In the decade since the introduction of the European Society of Radiology (ESR) undergraduate curriculum, undergraduate radiology education has evolved with the modernization of medical curricula as well as teaching practices [7] and ongoing efforts at harmonization. The current ESR survey follows previous ESR surveys (published and unpublished) and has highlighted the following. With the exception of a small minority of countries where there appears to be a lack of dedicated undergraduate radiology teaching (< 5% of respondents), radiology is an established part of undergraduate medical education, across all years of medical school. In total, 93% of respondents indicated that radiology education is based on a curriculum, which is essential to delivery of quality education, and is an improvement from a decade ago. In total, 75% of respondents also highlighted this was a national curriculum, which is higher than the 50% of a prior unpublished ESR survey in 2020.

There is greater involvement of radiologists in delivering undergraduate teaching compared to a decade ago, with 98% reporting that this is delivered by radiologists, alongside clinicians and scientists. This is important for students in terms of deeper insights from radiology, and for the clinical speciality of radiology, greater visibility. There is also diversity in teaching methods including the incorporation of online active and blended learning approaches and simulations, in part propelled by the need for alternative means of delivering education during the COVID pandemic [8]. Simulations involve a variety of patient model and computer-based programs mimicking real-world situations. Virtual reality provides an immersive experience, e.g., of anatomical dissection and interventional procedures.

These evolving teaching approaches have been shown to improve medical students' performance, satisfaction and engagement [9]. There also remains a strong trend for placements in radiology departments, and an opportunity to undertake research projects, and even research degrees, reported by 60% and 37% of respondents, respectively, which provides more in-depth exposure to advances in radiology. In particular, the opportunity to undertake a research degree has increased from 17% in the prior unpublished 2020 ESR survey, highlighting the efforts of university-affiliated radiologists to improve the prospect of medical students becoming interested in clinical radiology as a career specialty.

The survey also highlighted there is still heterogeneity in terms of the delivery of radiology teaching, and teaching hours (or number of credits) dedicated to radiology, ranging from 10 to 500 h in this survey reflecting ongoing differences in curricula type (conventional, problem based or hybrid medical curricula). However, even at the upper limit of the range of teaching hours, this is well below 5% of total available undergraduate teaching hours. There remains a paucity of data on the optimal number of teaching hours in order to develop sufficient radiological competencies, but more work is needed by the ESR education committee, toward defining minimal requirements and benchmarking of teaching hours. Even in European countries with well-established national radiological curricula, studies have shown that radiology teaching hours only represent a small fraction of the undergraduate teaching [10]. Previous studies have highlighted lack of time within the curriculum and resistance from other departments as barriers for change [11]. Further progress is also needed into provision of frameworks for delivery of radiological education given new learning tools [8]. For example, Collaborative Online International Learning (COIL) is an approach that may provide opportunities globally for intercultural radiology learning.

In terms of attracting medical students into radiology, in this survey 54% of radiology is still taught as a standalone subject. While this reflects conventional medical school curricula, facilitates content management and evaluation of competencies from the educator’s perspective and provides an overview of radiology to medical students, it has long been recognized that an integrated approach to radiology education is more effective [12]; students are more motivated and engaged when direct clinical utility is evident [13, 14]. Earlier exposure of medical students to clinical radiology improves their understanding of the imaging tests that they will order as young doctors, as well as communication with patients and their patient’s experience [15]. Early exposure may well increase their interest in undertaking a radiology elective, undertaking radiology research and eventually specializing in radiology [16]; though one study has found no association between teaching hours in radiology and medical student career choices [17].

One might question the usefulness of the ESR undergraduate curriculum given the use of national and local curricula in the majority of respondents. However, it is important for the ESR to provide a template upon which national and local curricula can be based, and it is reassuring that components of the curriculum are implemented in respondents’ respective institutions or countries (increasing from 58% in the previous unpublished 2020 survey to 67% currently), and provides a framework for radiologists undertaking undergraduate teaching. For countries where there is no such process, the ESR curriculum remains a valuable resource. On the other end of the spectrum, some respondents indicated that the ESR curriculum was too comprehensive for undergraduate teaching, hence why this was not implemented in their institution/country. The ESR undergraduate curriculum was intended to be inclusive with core as well as more advanced aspects that would be more suited for students with a special interest in radiology to provide a continuum for learning.

There are a number of limitations to this survey. First, the survey was completed by ESR members rather than individual European medical schools, which will present a selection bias. Future surveys should address this bias. Second, not all European countries were represented in the survey including lack of respondents from France, Portugal and Poland. Third, response bias is typical in survey-based studies. Data were not obtained from a stratified sample that considered specific institutional or country characteristics, and the reliability of certain responses may be questioned. However, the distribution of the survey was supervised by ESR and included membership of the education committee and national societies. Fourth, this survey has only included a limited number of questions to ensure a good response rate and comparability to prior surveys. Some aspects of radiology teaching may not have been captured through free text options were available to respondents to provide further comments. Evaluation was also not a focus of the current survey.

In conclusion, over the last decade there have been greater engagements of radiologists in the delivery of radiology education within medical schools in European countries affiliated to the ESR. Despite efforts toward harmonization, there is still ongoing variation within and across countries in education delivery. Moving forward, updated ESR guidance on minimum teaching hours for radiological competency, a framework for effective delivery of teaching that includes novel methods, and more outcome data are needed for future benchmarking.