AJTCCM VOL. 29 NO. 1 2023 12
RESEARCH
Background. Chest radiographs are a common diagnostic tool in the internal medicine department, and correct interpretation is imperative
for adequate patient management.
Objective. To determine the diagnostic accuracy of common pathologies in South Africa that are evident on chest radiographs, and to
determine whether there are discrepancies according to dierent levels of qualication of doctors rotating through the internal medicine
department, and which factors contribute to an accurate diagnosis.
Method. Fieen chest radiographs with common pathologies were given to all doctors rotating through the Department of Internal
Medicine at Chris Hani Baragwanath Academic Hospital, and they were asked to interpret them. Information pertaining to their experience,
designation and condence in chest radiograph interpretation was also obtained.
Results. Diagnostic accuracy according to years of experience was as follows: 0 - 5 years 27.0%, 6 - 10 years 43.0%, and >10 years 47.9%.
For dierent designations, accuracy was as follows: consultants 50.5%, registrars 40.9%, medical ocers 36.4%, and interns 19.5%.
Participants who were condent obtained a mean score of 39.4% and those who were not, a mean score of 31.6%.
Conclusion. Chest radiographs are readily accessible and used daily in clinical practice in numerous facilities. An accurate diagnosis is
important to provide quality healthcare. Improved training in interpretation for all, but especially for junior doctors, should be a priority
in our training facilities.
Keywords. Chest X-ray, diagnosis, competency, training, education, radiography, radiology, medical.
Afr J Thoracic Crit Care Med 2023;29(1):e265. https://doi.org/10.7196/AJTCCM.2023.v29i1.265
Chest radiographs are the most common radiological investigation
requested by the internal medicine department, and are oen interpreted
by departmental doctors and not radiologists.[1] Accurate diagnosis is of
the utmost importance, as clinical decisions are based on interpretation
of these radiographs and after-hours interpretation is often left to
interns, medical ocers or registrars.
Despite being the most commonly requested radiological investigation,
chest radiographs remain one of the most dicult to interpret. ey
play a vital role in diagnosing many diseases, ranging from acute life-
threatening conditions such as tension pneumothorax to less critical
conditions such as pulmonary tuberculosis or lung cancer, where the
chest radiograph is nonetheless an essential component of the work-up.[1]
Chest radiographs make up the bulk of radiological investigations
reported by non-radiologists and physicians, mainly owing to the
sheer numbers performed compared with other modalities. Various
factors, oen unrelated to the disease, make them dicult to interpret.
ese include technical factors such as over- or underexposure and
projection, overlapping structures and normal variants, to name but
a few.[1] Although it is important that non-radiological clinicians
receive appropriate training, the extent to which this occurs varies
Assessing and comparing chest radiograph interpretation in
the Department of Internal Medicine at the University of the
Witwatersrand medical school, according to seniority
R G Dreyer,1 MB ChB ; C M van der Merwe,2 MB ChB, MMed (Rad D), FC Rad Diag (SA);
M A Nicolaou,3 MB BCh, MMed (Rad D), FC Rad Diag (SA); G A Richards,4 MB BCh, PhD, FCP (SA), FRCP
1 Department of Radiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2 WESP Radiology, George, South Africa
3 Van Rensburg and Partners and Honorary Lecturer, Department of Radiology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg,
South Africa
4 Emeritus Professor of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: R G Dreyer (reinhardtdreyer@gmail.com)
Study synopsis
What the study adds. is study tested the diagnostic accuracy with regard to common pathologies present on chest X ray by doctors rotating
through, or stationed at the internal medicine department at an academic hospital.
Implications of the ndings. Interpretation of chest X-rays was generally poor but the study did nd that this improves with experience
and condence in diagnostic ability. ese ndings are signicant in that they indicate a need to implement improved teaching programs in
radiological interpretation, especially at an undergraduate level.
AJTCCM VOL. 29 NO. 1 2023 13
RESEARCH
widely. Overall, medical students in South Africa (SA) receive little
formal training in radiology, but despite this, it is expected that all
doctors should be able to interpret a chest radiograph.[2] Junior doctors
(interns, medical ocers and junior registrars) are responsible for
most on-site, aer-hours duties, where correct interpretation may be
critical to further management. Incorrectly interpreted lms can have
signicant adverse consequences, which as well as incorrect diagnoses
include over-diagnosis with performance of unnecessary expensive
investigations. ese negative outcomes can have disastrous eects
for the patient, as well as for the clinician’s career.[3]
The admission regulations to the Fellowship of the College
of Physicians of South Africa (FCP) state under the section on
management of patients that the candidate ought ‘to select and, where
needed, perform appropriate investigations and initiate appropriate
treatment based on best available evidence’.[4] is is relevant, in that
the portfolio of procedures to be mastered before admission as a Fellow
of the College of Physicians also does not specify the interpretation
of radiographs, even though specialist physicians are expected to
interpret them as part of their day-to-day practice.[5]
In addition to pre- and postgraduation training, clinical experience
plays a vital role in the ability to interpret radiographs. However, other
factors such as condence in one’s ability, the viewing environment and
access to appropriate clinical information also play a role.[6,7] A study
performed in the USA, dating as far back as 1993, found that 25% of
all radiological procedures were performed by non-radiologists.[8]
is included two-thirds of ultrasound scans, half of interventional
radiological procedures, including angiography, and 15- 16% of
general radiology. e remainder of the 25% was made up of computed
tomography and magnetic resonance imaging.
In an ideal world where staffing and funding are not limited,
all radiological investigations should be reported by a radiologist,
especially in the acute care setting, as their interpretation is more
accurate than that of emergency department physicians, and subtle
radiological abnormalities are less likely to be missed.[9,10] However,
even in a developed country such as Japan, an increase of 2.5 times
their current number of radiologists (an extra 8612radiologists) would
be required to provide quality healthcare and reporting.[11] In contrast,
SA is a developing country with limited resources,including limited
access to specialist radiologists and pulmonologists able to review every
chest radiograph performed, particularly aer hours. In SA, selective
reporting policies are oen implemented even by bigger health centres
where more radiologists are available, as is the case for the academic
hospitals aliated to the University of the Witwatersrand’s Faculty of
Health Sciences. Selective reporting is the process by which the clinician
decides which plain films they need assistance with and requests
reporting by a radiologist. is is an ecient method to reduce the
reporting workload without compromising patient care.[12]
Previous international studies have shown that interpretation of chest
radiographs is generally poor, but does improve with level of training
and condence in interpretation.[13-15]
e objective of the present study was to assess the variation in chest
radiograph interpretation in the Department of Internal Medicine at the
University of the Witwatersrand and to identify contributing factors.
Methods
A cross-sectional, prospective study was conducted at Chris Hani
Baragwanath Academic Hospital (CHBAH), which has ~3 400 beds,
in Johannesburg, Gauteng Province.
e study population included all levels of doctors (interns, medical
ocers, registrars and consultants) currently rotating through the
Department of Internal Medicine. All the subjects participated
voluntarily and provided informed consent. ere were no consent
refusals, but illegible answer sheets were excluded.
Fifteen chest radiographs that depicted conditions commonly
encountered in SA were selected from Radiopaedia (radiopaedia.
org). ese diagnoses were conrmed by the radiologists who had
submitted them to Radiopaedia, and also by an independent SA
radiologist, to ascertain whether they were fair and representative.
e chest radiographs were printed on photographic-grade paper
and placed in an image atlas, a copy of which was given to each
candidate. e chest radiographs used are listed in Table1, and can
be viewed on a supplementary le available online (https://www.
samedical.org/le/1971).
A questionnaire recording epidemiological information on the
participants and including data such as postgraduation year in
categories (0 - 5, 6 - 10 and >10 years), position held in the internal
medicine department and confidence in interpretation of chest
radiographs was handed to each participant along with the image
atlas, during either departmental or radiological meetings. After
completing the questionnaire, they were asked to provide a diagnosis
for each radiograph. If they were unable to give a diagnosis, they could
describe the ndings. No time frame was allocated to complete the
questionnaire, and no half marks were allocated. Full marks, i.e. 1, was
given for the correct diagnosis, and 0 for an incorrect diagnosis. If no
diagnosis was given but all the radiological features were described, a
full mark was given. If partial ndings or a diagnosis that would also
have led to the correct management were given (e.g. if a diagnosis of
‘pulmonary oedema’ was given for the radiograph showing congestive
cardiac failure), a mark was allocated. If the wrong side or the wrong
lobe was described, the participant scored zero, but where they did
not specify the side or lobe, but the diagnosis was correct (e.g. ‘lobar
pneumonia’ instead of right middle lobe pneumonia), they scored a
full mark.
Table1. Chest radiographs and diagnoses
Chest radiograph Diagnosis
1 Congestive cardiac failure
2 Pneumothorax
3 Right upper lobe atelectasis
4 Right pleural eusion
5 Right middle lobe pneumonia
6 Hyperination
7 Le lower lobe atelectasis
8 Misplaced central venous catheter
9 Le upper lobe mass
10 Right main bronchus intubation
11 Normal
12 Bronchiectasis
13 Cannonball lesions/lung metastasis
14 Pulmonary tuberculosis
15 Widened mediastinum
AJTCCM VOL. 29 NO. 1 2023 14
RESEARCH
Statistical analysis
Data from the questionnaires were captured
electronically by the researcher (RGD)
in Excel version 2301 (Microsoft, USA).
A correct interpretation of an image was
coded as 1 and if incorrect it was coded
as
0. Any further analysis was performed by
a statistician using SAS version 9.4 (SAS,
USA). A total score for each participant was
calculated by adding the scores obtained for all
15 images. Apercentage for each participant
was calculated by dividing the total score by
the number of images and multiplying by 100.
Descriptive statistics, namely frequencies and
percentages, were calculated for categorical
data, and means and standard deviations were
calculated for numerical data. The Shapiro-
Wilk test was used to investigate whether
numerical data followed a normal distribution.
Analytical statistics, namely the χ
2
test, was used
to compare percentages in dierent groups, the
independent t-test was used to compare mean
values in two different groups, and analysis
of variance (ANOVA) was used to compare
mean values in three or more dierent groups.
Asignicance level (α) of 0.05 was used.
Ethical considerations
An application for full ethical approval
was made to the Human Research Ethics
Committee (Medical) of the University of the
Witwatersrand, and ethics consent was received
on 10 December 2021 (ref. no. M210707).
Written informed consent was obtained
from all individual participants involved in the
study.
Results
There were a total of 82 participants in the
study, of whom 56.1% were in the 0 - 5 years,
24.4% in the 6 - 10 years and 19.5% in the >10
years postgraduation categories. Consultants
comprised 17.1% of the sample, registrars
37.8%, medical officers 12.2% and interns
32.4%. With regard to participants’ level of
condence in their ability to interpret chest
radiographs, 57.3% were not confident, but
the remainder were. In the 0 - 5 years category
26.1% were confident, in the 6 - 10 years
category 55.0% were condent, and in the >10
years category 75.0% were condent (p=0.001
between all groups).
With regard to designation, 71.4% of
consultants, 51.6% of registrars, 30.0% of medical
ocers and 22.2% of interns felt condent of their
ability to interpret chest radiographs (p=0.012).
e percentage of correct answers obtained for
the 15 chest radiographs for the entire cohort
was as follows: radiograph 1, 31.71%; radiograph
2, 15.9%; radiograph 3, 46.3%; radiograph 4,
64.6%; radiograph 5, 42.7%; radiograph 6,
48.8%; radiograph 7, 3.7%; radiograph 8, 1.2%;
radiograph 9, 45.1%; radiograph 10, 24.4%;
radiograph 11, 22.0%; radiograph 12, 22.0%;
radiograph 13, 89.0%; radiograph 14, 25.6%;
and radiograph 15, 41.5%.
e lowest score for the entire study was
1/15 and the highest 12/15 (80%), with one
participant scoring the former and two
thelatter, equating to 1.2% and 2.4% of the
study population, respectively. e majority
of the candidates scored between 4/15 and
7/15 (Fig.1). emean total score was 35.0%
for the entire study.
According to the Shapiro-Wilk test for normality,
the distribution of the total scores followed
a normal distribution (W=0.974; p=0.0918),
and consequently the mean and standard
deviation were reported. Fig.2 shows mean
total percentages obtained according to years
of experience (p<0.0001 as per the ANOVA),
which demonstrated that years of experience
signicantly improved interpretation.
Mean percentages obtained according
to designation were as follows: consultants
50.5%, registrars 40.9%, medical officers
36.4%, and interns 19.5%. Fig.3 illustrates the
individual radiographs identied correctly by
each designation.
Participants who were condent obtained a
mean score of 39.4%, v. 31.6% for those who
were not (p=0.045).
20
18
16
14
12
10
8
6
4
2
0
Participants, %
Score
0 1 2 3 4 5 6 7 8 9 10 12
Fig.1. Frequency distribution of the scores (N=82).
60
50
40
30
20
10
0
Mean score, %
0 - 5
27
6 - 10
43
>10
48
Years of experience
Fig.2. Mean scores according to number of years of experience (N=82)
AJTCCM VOL. 29 NO. 1 2023 15
RESEARCH
Discussion
Our study took place at a single academic
institution, which was similar to a study by
Eisen etal.[13] in which a number of radiographs
requiring emergency interventions were
included. ese diagnoses were missed more
often than not, with pneumothorax being
misdiagnosed 95% of the time. e participants
also struggled to interpret the normal chest
radiograph, even though they had been told
that one or more might be normal, unlike
in the present study, where the participants
were not informed that a normal lm might
be included. Condence and seniority were
shown to have a positive impact on the
accuracy of diagnosis, with worse performance
by medical students, interns and registrars.[13]
Mehdipoor et al.[14] compared general
practitioners and nal-year medical students
and found that overall interpretation was
poor, with no dierence noted between the
groups. ey also stressed the need for more
training. In a study similar to ours performed
in the UK by Satia etal.,[15] the researchers also
found improved interpretation with seniority,
and concluded that specialist registrars and
consultants should review all cases.
The four chest radiographs that were
misinterpreted most frequently in the present
study were images of a misplaced central
venous catheter, le lower lobe atelectasis, a
pneumothorax, and the normal lm. With
the exception of the le lower lobe atelectasis,
there was no signicant dierence between
designations as to the correct diagnosis given
for these.
Two of the chest radiographs could have
represented radiological emergencies or
immediately correctable pathologies, namely
the pneumothorax (Fig.4) and the misplaced
central venous catheter (Fig.5). e former
was mostly answered as hyperinflation,
chronic obstructive pulmonary disease or
a normal film, and whereas the latter had
multiple catheters and other findings that
some participants identified, almost all
of them failed to identify the misplaced
catheter. Another correctable pathology that
was frequently missed by interns, medical
ocers and registrars was that of a right main
bronchus intubation (Fig.6).
Although the right-sided pneumothorax
(Fig.4) was relatively subtle compared with
the contralateral side, it can be seen that
there are no clear peripheral lung markings,
especially in upper zones. is emphasises
the importance of comparing sides. Several
participants, especially the consultants and
the registrars, thought that the lung fields
in the normal radiograph were oligaemic,
and some consequently considered that it
might represent a pulmonary embolism.
Although the image is slightly overexposed,
it is nevertheless normal. e independent
radiologist who reviewed the lms felt that it
was fair to use this image, as technical factors
such as overexposure are common problems
faced daily when assessing printed plain lms
at the bedside.
Although the diagnosis given for chest
radiograph 14 was given as pulmonary
tuberculosis (Fig.7), it is recognised that these
ndings could be due to other conditions.
However, in the SA context these changes
are classic for pulmonary tuberculosis, and
furthermore no other appropriate alternative
diagnoses were given. Some of the juniors,
however, did think that this might be miliary
tuberculosis.
Plain lms remain a key tool in day-to-day
clinical practice, and probably will be for the
foreseeable future. As can be seen in our small
study, diagnostic accuracy does improve with
seniority; however, overall it remains poor.
Accordingly, the group that performed the
worst were the medical interns, which is a
reection of inadequate radiological teaching
at undergraduate level. All the pathologies
that were demonstrated should form part of
a core curriculum for nal-year students. e
study did not categorise the results according
to the university from which the participants
graduated, but it seems that it is a country-
wide problem that while some training is
oered by the various radiology departments,
it is generally insucient and there is a lack of
emphasis on its importance.
Although informal training is provided
by academic hospitals, there is no clear
formal training programme or assessment of
radiological interpretation, as stipulated by
the Colleges of Medicine of South Africa as a
requirement for the FCP (SA).[4] Interpersonal
variability was noted in the same groups,
Interns Registrars Medical ocers Consultants
0% 50% 100% 150% 200% 2500% 300% 350%
Bronchiectasis
Cannonball lesions/lung metastasis
Congestive cardiac failure
Hyperination
Left lower lobe atelectasis
Left upper lobe mass
Misplaced central venous catheter
Normal
Right pleural eusion
Pneumothorax
Pulmonary tuberculosis
Right main bronchus intubation
Right middle lobe pneumonia
Right upper lobe atelectasis
Widened mediastinum
Mean score
Fig.3. Frequency distribution of the cases identied correctly by designation (N=82).
AJTCCM VOL. 29 NO. 1 2023 16
RESEARCH
probably related to self-study, or to having a specific interest in
pulmonology or radiology, but this was not investigated.
SA is a resource-limited country in terms of both equipment and
sta. A number of regional and district hospitals have X-ray facilities
and radiographers, but no radiologists or specialist pulmonologists to
review the chest radiographs. e deciency in training will therefore
aect future service provision, as many interns will go on to become
community service medical ocers or general practitioners, and some
registrars may do sessional or outreach work in these more peripheral
hospitals.
ere are two possible solutions to the current deciency:[13] (i) all
lms could be reported by a radiologist or reviewed by a pulmonologist;
or (ii) interpretative skills could be improved. e former remains
unrealistic in our setting, particularly in the smaller, more peripheral
and rural centres. Teleradiology may represent a solution, but again
resources in terms of access to quality computer technology are scarce,
and the shortage of radiologists would be a limiting factor.
Fig. 6. Right main bronchus intubation (Radswiki T. Misplaced
endotracheal tube. Case study, Radiopaedia.org. https://doi.
org/10.53347/rID-11634).
Fig.7. Pulmonary tuberculosis (Yonso M. Pulmonary tuberculosis. Case
study, Radiopaedia.org. https://doi.org/10.53347/rID-96212).
Fig.4. Pneumothorax (Bickle I. Pneumothorax. Case study, Radiopaedia.
org. https://doi.org/10.53347/rID-56429).
Fig.5. Misplaced central venous catheter (Basiony M. Central venous
catheter inserted into le subclavian vein. Case study, Radiopaedia.org.
https://doi.org/10.53347/rID-74441).
AJTCCM VOL. 29 NO. 1 2023 17
RESEARCH
Training still represents the most reasonable objective. is is achievable
only by implementing more robust, goal-directed radiological training
programmes at SA universities for undergraduate students, as well
as for medical ocers and internal medicine registrars in training.
Such programmes have been shown to improve chest radiograph
interpretation dramatically.[13,16,17] Other studies indicate that
improved interpretation may possibly be achieved by using a picture
archiving and communication system (PACS) rather than plain lms,
owing to better resolution and the ability to modify the images by
altering the grey scale to reduce the eect of technical factors such as
incorrect exposure. Although the larger, metropolitan and academic
centres in SA do have PACS, it is unlikely that the smaller, district and
rural hospitals would have the budgets to incorporate this, given our
resource constraints.
ere are some limitations to this study. No histories or clinical
information were provided to the participants, and this may well
have improved interpretation if it had been available.[13,18,19] The
images were printed on paper, which although it was photographic
grade, will always result in some loss of resolution. The images
chosen were, however, classic examples of the pathology depicted,
and both the primary investigator and the independent radiologist
felt that use of paper images would be fair. e consultant group may
have been slightly skewed, as some were from subspecialties such as
rheumatology or haematology that do not have as much exposure to
chest radiograph interpretation as the pulmonologists and the general
ward sta would have.
Conclusion
Although improved chest radiograph interpretation was noted with
increasing seniority, overall interpretation was poor. e practical
implications of this situation are that service delivery across all
hospitals will be compromised. It is imperative that radiological
training is improved at all levels, but especially at an undergraduate
and intern level.
Declaration. GAR is a member of the editorial board. The research for
this study was done in partial fulfilment of the requirements for RGD’s
MMed (Diagnostic Radiology) degree at the University of the
Witwatersrand.
Acknowledgements. The authors acknowledge the Division of Radiology
and Internal Medicine, CHBAH and University of the Witwatersrand. We
further acknowledge Mrs M Viljoen, who conducted the statistical analysis,
and Radiopaedia as a platform for supplying us with the images used.
Author contributions. RGD was the main author and was responsible
for the idea, the protocol, data collection and compilation of the article.
GAR was the principal supervisor and assisted with project design, review,
analysis and editorial review. CMvdM made conceptual and editorial
contributions. MAN made conceptual and editorial contributions.
Funding.None.
Conicts of interest.None.
1. Kanne J, oongsuwan N, Stern E. Common errors and pitfalls in interpretation of the
adult chest radiograph. Clin Pulm Med 2005;12(2):97-114. https://doi.org/10.1097/01.
cpm.0000156704.33941.e2
2. Mehrotra P, Bosemani V, Cox J. Do radiologists still need to report chest x rays?
Postgrad Med J 2009;85(1005):339-341. https://doi.org/10.1136/pgmj.2007.066712
3. Pfeifer M. Nonradiologists reading radiographs: Good medicine or stretching the
scope of practice? J Cardiothorac Vasc Anesth 2001;15(6):675-676. https://doi.
org/10.1053/jcan.2001.29021
4. Colleges of Medicine of South Africa. Regulations for admission to the Fellowship of
the College of Physicians of South Africa FCP(SA). March 2019. https://www.cmsa.
co.za/view_exam.aspx?QualicationID=28 (accessed 1 February 2021).
5. Colleges of Medicine of South Africa. Portfolio of learning: Fellowship of the College
of Physicians of South Africa FCP(SA). 2021. https://www.cmsa.co.za/view_exam.
aspx?QualicationID=28 (accessed 1 February 2021).
6. Mayhue F, Rust D, Aldag J, Jenkins A, Ruthman J. Accuracy of interpretations of
emergency department radiographs: Eect of condence levels. Ann Emerg Med
1989;18(8):826-830. https://doi.org/10.1016/s0196-0644(89)80205-7
7. Potchen EJ, Cooper TG, Sierra AE, et al. Measuring performance in chest
radiography. Radiology 2000;217(2):456-459. https://doi.org/10.1148/
radiology.217.2.r00nv14456
8. Sunshine J, Bansal S, Evens R. Radiology performed by nonradiologists in the
United States: Who does what? AJR Am J Roentgenol 1993;161(2):419-429. https://
doi.org/10.2214/ajr.161.2.8333388
9. Gatt M. Chest radiographs in the emergency department: Is the radiologist
really necessary? Postgrad Med J 2003;79(930):214-217. https://doi.org/10.1136/
pmj.79.930.214
10. Eng J, Mysko W, Weller G, et al. Interpretation of emergency department
radiographs. AJR Am J Roentgenol 2000;175(5):1233-1238. https://doi.org/10.2214/
ajr.175.5.1751233
11. Nakajima Y, Yamada K, Imamura K, Kobayashi K. Radiologist supply and workload:
International comparison – Working Group of Japanese College of Radiology.
Radiat Med 2008;26(8):455-465. https://doi.org/10.1007/s11604-008-0259-2
12. Benger J, Lyburn I. What is the effect of reporting all emergency department
radiographs? Emerg Med J 2003;20(1):40-43. https://doi.org/10.1136/emj.20.1.40
13. Eisen L, Berger J, Hegde A, Schneider R. Competency in chest radiography: A
comparison of medical students, residents and fellows. Chest 2005;128(4):343S.
https://doi.org/10.1378/chest.128.4_meetingabstracts.343s-a
14. Mehdipoor G, Salmani F, Arjmand Shabestari A. Survey of practitioners’
competency for diagnosis of acute diseases manifest on chest X-ray. BMC Med
Imaging 2017;17(1):49. https://doi.org/10.1186/s12880-017-0222-8
15. Satia I, Bashagha S, Bibi A, Ahmed R, Mellor S, Zaman F. Assessing the accuracy
and certainty in interpreting chest X-rays in the medical division. Clin Med
2013;13(4):349-352. https://doi.org/10.7861/clinmedicine.13-4-349
16. Dawes T, Vowler S, Allen C, Dixon A. Training improves medical student
performance in image interpretation. Br J Radiol 2004;77(921):775-776. https://
doi.org/10.1259/bjr/66388556
17. Maleck M, Fischer M, Kammer B, etal. Do computers teach better? A media
comparison study for case-based teaching in radiology. Radiographics
2001;21(4):1025-1032. https://doi.org/10.1148/radiographics.21.4.g01jl26799
18. Schreiber M. e clinical history as a factor in roentgenogram interpretation. JAMA
1963;185(5):399. https://doi.org/10.1001/jama.1963.03060050077027
19. Loy C, Irwig L. Accuracy of diagnostic tests read with and without clinical
information. JAMA 2004;292(13):1602-1609. https://doi.org/10.1001/
jama.292.13.1602
Accepted 17 January 2023.
