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2007 ACR Diagnostic Radiology In-Training Exam Rationales
Section VIII General Competency
162. As the prevalence of disease increases in a population, the sensitivity of a
diagnostic test:
A. increases.
B. decreases.
C. is unchanged.
D. depends on the number of patients tested.
RATIONALES:
C. Correct. The sensitivity of a diagnostic test describes the test’s ability to
detect disease in a population with the disease of interest. It is independent of
prevalence, which describes the fraction of the population has the disease of
interest.
163. As the prevalence of disease increases in a population, the positive
predictive value of a diagnostic test:
A. increases.
B. decreases.
C. is unchanged.
D. depends on the number of patients tested.
RATIONALES:
A. Correct. Positive predictive value refers to the probability that a patient with a
positive test result has the disease of interest. As the prevalence of disease
increases, the more likely that a patient with a positive test result has the disease
of interest.

164. The accuracy of interpretation of pre-operative chest radiographs in a
Radiology Department is 98%. Which of the following statements is TRUE?
A. The interpretive skills of the department radiologists are of high quality.
B. The departmental imaging protocols are of high quality.
C. The diagnostic training of residents in the department is of high quality.
D. No meaningful inference can be made from the above statement.
RATIONALES:
D. Correct. Accuracy is defined as the total number of examinations with true
positive and true negative test results, out of the entire number of examinations
performed, and is influenced by both sensitivity and specificity. Without knowing
the sensitivity and specificity of the diagnostic test, no meaningful inference can
be made about the accuracy of the test.
For example, if you had 100 chest x-rays, two of which demonstrated a lung
cancer, but all 100 were read as negative, the sensitivity would be 0% (0 of 2),
the specificity would be 100% (98 of 98), and the accuracy would be 98%
Accuracy = TP + TN = 0 + 98 = 98%
TP + FN + TN +FP 0 + 2 + 98 + 0
165. A study reports that a diagnostic test has a positive predictive value of 90%.
What additional information is needed to determine whether a similar positive
predictive value can be achieved in your clinical practice?
A. Test sensitivity
B. Test specificity
C. Test accuracy
D. Disease prevalence
RATIONALES:
D. Correct. Positive predictive value increases with disease prevalence. If the
disease prevalence in your patient population is significantly lower than in the
study population, the same positive predictive value cannot be achieved

166. What is the best ethical argument for full medical disclosure when patients
have medical complications, which may have resulted from a physician’s mistake
or judgment?
A. To resolve patient concerns regarding the unknown etiology of a medical
problem
B. To avoid disciplinary action from the department chairperson
C. To avoid retribution from angry patients or their family members
D. To meet the requirements of the hospital/practice risk-management committee
RATIONALES:
A. Correct. “It is a fundamental ethical requirement that a physician should at all
times deal honestly and openly with patients…Situations occasionally occur in
which a patient suffers significant medical complications that may have resulted
from the physician’s mistake or judgment. In these situations, the physician is
ethically required to inform the patient of all of the facts necessary to ensure
understanding of what has occurred.” While it may be prudent to inform a
department chairperson and risk management committee/appointee of such
information, this is not an ethical requirement of the physician. While honest
communication with patient and family member often decreases legal liability,
this is not an ethical requirement of the physician.
References:
www.acr.org Education portal, Nonclinical Skills Webcast, Module 5: Ethics
section 8.12 “Patient Information,” AMA Council on Ethical and Judicial Affairs,
Code of Medical Ethics, Current Opinions, 1998

167. An ethical commitment or motivation is defined as the:
A. desire to comply with an ethical standard of care.
B. ability to weigh competing values and motives and commit to a course of
action.
C. ability to interpret the situation and perceive that one is an ethical “agent”
responsible for the welfare of others.
D. ability to formulate an ethically ideal course of action and to articulate a well-
formed line of reasoning for the position taken.
RATIONALES (This Test Item Was Not Scored)
A. While the desire to “comply with the ethical standard of care” may be
admirable it is not the definition of ethical commitment/motivation.
B. Ethical commitment/motivation is defined as “ability to weigh competing
values and motives and to commit to what one will actually do; incorporates
professional identity or role”.
C. Ethical sensitivity is defined as “ability to interpret the situation and perceive
that one is an ethical ‘agent’ capable of and responsible for impacting the welfare
of others; incorporates identification of ethical issues”.
D. Ethical reasoning is defined as “ability to formulate an ethically ideal course of
action, to articulate a well-formed ‘justification’ or line of reasoning for the ethical
position taken”.

168. The principles of medical ethics adopted by the American Medical
Association (AMA) standards of conduct state that a physician shall:
A. be obligated to provide care for all patients who seek it.
B. be board eligible or certified in a specialty or disclose otherwise to patients.
C. support access to medical care for all people.
D. only participate in research for which approval has been granted from
institutional IRB.
RATIONALES:
A. Incorrect. The sixth principle of medical ethics adopted by the American
Medical Association states “a physician shall, in the provision of appropriate
patient care, except in emergencies, be free to choose whom to serve, with
whom to associate, and the environment in which to provide medical care”.
B. Incorrect. The Principles of medical ethics adopted by the American Medical
Association do not address board eligibility/certification or disclosure of such
information. The fifth principle states “a physician shall continue to study, apply,
and advance scientific knowledge, maintain a commitment to medical education,
make relevant information available to patients, colleagues, and the public,
obtain consultation, and use the talents of other health professionals when
indicated”.
C. Correct. The nineteenth principle of medical ethics adopted by the American
Medical Association is “a physician shall support access to medical care for all
people”.
D. Incorrect. The Principles of medical ethics adopted by the American Medical
Association do not directly address research. However, the second principle states “a
physician shall uphold the standards of professional interactions…”. The third principle
states “a physician shall respect the law and also recognize a responsibility to seek
changes in those requirements which are contrary to the best interests of the patient”.
References:
www.acr.org Education portal, Nonclinical Skills Webcast, Module 5: Ethics

169. Which of the following statements accurately reflects the American College
of Radiology Code of Ethics?
A. The determination of whether or not to participate in quality assurance and
utilization review is based on the discretion of the radiologist.
B. With regard to expert medical testimony, members may accept compensation
contingent upon the outcome of litigation.
C. Prior to practicing in a hospital or other health-care entity, a radiologist must
be board eligible or board certified.
D. Members should not enter into an agreement that prohibits the provision of
medically necessary care or that requires care at below acceptable standards.
RATIONALES:
A. Incorrect. The Rules of Ethics from the ACR Code of Ethics state “…A
radiologist who regularly interprets radiographs and other images should
reasonably participate in quality assurance, utilization review and other matters
of policy that affect the quality of patient care…”.
B. Incorrect.The Rules of Ethics from the ACR Code of Ethics state “In providing
expert medical testimony, members should exercise extreme caution to ensure
that the testimony provided is non-partisan, scientifically correct, and clinically
accurate. The radiologist or radiation oncologist shall not accept compensation
that is contingent upon the outcome of litigation”.
C. Incorrect. The Rules of Ethics from the ACR Code of Ethics state “Prior to
practicing in a hospital or other health care entity, a radiologist or radiation
oncologist shall apply, and be accepted, as a member of that entity’s medical
staff in accordance with the medical staff’s bylaws and in the same manner as all
other physicians”.
D. Correct. The Rules of Ethics from the ACR Code of Ethics state “Members should
not enter into an agreement that prohibits the provision of medically necessary care or
that requires care at below acceptable standards. Notwithstanding policies of a health
plan, radiologists should advocate cost-effective appropriate studies or therapies that
will benefit the patient, whose welfare is paramount”.
References:
www.acr.org, business practice issues, ethics, ACR Code of Ethics

170. Which of the following statements accurately describes the American
College of Radiology Code of Ethics?
A. It is a framework by which radiologists may determine the propriety of conduct
in their relationship with patients, the public, colleagues, and members of allied
professions.
B. It is a set of laws that govern the methods by which radiology is practiced in
the United States.
C. It is composed of principles of ethics with no disciplinary procedures.
D. It should be used as a set of guidelines for evaluating a radiologist’s eligibility
for state licensure.
RATIONALES:
A. Correct. The Code of Ethics of the ACR states, “The Code of Ethics of the
American College of Radiology is intended to aid the radiology community,
individually and collectively, in maintaining a high level of ethical conduct. The
code is not a set of laws but rather a framework by which radiologists may
determine the propriety of conduct in their relationship with patients, with the
public, with colleagues, and with members of allied professions.” The ACR Code
of Ethics is composed of three sections, which include: Principles of Ethics,
Rules of Ethics, and Disciplinary Procedures for Violation of Rules of Ethics. The
ACR Code of Ethics is not intended to be used as criteria for a radiologist’s
eligibility for state licensure.
References:
www.acr.org, business practice issues, ethics, ACR Code of Ethics

171. Which of the following is TRUE concerning the American College of
Radiology practice guidelines on patient care and breast ultrasound?
A. An appropriate indication for breast ultrasonography is radiation therapy
planning.
B. Breast ultrasonography should be performed by a board-certified radiologist
only.
C. Breast ultrasonography may be performed by a radiation technologist when
the attending physician is present.
D. Breast ultrasonography may be performed with a real-time scanner that
operates at a center frequency of at least 5 MHz.
RATIONALES:
A. Correct. ACR Practice Guideline for Performing and Interpreting Diagnostic
Ultrasound Examination states “Physicians who perform and/or interpret
diagnostic ultrasound examinations should be licensed medical practitioners who
have a thorough understanding of the indications for ultrasound examinations as
well as a familiarity with the basic physical principles and limitations of the
technology of ultrasound imaging.” Regarding studies performed by a diagnostic
medical sonographer, it states “When a sonographer performs the examination,
that person should be qualified by appropriate training to do so. This qualification
can be demonstrated by certification or eligibility for same by a nationally
recognized certifying body.” Therefore, distractors B and C are incorrect. ACR
Guideline for the Performance of a Breast Ultrasound Examination states,
“Breast ultrasound should be performed with a high-resolution and real-time
linear array scanner operating at a center frequency of at least 7 MHz…”
Therefore, answer D is incorrect. Per ACR Practice guidelines, “appropriate
indications for breast sonography include: 1. Identification and characterization
of palpable and nonpalpable abnormalities and further evaluation of clinical and
mammographic findings. 2. Guidance of interventional procedures. 3. Evaluation
of problems associated with breast implants. 4. Treatment planning for radiation
therapy.”
References:
www.acr.org, Quality and Safety, Guidelines/Standards, Ultrasound, ACR
Practice Guideline for Performing and Interpreting Diagnostic Ultrasound
Examinations, ACR Practice Guideline for the Performance of a Breast
Ultrasound Examination

172. Which of the following is TRUE concerning the American College of
Radiology Practice Guidelines on patient care and pelvic ultrasound?
A. The endometrium does not need to be evaluated in asymptomatic
postmenopausal women.
B. A transrectal or transperineal approach is useful in patients who cannot
tolerate a vaginal probe.
C. Transabdominal and transvaginal imaging must both be performed as
patient’s initial evaluation at a hospital or health care facility.
D. No recommendations specific to an examination performed by male physician
or sonographer.
RATIONALES:
B. Correct. ACR Practice Guidelines for the Performance of Pelvic Ultrasound
state “…The endometrium should be analyzed for thickness, focal abnormality,
and the presence of fluid or mass in the endometrial cavity. Assessment of the
endometrium should allow for variations expected with phases of the menstrual
cycle and with hormonal supplementation. If the endometrial stripe is difficult to
image or ill-defined, a comment should be added to the report.” Therefore,
answer A is incorrect. While initial evaluation with both transabdominal and
transvaginal approach is ideal, this is not a requirement of the ACR Practice
Guidelines. The ACR Practice Guidelines state “All relevant structures should be
identified by the transabdominal or transvaginal approach. In many cases, both
will be needed…” Therefore C is incorrect. The ACR Practice Guidelines state
“When possible, a female member of the physician or hospital’s staff should be
present as a chaperone in the examining room if a male is performing the
examination.” Therefore, answer D is incorrect. The ACR Practice Guidelines
Specifications of the Examination state “…A Transrectal or transperineal
approach is useful in patients who cannot tolerate a vaginal probe (e.g. virgins,
postmenopausal women).” Therefore, answer B is correct.
References:
www.acr.org, Quality and Safety, Guidelines/Standards, Ultrasound, ACR
Practice Guideline for the Performance of Pelvic Ultrasound in Females

173. In the US, the background radiation is approximately 3.6 mSv (360 mrem)
per year. Which among the following contributes the MOST towards background
radiation?
A. Man-made radiation
B. Radon exposure
C. Cosmic radiation
D. Terrestrial radiation
RATIONALES:
A. Incorrect. Man-made radiation includes medical x-rays, nuclear medicine
procedures and others; however it contributes only 18% of the background
radiation.
B. Correct. Radon exposure accounts for nearly 55% and it arises from earth
crust.
C. Incorrect. It accounts to only 8% of the background radiation
D. Incorrect. It accounts to only 8% of the background radiation
References:
The Essential Physics of Medical Imaging, 2nd edition. J.T. Bushberg, J.A.
Seibert, E.M. Leidholdt, and J.M. Boone, Lippincott Williams & Wilkins (2002),
Chap 23, p 748.

174. Which of the tissue is the least sensitive to damage from ionizing radiation?
A. Breast tissue
B. Skin
C. GI tract
D. Gonads
RATIONALES:
A. Incorrect. Breast tissues are highly sensitive to ionizing radiation.
B. Correct. Among the tissues listed, skin is the least sensitive to damage. The
radiation damage to skin is mostly due to deterministic effect. The skin damage
occurs only if the skin receives greater than certain threshold dose (2 Gy) which
can results from prolonged fluoroscopy exposure.
C. Incorrect. GI tract are highly sensitive to ionizing radiation and is next only to
gonadal tissues in terms of sensitivity.
D. Incorrect. Gonads are the most sensitive tissues to damage from ionizing radiation
References:
Radiology Review - Radiologic Physics. Nickoloff EL & Ahmad N, Chapter 15.

175. According to HIPAA, the privacy rule gives patients the right to:
A. refuse treatment by a health-care provider.
B. refuse release of protected health information (PHI) to Health & Human
Services when it is undertaking a compliance investigation or review of
enforcement action.
C. request disclosure of PHI for a spouse, parent, or child who is older than 18
years of age without requiring consent of said party.
D. request that PHI in their records be corrected or changed.
RATIONALES:
D. Correct. A covered entity MUST disclose PHI (protected health information) in
only two situations: a. to individuals (or their personal representatives)
specifically when they request access to, or an accounting of disclosures of, their
PHI; and b. to HHS (Health & Human Service) when it is undertaking a
compliance investigation or review or enforcement action. Therefore, answer B is
incorrect. The Privacy rule does not allow disclosure of PHI of a patient, aged 18
years or older, to a family member without the patient’s consent. Answer A is
incorrect. The Privacy rule gives patients the right to: have their PHI protected,
inspect and copy their records, request that PHI in their records be corrected or
changed, ask for limits on how their PHI is used or shared, ask that they be
contacted such as at work and not at home, and get a list of disclosures made of
their PHI. The Privacy rule does not specifically address treatment issues or the
right to refuse treatment. The Privacy rule sets “national standards for the
protection of health information, as applied to the three types of covered entities:
health plans, health care clearinghouses, and health care providers who conduct
certain health care transactions electronically.” Therefore, answer A is incorrect.
References: United States Department of Health & Human Services OCR
Privacy summary www.hhs.gov/ocr/hipaa
University of Michigan Health Systems HIPAA Learning Module
www.med.umich.edu/hipaa

176. Concerning HIPAA, which of the following information is considered part of
the Protected Health Information (PHI)?
A. First names of patient’s children
B. Photograph of extremity
C. Name of employer
D. Patient’s e-mail address
RATIONALES:
Protected Health Information (PHI) includes “individually identifiable health
information” and “information that identifies the individual or for which there is a
reasonable basis to believe can be used to identify the individual”. The first
names of a patient’s children cannot be used to reliably identify a patient.
Therefore, answer A is incorrect. A full face photograph is considered part of
Protected Health Information (PHI). However, a photograph of an extremity
cannot reasonably be used to identify an individual. Therefore, a photograph of
an extremity is not part of PHI. Answer B is incorrect. The name of a patient’s
employer is not part of PHI. Answer C is incorrect. The patient’s e-mail address
can be used to identify an individual. E-mal address is part of PHI. Answer D is
correct.
References: United States Department of Health & Human Services OCR
Privacy summary www.hhs.gov/ocr/hipaa
University of Michigan Health Systems HIPAA Learning Module
www.med.umich.edu/hipaa

177. The American College of Radiology Practice Guidelines for patient care
and stereotactic breast biopsy state that:
A. a radiopaque marker or clip must be placed at the time of biopsy.
B. physicians participating in stereotactic biopsy of the breast should obtain 3
hours of Category 1 CMEs in stereotactically guided biopsy of the breast every 3
years.
C. the referring physician is responsible for obtaining the results of cytopathologic
or histopathologic sampling.
D. no specific requirements are required for the radiologic technologist
participating in stereotactic biopsy of the breast.
RATIONALES:
B. Correct. While many radiologists place a radiopaque marker/clip at the time of
stereotactic breast biopsy, this is not a requirement per the ACR Practice
guidelines. The ACR Practice guidelines do state that the physician’s report of
the procedure should include “clip placement, if performed”. Therefore, answer A
is incorrect.
The ACR Practice guidelines state “…Initially, 3 hours of Category 1 CME
didactic instruction in stereotactically guided biopsy and performance of at least
three stereotactic breast biopsy procedures under the supervision of a qualified
physician. Completion of a residency or fellowship program that includes
instruction in stereotactic breast needle procedures is also acceptable…The
physician should obtain 3 hours of Category 1 CME in stereotactically guided
breast biopsy every 3 years…”. Answer B is correct.
The ACR Practice guidelines state “…physician who performs the procedure is
responsible for obtaining the results of the cytopathologic or histopathologic
sampling to determine if the lesion has been adequately biopsied. These results
should be communicated to the referring physician and/or to the patient…”.
Therefore, answer C is incorrect.
The ACR Practice guidelines state the radiologic technologist participating in
stereotactic biopsy must have “…Initially, 3 hours of Category A continuing
education units in stereotactically guided biopsy, plus documentation of five
hands-on procedures under the guidance of a qualified technologist and/or the
manufacturer’s application specialist. For maintenance of competence,
participation in at least 12 stereotactically guided biopsies per year is
recommended…”. Therefore, answer D is incorrect.
References: www.acr.org, Quality and Safety, Guidelines/Standards, Breast
Imaging and Intervention, ACR Practice Guideline for the Performance of
Stereotactically Guided Breast Interventional Procedures

178. Using the following graph of test performance, which of the following
statements is CORRECT?
A. A positive test more reliably rules in the diagnosis than a negative test rules
out the diagnosis.
B. A negative test more reliably rules out the diagnosis than a positive test rules
in the diagnosis.
C. Test performance is dependent on the underlying population.
D. Test performance can not be determined from the information provided.
RATIONALES:
A. Correct. When a test has a very high sensitivity, a negative result effectively rules
out the diagnosis (SnNout). When a test has a very high specificity, a positive result
effectively rules in the diagnosis (SpPin).
References: Evidence-Based Medicine. Eds: Sackett et al. 2000. Churchill
Livingstone.

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