictive value’. Therefore, the correct answer is A (risk, positive predictive value). B and Care obviously untrue because of the definition of ‘sensitivity’ and ‘attributable risk’. Answer D is incor-rect, because specificity has no meaning for a study of a risk factor.

Disease Positive Disease Negative

Test Positive 40 60

Test Negative 10 90



118. You obtain a complete list of ALL lower extremity venous ultrasounds done at your hospitalover the past year. There were 200 that were positive for DVT. The results of D-Dimer bloodtests done on these patients within 24 hours of the ultrasound are available for 100 patients. Ofthese, 90 were positive and 10 were negative. What is the sensitivity of the D-Dimer blood testfor DVT as diagnosed by ultrasound?

A. 75% in all populations

B. 75% in the tested population

C. 90% in all populations

D. 90% in the tested population

Question #118

Rationale:

The problem is that only half of the disease positive cases had the D-Dimer test results available. Youhave no way of knowing the test status of the other 100 disease positive cases; the other 100 casesmight have been all negative or all positive on the D-Dimer test. Hence the estimate of D-Dimer testsensitivity can best be estimated in only in the tested population.



119. Summary receiver operating characteristic (SROC) curve analysis is the technique of choice formeta-analysis of diagnostic test accuracy studies when:

A. sensitivity and/or specificity are homogeneous.

B. sensitivity and/or specificity are heterogeneous.

C. sensitivity and specificity are negatively correlated.

D. sensitivity and specificity are positively correlated.

Question #119

Rationale:

Options A, B and D are incorrect. When preparing data for analysis, correlation testing (Spearman orPearson) must be performed for a threshold effect, which occurs if sensitivity and specificity are nega-tively correlated. In that situation, SROC analysis is performed to account for dependence of diagnosticaccuracy on study-specific positivity thresholds. If SROC analysis is not tenable, homogeneity testing isperformed after which homogeneous data are summarized by fixed-effect methods and heterogeneousdata by random effects methods.



120. Even if earlier diagnosis has no effect on the time of death from disease, survival time mayappear longer in patients who have undergone screening. What is this apparent increase in survivalknown as?

A. Lead time bias

B. Length bias

C. Overdiagnosis bias

D. Increased intensity of screening bias

Question #120

Rationale:

Lead time bias pertains to comparisons between screened and non-screened patients that are not adjust-ed for the timing of diagnosis. If the cancer is detected earlier but early diagnosis has no effect on thetime of death from disease, there is no actual survival benefit.



121. The purpose of screening is to prevent or delay the development of advanced disease and itsadverse effects. What is the MOST appropriate outcome measure in the evaluation of screeningeffectiveness?

A. Number of disease cases identified

B. Survival from time of diagnosis

C. Overall mortality

D. Disease specific mortality

Question #121

Rationale:

Screening aims to prevent or delay the effects of advanced disease. Depending on the contribution ofdisease-specific mortality to overall mortality, significantly reducing the death rate from a disease maystill have an almost immeasurable effect on the overall mortality rate. Thus, disease specific mortalityreduction is the most appropriate outcome measure in the evaluation of screening effectiveness.



122. Regarding the Privacy Rule established by the Health Insurance Portability and AccountabilityAct (HIPAA), which one statement is TRUE?

A. Only primary care providers must give patients an understandable notice of the ways in whichProtected Health Information will be used and disclosed.

B. The Privacy rule covers Protected Health Information for as long as the patient is alive.

C. The rule affects Protected Health Information in paper form.

D. Patient authorization is required when Protected Health Information is used and disclosed forresearch purposes.

Question #122

Rationale:

Option A is false because HIPAA covers all health care providers. Option B is false because the ruleapplies for as long as the covered entity (health care provider, health plan, or health care clearinghouse)retains the individual health information. Decedents’ health information is protected by this rule. OptionC is false because the rule affects protected Health Information in electronic, paper, or verbal form.



123. Concerning HIPAA, which of the following is considered part of the Protected HealthInformation (PHI)?

A. Nickname

B. Number of children

C. Vehicle identification number

D. Photograph of extremity

Question #123

Rationales:

A. Incorrect. Protected Health Information (PHI) includes “individually identifiable health informa-tion” and “information that identifies the individual or for which there is a reasonable basis tobelieve can be used to identify the individual”. Name is PHI. Nickname is not part of PHI.

B. Incorrect. Protected Health Information (PHI) includes “individually identifiable health informa-tion” and “information that identifies the individual or for which there is a reasonable basis tobelieve can be used to identify the individual”. The number of children a patient has cannot be usedto reliably identify a patient.

C. Correct. 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 canbe used to identify the individual”. Vehicle identification number can be used to identify an individ-ual. Therefore, VIN is part of PHI.

D. 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.



124. Concerning HIPAA, which of the following requires written authorization prior to disclosure ofProtected Health Information (PHI)?

A. Treatment, payment & health care operations

B. Public health activities

C. Psychotherapy notes

D. Cadaveric organ, eye, or tissue donation

Question #124

Rationales:

A. Incorrect. Permitted uses and disclosures of PHI include disclosure to related treatment, payment,and health care operations activities.

B. Incorrect. Disclosure for national priority purposes is permitted without authorization, includingdisclosure to public health authorities by law to collect and receive such information for disease pre-vention and control. Disclosure for FDA regulation and control of communicable diseases does notrequire authorization.

C. Correct. Disclosure of psychotherapy notes requires individual’s authorization with the followingexceptions: 1) originating covering entity may use notes for treatment or 2) covering entity maydisclose for own training or for legal defense in proceedings originated by individual, for HHS toinvestigate compliance with Privacy Rules, to avert imminent threat to public health or safety, or forlawful activities or medical examiner or coroner.

D. Incorrect. PHI may be disclosed without authorization to facilitate donation and transplantation ofcadaveric organs, eyes and tissue.



125. For general radiographic equipment, which of the following parameters is specified by regulatorylimits?

A. Maximum kVp

B. Maximum exposure rate

C. Minimum mA

D. Minimum beam half-value-layer

Question #125

Rationales:

A. Incorrect. There are no limits on kVp. Note that chest radiography has been performed at severalhundred kVp, and radiation therapy linear accelerators operate at tens of MV.

B. Incorrect. There are no limits on maximum exposure rate. Higher exposure rates permit shorterexposure times for a given mAs resulting in less motion blurring.

C. Incorrect. There are no limits on minimum mA. There is a limit on minimum exposure rate in mam-mography, but not mA.

D. Correct. Regulator limits from the FDA for x-ray medical devices, and from state regulations for x-ray generating equipment require a certain minimum x-ray beam filtration or measured beam half-value-layer, with the amount dependent on the kVp range of the equipment.



126. You interpret a pre-op chest radiograph performed on a 56-year-old man. There are nocomparison studies. There is a non-calcified 7-mm nodule in the left upper lobe, and the rest ofthe examination is negative. What is the MOST appropriate strategy to take concerning reportingthis case?

A. Dictate the findings, sign the report, and do nothing else

B. Contact the referring physician, convey the findings, and dictate the report to include language documenting your discussion

C. Dictate the findings, sign the report, and fax a copy to the referring physician’s office

D. Contact the patient directly without notifying the referring physician, tell him the findings, andarrange for him to come into your facility for chest CT scan for further evaluation

Question #126

Rationale:

This is exactly the sort of situation anticipated by the ACR Guideline on Communication in the sectiondealing with an “unexpected finding”. Option B is correct in that it conforms most closely to the ACRGuideline recommendations. The strategy articulated in answer A is one that the ACR Guideline isspecifically meant to discourage. Faxing a copy of the report (option C) may be convenient. However,faxes are imperfect means of communication and you have no record that the intended recipient actual-ly got the information and is a potential HIPAA violation. Although directly communicating with thepatient (option D) is listed in the ACR Guideline as an option when a responsible physician—or theiragent—cannot be contacted, ACR Guidelines recommend that reasonable attempts to contact the refer-ring physician be made.



127. At 7:30 A.M., you interpret a CT scan of the abdomen done for abdominal pain, fevers, and diar-rhea as being entirely negative. You phone the ER physician, and dictate a report that documentsyour conversation as well as the negative result. At lunch the same day, a surgical colleague tellsyou that she removed an inflamed appendix from the patient at 9:00 A.M. Upon returning fromlunch, you look at the CT scan again, and now see a subtle 7-mm tubular structure parallel to theterminal ileum. What is the LEAST appropriate action to take when you later electronically editand sign your report of this case?

A. Correct any spelling / grammar errors, leave the original content alone, and sign

B. Modify the report to include your new observation and sign

C. Add a paragraph to the report detailing your retrospective review, describing the new finding,and documenting your conversation with the surgeon

D. Sign the original report, and generate a separate addendum detailing your retrospective review,the new finding, and the conversation with the surgeon

Question #127

Rationales:

Options A, C, and D are all supportable depending on your personal philosophy and local policyabout handling errors of interpretation. All departments should have a mechanism for recording andreviewing such ‘problem cases’ and submission to this process would be reasonable in this situation.Option B is wrong on several levels, not the least of which, is that it is intellectually dishonest.Modifying a dictated report to fit subsequent clinical findings is especially problematic when a substan-tially different interpretation was verbally communicated and acted upon by the referring physician.



128. The ACR recommends that the interpreting physician communicate a significant change betweenpreliminary and final radiology reports directly to which individual?

A. Patient

B. Patient representative

C. Referring physician

D. Hospital attorney

Question #128

Rationales:

A. Incorrect. Reports are sent directly to patient if they are self-referred and have no physician ofrecord. However, the radiologist should recognize the potential obligations of assuming the care andtreatment of such patients and the necessity of appropriate follow-up.

B. Incorrect. While patient representatives deal with issues of quality of care and patient satisfaction,they are not providers and should not receive patient care documents.

C. Correct. In the absence of the referring physician, it may be necessary to communicate very urgentinformation to his/her designee or an appropriate individual in a manner that reasonably ensuresreceipt of findings.

D. Incorrect. Legal experts are not routine recipients of medical reports.



129. Concerning patient care, early (first-trimester) obstetric ultrasound demonstrates unexpected fetal demise. The attending radiologist is on-site and confirms the findings. Which one of thefollowing is the MOST appropriate action for the radiologist?

A. Dictate the final report and have technologist discharge patient from the department.

B. Notify the referring clinician and discuss the findings with the patient according to the directionof the referring clinician.

C. Inform the patient that the scan is abnormal and have the technologist discharge the patient fromthe department.

D. Notify the referring clinician of the findings and have the technologist discuss the findings withthe patient.

Question #129

Rationales:

A. Incorrect. In the setting of clinically significant unexpected findings, the referring clinician shouldbe notified of the results and recommendations per the ACR Practice Guideline for Communication:Diagnostic Radiology.

B. Correct. The referring clinician should be notified of the results and recommendations. Per theACR Practice Guideline for Communication: Diagnostic Radiology, “in those situations in whichthe interpreting physician feels that the finding do not warrant immediate treatment but constitutesignificant unexpected findings, the interpreting physician or his/her designee should communicatethe findings to the referring physician, other healthcare provider, or an appropriate individual in amanner that reasonably insures receipt of the findings.”

C. Incorrect. In the setting of clinically significant unexpected findings, the referring clinician shouldbe notified of the results and recommendations per the ACR Practice Guideline for Communication:Diagnostic Radiology.

D. Incorrect. It is not appropriate to have the technologist discuss the findings with the patient.



130. Concerning full disclosure after a medical error occurs, which one of the following is CORRECT?

A. It may avoid further harm through appropriate treatment.

B. It often harms patient-doctor trust and weakens patient-doctor relationship.

C. Honest communication often increases legal liability.

D. It is inappropriate for patients who do not desire this information.

Question #130

Rationales:

A. Correct. This is an important reason for full disclosure

B. Incorrect. May maintain patient-doctor trust and strengthen patient-doctor relationship

C. Incorrect. Honest communication often decreases legal liability

D. Incorrect. Truth telling respects patient autonomy



131. Concerning ethics, when a patient suffers a medical complication, that may have resulted fromthe physician’s mistake or judgment the physician is ethically required to:

A. inform the patient’s primary care physician of the facts.

B. report the facts to the department chairperson.

C. inform the patient of the facts necessary to understand what has occurred.

D. inform the hospital/practice risk management committee/appointee.

Question #131

Rationale:

“It is a fundamental ethical requirement that a physician should at all times deal honestly and openlywith patients…Situations occasionally occur in which a patient suffers significant medial complicationsthat may have resulted from the physician’s mistake or judgment. In these situations, the physician isethically required to inform the patient of all of the facts necessary to ensure understanding of what hasoccurred.” Ideally, the physicians should inform the patient and primary care physician of the factswhen medical complications occur. However, the physician is not ethically required to inform thepatient’s primary care physician. While it may be prudent to inform a department chairperson and riskmanagement committee/appointee of such information, this is not an ethical requirement of the physi-cian.



132. Concerning patient care, a supervising physician is necessary for the performance of an exami-nation for which intravascular contrast material is administered. Which of the following fulfillsthe minimal necessary requirements for the supervising physician?

A. Fellowship training in diagnostic radiology, which includes interpretation of contrast-enhancedstudies

B. Board certification in radiology or 6 months formal dedicated training in the interpretation and formal reporting of general radiographs

C. Licensed physician who demonstrates sufficient knowledge of pharmacology, indications, andcontraindications for the use of contrast agents

D. Medical degree or doctor of osteopathy

Question #132

Rationales:

ACR Practice Guideline for the Use of Intravascular Contrast Media state the supervising physicianneeds to a licensed physician with the following qualifications:

Certification in Radiology, Diagnostic Radiology, or Radiation Oncology by the American Board ofRadiology, the American Osteopathic Board of Radiology, the Royal College of Physicians andSurgeons of Canada or Le College des Medecins du Quebec.

Or

The physician shall have documented a minimum of 6 months of formal dedicated training in the inter-pretation and formal reporting of general radiographs, including patients of all ages, in an AccreditationCouncil for Graduate Medical Education (ACGME), approved residency program including radiograph-ic training on all body areas.

Or

The physician whose residency or fellowship training did not include the above may still be consideredqualified to administer contrast media provided the physician can demonstrate sufficient knowledge ofthe pharmacology, indications, and contraindications for the use of contrast agents to enable safeadministration and has the ability to recognize and initiate treatment for adverse reactions.

And

The physician supervising a contrast-enhanced imaging study should be familiar with the various con-trast agents available and the indications for each. The physician should also be familiar with the patientpreparation for the examination, including any necessary hydration or bowel preparation. She/he shouldhave an understanding about the volume and concentration of the appropriate contrast material requiredfor a given examination (see the ACR Manual on Contrast Media).

While Board certification in Radiology or 6 months of formal training in the interpretation and formalreporting of general radiographs meet the requirements, these exceed the minimal requirement and arenot the best answer. Fellowship training in a Diagnostic Radiology fellowship including the interpreta-tion of contrast enhanced studies is not a requirement to serve as supervising physician of a contrastenhanced study. MD and DO do not meet the minimal requirements to serve as the supervising physi-cian for a contrast enhanced study. A physician who, demonstrates sufficient knowledge of pharmacolo-gy, indications and contraindications for the use of contrast agents, meets the minimal requirement toserve as the supervising physician.



133. Professionalism is best defined as including the ability to demonstrate high standards of ethicaland moral behavior and which one of the following?

A. Awareness of one’s importance in providing care

B. Self-awareness and knowledge of limits

C. Delegation skills for assigning tasks to others

D. Ability to reach consensus regarding patient care

Question #133

Rationale:

Professionalism does not include an awareness of one’s importance (option A), or consensus agreementregarding patient care (option D). Professionalism includes respect for patient dignity and autonomy.



134. Concerning the American College of Radiology, which one of the following statements is true?

A. Its accreditation program defines how various radiological procedures should be performed.

B. Its Appropriateness Criteria® define the most appropriate way to diagnose or treat a given clini-cal condition with diagnostic/interventional radiology or radiation oncology.

C. Its certification program issues certificates to candidates who demonstrate adequate levels ofknowledge and ability on a written examination (Physics of Medical Imaging and DiagnosticImaging sections) and an oral examination.

D. Its Guidelines and Technical Standards program documents that standards are being met for vari-ous modalities in a practice using a survey process.

Question #134

Rationales:

Option A is false because the Standard Program defines how various radiological procedures should beperformed. Option C is false because The American Board of Radiology, not the American College ofRadiology, issues certificates to candidates in Diagnostic Radiology. Option D is false because theAccreditation program documents that Standards are being met.



135. What is the objective of ACR practice guidelines?

A. Ensure a successful outcome from radiological interventions

B. Establish legal standards for radiological practice

C. Assist radiologists in providing appropriate care

D. Ensure accurate radiological diagnosis

Question #135

Rationales:

Options A, B and D are incorrect. These guidelines are an educational tool designed to assist practition-ers in providing appropriate radiological care for patients. They are not inflexible rules or requirementsof practice and are not intended, nor should they be used, to establish a legal standard of care. The vari-ety and complexity of human conditions make it impossible to always reach the most appropriate diag-nosis or to predict with certainty a particular response to treatment. It should be recognized, therefore,that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. It isexpected that practitioners will follow a reasonable course of action based on current knowledge, avail-able resources, and the needs of the patient to deliver effective and safe medical care. The sole purposeof these guidelines is to assist practitioners in achieving this objective.



23204998

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