Radt12 Janfeb V83i3 CT

RADIOLOGIC GIC
Journal of the American Society of Radiologic Technologists Vol. 83, No. 3
COMPUTED TOMOGRAPHY EDITION
Inaugural
CT Issue!
Read more on page 215.
January/February 2012
Using Athletic Training Clinical Education Standards in Radiography Perceptions of the Use of Critical Thinking Teaching Methods Emotional Intelligence in Health Care Computed Tomography Angiography
American Society of Radiologic Technologists
An Official Journal Radiologic Technology (ISSN 0033-8397) is the official scholarly/professional journal of the American Society of Radiologic Technologists. It is published bimonthly at 15000 Central Ave SE, Albuquerque, NM 87123-3909. Months of issue are January/February, March/April, May/June, July/ August, September/October and November/ December. Periodical class postage paid at Albuquerque, NM, and at additional mailing offices. Printed in the United States. 2012 American Society of Radiologic Technologists. The research and information in Radiologic Technology are generally accepted as factual at the time of publication. However, the ASRT and authors disclaim responsibility for any new or contradictory data that may become available after publication. Opinions expressed in the Journal are those of the authors and do not necessarily reflect the views or policies of the ASRT. Postmaster Postmaster: Send change of address to Radiologic Technology, c/ the American Society of o Radiologic Technologists, 15000 Central Ave SE, Albuquerque, NM 87123-3909. Editorial Radiologic Technology is a peer-reviewed journal produced by the American Society of Radiologic Technologists for the benefit and advancement of all technological disciplines within medical imaging and radiation therapy. Editorial correspondence should be addressed to Radiologic Technology Editor at communications @asrt.org, 505-298-4500, or 15000 Central Ave SE, Albuquerque, NM 87123-3909. Letters of inquiry prior to finished manuscript production are encouraged and frequently may be reviewed by both the editor and the chairman of the Editorial Review Board. The initials R.T. following proper names in this journal refer to individuals certified by the American Registry of Radiologic Technologists. Subscriptions, Change of Address ASRT member change of address: Address correspondence to the American Society of Radiologic Technologists, Attention: Member Services, 15000 Central Ave SE, Albuquerque, NM 87123-3909. Call the ASRT office from 8 a.m. to 4:30 p.m. Mountain time at 800-444-2778; fax 505298-5063. ASRT members also can submit changes of address online at www.asrt.org/myinfo. Nonmember subscriber change of address: Send an old mailing label and the new address, including ZIP code, at least 6 weeks in advance to ASRT, Attention: Member Services, 15000 Central Ave SE, Albuquerque, NM 87123-3909. Claims are not allowed for issues lost as a result of insufficient notice of change of address. The publisher cannot accept responsibility for undelivered copies.
Subscription rates and order processing: Member subscription is $7.49 per year, included in ASRT member dues. Nonmember subscription of one volume of 6 issues is $70 within the United States for individuals; foreign, $105, including Canada. Institutional rates also are available. Discounted rates apply to 2- and 3-year subscriptions and subscription agencies. Single issues, both current and back, exist in limited quantities and are offered for sale. For prices and availability, visit www.asrt.org/store or phone ASRT Member Services at 800-444-2778. Journal orders must be paid in advance by check, money order, or credit card drawn on a U.S. bank in U.S. funds only. Send payment to ASRT, PO Box 27447, Albuquerque, NM 87125-7447. Prices are subject to change. Advertising All commercial display advertising and classified advertising is handled by the ASRT Corporate Relations Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909. For information on rates and deadlines, contact Robin Treaster at 800-444-2778, Ext. 1317, or e-mail adsales@asrt.org. Radiologic Technology reserves the right to reject or revise any advertising copy that it considers objectionable, either because said copy is not consistent with usual professional standards of propriety or for any other reason deemed material. In any event, the advertiser assumes full liability for the content of all advertising copy printed. All advertising materials submitted become the property of ASRT. Advertisements submitted beyond the deadline for proof service are done so at the advertisers risk. Publication of an advertisement in Radiologic Technology does not imply endorsement of its claims by the editor or publisher. For advertising specifically related to educational programs, ASRT does not guarantee, warrant, claim or in any way express an opinion relative to the accreditation status of said program. Rights Reserved All articles, illustrations and other materials carried herein are pending copyright under U.S. copyright laws, and all rights thereto are reserved by the publisher, the American Society of Radiologic Technologists. Any and all copying or reproduction of the contents herein for general distribution, for advertising or promotion, for creating new collective works or for resale is expressly forbidden without prior written approval by the publisher and, in some cases, the authors. Copying for personal use only through application and payment of a per-copy fee as required by the Copyright Clearance Center, under permission of Sections 107 and 108 of the U.S. copyright laws. Violators will be prosecuted.
Member of BPA International
214
January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY
New!
Computed Tomography
Edition
This is the rst issue of the CT edition of Radiologic Technology. The new targeted CT edition printed four times per year will help you develop your skills and stay current with advancing technology to enhance patient care.
Five CT CE Credits Per Year,
Guaranteed!
You will still receive a minimum of 12 CE credits each year to meet your ARRT CE requirement.
Find out more about the new CT-targeted edition of Radiologic Technology at
www.asrt.org/CT.
Radiologic Technology Editorial Review Board
Chairman Nina K Kowalczyk, PhD, R.T.(R)(CT)(QM), FASRT The Ohio State University Columbus, Ohio Vice Chairman James Johnston, PhD, R.T.(R)(CV) Midwestern State University Wichita Falls, Texas Members Laura Aaron, PhD, R.T.(R)(M)(QM) Northwestern State University Shreveport, Louisiana Melissa B Jackowski, EdD, R.T.(R)(M) University of North Carolina Chapel Hill, North Carolina Jeffrey S Legg, PhD, R.T.(R)(CT)(QM) Virginia Commonwealth University Richmond, Virginia Tricia Leggett, DHEd, R.T.(R)(QM) Zane State College Zanesville, Ohio Rebecca Ludwig, PhD, R.T.(R)(QM), FAEIRS, FASRT University of Arkansas for Medical Sciences Little Rock, Arkansas
Michael E Madden, PhD, R.T.(R)(CT)(MR) Fort Hays State University Hays, Kansas Kimberly Metcalf, EdD, R.T.(R)(T)(MR) Massachusetts General Hospital Institute of Health Professions Boston, Massachusetts Dwayne Richardson, MSN, R.T.(R), RN Hahnemann University Hospital Philadelphia, Pennsylvania Joan E Siederer, MPH, R.T.(R) Princeton, New Jersey Christina A Truluck, PhD, R.T.(N), CNMT Thomas Jefferson University Philadelphia, Pennsylvania Bettye G Wilson, MEd, R.T.(R)(CT), RDMS, FASRT University of Alabama at Birmingham Birmingham, Alabama Ben D Wood, MSRS, R.T.(R) Northwestern State University Shreveport, Louisiana
ASRT Journal Staff
Lisa Kisner, scientific journal editor Kim Agricola, scientific journal editor Jenna Frosch, associate editor Charles Poling, director of communications Ellen Lipman, director of professional development
Julie James-Griego, art director Marge Montreuil, graphic designer Laura Reed, graphic designer Loren Stacks, graphic designer
ASRT Office
15000 Central Ave SE Albuquerque, NM 87123-3909 Phone: 800-444-2778; Fax: 505-298-5063 For questions regarding subscriptions or missing issues, phone Member Services at 800-444-2778 or e-mail memberservices@asrt.org.
For advertising information, contact Robin Treaster, advertising and sponsorship coordinator, at Ext. 1317 or adsales@asrt.org. For questions about submitting an article, e-mail communications@asrt.org.
216
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTENTS
January/February 2012
Volume 83/Number 3
P EE R- RE VIE WE D ARTICL E S
Using Athletic Training Clinical Education Standards in Radiography Shelley Giordano, Katherine Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Perceptions of the Use of Critical Thinking Teaching Methods Nina Kowalczyk, Ruth Hackworth, Jane Case-Smith . . . . . . . . . . . . . . . . . . . . 226
D I R E CTE D RE ADIN G ARTICL E S

Emotional Intelligence in Health Care Kathryn Faguy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
On the Cover: A coronary computed tomography angiogram with intravenous contrast material becomes an old autumn tree when painted with cadmium red leaves. Cardiac Roots is the third painting in a radiograph landscape series by Lizzy Rainey, R.T.(R), of Lafayette, Indiana. The twisting roots represent the cardiac vessels highlighted by the dye.
Computed Tomography Angiography Bryant Furlow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261CT
C OL U MN S & DE PARTME N TS
My Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Writing & Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 On the Job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Teaching Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Open Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Patient Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3
217CT
. . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................
peer review
Using Athletic Training Clinical Education Standards in Radiography

SHELLEY GIORDANO, DHSc, R.T.(R)(MR) KATHERINE HARRIS, PhD
Background The selection of clinical education sites for radiography students is based on availability, access to radiographic examina-
tions, and appropriate student-to-technologist ratio. Radiography program directors are not required to evaluate sites based on their educational validity (eg, the clinical instructors knowledge of basic teaching and learning principles, how well the site communicates with the program, or the clinical instructors involvement in professional organizations). purpose The purpose of this study was to determine if a set of 12 clinical education standards used in athletic training would be applicable and beneficial to radiography program directors when selecting clinical sites for students. Methods A survey concerning the applicability of the athletic training standards to radiography site selection was completed by 270 directors of radiography programs accredited by the Joint Review Committee on Education in Radiologic Technology. results The survey results indicated the athletic training clinical education standards were considered applicable to the selection of clinical sites for radiography students and would be beneficial to radiography program directors when selecting sites.
variety of educational institutions offer radiography programs, including but not limited to certificate, associate, and baccalaureate degree programs. Regardless of the type of educational institution, all radiography programs are required to provide access to clinical instruction. Although some radiography programs such as hospital-based programs may offer clinical instruction at the institutions affiliated hospital or satellite facilities, most clinical sites are not affiliated with the institution. Prior to student placement, programs have to search for available sites, develop affiliations, and seek approval from the Joint Review Committee on Education in Radiologic Technology (JRCERT).1 According to Weidner and Laurent,2 the selection of clinical sites often is based on convenience, not educational validity, to secure student placement when the programs options are limited. The clinical education of radiography students is most similar to that of athletic training students; clinical instructors of both programs use a competencybased system and evaluation.3 Giordano compared athletic training programs to radiography programs and determined aspects of athletic training clinical education would be applicable to radiography clinical education.3 The research discussed a set of 12 standards developed by Weidner and Laurent2 to assist in the
218
selection of athletic training clinical sites that would provide educational value to the student. Currently, there are no specific standards set forth by JRCERT for the selection of clinical sites in radiography.1 The selection process requires completion of a JRCERT form to gain formal site recognition. The form only evaluates access to exams, number of available radiography rooms, and number of clinical staff to determine clinical capacity. The reason for determining clinical capacity is to ensure access to educational opportunities; however, there is no evaluation of the other aspects of clinical education important to the overall experience of the student. These other aspects include the clinical instructors professional behavior, mentoring skills, and involvement in professional activities or associations. The purpose of this research is to determine if the 12 standards developed by Weidner and Laurent2 would be applicable and beneficial to the selection of clinical sites in radiography.
Literature review
Clinical Education For many allied health programs, including radiologic technology, the clinical education site is an extension of didactic instruction and an integral part of the students education.4,5,6 The clinical setting is a vital component of the curriculum; it complements the
...........................................................................................................
GIORDANO, HARRIS
classroom learning experience.7,8 Clinical education gives students the opportunity to apply theory to practice and develop professional attitudes.9 Students entering radiography programs expect to be placed in clinical sites that provide adequate and appropriate instruction and ample opportunity for practice.8 The clinical site and, more importantly, the clinical instructor are key components in the integration of theory and practice and the success of the student.9,10 An effective clinical site could be created by effective clinical instructors; however, the effectiveness of clinical instructors varies significantly by site and can be unpredictable.9,11 According to Sand-Jecklin,11 this variability may create a negative learning environment for the student. Historically, the selection of clinical sites has been based on placing students where there is availability, not on the learning opportunities offered. This creates an environment where students participate in clinical study, but may not receive adequate clinical education.2 Clinical Site Selection The research by Giordano concluded that the clinical education of athletic training students was similar to that of radiography students, based on the determination that both programs use clinical instructors for evaluation of clinical competency.3 Because of this similarity, Giordano concluded that aspects of athletic training clinical education would be applicable to radiography clinical education. Clinical education, regardless of the field of study, provides students with handson experiences that complement didactic information.4 The selection of clinical education sites across programs was often random, fulfilling the programs need for student clinical placement without considering the educational value of the site.2 Weidner and Laurent developed 12 standards to help athletic training programs identify quality clinical sites for student instruction (see Box).2 Weidner and Laurent concluded that the standards should be used as a guide for athletic training programs when determining the validity of a clinical site.2 In addition, the authors stated the standards should not be applied as a set of minimum requirements for the selection of a clinical education setting; on the contrary, they should be used to aid in the overall evaluation of a site, including: Effectiveness of the clinical instructors. Communication between the site and educational program. Learning opportunities and resources available.
Use of the standards also would help programs identify administrative support required for student clinical placement, including release time for clinical instructors and methods of communication between the program and clinical site. In addition, the standards could be used to encourage clinical instructors to get involved in professional activities such as associations and conferences. As a follow-up to the development and testing of the standards, Laurent and Weidner researched the usefulness of the standards on the overall education and professional development of the student.12 The original purpose of the standards was to evaluate the overall site; the follow-up study was performed to determine whether application of the standards would aid in the professional development of the student. According to Laurent and Weidner, student professionalism primarily developed during clinical education rotations, thus supporting the use of the standards when choosing a clinical education setting.12 Selection of a clinical site using the standards would decrease the risk of chance learning and increase the probability of sites being selected on the basis of educational opportunities. Laurent and Weidner determined that use of the standards contribute to the development of a wellprepared, professional, entry-level athletic trainer; in addition, the effectiveness of the standards, as written, applied to all types of clinical education settings.12
Methods
Because the 12 standards developed by Weidner and Laurent2 were written for evaluation of athletic training clinical sites, the standards had to be modified to reflect radiography-specific clinical education. Modification of these standards did not change the purpose or intent of each standard. A Likert scale survey was developed to evaluate each standard in 3 areas: clarity of the standard, applicability to radiography, and benefit to radiography clinical site selection. In addition, 4 demographic questions were included. The Institutional Review Board at Quinnipiac University in Hamden, Connecticut, approved the survey for distribution to program directors of JRCERTaccredited radiography programs. The authors contacted the JRCERT for e-mail contacts of all program directors for radiography programs only; a contact list was provided in Excel (Microsoft Corporation, Redmond, Washington) format. The e-mail contacts for all program directors were imported into SurveyMonkey (Palo Alto, California), from which the survey was sent
219
...........................................................................................................
CLINICAL EDUCATION STANDARDS
Box Standards for Clinical Education in Athletic Training2

Standard 1: The clinical education setting provides an active, stimulating environment appropriate for the learning needs of the student. Standard 2: Clinical education programs are planned to meet specific objectives of the educational program and the individual student. Standard 3: The clinical education setting has a variety of learning experiences available to students. Standard 4: The clinical instructors practice ethically and legally. Standard 5: The clinical education setting demonstrates administrative interest in and support of athletic training clinical education. Standard 6: Communications within the clinical education setting are effective and positive. Standard 7: The clinical instructors are adequate in number to provide a good educational program for students. Standard 8: One clinical instructor with specific qualifications is responsible for coordinating the assignments and activities of the students at the clinical setting. Standard 9: Clinical instructors are selected based on specific criteria. Standard 10: Clinical instructors apply the basic principles of education, teaching, and learning to clinical education. Standard 11: The clinical instructors are interested and active in professional associations related to athletic training. Standard 12: Adequate space for study, conference, and treating athletes/ patients is available to students.
universities (13.8%), and other types (6.4%). The degree type awarded most often was the associate degree (65.2%), followed by certificate (32.9%), baccalaureate degree (8.3%), and other degrees (1.9%). Total responses are greater than 100% because some programs awarded more than 1 type of degree. Geographic representation also was noted, with 36.9% of respondents from the Southern region, 30.3% from the Midwest, 14.0% from the mid-Atlantic region, 7.0% from New England, 9.2% from the Southwest, 1.9% from the Northeast, and 0.6% from other areas. The final demographic question was related to the number of active clinical education sites used by each program. More than 60% of programs used 10 clinical sites or fewer, 35.4% used 0 to 5 sites, and 33.4% used 6 to 10 sites. The remainder included 15.9% with 11 to 15 sites, 8.0% with 16 to 20 sites, and 7.3% with 20 or more sites.
to the 629 accredited radiography program directors. The survey was available through a hyperlink in the e-mail message for 20 days. A reminder e-mail to all those who did not complete the survey was sent through SurveyMonkey 11 days after the original e-mail request. Data analysis included descriptive statistics generated by SurveyMonkey. Cross-tabulations using Excel were reviewed to assess whether program type, degree offered, or geographic region influenced the answers to the 3 questions about the 12 standards.
results
Of the 629 accredited radiography programs invited to participate in the study, 314 initiated the survey and 270 completed it. The overall survey response rate was 49.9%, with a completed survey rate of 42.9%. Demographics Table 1 presents the demographics of the radiography programs that participated in the survey. Types of programs included community colleges (60%), hospital-based programs (29.8%), 4-year colleges/
220
Responses to Specific Standard Questions The survey requested respondents answer 3 questions for each standard: 1. Rate the overall clarity of the standard. (Possible responses included: very clear, clear, somewhat clear, entirely not clear, and undecided.) 2. As written, this standard is applicable to clinical site selection and evaluation in radiography programs. (Possible responses included: strongly agree, agree, disagree, strongly disagree, and undecided.) 3. The standard would be beneficial during clinical site selection or evaluation. (Possible responses included: strongly agree, agree, disagree, strongly disagree, and undecided.) In response to question 1, the majority of program directors noted that the overall clarity of all 12 standards, as written, was clear or very clear, ranging from 62.2% for standard 1 (The clinical setting provides an active, stimulating environment appropriate for the learning needs of the student) to 83.1% for standard 3 (The clinical education setting has a variety
...........................................................................................................
GIORDANO, HARRIS
Table 1 Demographic Data

Characteristicsa Community college Hospital-based 4-year college/university Other Degree Offeredb Associate degree Certificate Baccalaureate degree Other Geographic Location Southern Midwest Mid-Atlantic Southwest New England Northwest Other No. of Active Clinical Sites 0-5 6-10 11-15 16-20 20 or more
a
All respondents n = 314 (%) 156 (50.0) 93 (29.8) 43 (13.8) 20 (6.4) 204 (65.2) 103 (32.9) 26 (8.3) 6 (1.9) 116 (36.9) 95 (30.3) 44 (14.0) 29 (9.2) 22 (7.0) 6 (1.9) 2 (0.6) 111 (35.4) 105 (33.4) 50 (15.9) 25 (8.0) 23 (7.3)
students). Table 3 shows how question 2 was answered for each of the 12 standards. The majority of responses to question 3 were agree or strongly agree that all 12 standards would be beneficial during clinical education site selection and evaluation, ranging from 55.3% for standard 11 (The clinical instructors are interested and active in professional associations related to radiography) to 85.4% for standard 7 (Clinical instructors are adequate in number to provide a good educational program for the students). Table 4 shows how question 3 was answered for each of the 12 standards. Data also was analyzed to determine if program type, number of clinical sites, geographic region, or a combination, influenced the answers to the questions. Regardless of demographic data collected, the majority of respondents indicated the overall clarity of the standard was clear or very clear. Regardless of demographic data collected, the majority of respondents also indicated they agreed the standard was applicable to clinical site selection and evaluation in radiography. Finally, regardless of demographic data collected, the majority of respondents indicated the standard would benefit their particular program.
Discussion
The purpose of this research was to determine if the 12 clinical education standards developed by Weidner and Laurent2 for athletic training clinical site selection would apply to clinical site selection for radiography programs. Currently, the JRCERT requires an application process for determining whether a clinical site can be used by a radiography program. However, this process occurs after a site has been identified and determined by the program to be valuable. No mechanisms or guidelines are in place for radiography programs to assess the value of a site prior to requesting JRCERTs approval. The 12 standards developed by Weidner and Laurent are meant to provide guidance for programs on selecting sites that offer appropriate education opportunities, student mentoring, professional behavior modeling, currency on clinical practices, and willingness to work with educational programs to properly instruct students. Based on the responses of 42.9% of program directors from JRCERT-accredited radiography programs, the standards may be of benefit for the selection of clinical sites that meet the current needs of radiography students. The results of the survey demonstrated all 12 standards were considered clear
221
Not all respondents answered all questions. b Respondents could answer more than 1 question.
of learning experiences available to students). Table 2 shows how question 1 was answered for each of the 12 standards. Responses to question 2 indicated the majority agreed or strongly agreed that all 12 standards were applicable to clinical education site selection and evaluation in radiography programs, ranging from 57.3% for standard 11 (The clinical instructors are interested and active in professional associations related to radiography) to 88.9% for standard 3 (The clinical education setting has a variety of learning experiences available to
...........................................................................................................
Table 2 Responses to Question 1: Clarity of the Standard

Question 1: Clarity Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Standard 8 Standard 9 Standard 10 Standard 11 Standard 12 Very Clear n (%) 43 (14.8) 56 (19.9) 79 (28.4) 65 (23.7) 70 (25.5) 57 (21.2) 73 (26.9) 67 (24.6) 53 (19.5) 49 (18) 41 (21.1) 69 (25.6) Clear n (%) 138 (47.4) 164 (58.2) 152 (54.7) 120 (43.8) 140 (51.1) 146 (54.3) 128 (47.2) 138 (50.7) 122 (44.9) 146 (53.7) 163 (61.1) 151 (55.9) Somewhat Clear n (%) 82 (28.2) 46 (16.3) 34 (12.2) 64 (23.4) 42 (15.3) 45 (16.7) 42 (15.5) 42 (15.4) 49 (18.0) 48 (17.6) 29 (10.7) 26 (9.6) Entirely Not Clear n (%) 9 (3.1) 6 (2.1) 5 (1.8) 9 (3.3) 6 (2.2) 4 (1.5) 14 (5.2) 7 (2.6) 22 (8.1) 8 (2.9) 5 (1.9) 7 (2.6) Undecided n (%) 19 (6.5) 10 (3.5) 8 (2.9) 16 (5.8) 16 (5.8) 17 (6.3) 14 (5.2) 18 (6.6) 26 (9.6) 21 (7.7) 14 (5.2) 17 (6.3)
Total % may not equal 100% because of rounding.
or very clear by the majority of respondents. Also, regardless of program type, geographic location, or number of clinical sites used, the majority of respondents found the standards to be applicable to radiography education and believed the standards would be beneficial to their program. The standards developed by Weidner and Laurent2 include criteria currently included in the clinical site selection process and designation of clinical instructors by radiography programs as mandated by the JRCERT. However, 5 standards (1, 5, 6, 10, and 11) address the evaluation of important aspects of the clinical education setting currently not required of radiography programs. The majority of respondents believed these 5 standards were clear or very clear. The standards evaluate the learning environment, how supportive the administration is of student clinical placement, how well the site communicates with the education program, the clinical instructors knowledge of basic teaching and learning principles, and the clinical instructors involvement in professional organizations. The evaluation of sites based on these standards may help ensure radiography students are exposed to a positive, educationally beneficial experience. The clinical instructors will be knowledgeable about how to
222
teach and adapt to different learning styles, the site will support the student and work closely with the program to meet the needs of the student, and the clinical instructors will recognize the value of involvement in professional organizations. As previously stated, the selection of clinical sites often is performed based on convenience and not how well the site educates students.2 The JRCERT requires that programs use Form 104R, an application form for formal recognition of a new radiography clinical education site.1 The form requests site information, including room and equipment identification (eg, emergency department, mobile, and surgery), and technologists assigned on a Monday through Friday schedule. The program does not calculate clinical capacity or the number of students that can be assigned to the site; JRCERT determines that number based on a 1:1 technologist-tostudent ratio and the number of rooms and equipment available.1 Calculation of clinical capacity by JRCERT is meant to ensure appropriate access to learning opportunities for the student. Although the determination of clinical capacity is important to ensure education opportunities, especially when radiography clinical education is competency based, it does not evaluate the overall experience of the student in a clinical setting. In
...........................................................................................................
GIORDANO, HARRIS
Table 3 Responses to Question 2: As written, this standard is applicable to clinical site selection and evaluation in radiography programs
Question 2: Applicable Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Standard 8 Standard 9 Standard 10 Standard 11 Standard 12 Strongly Agree n (%) 42 (14.7) 40 (14.4) 73 (26.4) 67 (24.4) 59 (21.5) 53 (19.6) 81 (29.8) 57 (21.0) 46 (16.9) 41 (15.1) 32 (11.9) 58 (21.7) Agree n (%) 181 (63.5) 199 (71.6) 173 (62.5) 140 (50.9) 161 (58.8) 163 (60.4) 150 (55.1) 143 (52.6) 144 (52.9) 163 (59.9) 122 (45.4) 142 (53.2) Disagree n (%) 20 (7.0) 11 (4.0) 7 (2.5) 25 (9.1) 11 (4.0) 11 (4.1) 11 (4.0) 25 (9.2) 29 (10.7) 22 (8.1) 52 (19.3) 18 (6.7) Strongly Disagree n (%) 4 (1.4) 2 (0.7) 5 (1.8) 5 (1.8) 1 (0.4) 2 (0.7) 5 (1.8) 9 (3.3) 6 (2.2) 3 (1.1) 11 (4.1) 7 (2.6) Undecided n (%) 40 (14) 26 (9.4) 19 (6.9) 39 (14.2) 42 (15.3) 41 (15.2) 25 (9.2) 38 (14.0) 48 (17.6) 45 (16.5) 53 (19.7) 42 (15.7)
addition to addressing access to learning opportunities, Weidner and Laurent examined other factors that influence the clinical education of a student (standard 3).2 According to Steves, clinical education is more than the teaching of skills to radiographers.7 Clinical education also encompasses modeling professional behaviors, integrating theory into clinical practice, and preparing students for future employment. A clinical site also must have instructors who can properly evaluate student performance, provide constructive criticism, and encourage student questioning. The clinical setting allows students to apply knowledge taught in the classroom, but it also provides an opportunity to learn how to function as a member of the health care team. Although the student capacity determination is beneficial when examining access to radiologic procedures, it does not determine the overall effectiveness of the site. The degree requirement for entry-level radiographers is changing to an associates degree as of January 1, 2015. The American Registry of Radiologic Technologists stated that the clinical setting will have an increased effect on the education of radiography students who will need to learn proper communication skills and understand social and psychological behaviors
and how these behaviors influence health care delivery.13 Clinical instructors will need to model these skills, which will be imperative to the learning proficiency of the student. The primary role of the clinical setting in radiography has traditionally been to teach technical skills to students and evaluate competency of those skills. As the profession begins to evolve, the role of the clinical site also needs to evolve and determining appropriateness of a site needs to expand beyond convenience and opportunities to perform examinations. In addition, the determination of clinical capacity as a measure of access to learning opportunities will no longer be appropriate. The 12 standards developed by Weidner and Laurent evaluate a site not only on access to clinical cases, but also the ethical behaviors of the staff and their professionalism, ability to teach and model appropriate skills including but not limited to radiography skills and involvement in professional societies that foster continued learning.2 Radiography program directors can use the 12 standards to select sites offering a well-rounded clinical experience that provides not only access to radiographic examinations, but also access to individuals who epitomize the qualities necessary to be a professional radiographer.
223
...........................................................................................................
Table 4 Responses to Question 3: The standard would be beneficial during clinical site selection or evaluation
Question 3: Beneficial Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Standard 8 Standard 9 Standard 10 Standard 11 Standard 12 Strongly Agree n (%) 34 (13.0) 39 (15.5) 65 (25.9) 70 (27.9) 64 (25.7) 56 (22.8) 79 (32.1) 52 (21.1) 48 (19.6) 42 (16.9) 31 (12.6) 54 (22.0) Agree n (%) 158 (60.5) 175 (69.4) 163 (64.7) 123 (49.0) 133 (53.4) 141 (57.3) 131 (53.3) 124 (50.2) 121 (49.4) 141 (56.9) 105 (42.7) 129 (52.4) Disagree n (%) 20 (7.7) 17 (6.7) 8 (3.2) 19 (7.6) 12 (4.8) 14 (5.7) 11 (4.5) 22 (8.9) 32 (13.1) 21 (8.5) 50 (20.3) 18 (7.3) Strongly Disagree n (%) 8 (3.1) 2 (0.8) 6 (2.4) 4 (1.6) 0 (0.0) 3 (1.2) 5 (2.0) 10 (4.0) 4 (1.6) 4 (1.6) 12 (4.9) 8 (3.3) Undecided n (%) 42 (16.1) 19 (7.5) 11 (4.4) 35 (13.9) 40 (16.1) 32 (13.0) 20 (8.1) 39 (15.8) 40 (16.3) 41 (16.5) 48 (19.5) 37 (15.0)
Recommendations There was limited research available related specifically to the selection and evaluation of clinical sites in radiography and this was a major limitation for this study. Another limitation of the study was the research available on how well clinical sites meet program and student learning objectives. Additional research should be performed to evaluate the methods used by program directors when selecting clinical sites and how well those sites meet the learning objectives of the program and student. JRCERT-accredited radiography programs are required to complete an application form to receive formal recognition of a clinical site prior to student clinical placement. It may be beneficial for program directors to use the 12 standards as a guide to determine which clinical sites will not only allow for student placement, but also provide the best overall clinical education experience for the student. Application of the standards may help reduce site selection based on convenience or access to examinations and focus the process on the overall educational value of the site. Future research should be performed to determine if radiography students overall education has improved because of the application of these standards when
224
selecting clinical sites. This research should compare the traditional method of selecting sites, including the JRCERTs recognition process, to the use of the standards to select a site in conjunction with the JRCERT process for recognition. The 2 methods should be compared to determine if a difference exists in the learning proficiencies of the students in the following areas: clinical skills; communication skills; knowledge of social and psychological behaviors and their effect on health care; and overall professional behaviors.
Conclusion
The purpose of this research was to determine if the clinical education standards developed for clinical site selection in athletic training were clear to program directors and applicable to radiography clinical education. The majority of survey respondents concluded the standards were both clear and applicable. Historically, educational programs have selected clinical sites for radiography students based on need rather than the quality of education offered at the site. Radiography programs are required to follow a formal recognition process to receive site approval prior to student placement; however, the process only examines the sites clinical capacity (eg, access to
...........................................................................................................
GIORDANO, HARRIS
clinical cases and appropriate supervision of students). Evaluation of the overall quality of education offered is not required. The 12 standards developed to evaluate clinical sites in athletic training, when modified for radiography clinical education, may be beneficial for site selection. The standards address not only the examination opportunities of the site, but also the involvement of the clinical instructors in professional organizations, commitment of the sites administration to education, clinical instructors knowledge of basic teaching and learning principles, and how well the clinical site communicates with the program.
of employed, entry-level certified athletic trainers. J Athl Train. 2002;37(suppl 4):S248-S254. 13. American Registry of Radiologic Technologists. 2015: associate degree requirements FAQs. www.arrt.org/FAQ /Associate-Degree-Requirement. Accessed March 2, 2011.
references
1. Application for recognition of a clinical education setting in radiography form 104R. JRCERT website. www .jrcert.org/acc_forms_radiography.html. Accessed March 2, 2011. 2. Weidner TG, Laurent T. Selection and evaluation guidelines for clinical education settings in athletic training. J Athl Train. 2001;36(1):62-67. 3. Giordano S. Improving clinical instruction: comparison of literature. Radiol Technol. 2008;79(4):289-96. 4. Coker CA. Consistency of learning styles of undergraduate athletic training students in the traditional classroom versus the clinical setting. J Athl Train. 2000;35(4):441-444. 5. Carr W, Drummond JL. Collaboration between athletic training clinical and classroom instructors. J Athl Train. 2002;37(suppl 4):S182-S188. 6. Moreno M, White ED, Flores ME, Riethmayer J. Student perceptions of clinical mistreatment. Radiol Technol. 2001;73(1):18-24. 7. Lauber CA, Toth E, Leary PA, Martin RD, Killian CB. Program directors and clinical instructors perceptions of important clinical-instructor behavior categories in the delivery of athletic training clinical instruction. J Athl Train. 2003;38(4):336-41. 8. Price R, Hopwood N, Pierce V. Auditing the clinical placement experience. Radiography. 2000;6:151-59. 9. Steves AM. Improving the clinical instruction of student technologists. J Nucl Med Technol. 2005;33(4):205-209. 10. Weidner TG, Henning JM. Development of standards and criteria for the selection, training, and evaluation of athletic training approved clinical instructors. J Athl Train. 2004;39(4):335-343. 11. Sand-Jecklin K. Assessing student nursing perceptions of the clinical learning environment: refinement and testing of the SECEE inventory. J Nurs Meas. 2009;17(3):235-246. 12. Laurent T, Weidner TG. Clinical-education-setting standards are helpful in the professional preparation
Shelley Giordano, DHSc, R.T.(R)(MR), is an associate professor and the department chair of the diagnostic imaging program at Quinnipiac University in Hamden, Connecticut. She can be reached at shelley.giordano@quinnipiac.edu. Katherine Harris, PhD, is an associate professor in the physical therapy program at Quinnipiac University. The authors would like to acknowledge Alicia Giaimo, MHS, ROT, R.T.(R)(M)(BD), assistant clinical professor of diagnostic imaging, for her assistance with the creation of the survey tool and the International Review Board approval process.
225
. . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................
peer review
Perceptions of the use of Critical Thinking Teaching Methods

NINA KOwALCzYK, PhD, R.T.(R)(CT)(QM), FASRT RuTH HACKwORTH, MS, R.T.(R)(T) JANE CASE-SMITH, EdD, OTR/L, FAOTA
Objective To identify the perceived level of competence in teaching and assessing critical thinking skills and the difficulties facing radiologic science program directors in implementing student-centered teaching methods. Methods A total of 692 program directors received an invitation to complete an electronic survey soliciting information regarding the importance of critical thinking skills, their confidence in applying teaching methods and assessing student performance, and perceived obstacles. Statistical analysis included descriptive data, correlation coefficients, and ANOVA. results Responses were received from 317 participants indicating program directors perceive critical thinking to be an essential element in the education of the student; however, they identified several areas for improvement. A high correlation was identified between the program directors perceived level of skill and their confidence in critical thinking, and between their perceived level of skill and ability to assess the students critical thinking. Key barriers to implementing critical thinking teaching strategies were identified. Conclusion Program directors value the importance of implementing critical thinking teaching methods and perceive a need for professional development in critical thinking educational methods. Regardless of the type of educational institution in which the academic program is located, the level of education held by the program director was a significant factor regarding perceived confidence in the ability to model critical thinking skills and the ability to assess student critical thinking skills.
dvances in technology create challenges in the radiologic science profession, making critical thinking skills essential for quality patient care in the clinical environment. In this study, critical thinking is defined as meaningful, unbiased decisions or judgments based on the use of interpretation, analysis, evaluation, inferences, and explanations of information as it relates to the evidence applied to a specific discipline.1 Critical thinking skills are developed through education, practice, and experience. Therefore, the educational process must foster the development of the critical thinking skills required for current clinical practice, which requires educators to move from a teacher-centered approach to a learner-centered approach. This study seeks to identify the perceived level of competence in teaching and assessing critical thinking skills and the difficulties facing radiologic science program directors in implementing student-centered teaching methods.
Literature review
According to the literature found, the nursing profession embraced the concept of critical thinking long before the radiologic sciences profession. However, this review demonstrates that although nursing has a well-developed concept and definition of critical thinking, nursing educators have not demonstrated significant improvement of critical thinking skills in their graduates.2,3 Research shows educators continue to focus instruction on providing practice information rather than teaching reasoning and problem solving. Therefore, graduates have limited ability to analyze problems, adapt techniques, and make decisions in clinical practice.4,5 According to Mangena and Chabeli,6 many obstacles impede the use of critical thinking by nursing educators and students. In the study, focus group interviews were conducted with 7 educators and 12 fourth-year nursing students to explore and describe their perceptions of critical thinking in nursing education. One obstacle identified by the group was that
226
...........................................................................................................
KOwALCzYK, HACKwORTH, CASE-SMITH
some educators lacked adequate knowledge of critical thinking. Additionally, educators were uncomfortable with the transition from a teacher-centered to learnercentered approach to education when outcomes-based education was emphasized in the educational program, and this inadvertently caused some resistance to the change in instruction. Instructors also had difficulty incorporating critical thinking skills when student groups had a low level educational background.6 Shell conducted a survey of 262 baccalaureate program nurse educators about their perceptions of barriers that hindered the implementation of critical thinking strategies.7 She concluded that faculty encounter several barriers when incorporating critical thinking strategies into curriculum. The greatest barrier is students lack of motivation and resistance to active learning. Instructors also identified time constraints when trying to prepare and plan critical thinking activities because they could not find ample time in the classroom to incorporate the task. The amount of content or factual information required in the courses was overwhelming to both the instructor and student, leaving little time to incorporate critical thinking activities. Shell concluded that the nursing educators were only slightly confident in their knowledge of how to promote critical thinking in nursing students, and they felt additional education in critical thinking teaching methods was needed.7 In a study conducted by Raymond and ProfettoMcGrath,8 educators identified positive and negative factors that influenced their use of critical-thinking strategies in the classroom. Positive influences included faculty development opportunities, administrative support, freedom to experiment with new ideas, and mentorship. The negative barriers to implementation included intensive workloads, strict content delivery, lack of time for new ideas, fellow faculty members who were unreceptive to critical thinking, and students who displayed negative attitudes toward critical thinking teaching methods used in class. Educators not only need assistance in developing critical thinking skills but also would benefit from strategies used to combat the negative interaction with students and peers.8 OSullivan et al9 conducted a survey of deans and directors of nursing programs regarding successful implementation of critical thinking strategies within the classroom. Results of the survey indicated only 20 percent of the undergraduate nursing programs implemented critical thinking strategies. Difficulty in developing methods to teach critical thinking was the common
cause for the lack of implementation, as well as the resistance of faculty to change their teaching style.9 Walsh and Seldomridge10 explored the role and place of critical thinking in an undergraduate nursing program and examined whether critical thinking was being strengthened or diminished in the classroom and clinical sites. They identified several issues in reinforcing the importance of critical thinking in nursing education. It is understood that educators realize the role they play in developing students critical thinking skills, yet instructors are under significant pressure to cover content material required of the profession within a limited time frame. As a result, lecture seems to be the strategy most often used by nursing instructors.10 However, students need not only the content material to understand their profession, but also instruction on how to critically analyze this new knowledge. Clearly a new paradigm is needed, as students can learn in many ways other than lecture. In the radiologic sciences, a review of literature corroborates the fact that the profession lags behind other professions such as medicine and nursing in adopting critical thinking teaching methods. Much of the instruction requires memorization of information rather than synthesis and application of knowledge.11 Critical thinking is most effective when educators embed it into subjects already taught. The literature indicates instructors must change from passive, instructor-centered methods to active, student-centered learning such as small group activities, reflective journal writing, case studies, debates, and poster presentations.6,11 Although some radiologic science educators have applied critical thinking techniques in their classroom and clinical environment, little research has been conducted in this population. Until radiologic science educators can define the skills needed and the obstacles they face to promote critical thinking skills, this concept may not be fully embraced by the radiologic sciences.
Objectives
Critical thinking is an important concept in education; however, educators must be willing and able to change their teaching methods to foster the development of critical thinking skills in radiologic science graduates. Therefore, the purpose of this study was to identify radiologic science program directors perceptions of their current level of competence in teaching and assessing critical thinking skills and to identify the difficulties encountered when implementing student227
...........................................................................................................
CRITICAL THINKING TEACHING METHODS
centered teaching methods. This study sought to answer the following research questions: 1. What is the perceived level of confidence in the use of teaching strategies and assessment of critical thinking in the classroom and clinical setting? Is the education level of the program director related to the ability to teach and assess critical thinking skills? 2. What level of importance is placed on the use of critical thinking in the classroom and clinical setting? Does the importance placed on critical thinking relate to the type of academic institution in which the program is located? Is the age of the program director related to his or her perceived importance of critical thinking? 3. What is the perceived level of skill in using critical thinking teaching methods in the classroom? 4. To what extent do certain factors impede the use of strategies and assessment of critical thinking in the classroom?
Methods
This survey research study conducted in 2009 provides a descriptive analysis of radiography and radiation therapy program directors perceptions of critical thinking, their ability to use critical thinking teaching methods, and their ability to assess student critical thinking activities. The study was approved by The Ohio State University Institutional Review Board. Sample A total of 692 radiography and radiation therapy program directors from programmatically accredited educational programs were invited to participate in the electronic survey. The institutions solicited represented both degree-granting and certificate radiologic sciences programs. The program directors names and e-mail addresses were obtained from the Joint Review Committee on Education in Radiologic Technology (JRCERT). Frame error was controlled by assuring a current and accurate list was obtained from the JRCERT, and educator names and addresses were reviewed to assure duplicates were purged to control for selection error. Instrumentation The electronic survey instrument used for this study was modeled after a nurse educators survey developed by Shell7 to solicit perceived barriers that impede the
228
implementation of critical thinking strategies in the nursing profession. The revised survey instrument consisted of 4 sections. Section 1 obtained demographic information from the participants. Section 2 included Likert-style questions using a 6-point rating-scale (1 = strongly disagree to 6 = strongly agree) designed to assess the educators perceptions of critical thinking. Section 3 included 5-point frequency rating-scale questions (1 = never to 5 = always) to identify the frequency of obstacles occurrence in implementing critical thinking strategies. For analysis, questions in sections 2 and 3 were categorized as the following constructs: (1) confidence in the use of strategies and assessments, (2) importance of critical thinking, (3) skill in teaching critical thinking, and (4) frequency of obstacles encountered in implementing critical thinking teaching strategies. Section 4 was an openended question requesting program directors to further define the obstacles they have encountered when incorporating critical thinking teaching methods in the classroom and provide an explanation regarding their development, use, and assessment of students critical thinking skills. The surveys content validity was established by a panel of 4 highly regarded radiologic science educators chosen by the investigators for their expertise in critical thinking. The panel critiqued the survey content to ensure the instrument measured the desired affective constructs and provided suggestions for improvement. A field test was used to establish the face validity and suitability of the instrument prior to sending the survey to the 692 study participants. Data Collection An e-mail announcement was sent to all programmatically accredited radiography and radiation therapy program directors in the United States describing the research study and providing a link to the electronic survey site. Reminder e-mails were sent 1 and 2 weeks following the initial e-mailing of the survey. All data were collected through SurveyMonkey (Palo Alto, California), transferred to an Excel (Microsoft Corporation, Redmond, Washington) spreadsheet, and entered into SPSS (IBM Corporation, Armonk, New York) for statistical analysis. Data Analysis Descriptive statistics including means, standard deviations, and percentages were calculated for responses to sections 1, 2, and 3 of the survey questionnaire.
...........................................................................................................
Table 1 Respondent Education Level and Educational Institution Information

Type of Educational Institution 4-year college/university 2-year community college 2-year technical college Hospital certificate program Proprietary program Region Where Educational Program Resides Northeast Southeast Midwest South Central Northwest Southwest Highest Level of Program Directors Education Doctorate Masters Degree Bachelors Degree Associate Degree Other n (%) 59 (18.6) 131 (41.3) 28 (8.8) 93 (29.3) 6 (1.9) n (%) 61 (19.2) 83 (26.2) 97 (30.6) 32 (10.1) 17 (5.4) 27 (8.5) n (%) 22 (6.9) 266 (83.9) 18 (5.7) 8 (2.5) 3 (0.9)
sample of 686. The initial mailing yielded 232 responses from program directors. A second e-mail was sent a week later and yielded another 85 responses for a total sample of 317, providing a 45.8% response rate. Of the 317 respondents, 279 were radiography program directors and 38 were radiation therapy program directors. The largest numbers of program directors responding to the survey were affiliated with a 2-year community college. The second largest population represented program directors from hospital certificate programs, followed by program directors employed at a 4-year college or university and by program directors affiliated with programs at a 2-year technical college. Program directors from proprietary programs represented the smallest group responding to the survey. Although program directors responded from each region of the United States, the majority of the survey respondents resided in the Midwest and the Southeast. The majority of respondents highest level of education was a masters degree followed by a doctorate. It is interesting to note that 29 program directors reported an education level at or below the bachelors degree (see Table 1). The age of the respondents ranged from 29 to 69 years with an average age of 50.3 years. Years of experience as a radiologic science educator ranged from 1 to 40 years with an average of 18.2 years, and the average percentage of time devoted to teaching was 53% (see Table 2). Instrument Reliability The internal consistency of the survey was established using Cronbachs alpha coefficient for the survey questions pertaining to each of the variables. The
Pearson correlations were used to assess correlations between the program directors age and years of experience and perceived confidence, importance, skill level, or ability to assess critical thinking. A Spearman rho correlation was calculated to assess a relationship between the program directors educational level and his or her perception of the importance of critical thinking. A 1-way analysis of variance (ANOVA) was calculated to determine variances within and between groupings of respondents based on age, education level, and type of institution in which they are employed.
Table 2 Respondent Age and Experience

Average Age 50.3 years Average Years as Radiologic Science Educator 18.2 years Average Percentage of Time Devoted to Teaching 53% Range 29-69 years Range Standard Deviation 8.2 Standard Deviation 9.9 Standard Deviation 25.4
results
Study Sample An electronic invitation to participate in the survey was sent to 692 individuals. Six participant e-mails were returned stating they were either on sabbatical, no longer teaching, or the e-mail was not deliverable, leaving a total
1-40 years Range
10-100%
229
...........................................................................................................
closer the coefficient is to 1, the greater the internal consistency of the items.12 The Cronbachs alpha coefficients demonstrated moderate to high reliability for questions related to each construct as follows: educators confidence in the use of critical thinking strategies and assessments, = .84; the importance of critical thinking, = .77; skill in teaching critical thinking, = .77; and the ability to assess students critical thinking skills, = .62. Level of Confidence in Strategy and Assessment Use The program directors reporting a positive level of confidence in their use of strategies to teach and assess critical thinking in the classroom and clinical setting was 3.8 on a 6-point scale (standard deviation [SD] = 0.6). Only 37% of the respondents indicated they felt confident in their abilities to teach critical thinking skills, and only 39% indicated they could model critical thinking behaviors. When the program directors were asked if they needed further professional development to incorporate critical thinking into their teaching methods, 70.9% agreed or slightly agreed. Level of Importance Placed on Critical Thinking The importance program directors place on critical thinking in the classroom and clinical setting was measured using 9 survey questions. The mean measurement of importance was a 5.1 (SD = 0.5), indicating the respondents agreed that critical thinking is an important concept in education, and it should be implemented in radiologic science educational programs. A large percentage of the respondents agreed or strongly agreed critical thinking was necessary for success of the student, that critical thinking is a valuable education outcome, and that critical thinking is a primary objective of their teaching. Most respondents felt that using critical thinking skills in the classroom can enhance the students skills and that it is important to assess the students ability to think critically. To determine if the program directors education level was associated with their perceptions of the importance of critical thinking, a Spearman correlation was conducted. The Spearman rho coefficient (r = 0.009; P = .9) indicated no relationship between the 2 factors. Level of Skill in Using Critical Thinking Strategies in the Classroom Program directors perceived skill level was evaluated using 16 questions relating to their ability to demonstrate, model, or use strategies when incorporating
230
Table 3 Influence of Program Director Education Level and Type of Academic Institution on Teaching Critical Thinking
Variable Program Director Education Level F Level of confidence Level of importance Level of skill Ability to assess 2.68 1.44 3.08 1.62 Sig. 0.05 0.23 0.03 0.19 Type of Academic Institution F 0.38 1.26 0.31 1.34 Sig. 0.82 0.29 0.88 0.25
F = Frequency, Sig. = Significance
critical thinking into their teaching. It also measured satisfaction with their critical thinking methods. The mean score for the questions relating to the level of skill was 4.1 on a 6-point scale (SD = 0.6). The majority of program directors (52%) agreed their teaching strategies are designed to promote critical thinking skills; however, they did not highly rate their abilities to teach, demonstrate, implement, or assess critical thinking skills or new strategies, indicating the need for further professional development. In the open-ended responses, program directors indicated attendance at professional seminars or continuing education sessions were the most common development strategies used to further enhance teaching skills. Other development strategies included reading or researching topics pertaining to critical thinking and completion of advanced degree course work. A 1-way ANOVA was calculated to determine if the program directors level of skill, confidence in his or her critical thinking skills, and ability to assess critical thinking, as well as the level of importance they place on critical thinking in the classroom, were significantly different by education level and by the type of radiologic science program in which the program director was employed. As indicated in Table 3, there was no significance between the education level and the level of importance. There also was no significance between the education level and the program directors ability to assess critical thinking. Level of confidence and level of skill were significantly different based on the program directors highest level of education. The level of education within the institution was not significant for the 4 variables. A post hoc analysis using the Scheff method was used to
...........................................................................................................
for instructors to learn new teaching methods; and (4) lack of student Variable Age Experience in education motivation to become critical thinkers. Pearson Corr. Sig. (2-tailed) Pearson Corr. Sig. (2-tailed) The fourth section Level of confidence 0.01 0.83 0.05 0.37 allowed an open-ended Level of importance 0.04 0.51 -0.09 0.11 response regarding other obstacles encounLevel of skill 0.05 0.36 0.01 0.83 tered in incorporating Ability to assess -0.02 0.80 0.03 0.63 critical thinking skills. Correlation is significant at the 0.01 level (2-tailed). Of the 127 responses to the open question further analyze the differences in the program directors regarding obstacles, very few new obstacles were identieducation level compared with their level of confidence fied. The lack of faculty acceptance and reinforcement, and level of skill. The test reported the greatest signifias well as the need for a clear definition of critical cance for both perceived confidence (mean difference thinking specific to our profession, was listed by 4 = 0.6; P = .05) and skill level (mean difference = 0.4; respondents. One respondent identified the need for P = .03) between program directors holding a doctoral facilities for authentic assessment, and 1 respondent degree and a masters degree. Those program directors identified that retaining a behaviorist curriculum holding a doctorate were more confident and perceived a emphasizing behavioral objective outcomes leads to higher level of skill in using critical thinking strategies in rote memorization skills. Forty-eight respondents reitthe classroom. erated a lack of time because of constraints related A Pearson correlation was used to determine if the to administrative duties and the need to cover a large program directors age or years of experience related amount of coursework in a limited time frame. to perceived confidence, importance, skill level, or abilIt is interesting to note that although lack of approity to assess (see Table 4). A significant correlation was priate teaching materials was ranked eighth of the 17 not demonstrated between age or experience and the obstacles listed, this item was the second most frequent4 variables. However, a high correlation was identified ly mentioned obstacle in the open-ended responses between the program directors perceived level of skill (see Table 6). Additionally, although obstacles related and their confidence in critical thinking (r = 0.8; to educators knowledge of and expertise in implementP .001) and their perceived level of skill and their pering and assessing critical thinking teaching methods ceived ability to assess the students critical thinking ranked in the lower third of the responses, this area (r = 0.8; P .001). Although program directors perceive comprised the third most frequently mentioned obstacritical thinking skill assessment as imperative to the cle in the open-ended section of the survey. development of student skills, the results of this survey demonstrated a large variation in the program directors perception of their ability to assess critical thinkCurrent Use of Critical Thinking Teaching Strategies ing assignments. Of the 317 individuals responding to this survey, 81% provided information in the open-ended porObstacles to the Use of Critical Thinking tion of the survey describing how they believe they Teaching Methods incorporate critical thinking in their classroom. This The third section of the survey elicited responses high percentage appears encouraging; however, few from the program directors regarding the frequency of the teaching methods listed by program directors in which they face specific obstacles when implementhave been successfully used by nursing and other allied ing critical thinking teaching methods (see Table 5). health professions to promote critical thinking skills. The most frequently reported obstacles were: (1) the This finding emphasizes the need for a clear definition need to deliver a large amount of information to cover of critical thinking in the radiologic sciences and a content; (2) student concerns of getting a good grade need to develop critical thinking educational resources vs actually learning the content; (3) insufficient time for radiologic science educators. Although actively
Table 4 Correlation Between Variables and Program Director Age and Experience
231
...........................................................................................................
A students ability to apply critical thinkObstacle Frequencya ing skills is not only developed by the indiNeed to deliver a large amount of information to cover content. 3.48 vidual but also is fosStudent concerns of getting a good grade vs learning. 3.44 tered in the classroom Insufficient time to learn new teaching methods. 3.16 setting. Educators play a vital role in the overLack of student motivation to become critical thinkers. 3.11 all process, yet little Lack of time for preparing and planning critical thinking 3.00 is known about eduteaching strategies. cators perceptions Student expectation of lecture format instruction. 3.00 and abilities to apply critical thinking skills Student resistance to active learning. 2.91 in the classroom.13,14 Lack of appropriate instructional materials. 2.88 It is assumed educaInsufficient class time. 2.87 tors are experienced critical thinkers and Lack of time in assessing student critical thinking skills. 2.87 are therefore able to Lack of knowledge of how to promote students critical 2.6 use teaching stratethinking skills. gies effectively to Difficulty in assessing student work that reflects critical 2.55 help students develop thinking. their own skills. Yet evidence shows gaps Feelings of unpreparedness to teach critical thinking skills. 2.49 exist between what Lack of knowledge of what constitutes critical thinking. 2.38 the educators may Large number of students per class. 2.11 believe to be critical thinking and their Lack of administrative support in developing new teaching 1.98 abilities to promote methods. it within the classFear of negative student evaluations. 1.75 room.15,16 Mangena a 0= never; 4 = always and Chabeli found the facilitation of critical thinking was engaging students in the classroom supports adult impeded by nurse educators lack of critical thinking learning theories such as experiential learning and knowledge.6 Educators need to keep abreast of changes situated cognition, active engagement in the classroom in their field of education and the need for critical thinkdoes not necessarily lead to the development of critiing in developing lifelong learners in the students. To do cal thinking skills. The classroom activities included in so, educators must continually reflect on their teaching the responses that are supported by research studies skills, update critical thinking methods, and increase regarding critical thinking educational strategies in their knowledge of critical thinking. nursing and medicine include: Results of this survey showed program directors are Team-based learning. fairly confident in their ability to teach or demonstrate Collaborative projects. critical thinking, although they also expressed a need for Simulation modules. further professional development. These findings sup Scenarios with alternate methods/solutions. port previous research that emphasizes the importance of Concept mapping. modeling.5,6,15,16 When educators lack strong critical think Problem-based learning modules. ing skills, they cannot model this behavior to students. Reflective journaling and portfolio development. Within the radiologic sciences, almost all instructors were Research reports/critical analysis papers. first educated and employed as practitioners, and many
232 January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY
Table 5 Obstacles Encountered When Implementing Critical Thinking Strategies
Discussion
...........................................................................................................
Table 6 Perceived Barriers to Implementing Critical Thinking Teaching Strategies

Topic Lack of appropriate teaching materials Comments Lack of continuing education information regarding improvement of critical thinking skills. Lack of facilities for authentic assessment. Critical thinking materials/texts/exercises relevant to radiation therapy seem to be completely lacking. Lack of textbooks to supplement. Lack of good educational presentations. Lack of good educational materials/scenarios. Lack of instructional resources/materials/models. Examples of critical thinking activities used by other radiologic science educators would be valuable. Laboratory resources. Instructional models. Easy access to ideas. My area of expertise is radiation physics. I would love some suggestions for how to incorporate critical thinking into that class that wouldnt take up too much of my 3-hour lecture once a week. Critical thinking is fun, but I completely fill my 3 hours of time with lecture. I would need more time if I did more of the fun learning. Educators knowledge of and expertise in implementing and assessing critical thinking teaching methods Better understanding of how to teach critical thinking. Need more education, support, and tools on how to teach critical thinking. Difficulty in persuading clinical instructors to view critical thinking as a teachable skill. I sometimes am spread a bit too thin to be as creative as I might be otherwise. It would be nice to have examples from other instructors on critical thinking methods they use. Just lack of knowledge on how to do it. Lack of continuing education info regarding improvement of critical thinking skills. Need fundamental knowledge to begin the process of critical thinking. Unsure how to apply to all areas of radiographic imaging. Critical thinking activities I have seen are high schoolish and are like a game, and we do not have the luxury of the time to play games.
radiologic science educators have not pursued additional coursework in educational methodology and adult learning.17 This hinders the ability of radiologic science educators to serve as good critical thinking models, limits their ability to implement critical thinking teaching methods, and limits their ability to assess student progress.
Confidence in using critical thinking teaching strategies may take years to develop, and advanced education helps to formulate adult learning methods and ideas. This survey demonstrated a significant difference in the program directors confidence based on highest level of education; program directors holding
233
...........................................................................................................
a doctoral degree reported the highest confidence level within the study. This also is supported through the open-ended responses in which program directors stated they have developed their critical thinking skills and teaching methods through advanced-level education courses. However, only 0.15% of technologists credentialed by the American Registry of Radiologic Technologists hold a doctorate, and these individuals are not all employed in education.18 In fact, the majority of academic institutions with a radiologic science program do not traditionally offer tenure positions or promote doctoral degree attainment. This great disparity between radiologic science educators compared with other disciplines in 2-year and 4-year institutions in terms of tenure status negatively affects professionalism in the discipline.19 Thus, we inadvertently may be creating an additional barrier specific to our profession that inhibits the implementation of critical thinking educational methods. Respondents to this survey agreed with the necessity of applying critical thinking skills in the classroom, and they valued its development as an educational outcome for the student. Devoting classroom time to critical thinking activities continues to be a barrier because instructors seem to prefer lecturing to convey content. These findings suggest that helping students develop critical thinking is not yet a high priority for most educators. Additionally, more than 30% of respondents expressed concern regarding their ability to assess the students skills in critical thinking. This implies educators may be unsure of how to combine content coverage with the development of critical thinking skills, and these findings support previous research.7,10 Students not only need the content material to understand their profession, but they also need instruction on applying the knowledge using critical thinking. Educators should acknowledge that total coverage of content is the purpose of textbooks, and they should avoid lecturing facts that can be obtained from other resources; instead, they should provide students with guidelines to help develop problem-solving or decision-making skills. In the radiologic sciences, the profession drives course content. However, curriculum guides only provide the content, and it is the educators responsibility to define the mechanisms that will enable the students to grasp the knowledge.11,20 Students must be able to create a relationship between content and professional practice because true learning only occurs through application of the new knowledge. Researchers have demonstrated that a better method may be to merely
234
review the content material and, more importantly, manipulate it to focus on critical thinking strategies in the context of professional practice.6,14 This allows students to think about content from a different perspective and reflect on application in clinical practice. The results of this study demonstrated the program directors ages and years of teaching experience were not related to their skills in teaching critical reasoning. This contradicts the findings of Zygmont and Schaefer,5 who suggest educators advanced in age are less likely to engage in critical evaluation, lack the ability to transfer information from 1 situation to another, and tend to apply an inflexible approach to educational situations. This survey identified limited support from administration (ie, workload demands on the educator were high) and that funding for tools to implement critical thinking strategies were not provided. Factors often expressed in the open-ended responses included concerns regarding a lack of materials, instructional resources, exercises, or tools needed to teach critical thinking. Raymond and Profetto-McGrath presented similar barriers to implementing new teaching methods, including intensive workloads, strict content delivery, not allowing time for new ideas, fellow faculty members who were unreceptive to critical thinking, and students who displayed negative attitudes toward critical thinking ideas used in class.8 Nonetheless, they suggested positive influences such as faculty development opportunities, administrative support, freedom to experiment with new ideas, and mentorship could help overcome these perceived barriers.
Limitations
The study has several limitations. Of the 817 radiologic science programs existing at the time of this study, only 86.5% maintain JRCERT program accreditation. Because the survey only targeted program directors associated with JRCERT-accredited programs, the results can only be generalized to this population. Additionally, this study only solicited information from program directors; therefore, not all levels of educators within the radiologic sciences programs are represented. The questionnaire used in this study captured self-reported perceptions of the program directors and therefore is not a direct measurement of their actual critical thinking abilities or teaching and assessment skills. The response rate also limits the generalizability of this study, as nonrespondents may hold different perceptions than those responding to the survey.
...........................................................................................................
Implications and Need for Further Research The number of faculty in the radiologic sciences prepared at the doctoral level lags behind nursing and many other health disciplines, which also may serve as a barrier in implementing critical thinking teaching methods in the radiologic science educational arena. Because many radiologic science programs are housed in community colleges, the lack of appointment, promotion, and tenure terminal-degree requirements for faculty also may limit the number of faculty obtaining doctorates. Additionally, radiologic science faculty generally carry high teaching loads compared with other allied health disciplines, regardless of the type of academic institution in which they are employed, thus limiting time availability for continued professional development and curricular revisions. Limited research is available specific to the radiologic sciences in terms of measureable educational outcomes; therefore, rigorous research is needed in reference to critical thinking teaching methods that provide measureable positive outcomes in student performance. In addition, an evaluation of educational research conducted in other health disciplines is warranted and may provide important information to radiologic science educators regarding exemplary teaching strategies and curricular integration.
professional courses. Perhaps these academic faculty and programs could serve as role models for radiologic science educators. Results also indicate the highest level of education held by program directors is a significant factor in their perceived confidence, ability to model critical thinking skills, and ability to assess student critical thinking skills regardless of the institutional level of education (ie, baccalaureate, associate, or certificate) of the academic program. Many of the educators expressed a need for professional development in critical thinking educational methods. Research demonstrates a low number of radiologic science educators prepared at the doctoral level and tenure levels lagging behind other disciplines.18 These important educational issues must be addressed by our profession to move forward in a positive direction.
references
1. Facione P. Critical Thinking: What It Is and Why It Counts. Millbrae, CA: The California Academic Press; 1998. 2. Brock A, Butts JB. On target: a model to teach baccalaureate nursing students to apply critical thinking. Nurs Forum. 1998;33(3):5-10. 3. Fitzpatrick JJ. Critical thinking: how do we know it in nursing education and practice? Nurs Educ Perspect. 2005;26(5):261. 4. Forneris SG. Exploring the attributes of critical thinking: a conceptual basis. Int J Nurs Educ Scholarsh. 2004;1(1):article 9. 5. Zygmont DM, Schaefer KM. Assessing the critical thinking skills of faculty: what do the findings mean for nursing education? Nurs Educ Perspect. 2006;27(5):260-268. 6. Mangena A, Chabeli MM. Strategies to overcome obstacles in the facilitation of critical thinking in nursing education. Nurs Educ Today. 2005;25(4):291-298. 7. Shell R. Perceived barriers to teaching for critical thinking by BSN nursing faculty. Nurs Health Care Perspect. 2001;22(6);286-292. 8. Raymond CL, Profetto-McGrath J. Nurse educators critical thinking: reflection and measurement. Nurse Educ Pract. 2005;5:209-217. 9. OSullivan PS, Blevins-Stephens WL, Smith FM, VaughanWrobel B. Addressing the national league for nursing critical thinking outcome. Nurse Educ. 1997;22(1):23-29. 10. Walsh CM, Seldomridge LA. Critical thinking: back to square two. J Nurs Educ. 2006;45(6):212-219. 11. Kowalczyk N, Leggett TD. Teaching critical thinking skills through group-based learning. Radiol Technol. 2005;77(1):24-31. 12. Gliem JA, Gliem RR. Calculating, interpreting, and reporting Cronbachs alpha reliability coefficient for Likert-type
Conclusion
The results of this survey suggested radiologic science program directors value the importance of implementing critical thinking teaching methods. Students must be encouraged to develop alternative methods of thinking through interpretation, analysis, evaluation, inferences, and explanations of information as it relates to the evidence applied to the radiologic sciences. Barriers in applying critical thinking teaching strategies identified in this study include: Balancing limited classroom time with the need to deliver a significant amount of content information. Student resistance to critical thinking teaching methods. Lack of student motivation. High instructional workloads resulting in insufficient time for program directors to learn and implement new teaching methods. The lack of appropriate teaching materials. A review of the literature demonstrates similar obstacles in nursing and other allied health disciplines. However, many programs have overcome the barriers and integrate critical thinking teaching strategies into
235
...........................................................................................................
13. 14.
15. 16. 17. 18.
19. 20.
scales. Course presented at: Midwest Research to Practice Conference in Adult, Continuing, and Community Education; October 8-10, 2003; Columbus, OH. Browne, MN, Freeman K. Distinguishing features of critical thinking classrooms. Teach High Educ. 2000;5(3):301-309. Halx MD, Reybold LE. A pedagogy of force: faculty perspectives of critical thinking capacity in undergraduate students. J Gen Educ. 2005;54(4):293-315. Adams BL. Nursing education for critical thinking: an integrative review. J Nurs Educ. 1999;38(3):111-120. Mundy K, Denham SA. Nurse educators: still challenged by critical thinking. Teach Learn Nurs. 2008;3:94-99. Aaron L. Program director satisfaction with leadership skills. Radiol Technol. 2006;78(2):104-112. Metcalf KL, Adams RD, Qaqish B, Church JA. Survey of RTs with doctorates: barriers to conducting research. Radiol Technol. 2010;81(5):417-427. Legg JS. Academic tenure in radiologic technology revisited. Radiol Technol. 2007;78(3):191-196. Aaron L, Haynes K. Critical thinking: a method for program evaluation. Radiol Sci Educ. 2005;10(2):5-11.
Nina Kowalczyk, PhD, R.T.(R)(CT)(QM), FASRT, is an assistant professor in the radiologic sciences and therapy department in the School of Allied Medical Professions at The Ohio State University in Columbus. She is also chairman of the Radiologic Technology Editorial Review Board. Ruth Hackworth, MS, R.T.(R)(T), is the radiation therapy program director in the radiologic sciences and therapy department in the School of Allied Medical Professions at The Ohio State University. Jane Case-Smith, EdD, OTR/L, FAOTA, is a professor and chairperson of the occupational therapy division in the School of Allied Medical Professions at The Ohio State University.
236
....................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . .
CE
DIRECTED READING
Emotional Intelligence in Health Care

KATHRYN FAGuY, MA, ELS
Emotional intelligence (EI), the ability to understand and manage emotions in oneself and others, is a valuable asset for health care professionals. This article discusses the emergence of EI, different notions about what constitutes EI, what EI looks like on the job, and simple ways to boost EI. Results of research studies examining EI in health care students and professionals also are reported. This article is a Directed Reading. This article meets Category A and Medical Dosimetrist Certification Board CE requirements. Your access to Directed Reading quizzes for continuing education credit is determined by your CE preference. For access to other quizzes, go to www.asrt.org /store.
After completing this article, readers should be able to:
n Define emotional intelligence (EI) and explain how it is measured. n Trace the history and development of EI. n Compare different concepts of EI. n Describe characteristics of emotionally intelligent people. n Discuss the importance of EI and suggest ways to increase it. n Summarize research studies on EI in health care students and professionals.
That man is disciplined and happy who can prevail over the turmoil that springs from desire and anger. Bhagavad Gita, ancient Hindu text Rule your feelings, lest your feelings rule you. Publilius Syrus, first century BCE t first glance, emotional intelligence might seem like a contradiction in terms. After all, intense emotions sometimes interfere with intelligent behavior, such as when we blurt out a comment in the heat of the moment that in retrospect would have been better left unsaid or act on strong feelings without thinking through the consequences. Indeed, as the founding fathers of the emotional intelligence movement pointed out, emotion is sometimes considered a loss of cerebral control.1 On the other hand, emotions are also a key motivation for action and serve as a valuable guide to success and happiness. As psychologist Harvey Deutschendorf wrote, instead of tuning
out our emotions, we need to get more in touch with them. To live an authentic, rewarding, and self-fulfilling life requires that we make use of both our intellect and feelings.2 Paying attention to emotions, understanding them, and using them wisely can help us lead better lives, both personally and professionally. This, in a nutshell, is emotional intelligence (EI).
Defining Emotional Intelligence

Broadly understood, intelligence is the aggregate or global capacity of the individual to act purposefully, to think rationally, and to deal effectively with his environment.1 Today, the concept of intelligence includes verbal intelligence, visual/spatial intelligence, social intelligence, and, most recently, emotional intelligence. Perhaps because it is still an evolving concept, EI researchers have defined the term in a variety of ways. In their groundbreaking 1990 article, Salovey and Mayer defined EI as the subset of social intelligence that involves the ability to monitor
237
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
EMOTIONAL INTELLIGENCE
ones own and others feelings and emotions, to discriminate among them and to use this information to guide ones thinking and actions.1 In 1997 they refined their original definition3 :
Emotional intelligence is the ability to perceive accurately, appraise, and express emotion; the ability to access and/or generate feelings when they facilitate thought; the ability to understand emotion and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth.
Golemans definition additionally mentions EIs role in self-motivation4 : Emotional intelligence refers to the capacity for recognizing our own feelings and those of others, for motivating ourselves, and for managing emotions well in ourselves and in our relationships. Bradberry and Greaves, like Goleman, emphasized EIs role in shaping behavior5 : EI is your ability to recognize and understand emotions in yourself and others, and your ability to use this awareness to manage your behavior and relationships. Finally, for Meyer et al, EI focuses on the perception and analysis of emotion. According to them, EI includes the ability to identify and express emotions, distinguish among emotions, and analyze and regulate emotions.6 Although different researchers define EI differently, some key points are agreed upon7 : n EI is different from, but related to, other types of intelligence. For example, cognitive intelligence is based in the brains neocortex; emotion is based in the lower, more ancient subcortex. EI involves both parts of the brain working together.4 n EI varies among individuals. Some people are naturally more emotionally intelligent than others. n EI can be learned and developed throughout life. n In essence, EI is the ability to perceive, identify, understand, and manage emotions. There is also consensus about what EI is not.8 It isnt: n The same as being nice to other people. In fact, EI sometimes requires saying difficult or uncomfortable things. n The same as freely expressing emotions. Instead, it entails managing ones feelings and expressing them appropriately and for specific purposes. n Genetically fixed. Although some people are naturally more emotionally intelligent than others, a high EQ [ones emotional intelligence quotient] can be developed even if you arent born with it.5 And EI can be improved by anyone, at any stage in life.
238
The notion that there are different kinds of intelligence was first proposed by EL Thorndike in 1920. Thorndike divided intelligence into 3 types: abstract intelligence (understanding of ideas), mechanical intelligence (understanding of objects), and social intelligence (understanding of people).9 As he explained: By social intelligence is meant the ability to understand and manage men and women, boys and girls to act wisely in human relations.9 Another social scientist expanded and refined Thorndikes definition in the 1930s, describing social intelligence as the ability to get along with people in general, social technique or ease in society, knowledge of social matters, as well as insight into the temporary moods or underlying personality traits of strangers.9 Social intelligence is somewhat different from EI in that social intelligence focuses on relationships generally, whereas EI is concerned with understanding ones own emotions as well as those of others, and how emotions affect relationships. Thus, EI can be considered an aspect or subset of social intelligence.1 In 1940, David Wechsler, a pioneer in the field of intelligence testing, suggested including non-intellective aspects of general intelligence, such as social intelligence, in intelligence quotient (IQ) testing. However, Wechslers suggestion was ignored10 and it was years before tests were developed to assess other kinds of intelligence. The first definitive use of the term emotional intelligence is believed to be in a doctoral dissertation by Wayne Payne in 1968. However, Paynes theory was never published. In 1983, psychologist Howard Gardner proposed 7 different types of intelligence, including knowing ones inner world and social adeptness.4 Those 2 notions together come close to capturing EI as it is currently understood. The seminal work on EI was an article by Peter Salovey of Yale University and John D Mayer of the University of New Hampshire published in 1990 in the journal Imagination, Cognition and Personality. Their article, titled simply Emotional Intelligence, laid the groundwork for all subsequent research and thinking on EI. Daniel Goleman, a clinical psychologist and contributing writer for The New York Times, read Salovey and Mayers article while researching his book about emotional literacy. Goleman subsequently titled his book Emotional Intelligence: Why It Can Matter More Than IQ. It was published in 1995 and became a bestseller, helping to popularize EI. Time magazine featured a cover
A Brief History of EI
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Emotional Intelligence
Appraisal and Expression of Emotion
Regulation of Emotion
Utilization of Emotion
Self
Other In Self In Other Flexible Planning
Creative Redirected Motivation Thinking Attention
Figure 1.
Verbal NonVerbal
NonVerbal Perception
Empathy
Conceptualization of emotional intelligence. Reprinted with permission from Salovey P, Mayer JD. Emotional intelligence. Imagin Cogn Pers. 1990;9(3):190.
story on the topic later that year and Goleman was a guest on Oprah Winfreys television show. In 1998, the Harvard Business Review featured an article on EI that became the most-read article published in the journal in the previous 40 years.11 Several tools have been developed to screen for and measure EI, and there are now countless EI training programs, books, and seminars. Since EI became a hot topic, there has been plenty of excitement, confusion, and raised eyebrows with respect to emotional intelligence in general and, more specifically, EI and its value as a corporate training objective.11 Some may dismiss EI as a passing psychological fad or management trend, but Freshman and Rubino argued that it is in fact a useful approach of applying age-old wisdom to personal and organizational development. Furthermore, What is new and promising about the work being done with EI is that now these competencies are being viewed as skills to be developed, rather than in-born traits.11
The Components of EI
Just as definitions of EI vary, so too do the ways in which different researchers and theorists have conceived of EI. In their foundational 1990 article, Salovey and Mayer envisioned EI as composed of 3 related mental processes: appraising and expressing emotion, regulating emotion, and using emotion (see Figure 1).1
Appraising and expressing emotions, both ones own and those of others, requires skill at interpreting a variety of verbal and nonverbal information. For instance, we must interpret the unspoken message in someones facial expression, tone of voice, and body language, as well as the words they choose. A good understanding of ones own emotions is key to understanding others emotions; in fact, the 2 processes are so closely related that they may not exist without the other.1 Some people cannot appraise or express their own emotions; this psychiatric disorder is termed alexithymia and may be due to blockages between the brains hemispheres or between the limbic system and the higher cortical activities. Different tools are used to measure individuals ability to express their emotions and their skill at reading others emotions. For example, the Affect Sensitivity Test involves showing videotaped scenes of individuals interacting with each other; participants then describe how the people in the video are feeling and what they might be thinking.1 Regulating or managing emotion is something we all do, but the emotionally intelligent person does especially well and has a way of meeting particular goals, Salovey and Mayer noted. For example, an emotionally intelligent speaker can evoke a strong reaction from an audience; an emotionally intelligent job candidate can leave an interviewer with a positive impression.
239
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Emotional Intelligence
Figure 2. Revised conceptualization of emotional intelligence. Reprinted with permission from Mayer JD, Salovey P. What is emotional
intelligence? In: Salovey P, Sluyter DJ, eds. Emotional Development and Emotional Intelligence. New York, NY: Basic Books; 1997.
Emotionally intelligent people also are adept at changing or sustaining their own moods.1 EI has many different uses, Salovey and Mayer postulated. Individuals with high EI may be more creative and flexible in arriving at possible alternatives to problems. They are also more apt to integrate emotional considerations when choosing among alternatives. Such an approach will lead to behavior that is considerate and respectful of the internal experience of themselves and others.1 In addition, EI can help people plan more flexibly because changing moods allow them to see a variety of different outcomes. EI also can assist with motivation and redirecting attention to pressing problems.1 Interestingly, Salovey and Mayer pointed out that EI can be used for bad as well as good purposes1:
On the positive side [emotionally intelligent people] may enhance their own and others moods and even manage emotions so as to motivate others charismatically toward a worthwhile end. On the negative side, those whose skills are channeled 240
antisocially may create manipulative scenes or lead others sociopathically to nefarious ends.
In 1997, Salovey and Mayer revised their original conception to reflect 4 branches of EI, from basic to higher levels (see Figure 2).3 Each branch is associated with 4 abilities or traits that support or are related to it. The traits and abilities are described below each branch and generally develop sequentially, from left to right. Perception, appraisal, and expression are a part of the most basic branch of EI and reflect a fundamental ability to identify emotion, including true vs false emotion, as well as the ability to accurately express emotions. The second branch, emotional facilitation of thinking, has to do with the ability to use emotions in ones thought, such as recalling an emotion clearly. The next branch, understanding and analyzing emotions, reflects a more sophisticated knowledge of emotions and how they operate, such as complex combinations of emotions and emotional transitions. Finally, the fourth branch relates to the ability to regulate emotions, such as detaching from emotions that are not immediately useful.3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Goleman modified the original theory proposed by Salovey and Mayer, proposing instead the following 5 EI competencies12 : n Self-awareness: Understanding ones own emotions and abilities. n Self-regulation: Managing ones emotions well. n Motivation: Using ones preferences to stay focused on goals and cope with setbacks. n Empathy: Being sensitive to and aware of others feelings. n Social Skills: Using sensitivity to emotions to interact effectively with others (eg, to lead, motivate, or resolve disagreements). In their book Emotional Intelligence 2.0, Bradberry and Greaves broke the skills underlying EI into 2 main areas of competence: personal competence and social competence. The 2 skills that make up personal competence are self-awareness and self-management. The 2 skills that compose social competence are social awareness and relationship management.13 Reuven Bar-On, developer of the Bar-On Emotional Quotient Inventory, based his conception of EI and his assessment tool on 5 scales: intrapersonal, interpersonal, adaptability, stress management, and general mood. Each of the scales has multiple subscales (see Table).14 Wagner et al summarized the diversity of views on what exactly constitutes EI by noting that theorists conceptualizations of EI vary, yet most agree that EI describes characteristics beyond technical skill and traditional cognitive intelligence, including factors such as awareness of and ability to modulate ones own emotional responses and to understand others.14
Measuring Emotional Intelligence

As mentioned previously, there are several tools for assessing EI. These include a self-assessment known as the Emotional Quotient Inventory (EQ-i) distributed by Multi-Health Systems (Toronto, Canada); an abilitybased test designed by Salovey, Mayer, and their colleague David Caruso called the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and Daniel Golemans Emotional Competency Index, among others.7 The Schutte Emotional Intelligence Scale (SEIS) is based on Salovey and Mayers early conceptual model. It is a self-reporting assessment that includes 33 items with Likert-scale responses. Scores range from 33 to 165, with higher scores indicating higher EI. The reliability and validity of the SEIS are well established.15 The EQ-i includes 133 items that describe emotional functioning. As with the SEIS, respondents
rate themselves on a 5-point Likert scale. The EQ-i was based (normed) on 4000 North American respondents. Most were white and younger than 30 years of age, with men and women equally represented.16 There is a shortened version of the EQ-i with 52 items and a version designed for children aged 7 to 15 years. The tool has been translated into more than a dozen languages for use in Europe and Israel.16 The stability, reliability, and validity of the assessment have all been tested and reported.16 The Emotional Competence Inventory, developed by Goleman and colleague Richard Boyzatis, is a 360-degree instrument that relies on others assessments of an individuals EI. For example, peers, supervisors, and direct reports might all be asked to rate an employees EI using this tool.11 A major criticism of EI assessment revolves around the fact that some of the tools are based on selfreporting, which might not be accurate for a variety of reasons. Some people intentionally misrepresent themselves on self-assessments to make themselves look good. (However, some EI assessments are designed to flag evaluations in which an individual might be trying to skew the results.) Other people simply arent emotionally aware enough to report on themselves accurately. Furthermore, some individuals may be unduly critical in assessing themselves; other people are inaccurately generous in their self-ratings. Likewise, evaluations by others may not be accurate, either. Friends may paint an inaccurately positive picture of each other, while other people might use an EI evaluation to retaliate against coworkers as part of office politics. Also, employees might be hesitant to be critical of their supervisors or others in positions of power. Reports and assessments from multiple sources might be more accurate than a single source.17 Or, they might simply confuse the picture further. While conducting research for this article, I discovered that it is fairly easy to skew the results of an EI assessment. I took an online self-reporting assessment, the Emotional Intelligence Appraisal offered by Talent Smart (San Diego, California), twice within a period of a few days. This short assessment takes 7 minutes to complete, on average.16 The first time I took it, I tried to be candid about my true tendencies and not overthink my responses. I scored poorly, in the bottom 20% of the population overall. The second time I took the appraisal, I responded with what seemed to be the right answers (ie, the ones associated with high EI). My score soared to the top 3%. I did not complete any EI training or make
241
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Table Emotional Quotient Inventory Subscales and Descriptions

Composite Scale Intrapersonal Subscale Self-regard Emotional self-awareness Assertiveness Independence Self-actualization Interpersonal Empathy Social responsibility Description Self-respect and acceptance Good self-esteem, feel positive about themselves In touch with their feelings Understand what and why they feel what they do Ability to express feelings, thoughts, and beliefs in a nondestructive manner Self-reliant and independent in thinking and actions Ability to realize ones full potential Live rich and meaningful lives Aware of and appreciates the feelings of others Cooperating and contributing members of social groups
Interpersonal relationships Ability to establish and maintain relationships with others and give and receive affection Adaptability Reality testing Flexibility Problem solving Stress management Stress tolerance Impulse control General mood Optimism Happiness Realistic, well grounded Good at sizing up the situation Able to adjust their emotions, thoughts, and behaviors according to the changing environment Adept at recognizing problems and generating solutions Can cope with stress actively and positively Calm and rarely anxious Able to resist or delay impulses Rarely impatient Look at the bright side of life Feel satisfied with their lives, genuinely enjoying other people Happy and pleasant
Reprinted with permission from Wagner PJ, Moseley GC, Grant MM, Gore JR, Owens C. Physicians emotional intelligence and patient satisfaction. Fam Med. 2002;34(10):751. Based on Bar-On R. Bar-On Emotional Quotient Inventory, Facilitators Resource Manual. Toronto, ON: Multi-Health Systems Inc; 1998:2.
any effort to increase my EI in the interim, beyond doing some general reading on the subject. Other EI assessment tools do not rely on selfreporting or evaluation by colleagues. One of these is the MSCEIT, an ability-based test that reportedly measures a persons capacity for reasoning with emotional information.18 The MSCEIT was based (normed) on 5000 respondents worldwide, mostly white women younger than 30 years of age.16 This test takes 30 to 45 minutes to administer and is designed for adults aged 17 and older. Test takers perform a variety of tasks, such as rating the extent and type of emotion
242
depicted in pictures and choosing techniques for effectively managing their own and others emotions.16 Because the MSCEIT is an ability-based measure, it is very difficult for respondents to fake a good performance. As such, the MSCEIT is ideal for testing in situations in which it is expected that respondents will want to create a positive impression.18 Unlike IQ, which is fairly stable from childhood on, EI tends to increase steadily from the late teens until the 40s, when it peaks. After age 50, EI begins to taper off, but only slightly.10 These conclusions were based on a study of 4000 people in the United States and
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Canada. However, as mentioned previously, it is possible to increase EI during every decade of life.19 It is also interesting to note that there is no correlation between IQ and EI. As Goleman pointed out, almost everyone knows someone with a high IQ whose success in life doesnt match his or her IQ score, perhaps because that person lacked in EI.12 On the other hand, high achievers often have both high EI and high IQs. Goleman speculated that the relationship between EI and IQ works this way: IQ determines which occupations are open to individuals, while EI determines which individuals excel in the jobs they choose.16 As a group, women are no more emotionally intelligent than men, even though women are generally considered to be more sensitive and emotionally expressive than men. Every individual has a unique set of strengths and weaknesses when it comes to EI, and the strengths of one sex tend to balance those of the opposite sex.8 As Deutschendorf explained20 :
When we add up male/female profiles, we find that women on the whole are more aware of their emotions and are better at forming relationships with others while men adapt more easily and handle stress better. However, it is important to remember that this finding does not account for individual variations where these differences could be reversed. There are men who are very aware of their emotions and are able to form strong relationships, just as there are women who adapt easily and are good at handling stress.
Box 1 Common EI Characteristics13

Highly self-aware people tend to be: Calm, cool, and collected. Honest about their feelings. Open and authentic. Up-front and dont play mind games. Those low in self-awareness may: Project stress and urgency. Be defensive, aggressive, or demanding. Fail to notice how they affect others. Talk over others. Individuals with good self-management skills are likely to be: Patient and understanding. Sensitive but direct. Able to think on their feet. Good at handling stress. Polite and professional regardless of circumstances. Those who lack self-management skills tend to: Respond too quickly or sharply. Panic. Be prone to verbal outbursts. Share their negative emotions with others too much. Display their stress in front of others. People with high social awareness typically: Read others emotions well. Acknowledge others feelings. Make an effort to get to know others personally. Listen respectfully. Show sincere interest in others. Put others at ease. Motivate people. A person with little social awareness may be: Impatient while others are expressing their ideas. Inattentive to others. Disinclined to socialize. Inflexible. Caught up in his or her own thoughts. Individuals who are good at relationship management often: Excel at listening. Know how to make others feel better, even when theyve made an error. Are nonjudgmental. Praise and encourage others, when appropriate. Make others feel as though they have been heard and understood. Those who struggle with relationship management may: Make others feel discounted or minimized. Dismiss others ideas. Not try to get to know people better.
Nor does one race or ethnicity score significantly better than others on EI assessments. In a study of 1000 North Americans, average differences in scores by race/ ethnicity were less than 5%, a difference that could be attributable to chance alone.21 In this study, African Americans scored slightly higher than other groups, followed by Hispanics, Caucasians, and Asians.21 Bradberry and Greaves profiled people high and low in EI from a variety of different walks of life. Several common characteristics emerged from their descriptions (see Box 1).13 Goleman discussed a worrisome trend among American children. Tests of EI in groups of children conducted 15 years apart showed that childrens EI is declining. On average, kids are more anxious, depressed, angry, and lonely than they were just a decade and a half earlier, and are less able to cope with their feelings.19 Goleman emphasized the role of parents as their childrens first emotional coaches and role models, and suggested that EI training in the schools also can help reverse this decline.19
243
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Why Is Emotional Intelligence Important?

Proponents of EI maintain it has important associations with health, happiness, and well-being. For example, a meta-analysis by Schutte et al involving 7898 participants concluded that EI was associated with better health, including both mental and physical well-being.22 This finding was confirmed by Martins et al in an even larger meta-analysis published in 2010.23 In addition, low EI has been associated with violent behavior, use of street drugs, and delinquency.16 A large body of research has focused on the connection between EI and success on the job, and many studies have identified a positive relationship between the 2. Freshman and Rubino summarized some of that research, noting, for example, that:
Rosenthal found that people who could better identify the emotions of others were also more successful at work and in social settings. Bachmans study on leadership in the US Navy found warmth, emotional expression, and sociability to be key factors in effectiveness. A study of retail chain managers revealed that the ability to handle stress predicted net profits.11
concluded, emotional competencies were twice as important in contributing to excellence as were pure intellect and expertise.24
Emotional Intelligence and Health Care Professionals

The health care industry has been somewhat slow to embrace EI and incorporate it into educational and training programs.11 Freshman and Rubino speculated this might be due to the fact that health care professionals do not believe they need to improve their EI skills because they are caring people who were drawn to the health care field in the first place because of their compassion.11 Yet research indicates that EI varies among health care professionals, just as it does in the population as a whole. And higher EI has many benefits for health care professionals, students in the health care profession, and the patients they care for. According to Bradberry and Greaves, EQ is so critical to success that it accounts for 58% of performance in all types of jobs and is the single biggest predictor of performance in the workplace.5 Furthermore, for every 1-point increase in EI, individuals earn on average an additional $1300 per year, they noted.5 Goleman discussed physicians and their interaction with patients, reporting that25 :
Physicians who are better at recognizing emotions in their patients are more successful in treating them than their less sensitive colleagues. Physicians, of course, need to sense the anxiety and discomfort of their patients so they can treat them effectively, but a study found how rarely they listen. Patients usually had an average of 4 questions in mind to ask, but during the visits they were able to ask just 1 or 2. Once a patient started speaking, the first interruption by the physician occurred, on average, within 18 seconds.
Meyer et al listed several proposed benefits of high EI on the job, including better performance, enhanced ability to cope with job-related tension, improved conflict resolution, and more effective leadership.6 In addition, studies of excellence on the job have shown that in general, emotional competencies play a far larger role in superior job performance than do cognitive abilities and technical expertise.24 Goleman explained there are 2 levels of job competence: threshold competencies and distinguishing competencies. Threshold competency includes the minimum skills needed to perform a job. Distinguishing competencies are the abilities that set star performers apart from others. For a radiologic technologist or radiologist assistant, threshold competency would include the skills and knowledge needed to pass a certifying examination and demonstrate the mandatory clinical competencies. Distinguishing competencies include the ability to influence others and the drive to improve ones skills.24 Goleman worked with researchers who assessed employee competence at 40 companies, examining the differences between star performers and average performers. The stars were 27% more likely to score high in terms of cognitive ability than the average group; they were also 53% more likely to score high on emotional competency. In other words, Goleman
244
Physicians who dont listen well are sued more often than peers who communicate better with patients, Goleman added. Good communicators take time to tell patients what to expect from a treatment, to laugh and joke, to ask the patients opinion and check their understanding, and to encourage patients to talk.25 Furthermore, Goleman pointed out that it took just 3 minutes for a physician to demonstrate his or her empathy with a patient.25 On the other hand, it takes only seconds for a physician or other health care provider to demonstrate that he or she is not empathetic. Goleman related the story of a friend who consulted a physician about treatment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
for a blood clot in her leg. The physician informed Golemans friend there was a possibility she might lose her leg because of the clot, and the patient began to cry. The physician then said: If youre going to cry, youll have to find another doctor. She did, of course.19 Health Care Students, EI, and Stress Birks et al examined EI and stress in 4 groups of health care profession students in the United Kingdom: undergraduate dental, nursing, and medical students, and postgraduate mental health care students.26 The aim of the study was to determine whether there were differences between the groups and whether EI might serve as a buffer for stress. All of the students were in their first year of professional study. The rationale for focusing on first-year students was that this might help identify those who were highly stressed or especially low in EI, and therefore allow early intervention and support.26 Perceived stress levels are reportedly high among health care students and have been connected with depression, drug and alcohol use, anxiety, and attrition, Birks et al noted. EI is one factor that may be related to and predictive of stress. Consequently, Recent calls have been made to include training in emotional intelligence in health care workers as a means of improving leadership qualities, preventing burnout and stress, and improving curricula and communication skills.26 Birks et al administered the Schutte Emotional Intelligence and the Perceived Stress Scale instruments. Both are brief, self-reporting scales that use the 5-point Likert response format. Response rates ranged from 62% for dental students to 91% for the nursing students. A total of 147 students completed the assessments twice: in the fall of 2005 and summer 2006. Results indicated that EI was relatively stable over time, while stress levels increased between the first evaluation and the second, possibly because the second administration was close to end-of-year exam time.26 Statistical analysis showed no differences between the groups of students in terms of EI. Nor were age or sex associated with significant EI differences. (Students ranged in age from 18 years to 50 years; women made up the majority of all 4 groups.) Both at the baseline point and at follow-up, higher EI was correlated with lower perceived stress. Interestingly, the authors suggested that while EI might help moderate stress at lower levels, when there is an acute stressor such as end-of-year exams, the effect of EI may be lessened.26
For most of the students, EI was relatively stable during the study period. However, some students showed a change in EI of up to approximately 20%. Among students who experienced a change, those with increased EI had a significant decrease in stress and vice versa.26 Birks et al concluded that EI was at some level a moderator of stress. The study was correlational and therefore could not determine the direction of the relationship. However, because EI is more stable than stress, it might make sense to hypothesize that it is EI that is affecting stress rather than the other way around.26 While this study suggests the link between EI and stress may be worth pursuing, much work remains to be done to fully explore the relationships between emotional intelligence and stress in students in various health professions, the researchers concluded, adding that26 :
One limitation of the present study is that it is based on correlational rather than experimental evidence, a limitation inherent in many studies of personal attributes. Further work will be required to determine how EI impacts stress, and also on adaptation or coping and whether interventions may facilitate development of effective strategies.
In particular, the authors suggested repeating the study with more students and different groups of students to determine how health care students differ from students in other types of programs.26 Pau and colleagues conducted a qualitative study to examine EI in dental students in the United Kingdom and how those students coped with stress related to their education and training.27 They assessed a total of 213 students using the Schutte EI scale to identify the students with the highest and lowest scores. A total of 20 students were recruited for in-person interviews, including the highest and lowest scoring men and women volunteers from each year of the 5-year undergraduate program. Trained interviewers met with each student to discuss whether they had experienced stress recently, what their stress had been like, and how they coped with it. The recorded interviews were analyzed for common themes.27 Almost all of the students reported they had experienced stress recently, and several key differences emerged between the high-EI students and those who scored lowest on EI.27 For example, the high-EI students showed more skill and willingness to use their social support networks as a means of coping with stress, whereas the low-EI students tended to either reject
245
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
their social networks or believed they would not be helpful. As a low-EI male student explained, I dont tell my friends when Ive got problems because I dont like whinging [sic] about things. (Whinging is a British term for whining.) A high-scoring female student said, I have to say my friends help me a lot because they go through these similar things.27 Another difference between the high and low scorers was in the area of lifestyle choices used to cope with stress. The students with low EI were more likely to engage in self-destructive or risky behavior, while highEI students tended not to engage in those behaviors and to consider them unhelpful. One female student who scored low in EI reported that when under stress she would eat more, smoke go out and get drunk. A male student who scored low in EI told the interviewer, if Im sort of stressed Ill get on my bike and go mad just going at stupid speeds. A high-scoring female student, on the other hand, noted that I used to smoke [but] I dont find that helps me calm down.27 Yet another area of difference was in time management and organizational skills. High-EI students tended to be confident in their ability to cope with stress because of their skill in managing time and getting organized; the low-EI students were less certain about these areas or tended to blame factors outside their control for difficulty with meeting deadlines and staying organized.27 Because students academic progress may be affected if they cannot cope effectively with stress, Pau et al suggested that it is important to monitor students emotional well-being, train them in techniques for coping with stress, and revise the curriculum to improve EI.27 Por et al studied 130 nursing students in programs for mature students.15 Half of the students were enrolled in a 3-year diploma program, one-third were in a 3-year degree program and less than one-fifth were in a 2-year accelerated diploma program. The mean age of the participants was 28 years. The studys aim was to measure EI using the SEIS and assess EIs relationship to stress, well-being, perceived competency, and academic performance.15
There were significant differences in the EI score, perceived stress, coping strategies, and perceived nursing competency between the participants from the different educational pathways. The diploma students had the highest EI score and the lowest level of perceived stress, whereas the degree students had the lowest EI score and the highest level of perceived stress. 246
The reasons behind this finding are not clear, although the authors pointed out that the degree programs curriculum was demanding and instructors in that program had high expectations.15 Overall, there was a strong negative correlation between EI and perceived stress. In addition, student nurses with high EI scores also had high perceived competency, Por et al reported.15 The researchers speculated that students with high EI were able to maintain positive moods longer and generate positive moods even in negative situations. Redirecting emotions in a positive way may help nursing students remain calm and professional despite the inherent stresses, they conjectured. Unfortunately, they found little emphasis on EI in the nursing curriculum. Technical skills and intellectual understanding are not sufficient for success in a nursing career, and EI should be included in the professional curriculum, they concluded.15 Nurses, EI, and Professional Performance High EI levels also seem to benefit health care professionals and their employers. For example, Codier et al studied nurses in a large medical center in Hawaii.28 The study used the MSCEIT to measure EI for 193 clinical staff nurses. The researchers also evaluated subjects in terms of retention, commitment, and performance. Measures of retention included years in ones current job, years in the nursing profession, and anticipated length of career. These researchers found a positive correlation between EI and both performance level and retention.28 In an article about the value of EI for nurse managers, Merkey outlined several situations in which managers frequently demonstrate a lack of EI.29 One of these occurs when a nurse develops an adversarial relationship with a physician. The situation becomes emotionally charged and the nursing leader becomes reactive and defensive, Merkey wrote. To make matters worse, the [nurse] decides to involve the staff in the dispute to create even more drama. Often, the nurse manager becomes entrenched in his or her position and loses sight of alternatives.29 Obviously, this behavior does not benefit the patients or the health care team. Merkey also discussed the situation in which a nurse who was recently promoted to a management position lost touch with his or her team because of a personal agenda. The managers staff became disillusioned and disappointed in the new leader.29 Just a little effort
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
at remaining self-aware and managing emotions can make managers more effective and improve the health care work environment, Merkey concluded.29 Physicians, EI, and Patient Satisfaction Stein and Book, in their book The EQ Edge, reported that EI testing of physicians revealed that they scored lower, as a group, than the population as a whole. Physicians scored highest in stress tolerance and lowest in empathy, happiness, and social responsibility.30 Unfortunately, physician happiness seems to be one component of EI that is associated with patient satisfaction, according to a study by Wagner et al.14 Wagner and her colleagues measured EI in 14 faculty members and 16 resident physicians in a family medicine department in the southern United States using the EQ-i. They also measured patient satisfaction in a group of 232 ambulatory patients using an 11-item questionnaire.14 Results showed only a limited relationship between satisfaction and physicians emotional intelligence scores.14 Only one subscale measured by the EQ-i, happiness, proved to be related to patient satisfaction. It is not surprising that a physicians own happiness transmits across the patient-physician relationship to increased patient satisfaction with care, the researchers wrote. What is perplexing is the elements of EI that describe self-awareness, stress control, emotional functioning, and adaptability do not, at least in this limited sample, relate to patient satisfaction.14 Nevertheless, If one of the outcomes we want to maximize in the future of health care is patient satisfaction, then helping our learners increase their level of personal happiness and life satisfaction may be the best starting point for EI coaching.14 Wagner et al suggested medical school courses focused on improving the physician-patient relationship would be a good place to incorporate EI in the curriculum. The authors noted limitations of their study such as the small sample size and use of a selfreporting instrument to measure EI.14 Raising EI in a Dental Practice Meyer et al examined whether a 1-day intervention could help improve EI scores among dentists and administrators at a multisite dental practice.6 (No dental hygienists, dental assistants, or other employees were included in the study.) Fifteen people completed the MSCEIT before and after the intervention. The adventure-based training program was an indoor/
outdoor ropes and challenge course. This intervention focused on building trust, communication, and teamwork. Facilitators led discussions throughout the day to help the participants find meaning in the experience and apply what they had learned to the workplace. The researchers reported there were no statistically significant changes in EI following the intervention; however, there were small improvements in overall EI.6
The small yet positive improvements in overall EI suggest that health care administrators and providers are able to enhance their interpersonal skills, which creates the potential for a more collegial and productive work environment. Similarly, the improvements in understanding emotion may facilitate among employees the empathy or compassion necessary to treat fearful or anxious clients.
The authors offered several possible reasons why the improvements werent statistically significant, including the small sample size, above-average EI scores before the intervention, and the fact that the intervention was short and not focused specifically on improving EI.6 EI and the Health Care Team When individuals who work together have high EI, the team functions better. As Hughes reported, teams with members who had high EI felt greater psychological safety with each other, had lower levels of conflict, made decisions more collaboratively together, and experienced greater team learning.31 Thus, training work groups in EI could pay off for the group as a whole, as well as for the individuals who make up the team.
Techniques for Improving EI

Establishing new patterns of thought and behavior takes time. Although it is possible to increase ones self-awareness, ability to manage emotions, empathy, and social skills, it can be a long process and depends on baseline abilities. The Consortium for Research on Emotional Intelligence in Organizations recommended corporate EI training include 4 phases: preparation, training, transfer/maintenance, and evaluation.11 During the first phase, organizations should assess their needs and readiness to implement an EI program, encourage participation, and adjust expectations. In phase 2, its important to build rapport between the trainer and participants, set goals, provide opportunities to practice, offer feedback, use modeling, and provide facilitation to help participants gain insight. During phase 3, organizations must encourage the use
247
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
of newly learned skills to prevent relapse into old habits. The final phase allows for continuous improvement of an EI program through evaluation and feedback.11 Failing to use a well-planned EI training model could be a costly mistake for organizations.11 Goleman and Boyzatis developed a training program for improving EI over the course of 1 year. The Mastering Emotional Intelligence Program (MEIP) begins with a 2-day workshop designed to help participants develop emotional awareness, both in themselves and others. This is followed later in the year by another 2-day workshop that focuses on the EI competencies participants are weakest in. Each participant receives individual counseling in these areas. The program concludes with a 1-day workshop that involves practicing EI behaviors. Throughout the program, participants are encouraged to support each other and offer feedback.16 Assessments taken 14 months apart demonstrated that the MEIP does in fact raise scores on the Emotional Competency Inventory. A group of Brazilian managers who completed the program increased their scores by approximately 14%; a group of government accountants in the United States raised their scores by an average of 24% after completing the training.16 Goleman wrote that simulations, games, and roleplaying all can be good methods for developing EI competencies, but they should be carefully planned, focus on specific competencies that are clearly described to participants, and end with a debriefing of the experience.17 Computer training is better for learning technical skills than EI, according to Goleman. However, computer-based learning might be helpful for individual practice as part of an overall training program. Online support groups also can be useful for learning EI, but the face-to-face human element is critical: Training must be provided by trainers who are themselves emotionally intelligent.17 Generally speaking, a one-size-fits-all approach to EI training is much less effective than a more personalized approach.16 It also is possible to work on building EI independently, although its still useful to seek input from others. For example, it may be helpful to gather information from people who know you well and are willing to discuss your strengths and weaknesses, or to work with a mentor who is highly emotionally intelligent. Self-awareness Self-awareness is at the very core of EI. In essence, it is knowing what emotions you are feeling, why you are feeling them, and how they affect what you are doing
248
and thinking. We tend not to be tuned in to our emotions, although they are always present. Usually, we focus on them only when they are extreme.19 However, most of us would be well-served by paying more attention to our emotions. As Deutschendorf pointed out, Our feelings do not lie.2 They are a reliable guide to our fears, desires, and motivations. When you are self-aware, Bradberry and Greaves explained, you are far more likely to pursue the right opportunities, put your strengths to work, and perhaps most importantly keep your emotions from holding you back.13 Being in tune with our feelings helps us choose projects that use our best talents and are congruent with our values. Self-awareness also ties in with self-control. Without self-awareness, we are vulnerable to being sidetracked by our emotions, according to Goleman.32 Self-awareness is also key to helping us deal with stress. Without paying attention to emotions, we can be surprisingly oblivious to just how stressful our work life really is.33 Finally, understanding our own emotions is the basis for understanding others emotions or empathy. These skills are especially critical for people whose jobs involve sensitive matters, such as health care professionals. Some effective techniques for raising self-awareness include regularly writing in a journal about ones emotions. Deutschendorf recommended setting aside a few minutes each day to reflect on ones emotions, re-create them, and record them in a notebook. This helps people learn to better identify their emotions.2 After a few weeks, it may be useful to review what youve written to look for patterns: Which emotions predominate? Are any emotions missing? What triggered the emotions? Bradberry and Greaves offered these suggestions for people who are working to improve awareness of their emotions34 : n Notice your emotions, but dont judge them. Judging emotions unnecessarily complicates the situation. Emotions are neither good nor bad, and all of them are useful. As Anthony Robbins wrote: The only way to effectively use your emotions is to understand that they all serve you. You must learn from your emotions and use them to create the results you want The emotions you once thought of as negative are merely a call to action.35 n Dont ignore or dismiss emotions. Feel them fully, even if they are uncomfortable. n Notice your bodys reactions to emotions, such as changes in breathing, heart rate, perspiration,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
muscle tension, and posture. Eventually, you can become physically aware of emotions before you are mentally aware of them. n Recognize what specific situations tend to trigger emotional reactions in you. This will help you control your reactions. Self-management After building emotional self-awareness, the next step in becoming more emotionally intelligent is to increase ones ability to manage emotions. Managing emotions is not the same as suppressing or stifling them. Stifling emotions does not make them disappear, but leaves them to fester. In addition, attempting to suppress emotion deprives us of useful information about ourselves. Rather, as psychologist Hendrie Weisinger wrote, managing emotions means understanding them and using that understanding in beneficial ways.36 Weisinger offered this scenario to demonstrate skillful and less skilled management of emotions at work: Imagine you have just offered a suggestion at a meeting and your supervisor belittles it in front of the group. An emotionally unintelligent response might be to blow up in anger during the meeting or stew over the situation for days, but not address the matter. An emotionally intelligent response, on the other hand, would be to allow yourself to briefly feel the anger and then begin an internal dialogue. For example, you might say to yourself: Hes being unreasonable. I will not sink to his level. I will not allow my anger to show. I know my idea is a good one.36 Notice the physical symptoms of anger, such as a clenched jaw or rapid breathing, and consciously relax. If necessary, take a short break from the situation. Later, find a way to address it.36 Many EI experts recommend regularly practicing a relaxation technique, which could be meditation, yoga, aerobic exercise, prayer, walks in nature, long baths, or some other activity that is calming and centering. Having such a relaxation method in our repertoire does not mean that we wont feel upset and distressed from time to time. But regular, daily practice of a relaxation method seems to reset the trigger point for the amygdala (the brains emotional center), making it less easily provoked.33 As a consequence, people who practice relaxation techniques are distressed less often and for shorter periods (see Box 2).33 If you do find yourself involved in a heated exchange with a coworker, supervisor, or someone else at work, Weisinger advises calmly let the other person know you are feeling angry and that you need
Box 2 Additional Suggestions for Improving Self-management19,37

Practice proper breathing: Take full, deep breaths that expand the abdomen. Keeping the body well oxygenated calms you down. When you feel angry or frustrated, count to 10 before you react. This simple, time-tested tip gives the rational mind a chance to catch up with the emotions. Give yourself time to think things over. Time brings clarity to emotionally charged situations. If necessary, let the other person know youll think things over and get back to him or her later. Ask for help from someone who manages his or her emotions well. Find out how that person copes with situations that are especially difficult for you. Try to limit your negative self-talk or make it more positive. For example, instead of berating yourself for something that went wrong, simply acknowledge that you made a mistake. Pay attention to the things you can control, rather than the things you cant. Talk over an emotionally challenging situation with someone who is objective about it. When you find youve reacted out of anger, fear, or some other strong emotion, think about what you might have done differently and resolve to act that way next time.2
some time. You might say something like: I would like to stop arguing for a little while so I can think more clearly. Then Id like to get back together with you and talk this thing through. After the conversation ends, calm yourself with deep breathing and stay occupied with busywork. Come back to the discussion when you are better prepared to handle it. Dont ignore the situation, hoping it will resolve itself.36 Empathy and Social Awareness Empathy, it is important to note, is not the same as sympathy. Sympathy is an inclination to think or feel alike,38 to share in anothers feelings, to feel someones pain (or joy, sorrow, etc). Empathy on the other hand is the ability to see the world from another persons perspective, the capacity to tune into what someone else might be thinking and feeling about a situation regardless of how that view might differ from your own perception.39 When we sympathize with
249
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
someone, we feel for them. When we empathize with someone, we understand how they are feeling, whether or not we feel the same way. Empathy does not imply a judgment about the validity of someone elses feelings; its simply recognition of those feelings. Stein pointed out that empathy is an extremely powerful interpersonal tool that can forge bonds and help restore harmony.39 When you make an empathic statement, even in the midst of an otherwise tense or antagonistic encounter, you shift the balance. A contentious and uneasy interchange becomes a more collaborative alliance.39 Because empathy involves being extremely tuned in to others, it requires first of all that we understand and can manage our own emotions. Without self-awareness and self-control, we are liable to be hijacked by our own emotions, and thus unable to pick up on the sometimes subtle emotional cues others are sending.25 The most important tool for achieving empathy, according to Goleman, is active listening, which involves paying close attention to what someone else is saying and then asking questions and restating what the other person has said.25 Some other tips for listening actively include using acknowledgement phrases to let the other person know you are listening to them, such as saying I see or Id like to hear more about that.40 Also use nonverbal cues to convey your interest and attention, such as maintaining eye contact or leaning toward the speaker. However, Weisinger warned against following these practices if you are not actually paying attention. Such deception can hamper good communication and trust.40 Deutschendorf recommended these exercises for building empathy41: n Choose a conversation that you are not involved in and observe it closely. Try to discern each participants feelings about the discussion. Home in on the tones of the voices, facial expressions, and body language. n Pick someone you are close to and practice really listening to what he or she is saying. Resist the urge to pass judgment or offer advice or suggestions. When that person is finished speaking, restate what he or she just said and how you think he or she feels about the subject. Check to see whether you are correct. Bradberry and Greaves offered these complementary suggestions42 : n When talking to another, focus fully on that person and allow him or her to finish speaking.
250
Avoid multitasking and thinking about other things. n When you are uncertain how others are feeling about a particular situation, ask! Tell the person how you perceive his or her emotions and ask whether youre correct. Its also important to realize how much of emotional communication is unspoken. Others rarely tell us in words what they feel; instead they tell us in their tone of voice, facial expression, or other nonverbal ways, Goleman wrote. Sensing what others feel without their saying so captures the essence of empathy.25 To practice this skill, try watching a movie or TV show with the volume turned down. Try to gauge the characters emotions. Then watch again with the volume up to hear how accurate your assessment was.42 As Weisinger did, Goleman emphasized that empathy must be sincere, not feigned, or it could backfire. He described a situation in which an industrial plant was scheduled to open near a school. The companys president told parents he understood their worry over their childrens well-being and the plant would close if we find anything that might harm the kids.25 One of the parents questioned the president about some specific risks, and the president quickly became flustered, defensive, and antagonistic. Trust was destroyed when it became obvious that the company didnt truly empathize with the parents concerns or put childrens safety above profit.25 Sometimes empathy in the workplace should be tempered for the good of the organization. This might be the case, for example, when allocating limited resources, Goleman wrote.25 Another concern, especially in the health care workplace is empathy distress, in which a health care professional catches a patients distress and cannot help the patient cope with those feelings. Goleman related the story of a pediatric nurse who wanted a transfer because I just cant take holding another little kid who is going to die of cancer. Its too hard on me.25 This is a common problem in the helping professions; the solution, Goleman wrote, is emotional self-management. Health care workers should be careful not to become overwhelmed by the emotions their patients are experiencing. As mentioned previously, one of the biggest impediments to empathy is failing to manage our own emotions. When we feel angry, overwhelmed or threatened, were less able to listen actively and empathize fully with others.43 Thus, its critical to know ourselves and our emotional triggers.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Managing Relationships Weisinger wrote that all relationships, whether workrelated or personal, have 3 bases: meeting each others needs, relating to each other over time, and exchanging information about feelings, thoughts, and ideas.44 By paying attention to each of these areas, we can grow new relationships and improve existing ones. First, every relationship must be reciprocal in that both parties benefit in some way. The task is to find out what the other persons needs are through active listening, empathy, or just by asking and then to meet those needs. For example, radiologic technologists who work together might look to one another for help with moving patients, suggestions for alternative positioning, advice on dealing with a supervisor, or support for ideas on how to improve workflow in the department. Second, relationships must be supported by ongoing contact. This allows the people involved to get to know each other under a variety of circumstances and to build trust and rapport, which in turn improves the ability to meet each others needs and strengthens the relationship. Third, sharing thoughts and feelings deepens the relationship, further improves your understanding of each other, and enables you to interact more sensitively and effectively with one another.44 Adele Lynn, an EI consultant, speaker, and author, suggested these steps for improving and managing relationships on the job45 : n When you can, offer your help without being asked. n Smile, say hello, and greet people by name. Talk about subjects other than those you normally discuss on the job, such as family, friends, or hobbies. Whenever you speak with someone, try to remember something he or she talked about. Ask about it the next time you meet. n Encourage coworkers to share their opinions and ideas about work-related matters. Respect their input and give it due consideration. n When you are involved in a conflict situation, listen actively and seek out common ground. Try to build a solution based on areas of agreement. n Join and get actively involved in professional organizations.
is a prerequisite for success. This is especially true in the health care workplace, where stress is a constant pressure. The good news is that unlike cognitive intelligence, EI can be learned and developed. Employers are beginning to recognize the value of increasing EI among staff members and incorporating EI training on the job, and individuals can take steps to improve their EI independently by learning about the subject and practicing suggestions like those discussed in this article. As research into EI continues, we will have better ways to assess and improve EI, as well as a clearer picture of its many benefits on and off the job.
1. Salovey P, Mayer JD. Emotional intelligence. Imagin Cogn Pers. 1990;9(3):185-211. 2. Deutschendorf H. Emotional self-awareness. In: The Other Kind of Smart. Simple Ways To Boost Your Emotional Intelligence for Greater Personal Effectiveness and Success. New York, NY: American Management Association; 2009:35-42. 3. Mayer JD, Salovey P. What is emotional intelligence? In: Salovey P, Sluyter D, eds. Emotional Development and Emotional Intelligence. Educational Implications. New York, NY: Basic Books; 1997:3-31. 4. Goleman D. Appendix 1. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:317-318. 5. Bradberry T, Greaves J. The big picture. In: Emotional Intelligence 2.0. TalentSmart: San Diego, CA; 2009:13-22. 6. Meyer BB, Fletcher TB, Parker SJ. Enhancing emotional intelligence in the health care environment: an exploratory study. Health Care Manag. 2004;23(3):225-234. 7. Ashkanasy NM, Daus CS. Rumors of the death of emotional intelligence in organizational behavior are vastly exaggerated. J Organ Behav. 2005;26(4):441-452. 8. Goleman D. The new yardstick. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:3-14. 9. Kihlstrom JF, Cantor C. Social intelligence. http://socrates .berkeley.edu/~kihlstrm/social_intelligence.htm. Accessed March 29, 2011. 10. Stein SJ, Book HE. Exploring emotional intelligence. In: The EQ Edge: Emotional Intelligence and Your Success. Mississauga, ON: John Wiley and Sons Ltd; 2006:11-33. 11. Freshman B, Rubino L. Emotional intelligence: a core competency for health care administrators. Health Care Manag. 2002;20(4):1-9. 12. Goleman D. Competencies of the stars. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:15-29. 13. Bradberry T, Greaves J. What emotional intelligence looks like: understanding the four skills. In: Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009:23-50. 14. Wagner PJ, Moseley GC, Grant MM, Gore JR, Owens C.
References
Conclusion
Although it only gained popularity in the 1990s, EI is based on the ancient idea that understanding and managing emotions, both in ourselves and in others,
251
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
15.
16.
17. 18.
19. 20.
21.
22.
23.
24. 25. 26.
27.
28.
29. 30.
Physicians emotional intelligence and patient satisfaction. Fam Med. 2002;34(10):750-754. Por J, Barriball L, Fitzpatrick J, Roberts J. Emotional intelligence: its relationship to stress, coping, well-being and professional performance in nursing students. Nurse Educ Today. 2011 (in press). doi:10.1016/j.nedt.2010.12.023. Stys Y, Brown SL. A review of the emotional intelligence literature and implications for corrections. Ottawa, Ontario: Research Branch, Correctional Service of Canada. www.csc.-scc.gc.ca/text/rsrch/reports/r150/r150_e.pdf. Published March 2004. Accessed April 19, 2011. Goleman D. Appendix 5. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:326-330. Psychological test materials. Mayer-Salovey-Caruso emotional intelligence test. PsychPress Talent Management Psychologists. www.psychpress.com.au /psychometric/product-page.asp?ProductID=3454. Accessed April 22, 2011. Emotional Intelligence With Daniel Goleman [video recording]. Washington, DC: WETA; 1999. Deutschendorf H. What is EI? In: The Other Kind of Smart. Simple Ways To Boost Your Emotional Intelligence for Greater Personal Effectiveness and Success. New York, NY: American Management Association; 2009:9-13. Stein SJ, Book HE. Introduction. In: The EQ Edge: Emotional Intelligence and Your Success. Mississauga, ON: John Wiley and Sons Ltd; 2006:1-8. Schutte NS, Malouff JM, Thorsteinsson EB, Bhullar N, Rooke SE. A meta-analytic investigation of the relationship between emotional intelligence and health. Pers Individ Dif. 2007;42(6):921-933. Martins A, Ramalho N, Morin E. A comprehensive metaanalysis of the relationship between emotional intelligence and health. Pers Individ Dif. 2010;49:554-564. Goleman D. Appendix 2. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:319-321. Goleman D. Social radar. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:133-162. Birks Y, McKendree J, Watt I. Emotional intelligence and perceived stress in healthcare students: a multi-institutional, multi-professional survey. BMC Med Educ. 2009;9:61. doi:10.1186/1472-6920-9-61. Pau AKH, Croucher R, Sohanpal R, Muirhead V, Seymour K. Emotional intelligence and stress coping in dental undergraduates a qualitative study. Br Dent J. 2004;197(4):205-209. Codier E, Kamikawa C, Kooker BM, Shoultz J. Emotional intelligence, performance, and retention in clinical staff nurses. Nurs Adm Q. 2009;33(4):310-316. Merkey LL. Emotional intelligence: do you have it? Okla Nurse. 2010;55(4):14. Stein SJ, Book HE. The star performers. In: The EQ Edge:
31.
32. 33. 34.
35.
36.
37.
38. 39.
40.
41.
42.
43.
44.
45.
Emotional Intelligence and Your Success. Mississauga, ON: John Wiley and Sons Ltd; 2006:243-272. Hughes M, Terrell JB. The business case for team emotional intelligence. In: The Emotionally Intelligent Team: Understanding and Developing the Behaviors of Success. San Francisco, CA: Jossey-Bass; 2007:26-33. Goleman D. The inner rudder. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:49-72. Goleman D. Self-control. In: Working With Emotional Intelligence. New York, NY: Bantam Books; 1998:73-104. Bradberry T, Greaves J. Self-awareness strategies. In: Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009:61-95. Robbins A. The 10 emotions of power. In: Awaken the Giant Within. How To Take Immediate Control of Your Mental, Emotional, Physical and Financial Destiny. New York, NY: Free Press; 1991:246-270. Weisinger H. Managing your emotions. In: Emotional Intelligence at Work. The Untapped Edge for Success. San Francisco, CA: Jossey-Bass Inc; 1998:27-60. Bradberry T, Greaves J. Self-management strategies. In: Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009:97-134. Merriam Websters Collegiate Dictionary. 10th ed. Springfield, MA: Merriam-Webster Inc; 1994. Stein SJ, Book HE. Empathy. In: The EQ Edge: Emotional Intelligence and Your Success. Mississauga, ON: John Wiley and Sons Ltd; 2006:125-139. Weisinger H. Developing effective communication skills. In: Emotional Intelligence at Work. The Untapped Edge for Success. San Francisco, CA: Jossey-Bass Inc; 1998:107-149. Deutschendorf H. Empathy. In: The Other Kind of Smart. Simple Ways To Boost Your Emotional Intelligence for Greater Personal Effectiveness and Success. New York, NY: American Management Association; 2009:75-86. Bradberry T, Greaves J. Social awareness strategies. In: Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009:135-175. Lynn AB. Empathy at work. In: The EQ Difference. A Powerful Plan for Putting Emotional Intelligence to Work. New York, NY: AMACOM; 2005:185-196. Weisinger H. Developing interpersonal expertise. In: Emotional Intelligence at Work. The Untapped Edge for Success. San Francisco, CA: Jossey-Bass Inc; 1998:151-181. Lynn AB. Social expertness at work. In: The EQ Difference. A Powerful Plan for Putting Emotional Intelligence to Work. New York, NY: AMACOM; 2005:197-212.
Kathryn Faguy, MA, ELS, was the publications manager at ASRT from 2008 to 2011 and has worked as a newspaper reporter, magazine staff writer, scientific journal editor, and
252
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
freelance writer. She lives near Salt Lake City, Utah, and is writing a novel that has to do with medical imaging. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail communications@asrt.org. 2012 by the American Society of Radiologic Technologists.
Errata
An error occurred in the Directed Reading, A Review of Ethics for the Radiologic Technologist, which appeared in the July/August 2011 issue. The second sentence in the second paragraph on Page 534 should read: As discussed in Rule 19 of the Rules of Ethics, 2 questions related to ethics are asked as part of the renewal of registration. The error did not affect the post-test. We thank the reader who brought this error to our attention.
253
Directed Reading Continuing Education Quiz

#12801-01
Expiration Date: Feb. 28, 2014* Approved for 1.5 Cat. A and 1.5 MDCB CE credits
Emotional Intelligence in Health Care
To receive Category A continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on Page 260 and then follow the directions for submitting the answer sheet. You also may take Directed Reading quizzes online at www.asrt.org. New and reinstated members are ineligible to take DRs from journals published prior to their most recent join date unless they have purchased access to the quiz from the ASRT. Your access to Directed Reading quizzes for continuing education credit is determined by your CE preference. For access to other quizzes, go to www.asrt.org/store. *Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date. 1. In which part of the brain is emotion based? a. corpus callosum b. neocortex c. subcortex d. both the neocortex and the subcortex
5.
2.
Part of emotional intelligence (EI) is freely expressing ones emotions. a. true b. false
Which psychologist proposed knowing ones own inner world as a distinct type of intelligence in 1983? a. Salovey b. Thorndike c. Bar-On d. Gardner
6.
3.
EI is fixed at birth. a. true b. false
Who popularized the concept of EI in a bestselling book published in 1995? a. Wayne Payne b. Barbara B Meyer c. Daniel Goleman d. Peter Salovey
4.
Thorndike divided intelligence into which 3 types? a. emotional, intellectual, and physical b. instinctual, conceptual, and kinesthetic c. abstract, mechanical, and social d. theoretical, practical, and emotional
7.
Alexithymia means: a. devoid of emotion. b. unable to appraise or express ones emotions. c. hypersensitivity to others emotions. d. unable to regulate or manage ones emotions.
Continued on next page


8. Which of the following is not one of the 5 EI competencies proposed by Daniel Goleman? a. self-regulation b. regulation of others c. empathy d. motivation 12. Someone who often appears to be caught up in his or her own thoughts could have: a. good empathy with others. b. low self-awareness. c. low social awareness. d. alexithymia.
9.
Which of the following are criticisms of selfreporting EI assessments? 1. Some people arent sufficiently emotionally aware to evaluate themselves accurately. 2. The outcome is highly dependent on the individuals mood during the assessment. 3. Some people intentionally misrepresent themselves to look good. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
13. In his study of star performers, Goleman asserted that emotional competencies are _______ as important as intellect and expertise in contributing to excellence on the job. a. not b. nearly c. equally d. twice
10. According to the Directed Reading, after the age of 50 EI tends to: a. continue rising until extreme old age. b. remain constant in most people. c. wax and wane, depending on health status. d. taper off, but only slightly.
14. Bradberry and Greaves stated that ones emotional intelligence quotient accounts for _______ % of performance in all types of jobs. a. 28 b. 38 c. 48 d. 58
11. People who are highly skilled in selfmanagement: 1. are sensitive but direct. 2. think on their feet. 3. cope with stress by venting in front of others. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
15. How soon after a patient begins speaking does a physician typically interrupt him or her? a. 18 seconds b. 36 seconds c. 54 seconds d. 1 minute, 12 seconds
16. In the study by Birks et al comparing EI in different groups of health profession students in the United Kingdom, which group scored lowest in EI? a. dental students b. nursing students c. mental health care students d. There were no differences among the groups.

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3 255

17. Birks et al found that EI might help to: a. moderate stress at lower levels. b. eliminate acute stress. c. increase awareness of stress. d. raise stress levels during end-of-year exams. 22. Recommended techniques for increasing selfawareness include which of the following? 1. Dont ignore emotions, even if they are uncomfortable. 2. Whenever you experience a strong emotion, determine whether it is good or bad. 3. Notice how your body reacts to emotions. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
18. In the study by Codier et al of nurses in Hawaii, EI was positively associated with _______ and _______ . a. health; happiness b. absenteeism; on-the-job injuries c. personal satisfaction; commitment to ones career d. performance level; retention
19. According to Stein and Book, in which of the following EI areas did physicians score highest? a. empathy b. social responsibility c. happiness d. stress tolerance
23. People who regularly practice a relaxation technique such as meditation are: a. distressed less often and for shorter periods. b. immune to stress. c. more cognizant of stressful situations. d. more likely to discuss their stress with others.
20. In the study of family medicine physicians by Wagner et al, which EI subscale was positively correlated with patient satisfaction? a. flexibility b. empathy c. problem solving d. happiness
24. Which one of the following is not a suggested technique for improving self-management skills? a. Limit negative self-talk. b. Breathe fully and deeply. c. Discuss an emotionally charged situation with someone who is also involved and probably feels the same way you do. d. Take time to think things over.
21. According to Goleman, effective training activities for building EI should: 1. occur spontaneously. 2. focus on specific competencies. 3. end with a debriefing. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
25. When you find yourself in a heated exchange, you should: a. immediately change the subject. b. firmly stand your ground. c. politely agree to disagree. d. calmly let the other person know you feel angry.


26. What is empathy? a. feeling the same way someone else does about a particular situation b. trying to help another get over difficult or painful feelings c. really understanding how someone else feels d. letting someone talk through his or her feelings with you
27. The most important tool for achieving empathy, according to Goleman, is: a. relating anothers experience to something that happened to you. b. feigning interest in what the other person is saying. c. displaying emotions that mirror the other persons. d. active listening.
28. Empathy distress is when the: a. patient catches the health care professionals distress over the patients illness or injury. b. health care professional catches the patients distress and cant help the patient cope. c. health care professional becomes numb to the patients distress and can no longer empathize. d. patient becomes distressed by an apparent lack of empathy on the part of the health care professional.
257
Carefully cut or tear here.
....................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . .
CE
DIRECTED READING
Computed Tomography Angiography

BRYANT FURLOW, BA
Cardiovascular disease kills more adults in the United States each year than any other medical condition. Although these diseases are largely preventable, the number of newly diagnosed patients continues to climb. Angiography traditionally involves invasive catheter examinations, but recent advances have allowed computed tomography angiography (CTA) to supplant traditional angiography as a first-line diagnostic imaging modality to assess cardiovascular disease. Often used to diagnose vascular pathologies in symptomatic patients, CTA also is useful in early detection of coronary and peripheral artery diseases. CTA will play an increasingly important role in cardiovascular medicine as technological advances improve image data acquisition, processing speeds, and image reconstruction. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your CE preference. For access to other quizzes, go to www.asrt.org/store.
After completing this article, readers should be able to:
n Discuss the epidemiology, pathobiology, and economic costs of cardiovascular disease. n Describe the staging and grading of atherosclerotic plaque occlusions. n Summarize computed tomography coronary arterial calcium quantification. n List key computed tomography angiography (CTA) acquisition parameters and describe their effects on image quality and patient radiation dose. n Describe contrast agent contraindications and administration in CTA examinations, as well as contrast injection protocol. n Describe prospective and retrospective electrocardiogram-gating techniques.
ardiovascular diseases and the emergencies frequently attributed to them, such as heart attacks, pulmonary embolisms, and strokes, are largely preventable through long-term lifestyle and diet modification. However, in the United States, cardiovascular disease represents the single leading cause of death for adults, as well as a major source of disability.1,2 More than 616 000 Americans die each year of coronary heart disease a mortality rate of 204 per 100 000 people.2 With the aging U.S. population, cardiovascular disease will cause a growing number of deaths despite declining incidence rates.1,3 Although age is an important risk factor, 150 000 adults younger than 65 years of age died of cardiovascular disease in 2007.1,2 Cardiovascular disease mortality rates have decreased in the past 20 years, but still remain high disproportionately so in some minority populations.1,2 Mortality rates are particularly high among African Americans, residents of the southeastern United
States, and people with low incomes.1 For example, African Americans face a first-stroke risk twice as high as that seen among whites; American Indians and Alaska Natives face higher heart disease and heart disease mortality rates than any other population.1 As cardiovascular medicine improves survival rates, more people are living with cardiovascular disease.4 Approximately 34 million adults have uncontrolled high blood pressure and 71 million adults have high levels of low-density lipoprotein (LDL) cholesterol, both of which are risk factors for cardiovascular diseases.1 Currently, more than 83 million American adults live with cardiovascular disease, leading to 935 000 heart attacks and 795 000 strokes annually.1 Nearly 4 million adults in the United States suffer disabilities related to cardiovascular disease.1 The total direct and indirect costs of cardiovascular disease are estimated to be more than $440 billion, and nearly 17% of U.S. health care spending is attributable to cardiovascular disease.1
261CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
These trends are set to be replicated around the world, with developing nations seeing rates of cardiovascular and other chronic lifestyle diseases climb to rival infectious disease as a leading source of mortality and disability.5 The United Nations held a special summit on chronic, noncommunicable diseases in September 2011 a first step toward a coordinated international response to this growing public health challenge. Diagnostic imaging of the cardiovascular system and its diseases is crucial in disease detection, characterization, risk stratification, treatment planning, and patient monitoring. The promise of angiography (ie, the medical imaging of the bodys blood vessels) was recognized early in radiology, but it took several decades to develop safe angiographic procedures. A month after Wilhelm Conrad Roentgen published his 1896 study on the medical uses of x-rays, researchers began to publish reports on vascular radiography using injected contrast agents. Their results yielded more precise visualizations of research cadavers vascular networks than had been possible with surgical dissection.6,7 Sodium iodide contrast was first successfully used in experimental angiography of a living subject in 1924, and by the 1960s, angiography was a first-line diagnostic imaging technique for assessing pathologies of the aorta and larger arteries.6,7 By 1970, coronary catheter arteriography was the gold standard for characterizing arterial stenosis, the efficacy of coronary bypass surgeries, and congenital heart anomalies.6,7 The development of helical computed tomography (CT) scanners in the early 1990s allowed the emergence of less invasive CT angiography (CTA).8 Multidetector CT (MDCT) technology, also called multislice CT, hastened the widespread availability of CTA in the late 1990s, initially for aortic imaging and subsequently for imaging smaller blood vessels.8
a restricted blood supply (ischemia) to tissues in the heart and other organs, frequently leading to tissue death (infarction).4 The best-known types of ischemic infarction are heart attacks and cerebral strokes. In the United States, coronary artery disease alone causes 1 in 5 deaths.9 Although early stages of coronary artery disease frequently are discernible in young adults, this disease and other atherosclerotic diseases often goes unnoticed until acute emergencies arise, typically after the fifth decade of life. In half of heart attack cases, infarction is the first clinical sign of underlying coronary artery disease.3 Other clinical signs of coronary artery disease include oxygen deprivation and stable chest pain (angina pectoris).3 Peripheral artery disease affects blood vessels outside the heart, lungs, and brain. Frequently painful, it indicates systemic, widespread atherosclerosis. Peripheral artery disease often is diagnosed in patients with coronary artery disease and is linked to an increased risk of heart attack and stroke.10 It typically is first diagnosed in the legs and kidneys. Pulmonary embolism is another common emergency resulting from atherosclerotic disease. In the United States, it has an annual incidence rate of 3 per 1000 adults, and 1 in 5 patients who die of pulmonary embolism could have survived had they been properly diagnosed.11 Risk Factors As with many other chronic diseases, atherosclerosis appears to result from genetic, environmental, and behavioral risk factors over a patients lifetime (see Box 1).4 Emotional stress also might play a role in atherosclerosis. Clinical depression and anger correlate with poorer prognosis and may be physiologically linked to atherosclerotic plaque formation, possibly in part via glucocorticosteroid stress hormone pathways.4,12-15 Some major risk factors appear to interact with one another to increase the risk of cardiovascular disease. These include hypertension, tobacco use, diabetes, elevated cholesterol in the blood (serum cholesterol), and a family history of cardiovascular disease.4 However, deciphering the physiological pathways of these interactions has proven challenging. Hypertension is a well-known risk factor for cardiovascular disease and is common among tobacco smokers and diabetics.4 In addition, tobacco smoking magnifies the risks posed by diabetes, hypertension, and high serum lipid levels.4 Obesity is a risk factor for insulin dysregulation and type 2 diabetes, which in turn can
Epidemiology
The term cardiovascular disease sometimes includes congenital malformations and malignant neoplasms (heart or vascular cancers), but it more commonly describes medical conditions and events involving atherosclerosis. Atherosclerosis is a progressive, life-threatening chronic inflammatory disorder of vascular walls. This condition is common in industrialized nations and leads to as many as half of all deaths in the United States.1,4 Atherosclerosis involves fat (lipid) and fibrotic tissue accumulation in arterial walls, and may lead to coronary artery disease, peripheral artery disease, aneurysm, thrombosis, and embolism. Vascular clots and occlusions such as thrombi and emboli cause
262CT
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Box 1 Atherosclerosis Risk Factors4

Risk factors with genetic components include: n Elevated levels of low-density lipoprotein. n Low levels of high-density lipoprotein. n Elevated blood pressure. n Elevated levels of homocysteine. n Metabolic syndrome. n Clinical depression. n A family history of cardiovascular disease, diabetes, and systemic inflammation disorders. n Obesity. Behavioral or environmental risk factors include: n Diets high in fat. n Tobacco smoking. n Sedentary lifestyle. n Obesity. n Certain infections such as Chlamydia bacteria, herpes virus, or cytomegalovirus. n Low dietary intake of antioxidants.
cause elevated serum lipid concentrations (hyperlipidemia).4 Adipose fat tissue can increase cytokine production, which increases insulin sensitivity and triggers systemic inflammation.4 Increased blood pressure is thought to stress and injure vascular walls, triggering inflammation processes that hasten atherosclerotic plaque formation. Inflammation also may increase the risk of both atherosclerosis and hypertension, suggesting possible complex interactions between inflammation, hypertension, and atherosclerosis.4 Prevention and Maintenance Although atherosclerosis risk has a genetic component, it can be slowed and potentially even prevented through lifestyle, dietary, and pharmaceutical interventions. Major public health disease prevention campaigns have targeted 2 modifiable risk factors: tobacco smoking and cholesterol levels. As with numerous other chronic diseases, tobacco smoke is strongly tied to atherosclerosis. Smoking appears to hasten plaque development and risk of complications, cause 90% of nondiabetic cases of peripheral vascular atherosclerotic disease, elevate the bodys inflammatory markers, and cause blood platelet cell aggregation and thrombosis.4 Tobacco smoking has been implicated as a contributing factor in 36% of first
heart attacks, and one-third of smoking-related disease deaths involve cardiovascular disease.4 Smokers are more likely than nonsmokers to die of a sudden heart attack.4 It has been recognized since the 1970s that the risk of a second heart attack drops by half within 1 year of smoking cessation.16 In human and laboratory animal studies, a strong correlation exists between increased serum cholesterol and the risk of developing atherosclerosis.4,17 A 2011 meta-analysis of data from 7 studies, representing more than 50 000 patients, strongly suggested that intensive pharmaceutical LDL reduction therapy reduces atherosclerotic plaque progression and the risk of stroke, heart attack, and cardiovascular disease-related death.18 Despite the role of LDL oxidation in atherosclerosis and early epidemiological findings of an association between greater dietary fruit consumption and lower cardiovascular disease risk, antioxidant supplements do not appear to protect against cardiovascular disease. Recent clinical trials failed to demonstrate clear benefits.19,20 The relationship between dietary antioxidants and health is more complex than initially suspected, and the benefits of antioxidant supplements and foods are receiving new scrutiny from researchers.21
Functional Vascular Anatomy and Pathobiology

The arteries are blood vessels that carry oxygenated blood from the lungs throughout the body, and veins bring deoxygenated blood back to the lungs to expel the cellular metabolic byproduct carbon dioxide (see Figure 1). Reoxygenated blood from the lungs passes through the hearts left atrium and ventricle, and then through the aorta to the rest of the body via many arterial bifurcations into smaller and smaller blood vessels. As the diameter of blood vessels become smaller, the amount of smooth muscle fibers (cells) in the vascular walls increase, making smaller vessels more resilient and resistant to blood flow than larger vessels. Vascular wall endothelia, a layer of flat cells that line blood vessels, regulate vascular tone and responses to changing blood pressure.4 Normally, the endothelial cell layer also prevents adhesion and accumulation of platelets and immune cells on the interior arterial wall. Small areas of damaged endothelia, however, allow cellular material to accumulate. Arteries give way to smaller arterioles, which supply blood to yet smaller meta-arteries and capillaries. The capillary bed is a fine network of tiny vasculature
263CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Figure 1. Systemic arteries of the human body. Public
domain image by Mikael Haggstrom. http://commons .wikimedia.org/wiki/File:Arterial_System_-_complete.svg. Accessed October 8, 2011.
that delivers oxygen to tissue cells and carries away their metabolic wastes. Vascular walls at bifurcations experience high levels of shear stress from blood flow, which can damage the endothelial layer of the channel within the blood vessel, called the lumen (see Figure 2). These regions are frequently early sites for atherosclerosis.
264CT
Atherosclerosis Pathogenesis, Staging, and Grading Inflammation within blood vessels causes the accumulation of destructive fatty plaques in arterial walls.4 Although LDL accumulations begin long before plaques are discernible, the gradual buildup of plaques disrupts the structural and functional integrity of the vascular wall and lumen. The plaques cause progressive thickening of the lumen, eventually causing significant endothelial dysfunction, blood vessel occlusion, hemodynamic disruptions, and life-threatening events.4 Plaque accumulations can become dislodged, breaking up to create emboli or arterial blockages in the blood stream. The genesis of atherosclerosis involves a complex molecular process that is believed to begin with localized damage to the endothelial layer of the lumen, triggering inflammation and the accumulation of immune cells at endothelial gaps when endothelial cells respond to injury by releasing adhesion molecules.4 Diabetes and systemic inflammation, infections, radiation damage, oxidative stress, and toxins from cigarette smoke each can cause losses of arterial endothelial cells, predisposing regions of vasculature to atherosclerosis.4 Oxidative stress also promotes inflammation.4 Focal damage and inflammation lead to locally increased uptake of oxidized lipoproteins by the smooth muscle cells in vessel walls and aggregating macrophage immune system cells, creating foam cell accumulations. Foam cells represent a histologically identified precursor stage or first step in the development of atherosclerosis.22 Put simply, plaque development represents the gradual triumph of inflammatory molecular pathways over countervailing anti-inflammatory processes.4 This process occurs over a period of decades and can involve 6 distinct stages of endothelial dysfunction (see Figure 3). These categories of atherosclerotic progression correlate with increasingly serious grades of atherosclerotic disease and are identified in terms of cross-sectional luminal occlusion and endothelial wall disruption. They are: n Foam cells (also known as macrophage foam cells). n Fatty streak. n Intermediate atherosclerotic lesion. n Atheroma. n Fibrous plaque. n Complicated or ruptured atherosclerotic lesion. As a precursor to atherosclerosis that appears in the first or second decade of life, foam cells result from vascular wall damage and the resulting increased uptake
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
of oxidized lipoproteins by smooth muscle cells and macrophage cells in the vascular wall. Fatty streaks occur in the first phase of atherosclerotic plaque development. The streaks are focal accumulations of leukocytes and extracellular matrix material, resulting from the activity of foam cells.4 Fatty streaks frequently occur as early as childhood and even in fetuses, initially appearing at sharp vascular bends or bifurcations, where arteries split into smaller vessels and where blood pressure can damage the cell wall.4 Autopsies suggest most men and women have aortic fatty streaks by age 15 to 34.23 With the increasing accumulation of connective tissue molecules and Figure 2. Arterial wall anatomy. Public domain image by Stign AI Ghesquiere. http:// inflammation-promoting platelets commons.wikimedia.org/wiki/File:Anatomy_artery.png. Accessed October 8, 2011. and lipoprotein-accumulating smooth muscle and immune cells, fatty streaks evolve through intermediate-grade lesions to atheromas and fibrous plaques.4 The progressive accumulation of connective tissues and calcium increasingly compromise local arterial wall elasticity as plaques become larger and more complex. Both stable atheromas and vulnerable or complicated plaques seen in coronary artery disease are common in American adults.4 The latter can rupture or hemorrhage, causing thrombi or emboli that can disrupt blood flow locally or downstream, causing a stroke or heart attack. Occlusions are traditionally graded from 0 to 5, reflecting increasing intrusion into and occlusion of the blood vessel lumen (see Figure 4).24 Symptomatic stenosis, a buildup of atherosclerotic plaque into the arterial lumen, usually occurs at the atheroma phase.4 Stenosis causes vortex flows or blood flow eddies (ie, slowed or stagnant flow areas) and flow separation distal
Figure 3. Progression of atherosclerosis from earliest
fatty streaks to complicated plaque rupture, which can trigger heart attack, stroke, or embolism. Public domain image by Graham Child. http://commons.wikimedia .org/wiki/File:Endo_dysfunction_Athero.png. Accessed October 9, 2011. RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3 265CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Figure 4. Coronary atherosclerosis (cross-sections with stained arterial walls and plaques). A. Grade 0, normal ves-
sel. B. Grade 1, 19% to 35% reduction in lumen diameter. C. Grade 2, 36% to 50% occlusion of lumen. D. Grade 3, 51% to 74% occlusion. E. Grade 4, 75% to 99% occlusion of arterial lumen. F. Grade 5, 100% occlusion. Reprinted with permission from Edwards WD. Applied anatomy of the heart. In: Fundamentals and Practice; vol. 1. 2nd ed. St Louis, MO: Mosby-Year Book; 1991:99. Used with permission of the Mayo Foundation.
to stenoses. Flow separation occurs when a stenosis forces blood flowing immediately adjacent to the interior vascular wall to intrude into high-velocity flow regions deeper within the vessel lumen (see Figure 5). Diagnostic imaging rarely achieves the precision and accuracy of histological measurements; thus, angiographic classification systems for occlusion have been proposed as an alternative. However, the traditional grading scheme remains the gold standard in cardiovascular medicine. Occlusion can be reversed or modified with catheter balloon angioplasty and stenting, which expand and stabilize the arterial lumen to restore local blood flow (see Figure 6). Coronary artery stents are inserted via catheter angioplasty and can reduce chest pain and heart attack risk. However, a re-narrowing of stented vessels (restenosis) can and does occur, and stent patients undergo follow-up coronary imaging when restenosis is suspected. Physical occlusion by stenoses is not the only effect of atherosclerosis on vascular integrity. Inflammation266CT
facilitating or related molecules also cause increasing endothelial adhesiveness, permeability, endothelial cell proliferation rates, plaque rupture, and thrombosis.4
Figure 5. Hemodynamics at arterial stenosis. Smith KW.
Time-of-flight methods in MR angiography. Radiol Technol. 1994;65(3):160.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
initially contained within the vascular wall. Eventually, with increasing plaque volume, further accommodation is no longer possible; the plaque begins to intrude into the lumen and disrupt blood flow. High-grade coronary obstructions associated with remodeling typically cause myocardial ischemia and stable chest pain.3 The risk of plaque ruptures causing acute emergencies appears to be systemic rather than focal in nature. Therefore, the overall extent and grade of coronary atherosclerosis in coronary arteries may be more predictive of myocardial infarction risk than presence of a single site of advanced stenosis.3 More lipid-rich, visually yellow plaques may be more likely to rupture and cause acute emergencies than white, highly calcified plaques.3 However, the degree of calcification is a useful indicator of plaque stage. Because atheromas tend to become increasingly calcified as they grow, highly calcified plaques are a sign of advanced atherosclerosis.25 Cardiac CT coronary plaque calcification quantification is therefore a useful examination for patient risk assessment.
Diagnostic CT Angiography
Contemporary CTA applications and techniques are well standardized and allow rapid image acquisition, processing, and clinical interpretation.8 Using CT technology and intravenous contrast media, CTA acquires image data of arteries, blood vessels, and tissues that can be reconstructed in 2-D and 3-D representations. Several aspects of cardiovascular disease can be demonstrated, including arterial calcification and plaque composition, blood vessel remodeling, stenosis dimension and occlusion grade, and the presence of emboli and aneurysms. Early CTA equipment required the gantry to be repositioned incrementally between each slice acquisition, but multidetector electron-beam CT and spiral CT equipment can acquire volumetric data in 1 continuous process. Electron-beam CT scanners deflect electron beams through a series of magnets and focusing coils to focus the beam on target rings situated beneath the prone patient. Target rings then allow the beam to be swept upward through the specified target anatomy, to detectors positioned above the patient. Most MDCT examinations are now undertaken using spiral CT equipment, but MDCT also can be undertaken with nonspiral multidetector CT equipment. In spiral CT scanners, the x-ray tubes and detectors are arrayed opposite one another, with a slip ring for the rotating tube and detector electrical connection. Fanlike x-ray beams pass through sections of target anatomy at preset
267CT
Figure 6. Catheter placement of angioplastic balloon, which is
inflated to compress atherosclerotic plaque and restore blood flow. Public domain U.S. government image courtesy of the National Institutes of Health. www.nhlbi.nih.gov /health/dci/Diseases /Angioplasty/Angioplasty_WhatIs.html. Accessed October 9, 2011.
Collectively, endothelial disruption by atherosclerosis can lead to coronary artery disease, peripheral vascular disease and limb ischemia, heart attack, stroke, aneurysm, thrombosis, and embolism. Clinical coronary artery disease symptoms frequently are delayed until stenosis is severe because coronary arteries initially compensate for the narrowing lumen, a process known as coronary vessel remodeling.3 The arterial wall is reorganized to accommodate atherosclerotic plaques, so the bulk of the plaque volume is
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Table 1 Examples of Predictable CT Value Ranges

Material Air Fat Water Muscle Iodinated Contrast Material Calcium
HU = Hounsfield units
Box 2 CTA Scan Acquisition Parameters8

n Detector n Scan
Ranges (HU) -1000 -50 to -100 0 10 to 40 300 to 500 130 to 1500
thicknesses, and x-ray attenuation levels (scan data) of various tissues are collected and digitized for subsequent image reconstruction. Attenuation coefficients for target tissues are expressed as CT units called Hounsfield units (HU). CT values are represented visually as 2-D pixels or 3-D voxels. Different substances and tissue types have predictable ranges of CT values (see Table 1).26 Technological advances in recent decades have improved temporal and spatial resolution, leading to superior diagnostic use of CTA images.3 The patients heartbeat and the resulting waves of increasing and decreasing blood flow velocity in the arterial network posed a significant challenge to early CTA because of the relatively long periods required to acquire image data. Artifacts from heart contraction, respiration, patient and gantry motion, and contrast bolus timing all have the potential to complicate a successful CTA.26 However, with the introduction of electron-beam CT and spiral MDCT, acquisition times dropped from more than 500 milliseconds to fewer than 100 milliseconds. The faster time makes electrocardiogram (ECG)gated or triggered image acquisitions without motion artifacts possible, as long as the patients heart rate can be reduced to 60 to 65 beats per minute (see Box 2).3 Generally, optimal spatial resolution requires the thinnest possible CTA slice and a pitch of 1.5 to 2. Optimal temporal resolution frequently is achieved with the fastest available rotation time and low pitch, when a low patient heart rate (60 to 65 beats per minute) can be achieved.8 Because heart rate determines optimal imaging parameters, many modern CT scanners automatically calculate a recommended patient-specific heart rate-based optimal rotation time. However, the CT technologist must still alter rotation
268CT
row number (1 to 320) field of view (SFOV or FOV): the anatomic volume to be scanned n Section collimation: slice thickness in mm n Rotation time: duration in seconds for 1 tube rotation n Pitch: relationship between table feed and scanned volume width; for helical CT, maximum pitch is between 1.5 and 2. Pitch is inversely proportional to patient radiation dose. n Table feed per tube rotation: indicates table movement during rotation time n Scan length (cm) n Tube voltage (kVp): x-ray beam energy, also referred to as U n mA: tube load, directly proportional to patient radiation dose
time settings because they are not automated.3 Slice usually is set between 1 mm and 3 mm. Thinner slices are rarely used because of higher radiation doses and diminishing benefits to image quality.8 CTA Contrast Agents Blood and the blood vessels have similar CT values, so the CT contrast between these tissues is low. Iodinated contrast agents therefore are injected into the blood stream to increase tissue contrast during scan acquisition. Although contrast agents are not required in CT arterial calcium quantification, intravenous contrast agents are required in other CTA applications, including imaging poorly calcified plaques.3 Contrast CTA is less time-consuming than conventional contrast angiography and can be performed as an outpatient procedure. Iodinated contrast agents are widely used and safe water-soluble media. Contrast agents absorb x-rays, so increased x-ray attenuation and CT values are directly proportional to the concentration of contrast agent within target vasculature during scan acquisition. Iodinated contrast agents come in 2 classes: ionic and nonionic. Because nonionic iodinated contrast agents (eg, iopamidol and iodixanol) cause far fewer adverse effects than ionic contrast agents (eg, iothalamate and ioxaglate), they are preferred and more widely used.27 Nonionic contrasts have a reported overall adverse reaction rate of approximately 3%, and a severe reaction rate of just 0.04%.27,28
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Adverse reactions are dose-dependent or idiosyncratic, with the latter being less predictable and more frequently life threatening.27 Dose-dependent adverse reactions to contrast agent injection include nausea and vomiting, nephrotoxicity, cardiac arrhythmias, pulmonary edema, cardiac collapse, and death; however, these risks are primarily associated with ionic contrast media.27 In fewer than 1% of patients, the use of power injectors for intravenous contrast administration can cause the leakage of contrast material into fatty tissues around the injection site (extravasation).27,29 Extravasation is widely attributed to injection flow rate, but there is little empirical evidence for a correlation with injection rate or cannula size.29 Standard written protocols for contrast agent administration, including a screening procedure for identifying patients with contraindications, should be available at every diagnostic imaging facility. CTA Limitations and Contraindications Renal insufficiency, history of adverse reactions to contrast agents, and contrast agent contraindications must all be considered for CTA examinations that involve contrast agent administration.3 Contraindications for iodinated contrast agent injections include compromised kidney function, diabetes mellitus, hyperthyroidism, Graves disease, multinodular goiter, or patient use of other nephrotoxic medications such as loop diuretics, cyclosporine, or aminoglycoside antibiotics.27,30 If patient records or questionnaire responses indicate past kidney disease, kidney surgery or transplantation, diabetes, or heart failure, then normal renal function should be confirmed with serum creatinine prior to contrast administration.27 Similarly, cancer patients undergoing cisplatin-based chemotherapies should not undergo contrast CTA examinations because of cisplatins nephrotoxicity.27 A steady, slow heart rate is important for highquality CTA particularly coronary CTA images. Approximately 15% of patients may not be able to reduce their heart rate to below 65 beats per minute, even with beta-blocker administration. Because the diagnostic quality of CTA images for these patients can be compromised, proceeding with an imaging examination is frequently not justified. 3 Patients with arrhythmia are usually excluded from coronary CTA. 8 Radiation Dose Image quality is usually directly proportional to patient radiation dose.31 The central trade-off of
CTA and all CT imaging is that between radiation dose and image quality. An optimal CTA image acquired with 65-channel (detector) CT scanners can deliver doses as high as 60 mSv, with effective doses of 10 mSv for cardiac CT scans.8 As with all radiologic imaging procedures, CTA should be performed in compliance with the as low as reasonably achievable (ALARA) principle. In clinical practice, ALARA compliance requires routine quality assurance (eg, addressing staff training, equipment maintenance, and calibration for quality control) and dose-management practices (eg, avoiding unnecessary CT scans when equivalent, lower-dose imaging modalities are available).32 Dose management relies on routine maintenance, cleaning, and calibration of CT equipment, including monitoring and confirming the accuracy of alignment lights, table-to-gantry alignment and table-incrementation accuracy.32 Equipment performance reviews should be scheduled at least once per year to confirm radiation doses independently of the equipment display radiation exposure measurement.32 Patient radiation dose from a given CTA examination is affected by 3 scan-acquisition parameters: mA, kVp, and pitch.8,32 A patients radiation dose is directly proportional to mA, whereas pitch is inversely proportional to radiation dose.8 For a given mA setting, higher kVp settings will deliver higher patient radiation doses.8 With slender patients, lowering kVp can enhance visual contrast of coronary arteries and lower patient dose.8,33,34 ECG dose modulation is effective at low heart rates and can reduce patient radiation doses by half.8 Ways to minimize patient radiation dose include limiting scan range as much as possible, avoiding particularly radiosensitive tissues such as the eyes in the field of view, reducing kVp, and carefully observing contrast-injection protocols to avoid the need for repeated scans.8 In obese patients, higher doses may be necessary to achieve quality images because more x-ray energy is attenuated prior to reaching target vasculature.8 For these patients, thicker collimation (eg, 2.5 mm on MDCT scanners) will increase detector signal, and decreased pitch or rotation time can allow increased mA.8 Injecting a larger volume of contrast at a higher injection rate also may be helpful.8 Postprocessing and Image Reconstruction Pixel data from CTA primary 2-D planar axial slice reconstructions can be postprocessed to yield images from multiple view angles. Data from these primary images can be stacked by postprocessing software to
269CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Figure 7. Computed tomography angiography (CTA) image
reconstructions and volume-rendered postprocessed composite image. A. 864 contiguous primary planar transverse sections from peripheral CTA. B. 3-D postprocessing synthesizes data from all 864 2-D images in 1 volume-rendered image. Reprinted with permission from Rubin GD, Sedati P, Wei JL. Postprocessing and data analysis. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:192.
yield 2-D or 3-D surface-rendered images (see Figure 7).35 The 2-D multiplanar images use data from multiple primary planar images to reconstruct images in new
270CT
view-angle planes. Data from transverse primary planar images, for example, can be reconstructed to yield 2-D sagittal or orthogonal planar images. Ray casting similarly allows 3-D voxel data to be reconstructed into 2-D images. Ray casting calculates CT values along rays projected through 3-D volumetric datasets perpendicular to the desired 2-D image reconstruction view angle. Because of the tortuosity (twistedness) of blood vessels, 2-D images only visualize small portions of target vasculature. Curved planar reformations can be reconstructed to visualize complex 3-D vasculature, representing tortuous vascular pathways on a single 2-D image and allowing accurate assessment of vessel occlusions and calcifications.35 The 3-D deviation from the 2-D depiction can be depicted as wrinkles or folds in the 2-D image without compromising the 2-D spatial accuracy. These images are sometimes called the magic carpet view (see Figure 8).35 The sophistication and precision of image reconstructions have increased markedly in recent years, yielding remarkably realistic 3-D visualizations of patient anatomy. However, clinicians always review primary planar 2-D CTA images as well as complex postprocessed images to check for motion artifacts. Primary planar images frequently offer superior spatial resolution. Reconstructions involve algorithmic simplifications and assumptions that can yield misleading images under some circumstances. For example, contrast agent artifacts can create pseudo-occlusions in 3-D volumetric reconstructions that are accurately identified as signal voids within healthy vasculature upon review with primary planar reconstructions. Beam hardening artifacts also are more readily identified on primary images.35 Clinicians therefore should not rely solely on advanced image reconstructions for clinical interpretation and decision making.35 Grayscale window value settings are important for accurate image reconstructions. Grayscale settings should not be maximized to white for the blood vessels, for example, because doing so can yield inaccurate visualizations of lumen diameter and can visualize calcifications or stents as lumen wall anatomy.35 Similarly, representing calcium in small vessels or metallic components of stents as white can yield pseudo-stenoses, exaggerating plaque grade and potentially leading to unjustified medical interventions.35 Volumetric dataset image reconstruction involves several different rendering techniques, including maximum intensity pixel (MIP) projection, minimum-intensity projections, average-intensity ray sum projections,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
B
Figure 9. Postprocessing of aorta and renal artery CTAs.
Figure 8. A. Curved planar reformations are multiplanar reformations that follow a curved path through the imaging volume, visualizing that path in 2 dimensions. B. The curved plane can be represented in the magic carpet view, showing deviations from the plate through the lateral axis of the imaging volume without sacrificing the cross-sectional precision of the 2-D image. Reprinted with permission from Rubin GD, Sedati P, Wei JL. Postprocessing and data analysis. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:201.
A. Shaded-surface display postprocessed 3-D CTA. Grayscale visualizes depth information, with all visualized voxels above a selected CT value threshold. The arrows identify contour anomalies in the renal artery lumens, representing calcifications. B. MIP postprocessed version of the same CTA scan data. Grayscale encodes CT values and no depth information is visualized. Calcium deposits are brighter because of greater x-ray attenuation. Complete occlusion of the left renal arterial lumen is visual. Reprinted with permission from Rubin GD, Michael DD, Semba CP. Current status of 3-D spiral CT scanning for imaging the vasculature. Radiol Clin N Am. 1995;33(1):56.
contoured shaded-surface display renderings, and multiple threshold displays (see Figure 9). Each has strengths
and weaknesses, but execution of each varies between software packages, facilities, and technologists, which makes it difficult to identify a single, clearly superior approach.35 CTA researchers therefore emphasize the importance of readily switching between image reconstruction types for interactive exploration of the data and composite assessment of vascular anatomy and pathology.35 MIP image processing involves the ray tracing of volumetric scan slice data. Maximum CT values are
271CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Figure 10. Schematic diagram illustrating 3-D volume-rendering postprocessing and 2-D MIP postprocessing principles. A. Volume rendering clearly defines individual arteries. B. Maximum intensity projection reconstruction using the same volume scan data shows all vessels but outlines merge as the resulting image is compressed into 2 dimensions, such that spatial relationships between vessels are lost in the final MIP image. Ray casting through the CTA scan volume encodes maximum voxel CT values encountered for each ray, which are visualized on the final 2-D image. Depth information within the imaged volume is lost in MIP postprocessing. Reprinted with permission from Fishman EK, Ney DR, Heath DG, et al. Volume rendering versus maximum intensity projection in CT angiography: what works best, when, and why. Radiographics. 2006;26(3):905-922.
represented as the brightest voxel, and along each path a maximum value for visual representation in the final image is encoded (see Figure 10). Only the brightest voxel is represented for each ray path, so MIP yields 2-D grayscale images. Unfortunately, this also means that when rays pass through nontarget or background structures with high CT values, those noise values are represented on the resulting MIP image. MIPs are used for calcium density mapping. Background noise can compromise the visualization of small blood vessels and the extent of occlusions.35 The 3-D shaded-surface display images represent tissue density contrast data as variations in voxel brightness, with all visualized voxels representing CT values above a selected threshold value. With upper and lower boundary CT values set, the threshold CT value allows production of multiple threshold display images to limit further which tissues are visualized. As mentioned previously, different image reconstruction techniques have different strengths and weaknesses. In general, MIP images depict 3-D volumetric data in 2-D overview visualizations that depict anatomic context and adjacent structures well, but offer relatively poor visualization of blood vessel
272CT
dimensions compared to 2-D reconstructions and are subject to noise artifacts near heavy calcifications and metallic stent components. 35 MIP is widely known to yield exaggerated occlusion grade assessments. The 2-D multiplanar and curved planar images yield superior visualizations of vessel wall occlusions, calcification, and stented vasculature, but inferior depictions of adjacent anatomies and spatial relationships between structures. 35 Sophisticated contemporary volume rendering provides 3-D overview images with excellent spatial resolution, but as with MIPs, these should not be used to quantify blood vessel dimensions.35 Volume rendering with color-coded HU enhancement allows surface contour visualizations, semitransparent visualizations illustrating specified anatomy, and virtual fly-through angioscopic visualizations. Patient Preparation Clear and calm communication with patients is important to ensure patient autonomy and imaging success. The imaging goals and risks of any imaging procedure, including radiation risks, should be described clearly to patients at each imaging examination. Patient
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
compliance with instructions is crucial to obtaining high-quality diagnostic images.8 Upon arrival at the imaging department for a contrast CTA examination, patients should be interviewed and their records checked to identify any contraindications. Patients should not eat within 2 hours of CTA. If CTA is conducted with other diagnostic imaging examinations, it is important to confirm the patient has not received oral contrast administration. 8 Precontrast scans are rarely used with MDCT except in cases of suspected arterial hemorrhage or aortic dissection.8 The risk of respiratory motion artifacts is higher for chest and upper abdominal CTA than for other CT examinations particularly in singledetector row CTA.8 Chest and abdominal CTA are performed while patients hold their breath. Breath hold during scan acquisition is not necessary for CT neuroangiography, neck CTA, or abdomen-only CTA.8 The importance of avoiding motion artifacts should be clearly communicated to the patient. Rather than offering detailed breath-hold instructions, which may be difficult to follow and cause anxiety, patients should simply be told to inhale normally not deeply and calmly, and then to hold their breath.8 Valsalva maneuvers, in which air is forcefully but slowly exhaled through a mostly closed mouth with the nose pinched, is counterproductive for pulmonary artery contrast agent enhancement and should be avoided.27 The time required for a patient to inhale should be checked. With practice and voluntary hyperventilation immediately prior to scanning, patients should be capable of 30-second breath holds without abdominal movement.8 (For MDCT scanners with 16 or more detector rows, 15-second breath-holds should suffice.8) If an acute emergency patient (eg, presenting with suspected pulmonary embolism) is unable to hold his or her breath, then he or she should be instructed to breathe in and out deeply immediately before the scan, and to breathe shallowly during the scan.8 Although this will yield motion artifacts, the diagnostic data obtained often is sufficient to identify or rule out pulmonary embolism, which justifies the acquisition of a relatively low-quality image.8 The importance of a low heart rate should be explained to coronary CTA patients, and a low-stress environment will help patients maintain a low heart rate.8 Beta-blockers (eg, 50 mg to 100 mg oral metoprolol tartrate or 5 mg metoprolol tartrate administered intravenously) may be prescribed in consultation with a cardiologist to reduce heart rate to below 65
beats per minute for the CTA examination.3,8 Oral administration of beta-blockers should occur at least 1 hour prior to scan acquisition.8 Beta-blockers are administered intravenously on the CT table, 5 to 10 minutes before scan acquisition.8 Heart rate should be monitored carefully prior to CTA examinations to ensure a steady heartbeat of 60 to 65 beats per minute.8 Contraindications for beta-blockers include severe hypotension, heart failure, previous patient adverse reactions to beta-blockers, and severe bronchial asthma.8 Contrast Agent Administration As CTA acquisition times have decreased with each new generation of CT equipment, contrast agent administration protocols have been revised. However, modern 40- to 64-channel MDCT equipment outpaces the physiological pharmacokinetics of contrast agent circulation. Now, with the faster equipment, contrast CTA requires modification of the scan acquisition parameters, not contrast agent administration. Vascular contrast agent enhancement is a function of injected iodine concentration (mg) per second and blood flow (L/min).27 Contrast injection flow rate is therefore key to vascular enhancement, whereas total iodine dose would be key to enhancement of other organs.27 The scan delay is the pause following contrast injection that allows contrast to arrive at the target vasculature before initiation of scan acquisition. Contrast medium transit time (t CMT) refers to the time required for contrast to travel from the injection site to the target vasculature of interest a key variable in scan acquisition timing (see Figure 11).27 The t CMT reflects the distance between the injection site and the imaging target vasculature, patient blood flow rate (cardiac output), and to a much lesser, essentially negligible degree injection rate (iodine flux).27 The first pass effect refers to a sharp arrival of peak enhancement (vascular opacification) immediately following t CMT, the tail of which typically drops only gradually, without returning quickly to 0, because of recirculation. Doubling injection flow rate for a given duration will double the enhancement of the contrast agent.27 Put simply, after t CMT, a sharp enhancement period (first pass effect) marks the arrival of contrast agent at the target vessel, followed by less pronounced but continuous vessel enhancement for the duration of the injection, which drops sharply once the injection ends.27 Enhancement is proportionate not only to contrast agent injection rate, but also to total injection duration.27
273CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
Figure 11. Arterial enhancement achieved with intravenous
injection of 16 mL iodinated contrast medium at injection rate of 4 mL/s (for an iodine dose of 1.2 g/s). Contrast medium transit time in the second graph is at 8 seconds, followed by the first pass effect enhancement peak. Image used with permission from Dominik Fleischmann, MD, Department of Radiology, Stanford University Medical Center, Stanford, CA.
Scanning before t CMT and the first pass effect peak will yield images with poor vascular enhancement; conversely, if technologists wait too long to begin scanning, contrast may not be present to aid visualization during the entire scan. Hence, poorly timed contrast administration risks an unnecessary repeat examination. Optimal timing of the scan delay depends on patient factors (eg, body mass and blood flow rate) and the distance between the injection site and the target vasculature. Typically, for 10- to 20-second scans, scan delay is set at t CMT plus 8 seconds.27 Automated triggering is possible with most modern scanners, which monitor attenuation of a pulmonary artery or aorta and trigger scan acquisition as soon as a set threshold level of contrast arrives at the monitored vessel. A 20-mL test bolus also may be administered, and its transit monitored with test scans every 2 to 4 seconds.36 Scan data is then used to calculate a time-density curve for the region of interest, and the diagnostic scan delay is calculated so that scan acquisition begins at the onset of the initial first pass effect peak. Scan delays based on radiologist experience also are sometimes used, typically ranging from 10 to 20 seconds.36 The degree or magnitude of arterial enhancement varies up to 3-fold between patients, in part because of
274CT
variation in cardiac output and a significant negative correlation between magnitude of enhancement (measured as HU per mL) and patient body mass (kg).27 Higher cardiac output, which correlates with body mass, also decreases arterial enhancement.27 It is recommended that injection rate and injected contrast volume be increased for individuals weighing more than 90 kg and decreasing rate and volume for individuals who weigh less than 60 kg.27 Advances in MDCT scanner acquisition times require periodic modification of contrast agent injection protocols. Two broad contrast injection approaches one for slow scanning (4-channel MDCT or singlechannel CT) and another for fast scanning (eg, 8- or 16-channel MDCT) are described here, following protocols developed by Dominik Fleischmann, MD, of Stanford University Medical Center.27,37 Contrast agent injection protocols for slower CTA exams, such as those involving scan acquisition times of 20 seconds or longer, are based on a single-slice CT adage that injection duration equals scan time (after administration of a test bolus to determine t CMT and first pass effect time).27 For a 40-second abdominal CTA scan, therefore, injection duration of 40 seconds at an injection flow rate of 4 mL/s yields a total contrast agent dose of 160 mL.27 As noted previously, injection protocols must be modified for people who weigh significantly more or less than average. According to Dr Fleischmann, a 20% higher contrast agent volume and flow volume should be administered for patients weighing more than 90 kg, while a 20% lower contrast injection flow rate and volume should be administered to patients weighing less than 60 kg.27 For slow scan acquisitions (lasting 20 seconds or more), sequential injections at different injection flow rates may provide more uniform vascular enhancement than a prolonged, single injection.27 Biphasic administration makes little sense for shorter scan acquisition times because the enhancement after the first pass effect peak declines gradually and scans are complete before significant enhancement decline can occur.27 Faster CT scan acquisition times do not require smaller total volumes of contrast agent, nor can very short scan times accommodate the old adage that scan duration equals injection duration.27 Increasing contrast agent iodine concentration and injection flow rate accommodates faster scanners and examinations. For example, switching from a contrast agent with 300 mg of iodine per mL to one with 350 mgI/mL and increasing injection flow rate from 4 mL/s to 5 mL/s increases flow rate and arterial enhancement by 45%.27 Dr Fleischmann
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
also recommends increasing arterial enhancement for faster scan acquisitions by increasing injection duration so that it is 8 seconds longer than the scan time.27 Postinjection scan-initiation delay should be determined by test bolus or automated bolus triggering to accommodate transit/first pass effect peak time differences between patients.27 The 40and 64-channel MDCT scanners virtually eliminate technical trade-offs entailed in earlier-generation CTA, between spatial resolution and spatial coverage, according to Dr Fleischmann.37 Abdominal aortic CTA Figure 12. The coronary arteries. Public domain image used with permission by scientific using a 64-channel MDCT illustrator Patrick J Lynch, Yale University School of Medicine. http://commons.wikimedia.org/wiki scanner can be performed /File:Coronary_arteries.png. Accessed October 10, 2011. in fewer than 5 seconds, for 37 example. Just over a decade ago, a single-detector scanner would require 40 seconds to perform the same imagand lungs. The most common CTA applications are for ing examination.37 diagnostic assessments of heart (coronary) and lung Because new scanners move faster than the physi(pulmonary) vasculature. ological processes underlying contrast agent enhanceAlthough diagnostic MDCT-CTA imaging of periphment of vasculature, CTA protocols were modified to eral artery disease is not detailed in this article, the accommodate contrast injection protocols.27 This paragoals and image reconstruction strategies are very digm shift involves establishing individually tailored, similar to those employed for coronary artery disease, physiologically based contrast injection protocols for such as identifying and quantifying atherosclerotic a patient and then tailoring scanning protocols to the occlusions and emboli. Curved multiplanar projections injection protocol.27,37 are used frequently in diagnostic imaging of suspected Practically speaking, this involves intentionally slowperipheral artery disease, although primary axial ing MDCT scan acquisition times for scanners with 40 or images should always be used to confirm findings from more channels (or scan acquisition times shorter than 10 postprocessed images.10 CTAs diagnostic sensitivity and seconds) to well below their maximum speeds, prolongspecificity for peripheral artery disease exceed 94%.10 ing scan acquisition times.27 For 10- to 20-second scans, t CMT plus 8 seconds is recommended (eg, scan is triggered 8 seconds after contrast is detected in the aorta).37 Shorter (eg, 5-second) scans should involve scan delays of t CMT plus 10 seconds.27 Coronary CTA Because coronary artery disease affects the coronary arteries that provide blood and oxygen to the heart, it is responsible for 1 in every 5 deaths in the United States.9 In half of cases, heart attack is the first clinical sign of coronary artery disease.3 The coronary arteries are small, twisted blood vessels subject to continuous respiratory and cardiac motion (see Figure 12). Coronary artery
275CT
CTA Applications
The use of CTA is becoming widespread and its applications continue to grow, currently including diagnostic imaging of the limbs, kidneys, brain, heart,
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
disease is defined as an atherosclerotic narrowing of 50% or more of a major coronary artery or arterial branch.9 Angioplasty is typically indicated for patients in whom occlusion exceeds 70%.9 Patients with significantly occluded left main coronary artery or multiple arteries are candidates for coronary artery bypass graft surgery.9 Indications for coronary CTA vary between facilities and are not well established, but include intermediate risk patients with chest pain, known or suspected intermediate-risk coronary artery disease, or heart failure of unknown etiology.38,39 In general, coronary CTA is indicated to evaluate patients with acute or chronic chest pain and intermediate probability of coronary artery disease but equivocal ECG results or an inability to exercise, and for evaluating coronary arteries in heart failure patients.38 Coronary CTA is not widely used in coronary artery disease patient risk stratification, but CT calcium scoring can be used for that purpose. (Coronary CTA specificity may be compromised in patients with high calcium scores, so calcium scoring may provide important information with which to assess the reliability of coronary CTA examinations.38) Stress ECG is used in diagnosis of acute myocardial infarction accompanied by chest pain but has poor sensitivity for coronary artery disease. Coronary CTA imaging strategies are becoming widely used, and appear to be supplanting traditional catheter coronary angiography. Newer workstations can automatically segment the coronary arterial tree, allowing 3-D volume rendering image reconstructions that remove anatomy overlaying regions of interest.9 For example, the hearts left atrium auricle can be segmented and removed in image reconstruction to allow assessment of the left main coronary artery.9 The emerging evidence base for coronary CTA is encouraging, although too little clinical data is available for a coronary CTA risk assessment, particularly for asymptomatic patients.40 Calcium scoring is indicated when risk stratification for asymptomatic patients with suspected coronary artery disease is desired. A recent systematic review of data from 42 diagnostic accuracy studies found an overall coronary CTA coronary artery disease detection sensitivity of 98% and specificity of 85%, suggesting a high degree of diagnostic accuracy.41 A separate meta-analysis of data from 16 studies representing 1119 patients also suggests excellent MDCT coronary CTA detection of significant coronary artery disease stenosis in patients with acute chest pain.42 Similarly, a meta-analysis
276CT
of data from 10 studies of the prognostic value of 64-channel MDCT for predicting cardiac death or heart attacks found coronary CTA well differentiates high- and low-risk coronary artery disease patients, and the absence of coronary CTA-confirmed coronary artery disease correlates with excellent near-term survival rates.43 MDCT coronary CTA also appears to offer excellent sensitivity and specificity for the detection of coronary stent restenosis.44 Although few studies have directly compared the accuracy of coronary CTA and coronary magnetic resonance angiography, a 2010 meta-analysis of data from 5 such studies found coronary CTA to be more accurate than magnetic resonance overall, and that scanners with more than 16 detector rows and patients with slowed heart rates improved diagnostic sensitivity for coronary artery disease even further.45 Prospective ECG-gated electron-beam CT coronary artery imaging, developed in the late 1980s, ensures scan acquisition occurs during the mid-diastolic phase of the cardiac cycle, reducing cardiac motion artifacts.9 Because scan data only is acquired during a specific part of the heart cycle, extraneous data that could complicate image reconstruction and cause motion artifacts is not acquired. However, with equipment and software advances and improvements in temporal resolution, continuous scan acquisition can yield excellently reconstructed images using retrospective gating. Prospectively gated CT scan acquisition time therefore depends on heart rate, and can be shortened by hastening heart rate pharmaceutically with atropine administration.9 Cardiac arrhythmias can cause phase misregistration, yielding a stair step or stripedappearance artifact in image reconstructions. Another promising emerging strategy that may prove to represent a significant advance in coronary CTA radiation dose reduction is prospective ECG gating for MDCT (also called step-and-shoot or sequential mode coronary CTA).46 Preliminary data from a single-institution study of 434 patients, published in September 2011, suggested that prospectively ECGgated 64-channel MDCT coronary CTA can reduce patient effective radiation dose to 1.8 mSv, on average, while maintaining excellent diagnostic and prognostic value.46 A recent meta-analysis of data from 16 studies, representing 960 patients, suggested that low-dose prospective gating coronary CTA is as sensitive as traditional catheter-based angiography.47 Prospective gating may reduce coronary CTA patient radiation doses by as much as 80%.47 However, given the relatively small
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
number of patients studied, more research on ECGgated MDCT coronary CTA must be conducted.47,48 Subsequently developed and now widely used retrospective ECG gating allows MDCT-CTA data to be encoded alongside CT scan data throughout the cardiac cycle, which allows for phase-specific image selection in image reconstruction.9 Slower heart rate reduces the incidence of cardiac motion artifacts in ECG-gated MDCT, and beta-blockers may be administered to reduce patient heart rate to 60 to 65 beats per minute prior to CTA.9 Retrospective gating allows shorter acquisition durations and the continuous, gap-free capture of data for the entire target volume, providing a potentially richer source dataset with which to reconstruct images.9 However, in practice, much of the data acquired during retrospective gating goes unused and represents preventable systole-phase irradiation of the patient.9 (Reported patient doses for retrospectively gated coronary CTA have been as high as 20 mSv.49) Therefore, prospective ECG tube current modulation, in which tube current is minimized to 20% of nominal value during systole, has been developed to routinely reduce radiation doses from systole-phase acquisition by 50%.9,46 Patient doses below 9 mSv have been reported for ECG tube current-modulated retrospective ECGgated MDCT coronary CTA.49 Coronary arteries follow winding paths that complicate the use of primary planar images for detecting significant occlusions because these images are not well suited for following arterial pathways.9 The 3-D volume-rendering and virtual coronary endoscopy image reconstructions allow assessment of coronary arterial pathways, whereas 2-D MIP images are useful for characterizing potential stenoses identified using 3-D reconstructions.9 Different scoring systems have been developed for the coronary CTA grading of coronary arterial stenoses, including cross-sectional lumen and stenosis diameter, using multiplanar reformations or MIP images and automated software calculations.50,51 Few comparative studies of the accuracy of these methods appear to have been published. One preliminary study suggested regional variation in visual grading of stenosis severity on coronary CTA primary axial images. Results indicated moderate to high reliability (inter-observer agreement) for the right coronary artery, left main artery, left anterior descending artery, and its branches, but poorer reliability for stenoses in the posterior descending artery, posterolateral branch, obtuse
marginal branches, and distal circumflex.52 In this study, 64-channel MDCT scanner axial images yielded more valuable images than 16-channel scanners.52 Any findings made with postprocessed images must always be confirmed using primary planar axial CT slice images.9
Reporting
Reporting guidelines have been proposed for documenting and reporting coronary CTA findings.53,54 The Society of Cardiovascular Computed Tomography and the North American Society for Cardiac Imaging have recommended the use of a reporting template (see Box 3).53
Calcium Scoring
Calcified coronary artery plaques frequently are present in advanced atherosclerotic disease and therefore
Box 3 Recommended Reporting Template for Coronary CTA Findings53

1. Coronary CTA examination indication 2. Imaging technique a. Contrast agent administered b. CTA technique c. Use of beta-blocker or vasodilator d. Workstation image reconstruction/postprocessing methods e. Complications 3. Description of findings a. Overall description of image quality and diagnostic confidence b. Limitations (eg, motion artifacts) 4. Coronary arterial anatomy and anomalies (eg, location and size of arterial aneurysm or dilatation) 5. Atherosclerosis a. Calcium score, if performed b. Description of plaque narrowing of arteries 2 mm in diameter c. Location of atherosclerotic narrowing using anatomic landmarks or 15-segment conventional angiography model d. Diffuse or focal atherosclerosis noted e. Description of plaques: calcified, uncalcified, mixed 6. Additional information: cardiac ventricular size and function; extracardiac findings; summary/overall impression
277CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
serve as a proxy indicator of patient risk for heart attack and death.25 Calcium scoring has 2 possible indications: risk stratification and evaluating whether to undertake coronary CTA examinations. Because coronary CTA specificity can be compromised by high calcium scores, calcium scoring can be performed prior to coronary CTA to determine whether to proceed with the examination.38 Most calcium scoring is employed using MDCT, which has largely replaced electronbeam CT calcium scoring.25 Prospective ECG gating and breath hold techniques are used for calcium scoring. With modern MDCT equipment, breath hold time is fewer than 15 seconds and actual scan acquisition times can be fewer than 2 seconds.25 CT coronary calcium scoring Figure 13. Scout coronary noncontrast CT calcium scoring planning image, with involves no contrast injection, typically requires fewer than 10 minutes, and patient dash lines indicating superior and inferior extent of the scanning range. The start location is just below the carina; the end boundary is just inferior to the base of radiation doses of 1 mSv to 1.8 mSv.25,26 the heart. Cardiac position changes with respiration; it is important that the scout Patients should be instructed to avoid caffeine or other cardiac stimulants for at least image and diagnostic CT cardiac image be obtained at the same level of inspiration. Reprinted with permission from Brooks MA, Carr JJ. Quantifying coronary 12 hours prior to the examination. Betaartery calcium. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: blockers are unnecessary because image Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & motion artifacts are not a significant concern in cardiac calcium scoring, particularly Wilkins Health; 2008:485. with ECG gating.25 Workstation algorithms allow automated filling and After the patient is positioned and ECG electrodes quantification of calcified plaques after the CT techare placed for gating, a scout image is obtained, with nologist places points within visible plaque deposits. which the CT technologist identifies scan start and stop CT numbers are displayed alongside image reconboundaries. The scan start slice should be even with the structions using those values.25 Total calcium scoring left pulmonary artery to the left of the anterior descendis reported using Agatston weighing factors for calciing coronary artery, and the stop boundary should be fied plaques, based on the highest CT-value pixel or just below the base of the heart, at the diaphragm (see voxel within a plaque deposit (see Table 2). Figure 13).25 The number of pixels or voxels within a lesion is mulCT coronary calcium scoring involves acquisition tiplied by the Agatston weighting factor for the highest of late-diastolic axial images.25 Slice collimation typiCT value for the lesion. Each plaque deposit is scored, cally is set to between 2.5 mm and 3 mm, although and scores are added together for each blood vessel 16-channel and greater MDCT readily allow much to yield a vessel score.25 Patients with Agatston plaque thinner, submillimeter, slice image reconstruction.25 burdens of more than 100 face up to a 20-fold increased For example, a block of 8 slices of 2.5 mm each can risk of heart attack or coronary artery disease-associated be acquired during each heartbeat using the GE death.25 Healthcare (Waukesha, Wisconsin) LightSpeed 16 sys25 tem. Typical scan parameters are 120 kV and 50 mA Pulmonary Embolism CTA to 120 mA, reflecting patient body mass.25 For most Pulmonary embolism is one of the most common patients, 100 mm to 120 mm total scan length, involvdisorders in the United States.11 Pulmonary emboli are ing 6 heartbeats and an 11-second breath hold, will 25 blockages of the major arteries and branches of the lungs completely cover the coronary arteries.
278CT January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
Table 2 Agatston Weighting Factors

Weighting factor 0 1 2 3 4
HU = Hounsfield units
Brightest Pixel or Voxel (HU) < 130 130 to 199 200 to 299 300 to 399 > 399
As with coronary CTA, 3-D volume rendering image reconstructions can provide realistic visualizations of pulmonary vasculature and vascular pathologies. However, just as with coronary CTA, pulmonary CTA findings from postprocessed images should be confirmed with primary planar images. Because a typical 16-channel MDCT pulmonary CTA examination can yield 600 axial images, systematic review of these primary images is only feasibly accomplished in cine scroll-through mode.11 MIP reconstructions simplify visualizations of pulmonary vasculature without the loss of data about emboli.11
caused by the lodging of a foreign body from upstream in the blood flow. Disrupted atherosclerotic plaques can cause pulmonary embolism. Pulmonary embolism is the most common indication for diagnostic imaging of pulmonary vasculature, including pulmonary CTA.11 Contrast-enhanced MDCT pulmonary CTA is preferred for identifying pulmonary emboli and thrombi (blood clots), largely because of the ability to produce crosssectional images of pulmonary vasculature rapidly.11 CT also readily visualizes pulmonary embolism-associated vascular remodeling and lung parenchyma tissue infarction, and can be used to rule out alternative diagnoses in symptomatic patients, including cancer, aortic dissection, and pneumonia.11 Lower lung-lobe parenchymal infarction caused by acute pulmonary embolism can cause hazy wedge-shaped consolidation on CTA axial section images and multiplanar reformations reconstructions.11 Early-stage research suggests that some pulmonary embolism findings are significantly predictive of clinical outcomes. For example, a study of 152 patients in Germany found that CTA-determined pulmonary obstruction, venous contrast reflux, and CTA-identified pulmonary infarction predicted patients visits to the intensive care unit (ICU); venous contrast reflux predicted patient placement on mechanical ventilation at the ICU.55 Pulmonary CTA also is often employed in the diagnostic imaging of suspected pulmonary hypertension, congenital blood vessel malformations, and autoimmune or inflammation of arterial walls.11 Respiratory motion and patient obesity increase artifacts and noise in pulmonary arterial image reconstructions. Automated contrast bolus-triggered 64-channel MDCT-CTA can image the chest at 1-mm resolution in a single 5-second breath hold procedure.11 Although cardiac motion artifacts can complicate pulmonary CTA scanning, retrospective ECG gating can be used to avoid this problem.11
The Future of CTA

Advances in submillimeter-acquisition MDCT will continue to improve CTA detection of coronary artery disease lesions and the precision of CTA in characterizing atherosclerotic plaques, which will lead to better noninvasive patient risk assessment.3 Radiation dosereduction strategies, including advances in scan acquisition time and improved ECG dose modulation also promise to improve the safety of CTA in coming years.8 Advances in image data postprocessing also should improve accuracy and increase the applications of diagnostic CTA. Software platforms are in development to automate detection of pulmonary emboli-associated blood flow and filling defects, for example.11 Improving temporal resolution of standard chest CT examinations will increasingly allow identification of calcified coronary arterial plaques in noncardiac imaging, improving early detection of high-risk patients.25 Assuming early findings about the diagnostic and prognostic promise of prospectively ECG-gated MDCT coronary CTA are confirmed, this low-dose procedure also may allow more widespread noninvasive coronary artery disease screening. This potential advance in coronary artery disease detection and diagnosis could reduce heart disease mortality among patients in the United States and around the world.46
References
1. Heart disease and stroke prevention. Centers for Disease Control and Prevention website. www.cdc.gov/chronicdis ease/resources/publications/AAG/dhdsp.htm. Revised July 21, 2010. Accessed September 11, 2011. 2. FastStats: heart disease. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/fastats/heart.htm. Revised February 18, 2011. Accessed September 11, 2011. 3. Leber AW, Mani V, Aguinaldo JGS, Fayad ZA. Atherosclerosis: in vivo characterization. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive
279CT
.CE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
CT ANGIOGRAPHY
4.
5. 6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:278-294. Lee SU, Wykrzykowska JJ, Laham RJ. Atherosclerosis: epidemiology and pathophysiology. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:255-277. Two days in New York: reflections on the UN NCD summit [editorial]. Lancet Oncol. 2011;12(11):981. Abrams HL. Historical notes. In: Baum S, ed. Abrams Angiography:Vascular and Interventional Radiology; vol 1. 4th ed. Boston, MA: Little Brown and Company; 1997:3-12. Abrams HL. Forward. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins Health; 2008:2. Prokop M. Principles of computed tomographic angiography. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:3-86. Manning WJ, Becker CR, Rofsky NM. Coronary arteries. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:495-542. Lau JF, Weinberg MD, Olin JW. Peripheral artery disease. Part 1: clinical evaluation and noninvasive diagnosis. Nat Rev Cardiol. 2011;8(7):405-418. Schoepf UJ, Meaney JFM. Pulmonary vasculature. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:596-647. Rugulies R. Depression as a predictor for coronary heart disease: a review and meta-analysis. Am J Prev Med. 2002;23(1):51-61. Matthews KA, Gump BB, Harris KF, Haney TL, Barefoot JC. Hostile behaviors predict cardiovascular mortality among men enrolled in the Multiple Risk Factor Intervention Trial. Circulation. 2004;109(1):66-71. Razanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45(5):637-651. Newman JD, Davidson KW, Shaffer JA, et al. Observed hostility and the risk of incident ischemic heart disease: a prospective population study from the 1995 Canadian Nova Scotia Health Survey. J Am Coll Cardiol. 2011;58(12):1222-1228. Wilhelmsson C, Vedin JA, Elmfeldt D, Tibblin G, Wilhelmsen L. Smoking and myocardial infarction. Lancet. 1975;1(7904):415-420. Stamler J, Wentworth D, Neaton JD. Is relationship
18.
19.
20.
21. 22.
23.
24.
25.
26.
27.
28.
29.
30. 31.
between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA. 1986;256(20):2823-2828. Chan DK, ORourke F, Shen Q, Mak JC, Hung WT. Metaanalysis of the cardiovascular benefits of intensive lipid lowering with statins. Acta Neurol Scand. 2011;124(3):188-195. Asplund K. Antioxidant vitamins in the prevention of cardiovascular disease: a systematic review. J Intern Med. 2002;251(5):372-392. Clarke R, Armitage J. Antioxidant vitamins and risk of cardiovascular disease: review of large-scale randomized trials. Cardiovasc Drugs Ther. 2002;16(5):411-415. Stebbing J, Hart CA. Antioxidants and cancer. Lancet Oncol. 2011;12(11):996. Hassan HH, Denis M, Krimbou L, Marcil M, Genest J. Cellular cholesterol homeostasis in vascular endothelial cells. Can J Cardiol. 2006;22(suppl B):35B-40B. McGill HC Jr, McMahon CA, Zieske AW, et al. Association of coronary heart disease risk factors with microscopic qualities of atherosclerosis in youth. Circulation. 2000;102(4):374-379. Edwards WD. Applied anatomy of the heart. In: Giuliani ER, Fuster V, Gersch BJ, McGoon MD, McGoon DC, eds. Cardiology: Fundamentals and Practice. Vol 1. 2nd ed. St Louis, MO: Mosby-Year Book; 1991:47-112. Brooks MA, Carr JJ. Quantifying coronary artery calcium. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:482-494. Budoff MJ, Mao S, Colletti PM, Shinbane JS. Cardiovascular CT angiography: concepts important to image acquisition and reconstruction. In: Budoff MJ, Shinbane JS, eds. Handbook of Cardiovascular CT. London, England: Springer-Verlag; 2008:1-14. Fleischmann D. Contrast medium administration in computed tomographic angiography. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:128-154. Caro JJ, Trindade E, McGregor M. The risks of death and of severe nonfatal reactions with high- vs low-osmolality contrast media: a meta-analysis. AJR Am J Roentgenol. 1991;156(4):825-832. Proctor RD, Beckett D, Oakes JL. Over the limit: use of peripheral venous cannulae above the manufacturers recommended flow rates. Clin Radiol. 2011;66(5):456-458. Bettmann MA. Frequently asked questions: iodinated contrast agents. Radiographics. 2004;24(suppl 1):S3-S10. Payne JT. CT radiation dose and image quality. Radiol Clin N Am. 2006;43(6):953-962.
280CT
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ...
DIRECTED READING
32. Furlow B. Radiation dose in computed tomography. Radiol Technol. 2010;81(5):437-450. 33. Jung B, Mahnken AH, Stargardt A, et al. Individually weight-adapted examination protocol in retrospectively ECG-gated MSCT of the heart. Eur Radiol. 2003;13(12):2560-2566. 34. Tatsugami F, Husmann L, Herzog BA, et al. Evaluation of a body mass index-adapted protocol for low-dose 64-MDCT coronary angiography with prospective ECG triggering. AJR Am J Roentgenol. 2009;192(3):635-638. 35. Rubin GD, Sedati P, Wei JL. Postprocessing and data analysis. In: Rubin GD, Rofsky NM, eds. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott Williams & Wilkins Health; 2008:188-251. 36. Remy-Jardin M, Remy J, Mayo JR, Muller NL. CT Angiography of the Chest. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-14. 37. Fleischmann D. Contrast medium injection protocols for CT angiography. Controvers Consens Imag Intervention. 2006;4(2):22-26. 38. Lin EC. Coronary CT angiography. Medscape Reference website. http://emedicine.medscape.com/article/1603072-over view. Revised April 12, 2011. Accessed September 25, 2011. 39. Callister TQ. Cardiovascular CT imaging: essentials for clinical practice: patient selection and preparation. In: Budoff MJ, Shinbane JS, eds. Handbook of Cardiovascular CT. London, England: Springer-Verlog; 2008:15-20. 40. Chang HJ, Chung N. Clinical perspective of coronary computed tomographic angiography in diagnosis of coronary artery disease. Circul J. 2011;75(2):246-252. 41. Ollendorf DA, Kuba M, Pearson SD. The diagnostic performance of multislice coronary computed tomographic angiography: a systematic review. J Gen Intern Med. 26(3):307-316. 42. Athappan G, Habib M, Ponniah T, Jeyaseelan L. Multidetector computerized tomography angiography for evaluation of acute chest pain: a meta analysis and systematic review of the literature. Int J Cardiol. 2010;141(2):132-140. 43. Abdulla J, Asferg C, Kofoed KF. Prognostic value of absence or presence of coronary artery disease determined by 64-slice computed tomography coronary angiography: a systematic review and meta-analysis. Int J Cardiovasc Imag. 2011;27(3):413-420. 44. Sun Z, Almutairi AM. Diagnostic accuracy of 64 multislice CT angiography in the assessment of coronary in-stent restenosis: a meta-analysis. Eur J Radiol. 2010;73(2):266-273. 45. Schuetz GM, Zacharopoulou NM, Schlattmann P, Dewey M. Meta-analysis: noninvasive coronary angiography using computed tomography versus magnetic resonance imaging. Ann Intern Med. 2010;152(3):167-172. 46. Beuchel RR, Pazhenkottil AP, Herzog BA, et al. Prognostic performance of low-dose coronary CT angiography with
prospective ECG triggering. Heart. 2011;97(17):1385-1390. 47. von Ballmoos MW, Haring B, Juillerat P, Alkadhi H. Metaanalysis: diagnostic performance of low-radiation-dose coronary computed tomography angiography. Ann Intern Med. 2011;154(6):413-420. 48. Neefjes LA, de Feyter PJ. CT coronary angiography: a new unique prognosticator? Heart. 2011;97(17):1363-1364. 49. Jakobs TF, Becker CR, Ohnesorge B, et al. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECG-controlled tube current modulation. Eur Radiol. 2002;12(5):1081-1086. 50. Busch S, Johnson TR, Nikolaou K, et al. Visual and automatic grading of coronary artery stenoses with 64-slice CT angiography in reference to invasive angiography. Eur Radiol. 2007;17(6):1445-1551. 51. Schmermund A, Rensing BJ, Sheedy PF, Bell MR, Rumberger JA. Intravenous electron-beam computed tomographic coronary angiography for segmental analysis of coronary artery stenoses. J Am Coll Cardiol. 1998;31(7):1547-1554. 52. Choudhary G, Atalay MK, Ritter N, et al. Interobserver reliability in the assessment of coronary stenoses by multidetector computed tomography. J Comp Assist Tomogr. 2011;35(1):126-134. 53. Poon M, rubin GD, Achenbach S, et al. Consensus update on the appropriate usage of cardiac computed tomographic angiography. J Invasive Cardiol. 2007;19(11):484-490. 54. Stillman AE, Rubin GD, Teague SD, White RD, Woodard PK, Larson PA. Structured reporting: coronary CT angiography: a white paper from the American College of Radiology and the North American Society for Cardiovascular Imaging. J Am Coll Radiol. 2008;5(7):796-800. 55. Heyer CM, Lemburg SP, Knoop H, Holland-Letz T, Nicolas V, Roggenland D. Multidetector-CT angiography in pulmonary embolism: can image parameters predict clinical outcome? Eur Radiol. 2011;21(9):1928-1937.
Medical writer and health care journalist Bryant Furlow, BA, is a regular contributor to Radiologic Technology, The Lancet Oncology, and Oncology Nurse Advisor, where he writes about diagnostic imaging, clinical and radiation oncology, epidemiology, and health care policy. Furlow is a member of the Association of Health Care Journalists, Society of Professional Journalists, and Investigative Reporters and Editors. He has won awards for investigative reporting and journalism education. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail communications@asrt.org. 2012 by the American Society of Radiologic Technologists.
281CT

#12801-04
Expiration Date: Feb. 28, 2014* Approved for 2 Cat. A+ credits
Computed Tomography Angiography
To receive Category A+ continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on Page 288CT and then follow the directions for submitting the answer sheet. You also may take Directed Reading quizzes online at www.asrt.org. New and reinstated members are ineligible to take DRs from journals published prior to their most recent join date unless they have purchased access to the quiz from the ASRT. Your access to Directed Reading quizzes for continuing education credit is determined by your CE preference. For access to other quizzes, go to www.asrt.org/store. *Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date. 1. African Americans face a first-stroke risk _______ as high as that seen among whites. a. twice b. equally c. two-thirds d. one-half 4. _______ is a progressive, life-threatening chronic inflammatory disorder of vascular walls. a. Pulmonary embolism b. Atherosclerosis c. Thrombosis d. Hyperlipidemia
2.
More than 83 million Americans currently live with: a. high levels of low-density lipoprotein (LDL) cholesterol. b. cardiovascular disease. c. thrombosis. d. angina pectoris.
5.
Clinical signs of coronary artery disease include: 1. infarction. 2. oxygen deprivation. 3. angina pectoris. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
3.
The total direct and indirect costs of cardiovascular disease are an estimated $_______ billion annually. a. 240 b. 340 c. 440 d. 540


6. Pulmonary embolism is a common emergency resulting from atherosclerotic disease, and 1 in _______ patients who die of unsuspected pulmonary embolism could have survived with proper diagnosis. a. 5 b. 7 c. 10 d. 12 10. Symptomatic stenosis of the arterial lumen usually occurs during the _______ phase of atherosclerosis development. a. fatty streak b. foam cell c. atheroma d. fibrous plaque
7.
Atherosclerosis risk factors with genetic components include: 1. elevated levels of LDL. 2. elevated levels of homocysteine. 3. clinical depression. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3
11. The degree of calcification is a useful indicator of plaque stage. a. true b. false
12. The predictable range of computed tomography (CT) values for muscle is _______ HU. a. -50 to -100 b. 10 to 40 c. 300 to 500 d. 130 to 1500
8.
_______ has been implicated as a contributing factor in 36% of first heart attacks. a. Diabetes b. LDL oxidation c. Tobacco smoking d. Low dietary intake of antioxidants
13. Nonionic contrast agents have a reported overall adverse reaction rate of approximately _______ %. a. 3 b. 4 c. 5 d. 6
9.
Autopsies suggest most men and women have _______ by age 15 to 34. a. aortic fatty streaks b. ruptured atherosclerotic lesions c. atheromas d. fibrous plaques
14. Dose-dependent adverse reactions to contrast agents include: 1. nephrotoxicity. 2. pulmonary embolism. 3. cardiac collapse. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3 283CT

15. Contraindications for iodinated contrast agent injections include patient use of: a. nonaminoglycoside antibiotics. b. gemcitabine chemotherapy. c. loop diuretics. d. corticosteroids. 19. Grayscale settings should not be maximized to white for the _______ because doing so can yield inaccurate visualizations of lumen diameter. a. stents b. blood vessels c. fat d. smooth muscle
16. Approximately _______ % of patients may not be able to reduce their heart rate to below 65 beats per minute, even with beta-blocker administration. a. 15 b. 20 c. 25 d. 30
20. Precontrast scans are rarely used with multidetector CT (MDCT) except in cases of suspected: a. pulmonary embolism. b. ischemic stroke. c. arterial hemorrhage. d. coronary stenosis.
17. The _______ images use data from multiple primary planar images to reconstruct images in new view-angle planes. a. 2-D multiplanar b. maximum intensity pixel (MIP) c. primary axial d. curved planar reformations
21. The risk of respiratory motion artifacts is higher for _______ than for other CT examinations. a. chest and abdominal computed tomography angiography (CTA) b. CT neuroangiography c. neck CTA d. abdomen-only CTA
18. _______ can be constructed to visualize complex 3-D vasculature, representing tortuous vascular pathways on a single 2-D image and allowing accurate assessment of vessel occlusions and calcifications. a. Multiplanar reformations b. MIPs c. Primary axial images d. Curved planar reformations
22. Administration of beta-blockers prior to CTA examinations is contraindicated for which of the following medical conditions? 1. severe bronchial asthma 2. high blood pressure 3. heart failure a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3


23. _______ is key to vascular enhancement, whereas _______ would be key to enhancement of other organs. a. A 30-second breath hold; shallow breathing b. Shallow breathing; a 30-second breath hold c. Contrast injection flow rate; total iodine dose d. Total iodine dose; contrast injection flow rate 27. Coronary artery disease is an atherosclerotic narrowing of _______ % or more of a major coronary artery or branch. a. 20 b. 30 c. 40 d. 50
24. _______ refers to the time required for contrast to travel from the injection site to a region of interest. a. Contrast medium transit time (t CMT) b. t CMT plus 8 seconds c. Scan delay d. First pass effect
28. Patient radiation doses below _______ mSv have been reported for ECG tube current-modulated retrospective ECG-gated MDCT coronary CTA. a. 7 b. 8 c. 9 d. 10
25. CTA contrast enhancement is proportionate to injection rate and total injection: a. dose. b. fraction. c. duration. d. phase.
29. Most calcium scoring is employed using _______ , which has largely replaced _______ calcium scoring. a. MDCT; electron-beam CT b. MDCT; magnetic resonance c. magnetic resonance; MDCT d. electron-beam CT; MDCT
26. The magnitude of arterial enhancement varies up to _______ -fold between patients, in part because of variation in cardiac output and body mass. a. 2 b. 3 c. 4 d. 5
30. According to the Directed Reading, the most common indication for diagnostic imaging of pulmonary vasculature is pulmonary: a. sarcoidosis. b. fibrosis. c. embolism. d. emphysema.
285CT
Carefully cut or tear here.
...........................................................................................................
MY PERSPECTIVE
The Importance of Staying Offline

Anne Lowther My Perspective features guest editorials on topics in the radiologic sciences. Opinions expressed by writers do not necessarily reflect those of the ASRT. Those interested in writing an editorial should e-mail communications@asrt.org.
When was the last time your radiology department or facility lost Internet capabilities? Do you have offline options? What is your backup plan? Do you have one? Friday, July 3, 2011, began like a typical second shift for our small community hospital in Philadelphia, Pennsylvania. Emergency department (ED) patients were beginning to line up, inpatients were pending on the work list, and outpatients continued arriving. As I paused to collect my thoughts between patients, the overhead speaker announced that our radiology information system (RIS) was down. After a long and exaggerated grunt from all technologists, we proceeded with our work load. This sort of thing happens, right? Information systems personnel are called in to resolve the issue and usually accomplish the task within an hour but not this time. The unthinkable happened: All systems crashed and the hospital lost all Internet capabilities. This meant an interruption concerning every Internet-dependent system, including RIS, picture archive and communication system (PACS), laboratory results, patient transportation systems, computerized physician order entry, departmental schedules, and online medical records. Departments were unable to communicate electronically. We could not access our backup servers. This incident set our institution back 20 years in the blink of an eye. Hospital staff immediately burst into downtime mode. Laboratory results were hand written and retrieved manually, physicians wrote orders by hand, and nurses called to schedule patients manually. Radiologists read computed tomography (CT) images and radiographs within their respective departments. The hospital, including the radiology department, appeared to be functioning properly without so much as a hiccup. All appeared to be under control.
Around 10 pm the staff radiologist burst into the CT department, stating he had a family emergency and was leaving. I pleaded with him to contact a radiology resident to cover his shift. He dismissed my request stating that all systems would be up and running momentarily. What should I do now? ED patients were ready to be scanned and a patient waited on the CT table, so I alerted the radiology director of our situation. The director was calm as she patiently listened to my frantic situation. She instructed me to reboot the system, access the backup server, and use the printers and burn CD-ROMs of images for the patients all of which were not options. She simply could not fathom the concept of no connectivity. I couldnt print films or burn CDs because they require access to the Internet server. I couldnt access the backup server because the software requires Internet connection. The only uninterrupted task I was able to complete was the CT scan. As time passed, the ED physician called the CT department seeking a patients results. I informed him there was not a radiologist on site to dictate the examinations. He demanded results in the most respectful way he could, given the situation. Then he asked if our systems allowed us to burn CDs or print films to deliver them to our sister facility for interpretation. He constructed a sound plan; however, every piece of equipment used in our department was Internet dependent. I informed him that without connectivity, the only solution to view CT examinations was on the monitors located in the CT control room. The situation then took a turn for the worse. The hospital was forced to go on diversion and declare a state of disaster. We can estimate this action cost the hospital an exorbitant amount of money. Diversion may have prevented ambulances from transporting patients to our facility, but it could not hinder patients from walking through the doors.
289
...........................................................................................................
MY PERSPECTIVE
The next morning, all systems were restored and we had our work cut out for us. Affected department employees and managers spent 2 days cleaning up the mess. Staff was forced to input patient information manually and edit studies to integrate them to PACS and other patient management systems. This process was time-consuming and stressful for all involved. Monday morning (50 hours later), management congregated to devise a plan should this situation occur again. They proposed the following be immediately implemented: Install an offline CD burner and printer to print studies should Internet access be interrupted. Technologists would then be able to print examinations and physically transport them if necessary. Create a policy that requires radiologists to cover their shifts at all times, including a backup call list.
This case clearly represents our connectivity dependency in health care today. The Internet has become a pertinent, if not the most essential, component in providing quality customer care and service. Hospitals and radiology departments alike need to be prepared and able to function offline when the technology is unavailable to avoid future disasters. Anne Lowther, MSRS, R.T.(R)(CT), is assistant clinical professor in the radiologic technology program at Drexel University in Philadelphia, Pennsylvania.
290
...........................................................................................................
WRITIN WRITING & RESEARCH G ANCH
Submitting a Manuscript to the ASRT

Jenna R Frosch
Writing & Research discusses issues of concern to writers and researchers and is typically written by members of the Editorial Review Board. Comments and suggestions should be sent to communications@asrt.org.
The ASRT has made it easier than ever to submit manuscripts to Radiologic Technology through our new system that simplifies the process and allows authors to track their manuscript status. The system also makes it easier to communicate submission questions and concerns to the ASRT staff or, for peer-reviewed articles, Editorial Review Board members. The steps for peer-reviewed manuscripts in the new system are simple: 1. The author submits a manuscript. 2. The Editorial Review Board chairman assigns reviewers to the manuscript. 3. The reviewers assess the manuscript. 4. The chairman informs the author of the decision based on reviewer feedback. Column manuscript submissions are reviewed by the Journals managing editor, who will inform the author of the decision. Although the review steps may change slightly depending on the type of manuscript submitted, the author can track his or her manuscript through each stage of the review process.
Getting Started
The new website (asrt.msubmit.net) allows authors to create a passwordprotected account, in which they can update their personal information and submit, update, and track their manuscripts. Before submitting a manuscript, authors should carefully review the Journal Author Guide and related instructions, available on the sites Author Instructions page. Ensuring the article meets all requirements and is accompanied by all the necessary pieces means that it will be processed promptly and smoothly.
entering manuscript information, validating the information, and submitting the manuscript. First, authors are prompted to upload manuscript files. They can select the type, description, and order of their files for the editors to peruse after submission, and even remove and replace files as needed. This not only helps the Editorial Review Board and the ASRT staff, but also allows authors to give as much information about their files as possible, resulting in fewer subsequent author queries. Second, authors are prompted to provide information about their manuscript, including the title and abstract, authors, keywords and subject areas, and disclose research funding and publication in other scholarly journals. To keep the new system consistent, some information is required, as indicated by an asterisk (*). This information must be entered before the author can complete the submission. Third, the author must validate the files being submitted for review by verifying the manuscript has been uploaded and converted to the PDF format correctly. The screen displays all of the data submitted up until this point, allowing the author to go back and verify the information. Finally, the author submits the manuscript. The new system alerts the author if pieces are missing from the submission. If the manuscript is ready for submission, the author will be notified that all the requirements have been met.
Review Status
Instead of submitting and waiting, authors now may log on at any time and check the manuscript status. Not only does the new system streamline submissions and make it easier for authors to know where they are in the process, but it also allows the Editorial Review Board and ASRT
291
Manuscript Submissions
The submission process follows 4 easy-to-navigate steps: managing files,
...........................................................................................................
WRITING & RESEARCH
staff to easily navigate manuscripts and maintain communication with authors as needed throughout the review and editing stages. With the new system, contributing to the scientific journals will be faster and easier and may even help get your article published sooner. u Jenna R Frosch, MA, is the ASRT associate editor. She has written and edited for magazines and newspapers for more than 5 years.
Call for Columns

Interested in writing, but not sure where to start? The editors of Radiologic Technology are looking for column submissions on a variety of topics, including: n The importance of screening examinations. n Creative approaches to patient care, particularly dose reduction. n Safety or best practice tips for technologists. n Imaging head injuries. n Cutting-edge technologies. n Radiologic science practice around the world. Journal columns should be 500 to 2000 words in length. Column writing is perfect for building your professions body of knowledge without requiring lengthy research and peer review. Plus, if we accept your article, your name will appear with your column in the most widely distributed scholarly publication in the radiologic sciences. Whether you are a new writer or the author of numerous articles, we look forward to reading your submission.
292
...........................................................................................................
LITERATURE REVIEW
CT and Radiography
Literature Review features contributions from volunteer writers from the radiologic sciences, reviewing the latest in publications and communication materials produced for the profession. Suggestions and questions should be sent to communications@asrt.org.
COMPUTED TOMOGRAPHY, 3rd ed. Kalender WA. 2011. 372 pgs. Publicis Publishing. www.publicis-books.de. $70. Computed Tomography is one of the few comprehensive books about CT imaging principles. This landmark text originally was published in 2000. Dr Willi A Kalender has significantly updated and expanded his work in this third edition. It is important for readers to be aware that this is not a clinical guide to CT scanning. Therefore, it presents little information regarding the clinical applications of CT such as anatomy and pathology, contrast media, and protocol design. However, this edition is one of the most current, in-depth, and wellorganized texts on the physics and technical basis of CT imaging. The book begins with an introduction to the fundamental principles of CT image formation. Dr Kalender takes a decade-by-decade approach to describing the historical development of CT. He provides excellent details regarding the different scanner generations, including the clinical demands that lead to each advancement. A table concisely organizes the technical characteristics of CT systems through the years, providing a striking illustration of just how far the technology has come. Dr Kalender is widely considered the father of spiral CT and is responsible for much of its initial development. The subsequent resurgence of the modality in the 1990s can be traced directly to his groundbreaking work. Indeed, a particular strength of this text is the section on spiral techniques and principles. One potential weakness is the occasional
tendency to use information based on Siemens CT products. Dr Kalender worked in the research laboratories of Siemens Medical Systems in Erlangen, Germany, from 1979 to 1995. The prevalence of Siemens terminology may be a disadvantage to users of CT technology from the other major vendors. Many of the recent advances from these companies, such as General Electrics gemstone detectors and Toshibas 320-slice system, are mentioned only briefly. Dr Kalender includes descriptions of the x-ray components of a CT system, with a review of Siemens own Straton x-ray tube. Other important CT components are discussed, including detector elements, filtration, and the various collimators used to shape the CT beam. Several multidetector array designs are presented, each accompanied by detailed illustrations. Dr Kalender suggests that although questions remain regarding the optimal detector design for CT, the 64-row system seems to be an ideal balance between image quality and minimal dose. An additional strength of this work is the discussion of many new developments in CT technology, including advances in cardiac imaging, flat-panel detectors, dual-energy acquisition, and perfusion CT. In particular, this edition examines the viability of low-dose CT of the breast. Technologists likely will benefit from reviewing the sections on image display characteristics, CT image quality, and 3-D reconstruction techniques. However, the discussion of the mathematics of CT image reconstruction is beyond the scope of practice for the CT technologist and is likely inaccessible to anyone lacking an advanced degree in mathematics. The chapter on patient dose in CT may be of value to technologists. It offers a logical and rational approach to many of the recent controversial issues in this area. Dr Kalender reminds readers of the shortcomings of the widely publicized risk models and succinctly outlines methods for calculating accurate patient
293
...........................................................................................................
LITERATURE REVIEW
dose estimates. The chapter includes a set of guidelines for reducing patient dose during CT. Methods by which manufacturers can improve the dose efficiency of CT systems are described. Most importantly, the concept of ALARA is supported with a review of best practices for CT technologists to keep patient dose to a minimum. The accompanying DVD containing digital copies of all of the figures in the book may benefit medical imaging educators. In the preface of the text, Dr Kalender includes a generous invitation to educators to use the figures in their own presentations and teaching materials. Of course, standard copyright rules apply and the text should be cited as appropriate. The DVD also contains several clinical case studies and a downloadable image viewer. Computed Tomography contains the latest information, organized in a clear and logical format, written in language accessible to most imaging professionals. For the CT researcher, engineer, or educator, this near pocketsized book is an indispensable resource. The text is also extremely valuable for the experienced CT technologist seeking a comprehensive understanding of the technical aspects of CT imaging. Such information can greatly assist those who want to expand their clinical practice beyond simply implementing scan protocols. However, much of the material presented may be too in-depth for the novice technologist. In preparation for the ARRT examination in CT, entry-level students may wish to begin with more basic publications. Overall, I highly recommend Computed Tomography. Written by a true pioneer in the field, it is a high-quality addition to any CT library. Daniel N DeMaio, BS, R.T.(R)(CT) Radiologic Technology Program Director University of Hartford West Hartford, Connecticut
ESSENTIALS OF RADIOGRAPHIC PHYSICS AND IMAGING. Johnston J, Fauber TL. 2011. 264 pgs. Elsevier. www.elsevier.com. $92.95. Job well done and congratulations to coauthors James Johnston, PhD, R.T.(R)(CV), and
294
Terri L Fauber, EdD, R.T.(R)(M), on this first edition of Essentials of Radiographic Physics and Imaging. Distinctive writing styles from 2 highly respected radiologic science educators (Johnston is vice chairman of the Radiologic Technology Editorial Review Board) come together to create this transitional book that blends analog and digital radiographic physics and imaging. By combining the delivery of pertinent and essential analog concepts with digital imaging concepts, the authors allow the reader to appreciate both the similarities and the differences between these 2 imaging worlds. Seasoned radiologic science educators have been taunted by the dilemma of digital imaging rapidly replacing analog imaging. This textbook addresses analog concepts only to the level necessary to serve as a basic building block for digital imaging. The writing is very concise and easy to read, even when presenting complex digital concepts. The authors do a great job conveying content with the flow and feeling of a well-prepared live course lecture, often speaking to the reader as if in a face-to-face conversation. Before new concepts are introduced, the reader is referred to previously discussed concepts that might need review to advance the understanding of new and more complex physics and imaging concepts. Each chapter begins with an outline, list of learning objectives, and key terms that can be used as introductory and review tools. The use of color and blocked format in the Critical Concepts, Theory of Practice, and Making the Imaging Connection areas throughout the book highlight quick reference and review opportunities following all detailed discussions. Mathematical applications are highlighted, and include a step-by-step approach to problem solving and formula usage. The chapter summaries can be valuable for reviewing and second readings. The intended audience of Essentials of Radiographic Physics and Imaging includes students, imaging educators, and practicing technologists. With clarity for all levels of imaging professionals, the authors discuss many questions regarding the overuse of exposure and how to interpret the numerous vendor-specific exposure indices. The discussion on this concept alone makes this book a must-have for all radiologic science programs and departmental libraries. Seasoned technologists (those of us stuck in the analog state of mind) who would like a more in-depth understanding of the digital equipment in use will appreciate the essentials offered by this book. Clinical instructors responsible for future imaging professionals will love it for bridging the generation gap between imaging worlds of both instructors (analog) and
...........................................................................................................
students (digital). Offering a glance into the old world of film screen for todays students, this textbook affords a greater appreciation for the ease of imaging with digital technology and respect to those of us who really know what it means to make that perfect picture. Essentials of Radiographic Physics and Imaging is a wellconstructed hard copy textbook with appropriate font size and great use of visuals that help explain complex physics and imaging principles. The actual size of this book can be appreciated, too, for not being too large and bulky so it can easily be carried by the reader. This book contains the most current information available on digital radiography while curtailing the amount of analog information, making it a great addition to the limited resources available in the world of radiologic imaging. Kendall DeLacerda, MSRS, R.T.(R) Assistant Professor Bachelor of Science in Radiologic Sciences Program Northwestern State University Natchitoches, Louisiana MERRILLS POCKET GUIDE TO RADIOGRAPHY, 12th ed. Frank E, Long B, Smith B. 2011. 372 pgs. Elsevier. www.elsevier.com. $36.95. The most recent edition of Merrills Pocket Guide to Radiography includes more than 150 of the most commonly requested radiographic projections in a 5x7-in spiral-bound volume. Each projection is presented in a broadside 2-page format that will be familiar to users of previous editions. Also retained from previous editions are features such as the patient position photographs, the radiographs, a suggested kVp for each projection, and the exposure technique chart with space for noting both manual and AEC technical factors. It should be mentioned that the last edition of Merrills Pocket Guide was published in 2007 and was titled the 6th edition. The publisher chose to match the edition number of the latest revised pocket guide to the 12th edition of the Merrills Atlas of Radiographic Positioning and Procedures that it references. The 12th edition of Merrills Pocket Guide to Radiography is organized with an introduction, preface, and table of
contents followed by 6 sections of radiographic projections grouped by body region. Completing the volume is a section devoted to mobile radiography, followed by the appendices and a section for notes. A tabbed section divider made of heavier stock separates information for each body region from the others. Printed on each divider, an index of the projections for that body region provides the reader with easy access to the desired information. Many of the useful reference tables and diagrams from the 6th edition have been carried over to the new pocket guide. These features include the table of external body landmarks that reference internal bony structures, 2 illustrations of cranial lines and planes, the tables of SID and grid conversion factors, and the orthopedic cast table. Within the information provided for each radiographic projection, this edition retains patient position, part position, patient respiration directions, central ray coordinates, and suggested kVp information from the previous edition. New to the 12th edition is information about proper collimation for each projection. This is especially helpful to readers given the increased use of digital imaging equipment in the clinical environment. With its convenient size and wealth of fundamental information, the 12th edition of Merrills Pocket Guide to Radiography is an excellent quick-reference text and companion volume to the 12th edition of Merrills Atlas of Radiographic Positioning and Procedures. I enthusiastically recommend this valuable resource for radiologic science students, technologists, and educators. Elizabeth M Daigle, MEd, R.T.(R) Clinical Educator for Radiology Southcoast Hospitals Group Fall River, Massachusetts
295
...........................................................................................................
ON THE JOB
Cerebral Angiography
Lindsey J Schoennauer
On the Job focuses on issues of relevance to radiologic technologists in the clinic.
Cerebral angiography reveals the cerebrovascular system by means of catheter placement with the administration of contrast medium,1 and it has been evolving since its development in the 1920s. The ability to image opacified vessels is crucial in diagnosing and treating blood vessel issues.2 Because of angiography, we have a lifesaving gateway to accurate diagnosis of cerebral arterial diseases, malformations, and pathology, as well as continually increased treatment planning and corrective procedural effectiveness. Conventional catheter-based forms of cerebral angiography have changed over the years, but remain invaluable in the detection, treatment, prevention, and removal of deadly cerebrovascular diseases and pathologies. In addition, magnetic resonance angiography and computed tomography angiography (CTA) have enhanced cerebral vascular imaging capabilities, particularly as screening and diagnostic tools. Less invasive CTA techniques appear to have lowered the overall frequency of diagnostic catheter-based cerebral angiograms. However, despite this trend in diagnostic use, conventional angiograms are proving their value in the field of neuroendovascular intervention and treatment. Carotid arteries were first viewed radiographically in 1928, when carotids were directly injected with contrast through a needle.3 The Seldinger technique, a safer procedure that introduces contrast through sheaths and catheters advanced to specific arteries, was developed in 1953 and is still used today. Single-plane radiographs then were taken, allowing visualization of cerebral vasculature. This imaging method, angiography, is considered the forerunner of interventional radiology,3 which is the use of imaging guidance to affect treatment. The 2 are recognized as invaluable because they replace traditional surgical techniques and benefit many
patients and health care services.4 Digital subtraction angiography (DSA) techniques were introduced in the 1980s and are the preferred imaging method for viewing cerebral vessels because of their special processing abilities. DSA makes it possible for surrounding bones and structures which can overlay pertinent findings to be removed from the images, leaving only imaged vessels. Although advances in MR and CT imaging have made conventional cerebral DSA studies obsolete in many smaller medical institutions, cerebral DSA remains useful because of its high resolution and interactive nature during interventional procedures.
Advancements in Angiography
Improvements in instruments and techniques have been pursued in an effort to achieve greater safety and efficacy. Accessing the cerebral artery through an endovascular approach has evolved into a relatively streamlined and safe procedure.6 Heparin-coated guide wires help prevent clotting around inserted instruments and during procedures.3 Guide wires, about 0.025 inches in diameter,5 have safety designs that prevent the possibility of leaving broken pieces behind. The wires lead the catheter to the intended artery smoothly and securely. Changes in catheter construction and shape have helped make artery selection easier and increased maneuverability within arterial trees, along with access to small branches. This is because of the catheters thin materials and extreme flexibility. The catheter has a gel coating for easy gliding during intra-arterial movements and exchanges.11 The French gauge system is used to measure the outside diameter of catheters, which often begins at 6 Fr (2 mm) and then decreases in size to 4 Fr (1.35 mm) as the vasculature being reached decreases in size.5 Microcatheters as small as 1 Fr to 2 Fr (0.33 mm to 0.66 mm) are used for highly selective angiography of small,
296
...........................................................................................................
deep cranial vessels. The catheter allows for injection of contrast into the cerebral arteries. Current contrast agents are water soluble, nonionic, and far less toxic than earlier ones. Angiography is performed in a dedicated interventional suite where the patient lies on a special procedures table. The characteristics of the angiography table allow for easy patient access and relatively free movement of imaging equipment around the patients head. The table is supported by 1 stable floor base and is quite narrow, especially near the patients shoulders and head. The thickness of the table is minimal, allowing for more fluid movements and minimizing the possibility of artifacts from the table during imaging. Cerebral Arterial Imaging Cerebral arterial imaging is useful for detecting calcified arterial walls, occlusive lesions, carotid artery disease, and hemorrhaging, all of which can lead to strokes of all classifications. Bulging, weak arterial walls, known as aneurysms, also can be found and are one of the most common reasons for cerebral angiography studies. CTA has a particularly important role in cerebral vascular imaging because it is much more rapid, less expensive, less invasive, requires fewer staff, and has a diagnostic ability comparable to conventional angiography. These factors make it an excellent screening and diagnostic tool, but CT results often are not helpful during treatment, such as when choosing and placing correctly sized embolization coils that prevent blood flow to aneurysms or when positioning the proper stent to manage blockages. Conventional catheter-based angiography enables better spatial resolution of vessels and more accurate sizing of abnormalities, such as blockages or aneurysms, so that the corrective interventional procedure is efficient and effective.6 Because of this advantage of DSA and potential artifacts of CTA, catheter-based angiography often must be performed before an interventional treatment based on CTA findings. In institutions where cerebral interventional treatments are routinely performed, it often is recommended to perform a diagnostic DSA in an angiographic suite, especially if the probability of a follow-up procedure is likely.7 According to Sakamoto et al, the accuracy of CTA is also somewhat circumstantial.8 CTA is not always accurate in separating vessels from bony structures, especially near the base of the skull, where pathology often shows in the internal carotid artery. The scan can
be subject to interpretive error due to reconstruction artifacts in this area, as well as in heavily calcified arteries.8 Patients are exposed to higher radiation doses7 and the scan has a tendency to portray pathology size inaccurately. Conventional angiography often provides a significantly lower dose in addition to providing the highest degree of spatial resolution and image quality.7 Most often, patients are given mild oral or intravenous sedatives, usually benzodiazepines, before an angiogram or interventional procedure. Intraprocedural monitoring is accomplished through, yet not limited to, continuous electrocardiograms, arterial blood pressure, and oxygen saturation measured through a pulse oximeter on the great toe on the side of arterial access. General anesthesia, conscious sedation, local anesthetics, and neuromuscular relaxants can all be used during the angiogram and the interventional treatment.1 These agents can be introduced through the same catheter used to introduce the contrast and treatment materials, including a considerable amount of heparin solution flush to help prevent thromboembolic complications during or after the procedure.6 This anticoagulant dose requires careful management because it can increase the risk of hemorrhaging. Because of the large amounts of fluids being introduced, a bladder catheter often is placed in the patient before the procedure begins. The anesthesiologist plays an important role during intracranial procedures. His or her management of the patients conscious state, pain, and ability to move, as well as always being prepared in the event of a rare complication, is critical to the success of intracranial access procedures.9 Arterial access is achieved through 1 of 3 sites: the common femoral artery, transradial artery, or transbrachial artery. Access almost always is achieved on the right side because of physician comfort and familiarity, and the femoral artery is traditionally the point of choice. Recent studies, however, have shown transradial access to have the least complications and fewer postprocedure side effects.10 Transfemoral access requires uncomfortable groin compression and supine bed rest for 4 to 6 hours after the procedure. Complications such as local pseudoaneurysm, arteriovenous fistula, hematoma, or pulmonary embolism can occur following a femoral puncture, although these complications are rare. Potential side effects of transbrachial access are less severe, but this type of access can result in a massive hematoma or pulse deficiency.10 It is advantageous to have several puncture site options for cerebral artery
297
...........................................................................................................
ON THE JOB
access should a site be contraindicated for factors such as lack of collateral blood flow or arterial stenosis.11 Once catheterization is achieved, the contrast injection begins at a rate of 4mL/s12 into either the internal carotid or vertebral arteries.15 Imaging follows quickly to capture the cerebral arteries filled with contrast. Most large facilities that perform cerebral angiography use a ceiling-suspended C-arm that is computer operated and has rotational and 3-D reconstruction capabilities. Once the abnormality is diagnosed and prior to interventional treatment, the best working view is found, and the view is sent back to the C-arm so that a single-plane image can be acquired. This image can remain on the screen for use during the interventional procedure as a road map for the neuroradiologist. The C-arm can be maintained at a set angle or changed to be used for guidance under fluoroscopy to ensure correct location and treatment of the abnormality.15 C-Arm Flexibility and 3-D Reconstruction The past decade has seen an exciting integration of computer technology and radiology equipment capabilities. For years, anteroposterior and lateral 2-D, single-plane images were digitally subtracted to show only the contrast-filled vessels. Biplanar systems then developed, allowing simultaneous images of those projections to be taken at 90 from each other by a dualtube and dual-image intensifier C-arm system, with 1 image in anteroposterior projection, and the other in the lateral projection.13 These images are still useful during interventional procedures today, but they lack dimension and volume and can hide pathology behind overlapping vessels and anatomy. Soon after the development of biplanar systems, 3-D capabilities of CT took over, and the advances in C-arm abilities teamed with computer technology to form 3-D rotational angiography. The 3-D method offers multidimensional projections similar to CT and resolution comparable to that of conventional angiography.13 Angiography-specific C-arms can be programmed to rapidly arc 180 to 270 around the patients head (or other area of interest) while acquiring 100 images along the arc, creating a complete series from many angles, as opposed to only true anteroposterior and lateral projections. The arc can be performed at 30 caudad, 0, or 30 cephalad, accomplishing projections more closely perpendicular to the region of interest.13 The angiographic C-arms can be used in 2 different positions relative to the patient, creating 2 directions
298
of rotational sequences. One position is called the standard roll technique, where the C-arm is positioned perpendicular to the patients head. The second position, called the propeller rotation, is accomplished with the C-arm at the patients head, where it rotates. The roll method can only acquire images along a 180 to 200 angle at 20 to 30 per second, but the propeller rotation can move more than 240 with a maximum speed of 55 per second. Therefore, the propeller technique can increase the number and angles of images and decrease imaging time by about 2 seconds, which also decreases the amount of injected contrast medium necessary by approximately 40%. Additional contrast injections are needed for any additional imaging sequences required for diagnosis and treatment. The C-arm can remain in 1 position throughout all procedures if used in a propeller rotation.12 The system calibration compensates for typical varying distortion patterns, such as the pincushion effect, that are typical with the C-arm image intensifier.13 The computer then applies an algorithm to the series of images, creating a 3-D reconstruction of the intended vascular area after the calculations are complete. This image is interactive from the workstation located at the angiography table, which allows the neuroradiologist to turn the image and view the anatomy from different angles. Coupled with CT-like capabilities of 3-D reconstruction and a multifunctional C-arm, these angiograms are invaluable when treatments can immediately follow at the angiography table. According to Moret et al, This allows fast and accurate analysis in determination of the size and the relationship to parent vessels for safe decisions regarding the endovascular approach.13
Contraindications and Complications

Contraindications of conventional cerebral angiography must always be considered. They can include preexisting renal insufficiency that could possibly worsen with use of contrast, causing renal failure or diabetes.7 Advanced age, severe atherosclerosis, or acute subarachnoid hemorrhaging also can increase possible complications. Risks also are related to the length of the procedure, number of catheter exchanges, catheter size, extent of catheter manipulation, and amount of contrast media used,14 all of which have decreased significantly because of advances in imaging and materials. Complications are defined as anything that occurs within the following 24 hours and causes an increased level of care, whether minor or major. Less severe reactions include contrast allergies and puncture
...........................................................................................................
site complications such as pain and large, sometimes problematic, hematomas.6 Rarely, adverse neurological effects occur, including varying degrees of strokes. Institutions report different statistics regarding the percentages of conventional cerebral angiography complications, although occurrence has varied over the past decade from 2% to less than 1%,14 and even no neurological complications, according to 1 medical centers statistics.6 As always, risk vs benefit should be carefully weighed, but the benefit of noninvasive procedures over conventional neurosurgery usually outweighs risks.
date in their knowledge, skills, and comfort with catheterization procedures. In high-volume and technologically advanced practices, diagnostic angiography is the foundation for safe and successful neuroendovascular intervention.6 Once perceived to be on the road to extinction, conventional catheter-based cerebral angiography is gradually becoming an irreplaceable imaging modality, facilitating reliable treatments of lifethreatening disorders.
References
1. Snopek AM. Fundamentals of Special Radiographic Procedures. St Louis, MO: Saunders Elsevier; 2006:129-143,286-337. 2. Yamamoto M, Okura Y, Ishihara M, Kagemoto M, Harada K, Ishida T. Development of digital subtraction angiography for coronary artery. J Digit Imaging. 2009;22(3):319-325. 3. Baum S. Abrams Angiography: Vascular and Interventional Radiology, Vol. 1. 4th ed. New York, NY: Little Brown & Co; 1996. 4. Nicholson T, Adam A. The availability of interventional radiology: an issue of patient safety. Clin Risk. 2009;15: 43-46. 5. Gradinscak DJ, Young N, Jones Y, ONeil D, Sindhusake D. Risks of outpatient angiography and interventional procedures: a prospective study. AJR Am J Roentgenol. 2004;183(2):377. 6. Thiex R, Norbash A, Frerichs K. The safety of dedicatedteam catheter-based diagnostic cerebral angiography in the era of advanced noninvasive imaging. Am J Neuroradiol. 2009:31(2);230-234. 7. Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg. 2010;52(suppl 3):81S-91S. 8. Sakamoto S, Kiura Y, Shibukawa M, Ohba S, Arita K, Kurisu K. Subtracted 3-D CT angiography for evaluation of internal carotid artery aneurysms: comparison with conventional digital subtraction angiography. Am J Neuroradiol. 2005;27(6):1332. 9. Asouhidou I, Asteri T, Katsaridis V, Geordiadis G. Immediate anesthesia management of complications during embolization of cerebral vascular lesions. Internet J Anesthesiol. www.ispub.com/journal/the_internet _journal_of_anesthesiology/volume_14_number_2_1 /article /immediate_anesthesia_management_of_complica tions_during_embolization_of_cerebral_vascular_lesions .html. Accessed September 30, 2010. 10. Jo KW, Park SM, Kim SD, Kim SR, Baik MW, Kim YW. Is transradial cerebral angiography feasible and safe? A single centers experience. J Korean Neurosurg Soc. 2010;47(5):332-337. 11. Matsumoto Y, Hongo K, Toriyama T, Nagashima H, Kobayashi S. Transradial approach for diagnostic selective
Cerebral Intervention
Several abnormalities can be discovered through the performance of any type of cerebral angiogram. The most common are various types of strokes and aneurysms. In addition, carotid disease, tumors, and malformations can be detected. Aneurysms vary greatly in size. They weaken the areas in arterial walls, which causes the walls to burst, leading to hemorrhaging in the cerebral cavity. Strokes are defined by occlusion or halting of normal blood flow. Ischemic strokes are characterized by vessel obstruction and lack of oxygen. The most common ischemic attack is cerebral thrombosis, the formation of a clot in a vessel, often characterized by high cholesterol. Embolic strokes also are ischemic and occur through a dislodged clot that travels to a cerebral artery, re-lodging itself. These traveling clots often occur as the result of cardiac disease. Diagnosis and location can be followed immediately by corrective and lifesaving interventional procedures, should the treatment planning call for it, and if the diagnostic procedure is completed in the angiography suite. Cerebral intervention treats the previously mentioned disorders through image-guided procedures. Accessing the point of interest through 1 of the cerebral arteries, the common carotid or vertebral artery, allows for embolization techniques at the site of the bulging aneurysm or the removal of occlusions in the instance of a stroke. Accessing pathology is accomplished through use of the same methods and catheters as are contrast injections for angiograms. This is the reason diagnostic angiography performed in the hands of an experienced neurointerventional team also provides the advantage of immediately correcting many pathologies, as well as handling interprocedural complications.6 Catheter-based imaging likely will remain crucial to the effective treatment of aneurysms, strokes, and other conditions. Therefore, it is imperative for neuroradiologists and the entire angiography team to remain up-to-
299
...........................................................................................................
ON THE JOB
cerebral angiography: results of a consecutive series of 166 cases. Am J Neuroradiol. 2001;22(4):704. 12. Gaurvit J, Leclerc X, Vermandel M, et al. 3-D rotational angiography: use of propeller rotation for the evaluation of intracranial aneurysms. Am J Neuroradiol. 2005;26(1):163-165. 13. Moret J, Kemkers R, De Beek JO, Koppe R, Klotz E, Grass M. 3-D rotational angiography: clinical value in endovascular treatment. Philips Healthcare website. www.health care.philips.com/phpwc/main/about/assets/docs/medi camundi/mm_vol42_no3/mm_vol42_no3_article_3d_ rotational_angiography.pdf. Published 1998. Accessed September 30, 2010. 14. Wallace RC, Citron SJ, Lewis CA, et al. Quality improvement guidelines for adult diagnostic neuroangiography: cooperative study between the ASNR, ASITN, and the SCVIR. AJNR Am J Neuroradiol. 2000;21(1):146-150.
15. Anxionnat R, Bracard S, Braun M, et al. Intracranial aneurysms: clinical value of 3-D digital subtraction angiography in the therapeutic decision and endovascular treatment. Radiology. 2001;218(3):799-808.
Lindsey J Schoennauer, R.T.(R), is a graduate of Cabrillo College in Aptos, California, and is a case analyst at HeartFlow, Inc, in Redwood City, California. The author can be reached at lschoennauer@heartflow.com.
300
...........................................................................................................
TEACHING TECHNIQUES
QR Codes Quick Response

Internet search engines and social media sources such as YouTube (San Teaching Techniques Bruno, California) and Facebook (Palo discusses issues of concern to Alto, California) have turned medical educators. The primary focus professionals on to a global networking of the column is innovative system that shares and combines inforand interesting approaches mation in the world of radiology. to teaching. At our facility, staff and students have effectively made the most of these tools with concise, flexible, and on-the-go education for use in every day practice. Our radiology examination rooms provide computer access to the radiology positioning manual, which is updated and available both in text and audio formats (see Figure 1). Portable devices, such as the smartphone, also can be used for access to a quick response (QR) code (see Figures 2 and 3). A QR code is a matrix code (or 2-D bar code) created by Denso Wave Incorporated (Chita-hun Aichi, Japan) in 1994.1 The creator named these quick response codes because the intent was for the codes to allow their contents to be decoded at a high speed. The QR reader is a free download to smartphone devices through applications and is used more and more every day. The mobile device on which a QR reader is loaded must have Internet access and may need a camera option, depending on the brand of phone.2 The BlackBerry (Research in Motion Ltd, Waterloo, Ontario, Canada) scans the barcode without the use of the camera. Other smartphones require the user to download an application that will use the phones Figure 1. Radiology examination rooms provide comcamera to scan the puter access to the radiology positioning manual, which code. is updated and available both in text and audio formats.
Sharon Jacoby RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3
Figure 2. Portable devices such as smart-
phones, personal media players, and digital assistants can be used to access a quick response (QR) code.
At the Mayo Clinic radiography program, we allow connection to the radiology positioning manual and our radiography programs website. The website includes contact information and the application process for a variety of allied health programs. We have uploaded our positioning videos to the YouTube channel Radpositioning49 for student reference when students are away from clinical examination rooms. Users who do not have smartphones also have access to the website and can download informational videos from YouTube to mobile devices such as personal digital assistants and iPods. We have placed our radiology positioning QR code strategically in exam rooms or on equipment to be accessed at times when students and staff need the information most. This method allows the PRN technologists, new students, or rotating staff quick access to positioning data, technique charts, and protocols. The code data can be updated from the program or project website. Once a QR code is accessed, the site is always available on the smartphone device for future reference, and a feature of the application allows tracking of the QR code. The project owner can note where and at what time people access the code. This
301
...........................................................................................................
TEACHING TECHNIQUES
Figure 3. Accessing a QR code during imaging can help stu-
Other possible uses for QR codes include marketing and continuing education. For marketing purposes, codes could appear on business cards or giveaway items, such as coffee cups, to direct people to a facilitys website. For continuing education, a master QR code could link to the sponsoring organizations website and appear on site at the event. Users can bookmark the page in their smartphone Web browsers, scan the specific QR code to mark attendance, and evaluate sessions as they complete them. Staff can instantly tally attendance and award credit, avoiding some cumbersome paperwork. For example, a QR code from an educational conference (such as those put on by the ASRT) would direct to their website. Instead of signing out, at the end of a session the attendee could scan the code and their attendance would be automatically marked as complete by the credit-granting body. Program instructors can try out a free download application using Figures 4 and 5. Using a graphic design website (eg, www.smartytags.com), instructors can create codes to direct others instantly to any data instructors would like to make public.2 u
dents learn proper positioning, techniques, and protocols.
data could identify a need for training in specific areas or for specific groups. Our next endeavor is to provide QR code access to equipment usage and contact information. A number of QR code applications are used for patients. For example, the codes might include global positioning systems data in real time, which could direct patients to appropriate locations, such as hospital laboratories or radiology departments. QR code applications used for patient care include: n Use with global positioning system data in real time, which could direct patients to appropriate locations, such as hospital laboratory or radiology departments. n Procedure educational videos. n Medication labels as an alternative to printed versions. n Take home monitors for patients with regards to equipment use. n Placement on bracelets or necklaces for quick use at any health facility to gain access to patient health information. n Temporary QR tattoos for people with dementia to assist when they are lost or in distress.
302
Figure 4. Scan this QR code to access the
Mayo School of Health Sciences website.
Figure 5. Scan this QR code to visit the
Radpositioning49 YouTube channel that shows proper positioning techniques.
References
1. Definition of: QR code. PCMag.com. www.pcmag.com /encyclopedia_term/0,2542,t=QR+code&i=61424,00.asp. Accessed May 1, 2011. 2. What can I do with this code? SmartyTags website. www.smartytags.com/create-a-code. Accessed October 10, 2011.
Sharon Jacoby, R.T.(R), is a clinical instructor for the Mayo Clinic radiography program in Jacksonville, Florida.
...........................................................................................................
OPEN FORUM
Kudos and Concerns

Open Forum is open to all individuals interested in commenting on matters of concern to the radiologic sciences. Writers should e-mail their letters to communications@ asrt.org. Letters may be edited to conform with the Journals space or style requirements. Views expressed in this column do not necessarily reflect those of the ASRT.
Editor: The authors of Digital Pelvic Radiology: Increase Distance to Reduce Dose (September/October 2011; Vol. 83, No. 1) are to be commended for their illumination of the advantages of higher SID radiographic projections. Historically, the standard supine SID has progressed from 36 in to 40 in, and some collimator numerical scales even indicated a 44-in distance. This report acknowledged ceiling height and other distance restrictions that inhibit converting to an increased SID. Now, with the advent of elevating radiographic tables, their mechanics do allow for the easy conversion to an increased SID routine for all examinations, including upright imaging. In my experience as a health physicist, at all facility visits, I routinely produced comparative phantom/resolution images between the usual 40-in SID, and 1 taken by simply descending the table height to a 50-in distance. Most technologists found few objections to converting to a new 50-in routine. A person can elevate the table to the standard 40-in height to position the patient and load the receptor in the Bucky tray, and then someone lowers the table to a 50-in SID and assures the appropriate collimation, while setting the manual or auto exposure parameters. After the exposure, someone can stoop or re-elevate the table to retrieve the receptor. When radiologists viewed the 2 images side by side, their first impression was the difference 10 in made in subject magnification. Their second response was to recognize the enhanced detail and subject contrast, along with the expected reduction of the estimated patients skin entrance exposure. I found that in beam dose measurements in both the CR and off center revealed only minimal cut-off influenced by any out-of-grid focus range. There was some concern about the necessary increase in exposure duration and stasis
capture; however, higher mAs technique compensation and tube load didnt seem to be of much concern with the radiologist or others in management. It is pleasing to confirm this articles conclusion. I look forward to and fully expect that future clinical studies will substantiate and even inspire many facilities to implement this advanced method. Richard Warner, BS, R.T.(R) Retired Former chairman of the ASRT Committee on Physics and Radiation Safety, and x-ray history buff Seattle, Washington Editor: I received my September/October 2011 issue of Radiologic Technology in the mail and began reading the Osteoarthritis of the Knee Directed Reading. On Page 43, I spotted what I believe is an error. At the top of the page, there are 2 radiographs; 1 shows a nonweightbearing knee, and the other claims to show the same knee bearing weight. While the image certainly appears to be a weightbearing one, the technologists marker appears to indicate otherwise. The marker appears to contain radiopaque spheres at the bottom. My own personal markers contain these same spheres. They serve as a permanent mark on the image to indicate whether the image was taken upright or supine. If the patient/part was upright/erect, the spheres will fall and clump at the bottom of the marker; if the patient was supine, they will either clump in the middle (as mine do) or spread out evenly (as is shown in the image in the DR). In my 16 years of clinical practice, I have seen knee images taken in a supine AP projection that look identical to the 1 stated to be erect and weightbearing. I cannot say whether the author of the article was mistaken about what was shown or if the image contributor was
303
...........................................................................................................
OPEN FORUM
mistaken. Either way, it certainly appears to me that a mistake has been made, and an image is being misrepresented as weightbearing when it is not. Thank you very much for your time. Sean Thursby, R.T.(R) Junior PACS Administrator, St Lukes Hospital Jacksonville, Florida The radiologist responds: The astute person making this observation is absolutely correct. The small round balls on the technologists marker do indicate that the image is likely not weight bearing. If it were, the balls should layer dependently at the bottom. This is not fail-safe because some of these become damaged (or modified) and the balls no longer move freely; but nonetheless, the observer is likely correct.
This does not discount the fact that there are 2 images of the same knee performed around the same date, which show widely discrepant degrees of medial joint space narrowing. If an accurate assessment of the degree of joint space narrowing is desired, weight-bearing images are essential. Gary Mlady, MD Associate Professor of Radiology Medical Director, Department of Radiology Chief, Musculoskeletal Radiology University of New Mexico Albuquerque, New Mexico
304
......................................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . .
w
PATIENT PAGE
Angiography
This patient education page provides general information concerning the radiologic sciences. The ASRT suggests that you consult your physician for specific information concerning your imaging exam and medical condition. Health care professionals may reproduce these pages for noncommercial educational purposes. Reproduction for other reasons is subject to ASRT approval. Angiography is an x-ray examination of the blood vessels after they have been filled with a contrast agent (usually a type of fluid that makes the vessels visible on an x-ray image). Angiography is performed when your physician suspects that blockages in your arteries or veins are interfering with the normal flow of blood. Physicians also use angiography to find aneurysms (areas of a blood vessel that bulge out), to detect a stroke or bleeding in the brain, to plan some types of surgical procedures, and to find irregularities that can affect the heart or other organs. or vein. The catheter is a flexible, hollow tube about the size of a strand of spaghetti. It usually is inserted into an artery in your groin, although in some cases your arm or another site will be used. The radiologist gently guides the catheter to the correct area while watching it on a fluoroscope, which is an x-ray unit combined with a television monitor. You should not be able to feel the catheter moving through the vessel. When the catheter reaches the area under study, a contrast agent is injected through the catheter. By watching the fluoroscope screen, the radiologist can see the outline of your blood vessels and identify any blockages or other irregularities. Angiography procedures can range from less than an hour to 3 hours or more. It is important that you relax, follow breathing instructions, and remain as still as possible. The radiologic technologist, radiologist, and nurse will stay in the room with you throughout the procedure. If you experience any difficulty, let them know.
Patient Preparation
If you receive instructions on preparing for your procedure, follow them carefully. The day of your exam, a number of blood tests will be performed, and you will be asked about the medications you take, both prescription and over-the-counter. You also will be asked if you have any allergies. It is important to list all allergies to food and medicine, as well as hay fever or asthma. Existing allergies may indicate a possible reaction to the contrast agent that will be used during the procedure. If you are a woman of childbearing age, you also will be asked if there is any possibility that you are pregnant. An interventional radiologist a physician who specializes in minimally invasive treatment techniques guided by x-ray imaging will explain the procedure to you and answer any questions you might have. The radiologist may be assisted by a radiologic technologist, a registered radiologist assistant, and a nurse. The radiologic technologist is a skilled medical professional who has received specialized education in the areas of radiation protection, patient care, and x-ray exam procedures and positioning. You will be asked to put on a hospital gown and an intravenous line will be started. You will be given a medication to help you relax, but you will be awake enough to respond to instructions. Your blood pressure, heart rate, and oxygen level will be monitored during the procedure.
Postexamination Information
After the examination is complete, any bleeding is stopped and a dressing is placed over the cut. You will be moved to a room where you can rest and recover. Depending on your overall health and medical condition, you may be released after just a few hours or you may be admitted to the hospital for observation. Before you go home, you will be given instructions explaining how to care for the site where the catheter was inserted. Your physician also may recommend that you restrict your activities at home or rest in bed. Follow these instructions carefully. Any contrast agent that remains in your system will leave your body when you urinate. You may be advised to drink lots of water to help flush the contrast from your body. The radiologist will review your x-ray images, and your personal physician will receive a report of the findings. Your physician then will advise you of the results and discuss what further procedures, if any, are needed.
During the Examination

The radiologic technologist first positions you on the exam table. The radiologist will administer a local anesthetic and then make a small nick in your skin so a thin catheter can be inserted into an artery
For more information visit us online at www.asrt.org.

307
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . En. Espaol. .... ..........
PATIENT PAGE
Arteriografa
Esta pgina educacional del paciente prove informacin general en cuanto a la ciencia radiolgica. ASRT sugiere que usted consulte con su doctor para obtener informacin especfica concerniente a su examen de imagen y condiciones medicas. Los profesionales del cuidado de la salud pueden reproducir estas pginas para ser usadas sin recibir lucro econmico. La reproduccin de estos documentos para ser usadas para otros objetivos necesita la autorizacin del ASRT.
La arteriografa es un examen de rayos-X de los vasos sanguneos despus que han sido llenados con un medio de contraste (un tipo de fluido que hace que los vasos sanguneos sean visibles en una imagen de rayos-X). La arteriografa se realiza cuando su mdico sospecha que bloqueos en sus arterias o venas estn interfiriendo con el flujo normal de la sangre. Los mdicos tambin utilizan las arteriografas para encontrar aneurismas (zonas de un vaso sanguneo que estn abombadas), para detectar un derrame cerebral o hemorragias en el cerebro, para planear algunos tipos de procedimientos quirrgicos y para descubrir las irregularidades que pueden afectar al corazn u otros rganos.
Durante el Examen
El tecnlogo radiolgico primero le coloca en la mesa de exploracin. El radilogo le administrar un anestsico local y luego har un pequeo corte en su piel de forma que pueda introducirse un catter delgado en una arteria o vena. El catter es un tubo hueco, flexible del tamao de un espagueti aproximadamente. Normalmente se introduce en una arteria de su ingle, aunque en algunos casos puede utilizarse su brazo u otra zona. El radilogo gua suavemente el catter hasta la zona correcta mientras lo observa en un fluoroscopio, que es una unidad de rayos-X combinada con un monitor de televisin. Usted no debe ser capaz de sentir el catter movindose a travs del vaso sanguneo. Cuando el catter alcanza la zona bajo estudio, se inyecta un medio de contraste a travs del catter. Observando la pantalla del fluoroscopio, el radilogo puede ver el contorno de sus vasos sanguneos e identificar cualquier bloqueo u otras irregularidades. Los procedimientos de la arteriografa pueden variar en tiempo desde menos de una hora hasta tres horas o ms. Es importante que usted se relaje, siga las instrucciones sobre respiracin y permanezca tan inmvil como sea posible. El tecnlogo radiolgico, el radilogo y la enfermera permanecern en la habitacin con usted durante todo el procedimiento. Si usted experimenta algn problema, informe al radilogo.
Preparacin del Paciente

Si usted recibe instrucciones acerca de la preparacin para su procedimiento, sgalos atentamente. El da de su examen, se realizarn un nmero de pruebas sanguneas, y se le preguntar acerca de los medicamentos que toma, ya sean por prescripcin o medicamentos de venta sin receta. Tambin se le preguntar si tiene alguna alergia. Es importante que enumere todas las alergias a alimentos y medicamentos, as como tambin la fiebre del heno o asma. Las alergias existentes pueden indicar una posible reaccin al agente del contraste que se utilizar durante el procedimiento. Si usted es una mujer en edad frtil, se le preguntar si existe alguna posibilidad de que usted est embarazada. Un radilogo intervencionista un mdico que se especializa en las tcnicas de tratamiento mnimamente invasivas guiadas radiografas le explicar el procedimiento y responder a cualquier pregunta que pueda tener. El radilogo es asistido por un tecnlogo radiolgico, tambin conocido como tecnlogo intervencionista cardiovascular, y un enfermero/a. El tecnlogo radiolgico es un profesional mdico especializado que ha recibido una educacin especializada en las reas de proteccin radiolgica, cuidado del paciente y posicionamiento radiogrfico y procedimientos. Se le pedir que se ponga una bata de hospital y se le introducir una va IV. Se le administrar un medicamento para ayudarle a relajarse, pero estar lo suficientemente despierto para responder a las instrucciones. Se controlarn durante el procedimiento su tensin arterial, frecuencia cardaca y nivel de oxgeno.
308
Informacin de Pos-examen
Despus de completarse el examen, se para cualquier hemorragia y se coloca un apsito sobre el corte. Se le trasladar a una habitacin donde puede descansar y recuperarse. Dependiendo de su estado general de salud y de su condicin mdica, puede ser dado de alta simplemente en unas cuantas horas o puede ser ingresado en el hospital para observacin. Antes de irse a casa, se le darn instrucciones explicndole como cuidar la zona donde se introdujo el catter. Su mdico tambin puede recomendar que limite sus actividades o reposo en cama. Siga estas instrucciones atentamente. Para ms informacin vistenos en la web electrnica: www.asrt.org.
Impact
Elect national ofcers and chapter delegates who best represent you and the needs of medical imaging and radiation therapy.
Voting is among the most-valued privileges of ASRT membership. Now is your chance to select the next president-elect, vice president and secretary-treasurer, as well as representatives for each chapter. Elected ofcials inuence scope of practice, licensure, practice standards and safety issues. They also represent you before Congress and shape the ASRTs mission.
Your Point of
Log in and vote online at
2012
Polls are open Feb. 16 to March 16.
2011 ASRT. All rights reserved.
ELECTION
www.asrt.org/vote
GE Healthcare
CT Masters Series
LOWER DOSE BY DESIGN.
NEW! CT Low Dose Webinar Series

6 modules, 4 hours total A FREE, timely series presented by industry dustry experts. Learn about:

Current issues with CT radiation dose ose Technology innovations in CT image ge reconstruction and dose reduction i.e. ASiRTM n Dose reduction strategies in pediatric CT tric Dose reduction techniques for cardiac diac CT and neuroimaging
Approved by the ASRT for Category A CE credit. Flexible training at your own pace. Contact your local GE representative for ve Low Dose Technology upgrade (i.e. ASiR & VeoTM) .
Visit gehealthcare.com/ctedu/dosewebinar ebinar
Training opportunities for CT Technologists in 2012

Endorsed by the Society of Cardiovascular Computed Tomography, the professional society devoted exclusively to cardiovascular CT.
The CT Masters Series are advanced training courses designed for Radiologists, Cardiologists and CT Technologists. The courses are taught by expert care providers. Participants receive individual attention in order to maximize their learning experience and ensure that they acquire experts skills and condence. We are proud to offer unique training opportunities to CT technologists in Cardiac CT Angiography, CT Dose reduction techniques and Gemstone Spectral Imaging. Cardiovascular CTA for Technologists with Joey Glass RT(R)CT CT Dose Reduction and Scanning Techniques with Dr. Mannudeep K. Kalra
Target audience: radiologic technologists Two-day basic and advanced offerings, approved by the ASRT for 14 Cat A continuing education credits. Mobile, AL Dates: April 27-28, 2012 August 24-25, 2012
Target audience: radiologists and radiologic technologists Two-day course, approved by the ASRT for 12.75 Cat A continuing education credits. GE Healthcare Institute, Waukesha, WI Date: March 26-27, 2012
Target audience: radiologic technologists Three-day basic and advanced offerings, approved by the ASRT for 11.5 Cat A continuing education credits. Fairfax, VA Dates: February 27-29, 2012 April 23-25, 2012 June 4-6, 2012
Cardiovascular CTA for CT Technologists with Rob Jennings RT(R) and Judy Lane RT(R)(CT)
Gemstone Spectral Imaging Workshop with Dr. James P. Earls
Target audience: radiologists and radiologic technologists Three-day course, approved by the ASRT for 16.5 Cat A continuing education credits. GE Healthcare Institute, Waukesha, WI Date: February 27-28, 2012
Visit gehealthcare.com/gectmasters or call 262.312.7148 for details and 2012 dates

2011 General Electric Company DOC 1029212
imagination at work

Radt12 Janfeb V83i3 CT

Enviado por

Dados do documento

Descrição original:

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Radt12 Janfeb V83i3 CT

Enviado por

Direitos autorais:

Formatos disponíveis

RADIOLOGIC GIC

Journal of the American Society of Radiologic Technologists Vol. 83, No. 3

COMPUTED TOMOGRAPHY EDITION

American Society of Radiologic Technologists

Member of BPA International

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Five CT CE Credits Per Year,

Radiologic Technology Editorial Review Board

ASRT Journal Staff

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

D I R E CTE D RE ADIN G ARTICL E S

Computed Tomography Angiography Bryant Furlow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261CT

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Using Athletic Training Clinical Education Standards in Radiography

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Box Standards for Clinical Education in Athletic Training2

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Table 1 Demographic Data

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Table 2 Responses to Question 1: Clarity of the Standard

Total % may not equal 100% because of rounding.

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Total % may not equal 100% because of rounding.

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Total % may not equal 100% because of rounding.

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Perceptions of the use of Critical Thinking Teaching Methods

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Table 1 Respondent Education Level and Educational Institution Information

Table 2 Respondent Age and Experience

1-40 years Range

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

F = Frequency, Sig. = Significance

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Table 5 Obstacles Encountered When Implementing Critical Thinking Strategies

Table 6 Perceived Barriers to Implementing Critical Thinking Teaching Strategies

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

15. 16. 17. 18.

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Emotional Intelligence in Health Care

Defining Emotional Intelligence

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Appraisal and Expression of Emotion

Other In Self In Other Flexible Planning

Creative Redirected Motivation Thinking Attention

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Measuring Emotional Intelligence

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Table Emotional Quotient Inventory Subscales and Descriptions

January/February 2012, Vol. 83/No. 3 RADIOLOGIC TECHNOLOGY

Box 1 Common EI Characteristics13

RADIOLOGIC TECHNOLOGY January/February 2012, Vol. 83/No. 3

Why Is Emotional Intelligence Important?