Creating Teaching Files

1. What is the educational purpose of this case? (Default: Classic presentation, diagnostic pitfall, rare entity, or technique demonstration)
2. What modality and body region? (Default: Identify — CT chest, MRI brain, US thyroid, etc.)
3. Is there pathologic or surgical confirmation? (Default: Strongly preferred — document source)
4. Has the case been de-identified per HIPAA? (Default: Required before any sharing — verify removal of all 18 identifiers)
5. What is the target audience? (Default: Radiology residents — specify if fellows, technologists, referring clinicians, or CME)
6. What teaching-file system will this be published to? (Default: Institutional PACS teaching folder, MIRC, Radiopaedia, institutional LMS)
7. Is patient consent required for publication? (Default: De-identified cases generally exempt per HIPAA; check institutional IRB policy)

Documents to Request

• Imaging study with key images identified
• Complete radiology report
• Clinical history, presentation, and outcome
• Pathology/surgical report for confirmation
• Relevant laboratory data
• Follow-up imaging (if demonstrates disease evolution)
• Institutional HIPAA de-identification policy
• MIRC metadata template (if publishing to MIRC-compliant system)

Step 1: Case Selection Criteria

What Makes a Good Teaching Case?

Case Categories to Build a Comprehensive Collection

Step 2: Image Selection and Annotation

Key Image Selection Rules

1. Include the finding — at least one image clearly demonstrating the primary finding
2. Include context — surrounding anatomy to localize the finding
3. Include multiple planes — axial, coronal, sagittal when cross-sectional
4. Include comparison — normal side for paired structures; prior study for interval change
5. Include all relevant sequences/phases — DWI + ADC for stroke; arterial + venous for liver mass
6. Include pathology correlation — gross specimen or histology when available

Annotation Standards

Annotation Tools

• PACS annotation tools (arrows, text, measurements)
• Dedicated teaching-file software (MIRC, Pacsbin)
• Presentation software (PowerPoint, Keynote) for formatted case layout
• Open-source tools (3D Slicer, OHIF viewer) for advanced annotations

Step 3: Clinical Correlation and Case Write-Up

Teaching File Case Structure

1. Clinical Presentation

• Patient age range and sex (not exact age — de-identification)
• Chief complaint and relevant history
• Relevant physical exam findings
• Pertinent laboratory values
• Clinical question prompting the imaging study

2. Imaging Findings

• Modality, technique, and relevant protocol
• Systematic description of findings (as if writing the report)
• Annotated key images with findings highlighted
• Differential diagnosis (ranked by likelihood)

3. Diagnosis

• Final diagnosis with supporting evidence
• Pathology/surgical correlation (if available)
• How the diagnosis was confirmed

4. Discussion

• Disease background: etiology, epidemiology, pathophysiology
• Imaging features: classic and variant appearances across modalities
• Differential diagnosis discussion: how to distinguish from mimics
• Classification systems applied (BI-RADS, LI-RADS, etc.)
• Management implications based on imaging findings
• Relevant literature citations (key references, not exhaustive)

5. Teaching Points

• 3–5 key takeaways in bullet-point format
• Common pitfalls and how to avoid them
• Board-relevant pearls
• Links to related cases in the collection

Step 4: HIPAA De-Identification

18 HIPAA Identifiers That Must Be Removed

De-Identification Methods

• DICOM anonymization tools: CTP (Clinical Trial Processor), DicomCleaner, PACS built-in tools
• Burned-in pixel data: Must be removed or obscured; DICOM header cleaning alone is insufficient
• 3D facial reconstructions: Must be defaced or excluded — facial CT/MRI 3D reconstructions can identify patients
• Verification: Review every exported image for residual identifiers before publishing

Step 5: Publication and Metadata

MIRC/RSNA Teaching File Metadata

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the diagnosis confirmed by pathology, surgery, or strong clinical-imaging correlation?
2. Is the case fully de-identified per HIPAA (all 18 identifiers removed)?
3. Are images annotated with clear, consistent labels and arrows?
4. Does the discussion provide educational value with differential diagnosis and teaching points?
5. Is the case metadata complete for searchability?

Quality Audit

• Case meets selection criteria (diagnostic certainty, image quality, educational value)
• All 18 HIPAA identifiers are removed from images and metadata
• Burned-in pixel PHI is removed or obscured
• 3D facial reconstructions are defaced or excluded
• Key images clearly demonstrate the primary finding
• Images include appropriate window/level settings
• Annotations are consistent, clear, and correctly placed
• Clinical history is included (de-identified)
• Pathology or surgical confirmation is documented
• Differential diagnosis is discussed with distinguishing features
• Teaching points include 3–5 actionable takeaways
• Metadata is complete (title, keywords, anatomy, pathology, modality)
• Case is categorized within the teaching-file taxonomy
• Institutional IRB/compliance approval is obtained if required

Guidelines

1. Prioritize pathology-confirmed cases — a beautiful teaching case without diagnostic confirmation is unreliable for education.
2. De-identify thoroughly before any sharing — a single residual identifier is a HIPAA violation regardless of the educational value of the case.
3. Write teaching points as actionable clinical rules, not abstract facts — "Always check the posterior malleolus on ankle radiographs" is more educational than "Posterior malleolus fractures can occur."
4. Use RadLex terminology for keywords and metadata to ensure interoperability across teaching-file systems and maximize searchability.
5. Include the differential diagnosis in every teaching file — board exams and clinical practice require distinguishing entities from their mimics.
6. Build the teaching-file collection systematically to cover the ABR Core Exam curriculum — identify gaps in the collection and actively seek cases to fill them.
7. Review and update teaching files periodically — outdated classification systems or management recommendations reduce educational value.
8. Consider multi-case series for complex topics (e.g., LI-RADS scoring across all categories, Bosniak classification with examples of each class) rather than isolated single cases.