No matter what specialty they go into, medical students need to acquire a basic understanding of radiology and its use in contemporary medical practice. First, they need to know what tests to order. Should the patient with head trauma receive radiographs of the skull? What imaging test is most appropriate in a patient with an acute abdomen? What if the patient is pregnant? When should IV contrast material be ordered for a CT scan of the head?

Students also need to acquire basic skills in image interpretation so that they are adequately prepared for postgraduate training. It is embarrassing to be an intern in the emergency department who has no clue how to read a chest radiograph. Particularly in situations in which radiologic interpretation is not immediately available, students should learn to recognize urgent radiologic findings such as a malpositioned endotracheal tube, pneumothorax, pneumoperitoneum, and a large intracranial hemorrhage. In view of the integral role of radiology in contemporary medicine, how can medical schools presume to be doing a good job educating the next generation of physicians when their students receive little or no formal instruction in radiology?

Radiology provides an excellent forum in which to learn some of the most basic principles of medical reasoning. Many medical schools suppose they are providing adequate instruction in this area through courses in such subjects as biostatistics, but often nothing could be further from the truth. Divorced from the context of patient care and overly reliant on mathematic techniques, many biostatisticians leave medical students bewildered or simply cold, with little in the way of practically usable knowledge or skills. By contrast, radiology provides a context in which students can stop trying to juggle abstract probabilistic techniques and instead focus on integrating clinical features and imaging findings in the context of real cases. In the setting of lung cancer detection, what is the sensitivity, specificity, and accuracy of chest radiography and how does it compare with CT? What are the effects of pretest probability of disease, such as whether the patient has a long smoking history, and how does such information apply to the different contexts of screening and diagnosis? What roles in this equation are played by benefits such as prolonged survival and costs such as lost productivity? How can we assess the larger effectiveness and efficiency of diagnostic testing? Most importantly, how do these concepts pertain to this particular patient for whom we are thinking of ordering a chest radiograph?

Equally important, radiology provides an excellent forum in which to address the widely neglected topics of health promotion, disease prevention, and community health. The clinical curricula of many medical schools are focused almost exclusively on the diagnosis and treatment of disease in individual patients, a situation in which medicine's performance is mixed, at best. For example, the 5-year mortality rate of approximately 90% for bronchogenic carcinoma, the number one cancer killer in the United States, has changed relatively little over the past few decades. Approximately 90% of such cancers are attributable to cigarette smoking, and one of the most important predictors that a patient will attempt to quit smoking cigarettes is being advised to do so by a physician. Even when so advised, however, 90% of such attempts end in failure. The chest radiographs, CT scans, and nuclear medicine studies commonly used to diagnose, stage, and monitor progression of lung cancers provide medical students with vivid pictures of the insidious and relentless modus operandi of this disease, conferring on public health statistics an immediacy they might otherwise lack. Moreover, these images deserve wider use in such contexts as patient counseling and public health education, in which current smokers can be more effectively persuaded to kick the habit and school children can be more strongly dissuaded from ever adopting it. When people see firsthand what smoking can do to the human body, they are more inclined to take its risks seriously. A related discussion in which medical students need to be involved is the proposed use of chest CT to screen smokers for early-stage lung cancer, including such issues as the design of clinical trials, the potential biases of screening programs, and various methods for measuring their costs and benefits. Medical students should learn to think of health not only in terms of individual patients but populations as well. Radiology provides an excellent forum in which to discuss such principles.

Through exposure to radiology, students can learn the importance of communication, a vital but frequently neglected art in contemporary medical education. When a physician orders an imaging study, what sort of information should be provided? Is it enough to tell the radiologist that the study is being performed to rule out pneumonia, or does the radiologist need to know about fever, cough, chronicity of the complaints, and any underlying medical conditions? What sort of output should the referring physician expect to receive from the radiologist, and what is the effect of the quality of this output on the referring physician's ability to formulate a specific question or questions? What information is truly relevant in helping the radiologist to determine which examination to perform, how to perform it, or even whether an imaging examination is really indicated in the first place? What diagnostic information from the radiologist is truly relevant to the care of the patient, and how can that information be conveyed in a way that optimizes the contribution radiology makes to that larger objective? By showing students what can go wrong when communication is poor and the advantages offered by high-quality communication, we can show students important lessons that extend far beyond the confines of radiology