My journey from a three week medical student placement in radiology to publishing Chest X-rays for Medical Students book.
Now my second book Abdominal X-rays for Medical Students is finally published, I thought it would be interesting to look back at how it all started. Here is my experience of the process of creating and publishing a teaching resource, in this case my first book Chest X-rays for Medical Students.
It started in October 2008 when I was a medical student at the University of Leicester. I applied for a three week placement in dermatology (yeah... crazy I know!), didn't get it, and ended up with my second choice placement in radiology.
Now, during my clinical rotations I had difficulty presenting chest radiographs. I found basic tasks tricky, for example describing the normal anatomy accurately, recognising a tension pneumothorax or pointing out the level of a pleural effusion. Teaching was often inconsistent and given by doctors with varying levels of experience leading to confusion and in some cases inaccurate teaching. Furthermore there were no specific learning objectives from my medical school concerning chest x-rays and popular books at the time didn't contain many images, often not displaying pathology clearly.
After the first day of the radiology placement I had the idea that I could use my time in the department constructively to create a chest x-ray radiology teaching resource aimed at students. I told my supervising consultant Dr Tony Dux who was supportive of the idea.
The first step was to come up with clear aims and objectives. This was extremely important as the scope for this sort of teaching resource can quickly spiral out of control when boundaries are not set early! I didn't write them all down (some were in my head, others on paper), but I stuck to them from day one.
My aims were to teach medical students:
- a basic understanding of the principles of chest radiology.
- a system to use for analysing and presenting chest radiographs.
- how to recognise basic signs and pathology on a chest radiograph.
- the radiological signs and patterns associated with common medical conditions as seen on a chest radiograph.
I also had some personal aims which were to improve my knowledge of chest radiology, improve my written communication/teaching skills and collect together a large number of stock radiograph images, covering a range of clinical conditions, which could be used for teaching.
To get a list of objectives I decided to write down all the pathologies and signs I thought students should be able to recognise by the time they finished medical school, the standard being that required to function effectively as a Foundation Year 1 (FY1) doctor. On the second day of the placement I brought my list to Dr Dux (consultant radiologist) and together we came up with 35 specific learning objectives.
I was clear that I wanted to make a teaching rather than a revision guide. I decided to use Microsoft Word to make an A4 colour workbook that could be printed or easily converted to a PDF (Portable Document Format) for uploading online. My thought process was that this would make it easier for others to update when there were changes to the medical school curriculum. I specifically decided not to create a primary web based resource, because this would make it unnecessarily difficult and expensive for students to print out.
Looking back, I have no idea where I got the energy to write this but I started the process by creating headings for each of the learning objectives (consolidation, air bronchogram etc). As images were central to the book (it was a picture book after all) I obtained and annotated them first and it was only after the images were finished that I wrote about the topic in question.
Obtaining the images (radiographs)
The main problem I encountered was obtaining radiographs. I needed a large number of images showing different pathological signs, in a format that I could store on my PC and then edit. Thankfully, I discovered that it was relatively easy to save the images from the hospital's computer based Picture Archiving and Communication System (PACS) so I worked with radiologists to obtain images by attending ‘hot reporting’ sessions. This was fantastic because not only did I manage to get hold of lots of examples of different pathology, but I also received excellent teaching. I took my camera (a Canon 400D digital SLR) and tripod into the hospital and photographed over 60 old films that one of the consultants had collected over the years for teaching purposes. This way I was able to get examples of some of the rarer conditions. I systematically labelled and edited all of the images to remove any patient details and to improve contrast, brightness and exposure.
Annotating the images (radiographs)
Arguably the most important aspects of the workbook were the images and annotations. I used Adobe Photoshop to clearly colour and enhance the pathology or sign I wanted people to appreciate. Different colours were used to represent the different pathologies in the hope that this made it easier to remember for some students. I spent much of my second week of the placement marking and colouring radiographs. Many, for example pneumothorax, were easy to annotate as the abnormalities had clear borders on the radiograph.
An example of the way I presented the radiographs. Both are identical, however the right radiograph shows the pathology marked in colour. This makes it easier to see the abnormality (in this case a right pneumothorax)
Some signs and pathologies were much more difficult to appreciate and I found myself asking people how they would want the pathology shown in order to make it easy for them to see it. I experimented with many different enhancement techniques until I found one that worked. The result of this was that I have ended up using a range of different techniques to show or enhance some of the more tricky radiographs, as illustrated in the example below.
Septal lines illustrated using zoomed in sections of radiograph, arrows and magnifying glasses
A new systematic approach
We developed a simple 'ABCDE' approach to reading x-rays inspired by the well known resuscitation guidelines. This provided a structure to the book with which to order and present the content. I tried to avoid “information overload” by refining the content to an absolute minimum, while ensuring any new terms are fully explained.
By the end of the three week placement I had a collection of 125 radiographs, many of which were duplicated and annotated, and I had compiled a 70 page teaching workbook.
In December 2008 the medical school started producing an interactive version of my workbook for PC using Adobe Flash. The project was never completed, however an early version was displayed for her Majesty the Queen to see when she opened the David Wilson Library at the University of Leicester later that year. I was honoured that they used my radiology teaching resource to show her an example of chest x-ray teaching.
Screenshots from the interactive PC version of Chest X-rays for Medical Students made using Abobe Flash. This project was never completed.
A few months later the workbook had increased to 105 pages and was almost complete.
At this point I met with Dr Dux again, and together we went through the book, looking for errors and making sure that all the content was relevant to students. I also visited the Head of Medical Education at the medical school to request some feedback. Both were pleased with the book and agreed to let me trial sections of the workbook to a selection of second year medical students currently studying the respiratory module.
I split the book into 4 parts, printed 5 copies of each and gave them to 20 students with an attached feedback sheet to complete. I received 16 responses in total and the feedback was invaluable. Most comments were positive, however a few students identified better ways to annotate images, typos and other errors I had missed. After making more changes I organised a focus group with 6 students to go through the book and images in more detail. We met in the university library and spent a few hours discussing the best ways to present the material. Many said that it was amazing how clearly the x-rays showed the sign or pathology of interest and much of this was thanks to the prior feedback I received. I cannot over emphasise the importance of feedback when developing a teaching resource! The workbook was now complete and the medical school agreed to print copies for all students starting clinical rotations.
Chest X-rays for Medical Students workbook in 2009
I was pleased with what I'd achieved in 6 months and was ready to move on to another project...
That was until the medical school advised me that before printing copies for the students, I should first consider publishing the workbook. I haden't thought about publishing before this point, however it sounded like a great idea, especially as I had already done most of the hard work. It was a step into the unknown and I didn't know what to do so I simply picked a well known publisher (Wiley-Blackwell ) and went to their website.
On the publishers website I found a book proposal form. It seemed simple enough to complete so I answered all the questions and returned it with some sample pages attached.
My book proposal to the publishers
After a few weeks I received an email from the Senior Commissioning Editor for Medical Education at Wiley-Blackwell saying he was interested in the proposal. We got in contact and discussed the book. The editor wanted me to add some self-assessment questions and raised the possability of exending the series to include abdominal and musculoskeletal x-rays. There were few other changes and we agreed on a rough timescale for the publication. I was then informed that the editor would submit a proposal to the publications committee in March 2010 for approval.
In March 2010 Chest X-rays for Medical Students was accepted for publishing! A few emails later and we had agreed on a timescale and contracts were sent out and signed. The whole process of getting a book accepted took months, however in a way this was actually the easiest step, especially as I had already completed most of the content!
I very quickly realised that there was a lot more work to do in a very short time. I was put in contact with the in-house Development Editor at the publishers who was now my main point of contact. She helped me with many issues regarding formating and image quality. There are some things I didn't consider when publishing such as having to convert the images to a format suitable for printing (CMYK). This took ages, but in some cases I found changing the format drastically altered the colour so I had to make corrections to allow for this.
I also needed more radiograph examples for the book and finding these in the limited time available was a nightmare! I emailed many consultants, friends and colleagues, and went around the radiology department sticking up lists of x-rays I needed. The manuscript submission deadline had to be extended by a month and a half, but finally I got the radiographs and submitted the manuscript on a CD and via Dropbox.
This next phase was exciting! I was put in touch with the Production Editor whose job was to oversee of the manuscript until it was sent to press, and in particular maintain the production schedule. Now that the book was in production, I was told material could not be added or removed unless factually inaccurate or legally necessary (although I bent these rules a few times!).
The first stage of production was copy editing. The manuscript was sent to the copy editor to improve the formatting, style and accuracy of the text, and ensure consistency. I had to become pretty e-mail savy as there were many emails sent back and forth with queries that needed answering. A couple of examples included:
- The overview of chest x-ray pathologies page was very similar to the contents page, so I was asked if the overview could be removed.
- My chapter titles were all capatalised, however usually in the UK the style for chapter titles is to put them in sentence case, so this was changed.
I was also sent a set of scatter proofs which was a printout of all images used in the book. These proofs were essential because they allowed me to see more clearly how images would appear in print. I found 10-20 images that needed changing as the colours were not vibrant enough.
Typesetting and cover design
The second stage of production was typesetting. This was a fairly quick process and involved formatting the text, font and figures. I started receiving sample chapters and design layouts for the various sections of the book. It was now starting to look very professional. I was surprised at just how much input I had into the design and appearance of the book. All of my suggestions and changes were implemented and I felt I had a level of control over the appearance of the finished product.
Developmemt of the book cover from left to right: 1. My original design for the workbook, 2. Initial design by the publishers, 3. My suggested changes to the publishers design, 4. The final design
The development of the cover design demonstrates that the relationship with the publisher was very much a 2-way process. I liked the title style in the publishers design, however I did not like the purple colour or choice of radiographs for the cover. I suggested some other colours and changed some of the radiographs displayed on the front. The publisher implemented many of these changes to get the final red design.
Once the sample designs were approved the typesetting team got to work producing proofs of the whole book and a few weeks later PDF (electronic) proofs were available.
The book was not professionally proofread and it was my responsibility to read the text and check the figures. I had to download PDF files of the proofs and annotate them using Adobe software. I was given 21 days to do this. I sent the proofs to Dr Dux, my parents and a friend to check. It was painstaking work going through everything again with a fine tooth comb, however there were a few typos, changes to the wording I didn't agree with and formating issues we picked up. After returning the corrections, a set of revised PDFs were produced and sent back to the publishers in June 2011. It was at about this time that an indexer produced the index (I didn't have to do that thank goodness!).
I actually had little contact with the marketing side of things. The publishers had their own global marketing team and business connections so I did not have to worry about, for example, putting the book on Amazon . This was all done automatically. I did however want to set up a Facebook presence for the book so I created a page in April 2011. This proved to be very popular and after posting updates on the progress of the book, sample pages and example x-rays, by the end of 2013 it had over 30,000 likes! The Facebook page can be found at www.facebook.com/chestxrays .
Visit the official Facebook page
Well it was now August 2011, almost 3 years since I started the project and the book was finally going to print! The files were sent to the printer along with the scatter proofs that myself and the publishers had approved.
Unfortunately when the publishers reviewed the print quality the x-rays had a red tinge making some of the colours appear faded. Thankfully the Senior Commissioning Editor and Development Editor asked the printers to reprint the book and ensure the colour was correct, to make it look as good as possible. As the printing company was in Malaysia, it meant a further 2 month delay, however the most important thing for me was that the images looked great so I wasn't bothered one bit!
In October 2011 I received the first copy of my book.
First copy of Chest X-rays for Medical Students
Book on the cover of the Wiley-Blackwell Medical Education 2011 catalogue
This has been the most exciting and rewarding project I have attempted so far. I learned how to read a chest radiograph, improved my knowledge of radiology, my communication and teaching skills, and felt much more confident presenting a chest radiograph on the ward. I have learned some of the techniques used in communicating and presenting written information, and appreciate some of the difficulties encountered when creating a large learning resource. I feel that I have genuinely contributed to the education of my colleagues.
Since 2011 I have entered clinical radiology training and in October 2014 I became a Fellow of the Royal College of Radiologists.
Lessons I have learnt over the last few years:
- The best time to start making a resource is when you need it yourself as you are perfectly placed to gauge the level of understanding and needs of the target audience. However, remember to seek help from an experienced consultant.
- It takes a lot of time and effort to collect clinical material so start early!
- Don't give up on a good idea. Try to see it through.
View the book online
This article was written by Dr Christopher Clarke, an ST5 Clinical Radiology Trainee at Nottingham University Hospitals at time of publishing. If you would like to know more about the publication process or have any questions, please feel free to contact him via the contact us page.
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