Year: 2016

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Taking Oral Radiology Cases- A Lost Art?

oral

The lights go down as the radiologist in front of the classroom prepares the computer for a case presentation. A switch is flicked on. Suddenly, a black and white PowerPoint case begins to shine brightly on the screen in front of you. The radiologist glances about the room looking to see who would be the best fit for this next case. You begin to sweat and fidget with your hands, praying your faculty will not call on you next. The attending’s glance remains fixed upon you. He says, “Tell me about this patient with a 2-year history of a cough!”. You become flustered and unsure what to say.

The scenario above occurs commonly in radiology residencies across the country. However, since the oral exam has disappeared, I have noticed an overall decrease in proficiency in how residents present each radiological case. The art has been lost. You can blame some of it on poor teaching. Decreased time allotted to education may cause some of it. Some of it can relate to the emphasis on the new board examination system. And, perhaps the new radiology residency culture may be responsible for some of the changes.

In whatever case, it is a shame. Taking oral cases is a crucial step to becoming a well-rounded radiologist. You need to relate to your colleagues’ images in a timely, logical manner, no matter what you are looking at. If you want to look like a star, you need to have this process down cold. To enable you to have the tools to get through a radiological case, I will go through the basics, including determining the kind of study, presenting descriptive findings, coming up with a differential diagnosis, and ultimately determining proper management.

What The Bleep Am I Looking At?

Whenever your attending introduces you to a new oral case, the first thing you need to do is determine what you are looking at. Take your time and think about what kind of images you see. You often lose the case discussion even before you have begun because you never identify the correct study. Is it an ultrasound, CT scan, MRI, x-ray, or nuclear medicine study? Is the examination performed with or without contrast? During what phase?

For nuclear medicine studies in particular, if you can identify the study before going through the case, you have already completed 80 percent of the heavy lifting. You have already isolated the differential diagnosis if you can identify the radiopharmaceutical. If you are not sure, you should start describing the physiological distribution of activity to determine the type of study. Often the act of defining the distribution helps the resident to understand the kind of study.

Also, scan the images for any identifying information. If it is an ultrasound, it will often tell you which organ you are looking at. I have found it can become difficult to tell the testes, ovaries, and kidneys apart on a single image. Usually, the ultrasound technologist labels these studies so you can differentiate among the options.

Finally, make sure to look at the top of the film to see if you can find the patient’s age and sex. This information can also further help you to hone in upon the correct differential diagnosis.

Describing The Findings

This part of the oral case is when the newer residents fall short compared to residents studying to take the oral boards. Residents tend to stop very quickly at the description part of the puzzle and then enter rapidly into a differential diagnosis. Often, a poor quick description leads to a poor differential diagnosis. Again, you need to take your time to describe all the salient points.

So, what should you include in this part of the case? Always describe the location, the size, the intensity (if nuclear medicine), the shape, the density, and borders. Describe its effect upon adjacent structures. Make sure to use buzzwords if available. If you see an angry-looking mass on a CT scan that looks like a star, you may want to use the words spiculated or stellate. If a lesion enhances with rim nodularity and fills in from the edge to the center, use peripheral nodular enhancement with centripetal filling. These buzzwords connote certain types of differentials in the minds of the radiologist listeners. They provide information on the kind of disease entity even before going through a differential diagnosis.

Finally, don’t get happy eye syndrome. Look for other findings that may support or refute your differential diagnosis. I can’t tell you how many times a resident will stare at one section of the film to forget to look at the rest of the images or film. He loses the forest for the trees.

Concise Relevant Differential Diagnoses

A novice and more seasoned resident starkly differ when they give a concise and relevant differential diagnosis. The beginner will have no idea what to say. Or, she will continue to drone on about multiple different possibilities for the final diagnosis. She does not even differentiate between the zebra and the most common diagnosis.

Again, take your time before speaking. Before even starting this process, you should go through broad categories of differential diagnosis in your mind. Is it neoplasm, infection, inflammation, iatrogenic, congenital, etc.? When you have come up mentally with some reasonable possibilities, make sure to talk about no more than three etiologies of the most likely diagnoses. And start with the most feasible and then go down to the least likely. This process will allow you to speak logically. Also, it will enable you to show that you have thought about the differential analytically.

What Next For The Patient?

Three options exist for the further management of the case after you have completed the basics of determining the findings and differential diagnosis. The first possibility: the patient needs no further workup, and you have made a final diagnosis. One example would be an adrenal nodule with a Hounsfield unit of 2. This finding is consistent with an adrenal adenoma—end of story. No further workup is needed.

Alternatively, it may be imperative that you need another step to work up the case. For instance, if you need to determine the matrix of an aggressive osseous lesion on a musculoskeletal MRI without a final diagnosis, make sure to recommend a plain film. Otherwise, you may never determine the final disposition of the patient.

And lastly, you may find a lesion with low clinical significance but needs to be followed over time. This category includes the small lung nodule or the nonaggressive indeterminate liver lesion.

You can almost always categorize your case into one of these three groups. And, it will show that you thought about the ramifications of the imaging upon the clinical picture of the patient.

Final Thoughts: Taking Oral Cases Should Be Fun!!

Taking oral imaging cases should not be a difficult or embarrassing process. It should become something that you should look forward to, building your confidence and becoming a better radiologist. It sums up the essential ingredients needed to make an excellent radiologist: the ability to make the findings, synthesize the data, develop an outcome, and communicate the clinician’s results.

Unfortunately, in many programs, the radiologist just expects you to know how to take an oral case despite not having been taught the process. If so, now you have a framework of the fundamentals of how to take a case outlined above. Like anything else, being adept at taking oral cases is simply a matter of practice and knowing the process. Once you have the process down and the base knowledge, you can more easily build upon your abilities and become better and better over time. You, too, can become a star at taking cases!!!

 

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Radiology Residency Night Float Vs. Standard Call- A Perpetual Controversy!!!

night float

Blurry vision setting in; eyelids drooping just wanting to shut; difficulty communicating; and impending malaise. Rarely would I have any chance whatsoever to lay my head down even once. The films would keep on streaming in. These feelings were typical on that first night of call on a 1 or 2 weeknight float rotation block or the occasional Saturday overnight calls that we would have to do every once in a while. I dreaded those days. But, it is still standard for many radiology residency programs. It is almost impossible not to have at least a few overnight shifts like the ones I just described.

At one point or another, many radiology programs and residents have come up with different schedules and options to minimize this extreme fatigue. Some have instituted night float schedules. Others maintain a standard rotating call schedule Q4,5, or 6. Some have long and short call schedules.

The choice to do one system or another is not so clear-cut. Programs have many considerations before deciding to have either of these systems before implementation. Although I tend to favor the night float system since I remember it mitigated fatigue after the initial day or two of calls when taking overnights, the decision to have a night float program is probably unsuitable for all programs.

So what factors would lead one program to have a night float system and another to have a standard call system? Some of the issues we need to address are the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies, and emergency department requests. I will also review each system’s disadvantages and advantages, allowing a program to decide which approach is best.

Factors For Instituting A Night Float Coverage System

 

Size of the Program

The smaller the program is, the less likely there will be adequate coverage for rotations during the daytime, let alone the nighttime. In fact, at many programs, a small residency cohort prevents the institution of a night float system. In a program with three or fewer residents per year, it may not be possible to have a resident out every night to be on call without severely compromising resident education. Also, many programs cannot cover daytime obligations without a night float system.

Attending Coverage

Institutions with attending nighthawk coverage at nighttime allow more flexibility for scheduling of night float. Some programs do not need full-time resident coverage during the nights and may share call obligations with the attending. Therefore, it is significantly easier to institute a night float system for the residency program.

Resident Preferences/Culture

In some residencies, the radiology residents have instituted a night coverage system because of the preferences of the individual residents. Many residents have fully invested in a given scenario. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or fewer calls than they would have in the old system. So, the night coverage system becomes engrained into the fabric of the residency program.

Also, the program director may set up this schedule to accommodate specific residency daytime programs. A nighttime schedule may allow the resident to maximize daytime educational opportunities. For some programs, that may mean either a standard cyclical call schedule, and for other programs, it may mean a night float schedule.

Program Director/Chairman Preferences/Department Culture

In many programs, the leaders may institute nighttime coverage based on their preferences. The program director or chairperson may believe a night float system or standard call schedule may be better for a residency program. Or, perhaps there are coverage requirements that the department desires. In either case, the decision is not up to the residents.

Number of Studies

Perhaps you are in a residency program that is a level 1 trauma center with significant numbers of ER studies at night time. Some programs are so busy that they may need more than one resident or attending on-call each evening. This factor may allow less flexibility in scheduling a night float system since a program may not be able to accommodate the call coverage at nighttime.

Emergency Department Factors

Emergency departments may have specific requirements for radiology coverage at nighttime. Some programs may only want to have senior residents take call. Others specifically want attendings to cover during the evening. Depending upon the demands of the emergency department, this may dictate the numbers, type, and presence of residents or attendings on call. A night float system or standard call system may reflect the whims of the emergency department.

 

Advantages/Disadvantages of Night Float And Standard Call

Night float

Most people think night float coverage for a week or two mitigates fatigue the most. The body tends to get used to the nighttime schedule over time, allowing the resident to function better on call. Sure, the first few days can be challenging because the body and mind have to adjust. But overall, the experience is much improved.

On the other hand, when you are on a night float system, the resident may lose touch with the “educational” aspects of the residency program. You miss daytime lectures, conferences, and attending readouts for long periods. While the time spent on night float is essential for training, receiving all the benefits of daytime resident education is impossible. You may lose out on understanding the context of the images you interpret. Education, in this sense, may also be compromised.

Standard Call

Sometimes a Q4, 5, or 6-day call schedule integrates better with a program than a night float system, allowing the resident a better overall experience. The resident does not miss all the noon conferences and educational experiences they would miss over a long block on a night float.

The two significant disadvantages to the cyclical call schedule are overnight fatigue and the “lost day.” As I mentioned, I always found it much more taxing to have an occasional overnight than a night float block because my body never adjusted to the system, just like most residents. In addition, the resident loses an extra day of residency experience every time they work because they are obligated to have a day off afterward, “the post-call day.” This loss can significantly decrease the educational opportunities for the resident.

 

Residency Call- Night Float or Overnight Calls?

Nighttime call is a crucial facet of every radiologist’s education. Whether or not you have a say in constructing your program’s night coverage system, you now realize that what works for one program may not work for yours. The decision to have one or another method can be complex, but it is important to weigh each of the factors to come up with an outcome. The key is to make the learning opportunity pleasant and mitigate fatigue. Hopefully, your residency has chosen your institution’s most appropriate night coverage system!

 

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I’m a sick radiologist- Should I come to work?

I am confident that most of you, whether a radiology resident or an attending, have felt sick at one time or another. And, most likely, you were unsure about coming to work. Moreover, this decision can become incredibly complex.

Here are some of the issues you probably thought about. Is there adequate coverage? How sick are you? Are you going to be seeing patients for that day? Are you going to be sitting down in isolation for most of the day? Are your reads or your procedures going to be compromised by your illness? What is the group’s culture about taking a sick day? How will it affect your colleagues if you do not show up? Will it prevent you from being promoted? Unfortunately, these difficult questions compound when you cannot think clearly due to illness.

Even more confusing, most of the articles that I have read regarding physicians and sickness are not written directly for the radiologist. Radiologists are a bit different than other hospital or outpatient physicians. Depending upon the day, the rotation, or job description we may or may not have direct patient contact. So, we have to have to think about the question of missing a day of work differently from other physicians.

What about the literature regarding sickness for the general physician? Many articles say not to come to work if you are a sick physician. (1,2) And others are more indeterminate. (3,4) However, the body of research is sparse about whether the ill physician, let alone a radiologist, should come to work. In this post,  I will try to address the most common issues that may sway your decision one way or the other.

Continue reading I’m a sick radiologist- Should I come to work?

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Best Radiology Electives for the Senior Resident

radiology electives

It’s getting toward the end of your 3rd year, and you are studying intensely for your core examination. All of a sudden, you get a phone call from your chief resident. He says, ” We are making the schedule for next year. What would you like to do for your senior year radiology electives?” You realize you haven’t thought this through, and you are not sure what to do. He just assigns you to a standard fourth-year schedule.

Believe it or not, this is a situation that often happens to most residents. Choosing your fourth-year electives is not a decision you should take lightly. You should not have the choice made for you, nor should you choose without thinking deeply about what you want. Your senior year elective decisions can have repercussions upon your comfort zones in private practice. This decision can also influence your practice patterns for years to come. Today, we will discuss what not to do when you decide upon your senior schedule, which standard rotations are the best for senior electives, and finally, some innovative ideas for creating rotations on your fourth-year schedule that will really enhance your residency education and your career.

Which Fourth Year Radiology Electives Should You Avoid?

Don’t Repeat Your Fellowship!

When you create a schedule for your fourth year, I recommend avoiding adding scheduled rotations that duplicate your fellowship. Several times, residents have requested six months in mammography when they have already signed up for a mammography fellowship. What’s the point in that? In most residency programs throughout the country, 90 percent of residents eventually do private practice. And, only 10 percent work in academia. So, chances are you will not be working only within your specialty. In fact, according to many articles (1,2,3), most radiology job descriptions want the new radiologist to not only practice in one subspecialty but also to cover other areas within radiology. So, if you decide to do a half year in your fellowship’s subspecialty, you are also decreasing the opportunity to learn subspecialties outside of your comfort zone. And, you are also reducing your desirability for being hired by a private practice.

For instance, if there are two candidates, one who wants only mammography work and another that feels comfortable reading MSK MRI and being sub-specialized in mammography, which candidate will be chosen by a private practice? It’s relatively simple. It’s almost always the one that can do both. You are missing out on a potential opportunity if you choose to duplicate your fellowship.

Avoid What You Already Know

I would also avoid choosing fellowships that are within your comfort zone. If you feel like you know MSK MRI well, it doesn’t make sense to do half the senior year in the same subspecialty. In private practice, you generally do not want to pigeonhole yourself into only a few areas of a subspecialty. A series of fourth-year electives or “mini-fellowships” in only subspecialties that you are well-versed in will limit your ability to learn other subjects and ultimately prevent you from being comfortable in these modalities after you complete a residency.

The Conventional Fourth Year Elective Approach

If you are going down the conventional route of fourth-year electives, there are two routes I would choose. First, it would be reasonable to select an emphasis in an area that you are interested but in which you are not doing your fellowship. Since you will be completing these electives reasonably close in time to looking for full-time radiologist work, you will have a second area of subspecialty confidence and diversify your competencies when looking for a job.

Second, I would choose electives in areas of weakness. Residency is the time to get to know the different subspecialties and get your hands dirty. The more competent you are in all aspects of radiology, the more desirable you will be for private practices. It behooves the budding radiologist to get to the point of basic competency in as many areas as possible.

The Unconventional Fourth Year Elective Choice

What is the difference between a good and a great radiologist? It’s pretty simple. A good radiologist can generally make the correct imaging calls. A great radiologist can make the right call, understand the call’s deep clinical significance, and predict the subsequent patient outcomes. If I had to redo my residency again, I would choose the unconventional radiology elective approach.  Why? Because correlating imaging with the practical deepens these great clinical radiology qualities.

So, how do you arrange an elective choice such as this? It definitely will take a bit more work on the part of the radiology resident, and you will have to go out of your way to communicate with other specialty directors. Still, it pays to arrange a few weeks or a month rotating on a medical or surgical rotation with correlative imaging.

Example Of The Unconventional Elective Choice

For example, if you are interested in musculoskeletal radiology, I would highly recommend calling the surgical director of orthopedics and ask him/her if you can watch and participate in the clinical workup of patients, orthopedic surgeries, and the subsequent follow-up of patients. Then, when you work up a patient with a medial meniscal tear, you will have seen the surgery and the after-care follow-up of these patients. You will understand how the imaging fits into the equation and the significance of your imaging calls. The learning that you achieve will stick with you for the rest of your radiology career.

I would also recommend washing, rinsing, and repeating. If you can arrange this elective in multiple subspecialties, in whatever specialty area interests you, it would be a highly effective way to have a tremendous diverse overall fourth-year experience that will last a lifetime. Also, you will have clinical knowledge of the imaged patient that most other radiologists do not have.

Final Thoughts About Fourth Year Radiology Electives

The fourth year of radiology residency is a time to explore in more depth the subspecialties that you have encountered during your first three years. Because you are so close to becoming a board-certified practicing radiologist, fourth-year radiology electives take on a vital significance where the learned subjects will make a difference in your clinical practice. So, please pay attention to creating a tremendous fourth-year elective experience. Don’t squander the opportunity!!!

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Hiring Radiology Physician Extenders- Helpful for Residents?

physician extenders

Many radiology practices throughout the country are understaffed and overworked. But, it is not just the attending radiologist that can suffer the consequences of decreased time and increasing workload; it is also the radiology resident. Due to the increased burdens of radiologists, radiology residents may have reduced time to attend conferences. They may also have increased service obligations and less availability to perform procedures. Overall, the psychological stresses of residents to complete the daily work increase every year. One potential solution for the hospital-based radiology practice to improve these conditions is to hire physician extenders. So, I will briefly discuss the types of physician extenders, how programs can utilize them in practice, and finally, how residencies can use physician extenders to improve the residency program.

Types of Physician Extenders

Multiple excellent articles describe the roles of physician extenders. Some of these articles include an Applied Radiology summary called Physician Extenders: Which one is right for you?. Another one is an ACR article called Registered Radiology Assistant/Radiologist Practitioner Assistant. And, then there is a sirweb report called: Position Statement: The Role of Physician Assistants in Interventional Radiology. I highly recommend reading these articles to get the nitty-gritty details of each type of radiology physician extender.

But to summarize, I am going to list the different types and describe each briefly. These include Physician Assistants, Nurse Practitioners, Radiology Practitioner Assistants, and Registered Radiology Assistants. According to the sirweb article, only Physician Assistants and Nurse Practitioners can “order tests, write prescriptions, make diagnoses, and get reimbursed for services performed.” On the other hand, all of these physician extenders, including the Radiology Practitioner Assistants and Registered Radiology Assistants, can perform procedures. So, for a practice that needs more than just procedural help, Radiology Practitioner Assistants and Registered Radiology Assistants may not fit the bill.

How Programs Utilize The Physician Extender?

As I have perused the literature and forums on this topic, I have found that the responsibilities of the Physician Extender to be pretty varied. (1) Most commonly, they tend to work with interventional radiology and help to perform procedures such as Paracentesis, Thoracentesis, and Catheter Placements. But, they can involve themselves in more complex procedures such as Nephrostomy tube placements.

In addition to procedures in many practices, they also take responsibility for preliminarily approving patients for cases, taking patient histories, and getting consents for procedures. And Nurse Practitioners and Physician Assistants can write orders before and after cases. Also, they can create preliminary dictations. In some academic practices, they can even help out with data collection in research studies. So, their practice responsibilities can be beneficial to many different types of educational environments.

Are Physician Extenders Helpful For Residencies?

Do not fear radiology residents. Physician extenders are not here to take over the world!!! For most radiology residencies, the ability of the physician extender to perform such varied work allows the radiology resident and staff to focus on other more critical needed learning issues. These physician extenders are independent but not independent enough to run a department for themselves, so they will never take over the radiologist’s job.

What Can They Do?

At the same time, imagine you are responsible for getting consent during the daytime for all the PICC lines, and for the first time, the practice has introduced a physician extender. Now you can share in the responsibility of obtaining consents. They can write notes on the floors and talk to family members. These activities will allow you and your attendings to concentrate on some of the more advanced work in the department.

In addition, some physician extenders have lots of procedure experience and are excellent teachers. You may have a physician extender who can teach you how to do a PICC line or Portacath when the attending is not directly available. Or, the physician extender can perform procedures such as paracenteses and allow the attending and the resident to take care of other more complicated cases simultaneously.

My Experiences

Although I am not an interventional radiologist, my experiences with physician extenders have also been highly positive. When I was a resident, the practice hired a nurse practitioner, and he helped organize what we called “tube rounds.” It was a time in the morning when we would decide if we needed to pull catheter tubes, keep them in, or recommend other interventions. I learned a lot from both the physician running the “tube rounds” and the nurse practitioner who became adept at taking great clinical histories and understood the patients he followed very well. He also became friendly with many of the clinicians, such as the surgeons and GI doctors. It was a net positive for the medical team and my learning experience. Also, I’m sure he brought in more business for the hospital as well.

Physician Extenders Can Be A Radiologist’s And Residency Program’s Best Friend

In today’s demanding environment, a physician extender can be the right fit for an academic department. The ability of the extender to do procedures, teach, and consult can be a significant benefit for the busy attendings on staff and the residents in the department. Not only can it increase department productivity, but it can significantly increase the morale of the attendings and residents alike. It is a decision that programs and hospitals need to weigh carefully. But for many departments and residency programs, the physician extender brings significant long-term benefits.

(1) J Allied Health. 2015 Winter;44(4):219-24. Radiology Physician Extenders: A Literature Review of the History and Current Roles of Physician Extenders in Medical Imaging.

Sanders VL1, Flanagan J.

 

 

 

 

 

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The Other Struggling Radiology Residents

struggling radiology residents

A radiology residency program is like a family. When one person is afflicted academically or professionally, all of its members suffer down the road. Just as important as it is to be aware of and help the struggling radiology resident, it is also important to remember that one struggling resident can have severe repercussions for the remainder of the radiology residency program. It is not just the program director and chairman that reap the consequences of the struggling resident. Often unfairly, the class members take up much of the additional burden. The result be extra call shifts, less time spent on educational rotations, uncomfortable personality conflicts, or spare time spent educating the failing resident. So, I am dedicating this post to the other radiology residents affected by the struggling radiology resident. First, we will explore how other residents can appropriately identify and help the struggling resident and possibly get this person to the program director’s attention. Then we will go through what a resident should and should not do when a resident is academically or professionally struggling. And finally, we will examine how the residency program should commit its resources toward the struggling resident vs. the other radiology residents.

 

Identification of Struggling Residents by Colleagues

Often, the first residency program members to notice that a resident is struggling are not the program director, chairman, or attendings. Instead, it may be the struggling resident’s colleagues. Fellow residents are more likely to interact with struggling residents socially in a more comfortable setting. Here, the struggling resident is more likely to discuss his/her issues. This interaction is an opportunity to learn more about your classmates’ feelings about residency. They may even ask for your help. My advice is to give your classmate whatever assistance is reasonable so they can perform well. Residency is not a competition; it is a team environment. In addition, the help you give your fellow struggling resident will return to you many times. Whether you decide to teach your colleague or help them out with other residency issues, you will find that you will learn more about your material and yourself. Even better, you may be able to stem a progressive downward spiral to probation. Or, even better, prevent your classmates from suffering more dire consequences.

How To Identify The Resident

Sometimes the identification of the struggling resident is a bit more subtle than a simple comment about their struggles. Unlike an attending that sees a resident on a noon conference or a single day, you, as a fellow resident, may notice a pattern of taking cases and missing all the findings each time or multiple absences not recorded by the program. Or you may see bad habits such as drinking too much, something a little bit off, or a strange affect. These signs can be essential sentinel events. And you may want to address the issue with your program faculty to ensure the struggling resident gets the help they need.

In the end, it pays to identify the struggling resident. Remember, it often affects not just that resident but the entire program.

How Can The Residents Help With The Academically Struggling Resident?

The program directors, attendings, and chairman are primarily responsible for handling the academically struggling radiology residents. But, for the struggling resident’s rehabilitation to succeed, the program often needs to have the participation of all. The role of the other residents can be the key to the stability of the program through this trying time as well as increasing the likelihood that the struggling resident will eventually succeed.

Before any remediation, it is critical to determine if the struggling resident is willing to accept the help of the other program members. So, the role of the other residents can only begin when the struggling resident asks for help from their colleagues. You certainly cannot force a struggling resident to participate in remediation efforts if the struggling resident is unwilling or able.

Interventions To Help Academically

If you remember the previous article- The Struggling Radiology Resident, we discussed how the academically struggling radiology resident might have difficulty coping with the quantity or quality of their work. So, I will briefly review how the other residents should attend to these issues.

What should their colleagues do for a struggling resident who cannot schedule an appropriate time for studying? This dilemma becomes a time management issue. It would be fair to help the struggling resident to create a schedule for themselves. Sometimes it helps to sit down with the struggling resident and show them how you schedule your study time and what you have been reading on each rotation.

For a struggling resident with difficulty with the quality of study time, it would make sense to have group study time and present cases to one another to improve their presentation when reviewing studies. Or, it may be a good idea to go over questions with all the residents to practice testing skills. These processes help the struggling resident and may be good practice for the team.

How Can The Residents Help With The Professionally Struggling Resident?

Regarding a professionally struggling resident, fellow residents must be more careful with assisting in interventions. The intervention will depend on the primary cause of professionalism problems.

The Absent Resident

For the resident that is often absent, it may be possible to address this issue by asking the resident where they have been or why they have not been around in a non-confrontational manner. Sometimes the struggling resident may not be aware of the burden they are placing on the other residents. This interaction may make this resident aware of the issues he is causing and take responsibility for his actions. Again, if this does not work, bringing the matter to the program’s attention may just be as essential.

The Personality Dilemma

You must be more careful with the resident with personality issues, whether an abusive or unengaged resident. If you are friendly with this resident, it may pay to find out the cause of the behavior. But be careful not to be overly intrusive, as getting involved much further may be inappropriate. Indeed, if the struggling resident is amenable to helpful suggestions for conflict resolution within the residency, talk to this person about some of these issues in an appropriate setting. Or, it may be relevant to suggest this resident seek professional help if the resident is amenable.

In many programs, some struggling residents will experience psychiatric issues just like the general population. Or, they may get involved with alcohol or illicit drug use. These situations can be extremely touchy. Many of these residents may not have insight into their problems. And, they are likelier to refuse help from colleagues or attendings. Of course, a few may have an understanding. But, if you notice a struggling resident with one of these issues, it is usually best to bring the issue to the attention of the program director or chairperson of the department so that they can get the resident into the appropriate channels for treatment. Of course, there are exceptions to every rule. And occasionally, the struggling resident’s colleagues may have intimate knowledge of the resident. Therefore, they may be more likely to be able to get the resident appropriate help. But, be careful in this situation because there can occasionally be unforeseen legal and professional ramifications to the caring colleague. A resident without insight into their problems may see this helpful resident as antagonistic and can theoretically pursue these channels.

How to Commit the Program’s Resources

Over my tenure as associate residency director, I have learned that dealing with struggling radiology residents’ issues can drain a program’s administration and resources. The time you usually spend toward improving the residency program instead needs to be placed on the problems of the one resident. Especially in smaller programs with less faculty and monetary resources, the extra time can overwhelm the program directors, chairperson, and heads of Graduate Medical Education. While the struggling resident must get the necessary help and remediation, we have to remember that other residents also need to have a functional residency program. It is easy to forget about the other residents in this process. So, it is the residency director and chairman’s role to place additional efforts to concentrate on not just the struggling resident but the other residents at these times and to ensure the residency program continues running smoothly.

Back To The Other Residents

Every program, at one time or another, will have struggling radiology residents. And fellow resident colleagues need to help out, if possible, with identifying and remedying the struggling resident. But, the other residents often suffer the most from the consequences of a struggling resident’s actions. And the residents can be hurt by the administration’s choices to help the struggling resident. So, everyone involved needs to make a concerted effort not to forget about the struggling resident’s colleagues. Or else, these residents can truly become the “other struggling residents.”

 

 

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Do Caribbean Trained Medical Students Make Better Radiologists?

Before I begin addressing the title question of this article, I think it is essential to provide you with my background. I have gone to an American medical school (Albert Einstein College of Medicine) and have trained at all American institutions throughout my residency and fellowship.  During my time as an associate program director, I have taught mostly American and Caribbean trained medical students. Additionally, we have had a smattering of a few other scattered foreign-trained medical students in our program. Our institution has a connection to St George’s University. Also, a majority of the Caribbean medical graduates that attend our radiology residency come from this institution. So, my training and the mix of students in our program may reflect my biases. Other program directors may have different opinions based upon their own experiences and combination of residents.

In the United States, we think of Caribbean schools as a place for college graduates to go when they cannot get into an American medical school. When I first started working at Saint Barnabas Medical Center back in 2006, if you would have told me the best trainees come from Caribbean medical schools, I would have looked at you funny and said “Really?”.  However, as time went on, my biases have significantly changed. So, what are some measures of the Caribbean versus American resident quality to justify this change in opinion?

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The Struggling Radiology Resident

struggling

In any profession or career, some employees lag the performance of their peers. It turns out that radiology residency is no different from any other job in this respect. The key, however, is that the employer can identify the struggling worker or that the employee can recognize that he or she is struggling. It is only when this process happens that interventions can occur. Also, this process of identification needs to be early and effective. The radiology program’s goal is to help these residents along as soon as possible to allow rapid and more effective remediation. Early remediation can prevent a struggling resident’s further downward spiral that could lead to probation, suspension, or even worse, job loss. On occasion, there is no effective remediation for specific individuals, but that is instead the exception rather than the rule.

No matter how you slice it, the loss of a resident is devastating for both the radiology program and the radiology resident alike. So, my goal for today’s discussion is to help the individual struggling radiology resident and prevent him from going down this pathway. We will discuss how to identify oneself as struggling, what you can do to intervene before more severe repercussions, and how to deal with your attendings and colleagues when you are the “struggling resident.”

Self Identification

As is said, you cannot fix a problem unless you know a problem exists. So, self-identification of oneself as struggling becomes crucial. Some residents know from the very beginning that they are having difficulties and have good insight into their situation. Others may be having challenges but are not aware. Additionally, sometimes the feedback that residents get from attendings, technologists, nurses, and administrators can be different from the truth and outright misleading. Given that radiology residents tend to have limited responsibilities during their first year of residency, this issue is more likely to go unnoticed during this first formative year of residency. So, we will first talk briefly about some indicators that you are struggling during residency.

I will also classify the reasons for the struggling resident as either academic or professional, to simplify and organize the discussion. Let’s first start by discussing some of the indicators that a resident may be struggling in academics.

How to Know If You Are Struggling Academically

Noon Conference and Readouts

Noon conference can be an excellent time to discover your position relative to your colleagues. If you notice that you are unable to answer questions that your colleagues quickly answer consistently, that can be a red flag. If you have a hard time describing or making a finding on studies geared to the first-year resident, you may be struggling. Or, if different attendings become consistently frustrated with your answers while giving the noon conference, you may want to consider that you are having difficulties.

Readouts with your attending may help to determine whether you are struggling. Are you able to answer routine questions appropriately? Is an attending that typically accepts resident dictations re-dictating everything you write? Is your supervisor frustrated with you? Do your attendings provide you with some sense of independence during procedures similar to others in your program? These are some hints that all may not be quite right.

Call

Next, think about your experiences on “buddy call.” Do you feel comfortable going over films with your colleagues, attendings, and other clinicians? Is there a sense of frustration from these people with your reads? Are attendings not satisfied when they find out they are on call with you?

Feedback and Exams

How about feedback and evaluations? Is the feedback you receive from attendings routinely negative. Are milestone evaluations always below par? Do you receive comments from attendings that are uniformly negative?

You might think that the in-service exam or Radexam would also be a useful metric of resident performance. It turns out that as an associate program director, I put much less faith in academic evaluations based upon the in-service examination as a sole means of assessment. I have found a weak correlation with resident academic performance. So as a resident, I would put less stake in this form of self-assessment. However, in combination with the in-service exam, if you are underperforming in other residency-based quizzes or examinations, this can be an indicator of real academic issues.

How to Know If You Are Struggling Professionally

This area can be harder to recognize for a struggling resident. Many don’t realize they have a problem until it’s too late. But, we will go through some examples that you may be able to self-identify.

Absences

Absences, in its many forms, is a leading indicator of professionalism based struggles. Are you routinely late to conferences and readouts, and do you sense the frustration in others? Do your colleagues too often have to cover for you because you are not available? Have you been cited multiple times for missing conferences or required meetings?

Conflicts

Conflicts with classmates and colleagues can be an indicator of professionalism struggles. Are there routine yelling matches with your fellow residents? Do your colleagues not want to help you out with call coverage, studying, or other everyday residency issues? Are you routinely fighting with the secretaries, nurses, technologists, or even attendings?

Substance abuse

Substance abuse is all too common a cause for having a problematic residency. Take a serious look at your habits and if they may be genuinely affecting your performance. Are you routinely using alcohol or other illicit substances?

Organic causes

Chronic disease can be a cause of day to day residency struggles. Cancer, hepatitis, infectious diseases are all problems that can cause fatigue and difficulty with concentrating on a long shift.

And of course, there are psychological issues such as depression, anxiety, schizophrenia, and more. These issues are more likely to go unnoticed by the afflicted resident. But some residents, already diagnosed with these disorders, may have better insight. These residents need to take a hard look and see if these problems are affecting their residency performance.

Self-interventions

The next step in the process is to figure out how to remedy the situation before more significant repercussions. If you know your issues are academic or professional, you can certainly take measures to stem the riptide. We will go through several of these avenues.

You’ve decided that you are struggling academically. What do you do? The next step is taking a realistic assessment of why you are having difficulties. For some people, it may be the quantity, and for others, it may be the quality of their studies.

Quantity of Learning

Having been through the residency process and supervising many residents over the years, I have learned that radiology is a reading-intensive specialty. Moreover, to increase one’s knowledge base, a resident needs to create a means to cover all the essential and relevant topics within the residency program. So, the first question is: on what do you base your study schedule? Some residents will use the curriculum guidelines from their residency program. Others will split the ABR core exam topics into bits of information that they can review. Even others may use STATDx/Radprimer to guide their studying. The bottom line is that you need to find some guidelines that will allow you to cover all the topics that you need to know.

The second question: have you created a schedule that allows you to cover the critical topics during residency. And what are some options for the resident? Many residents don’t realize the amount they need to learn to become a proficient radiologist. A schedule, therefore, becomes very important for the struggling resident. Plans can vary from one person to the next. Some people do better with studying for short blocks of time. Others prefer to slog it out for a long block at once. It doesn’t matter how you complete the necessary work, whether you take 2,3, or 4 topics per evening, but the work needs to get finished. A regimented schedule will allow you to get through the appropriate information for each rotation.

Quality of Learning

The next step is to assess if it is how you are studying, that is the problem. Some residents read for hours every night, only to find that their knowledge base is not to par. You would think that by the time one gets into the radiology specialty, they would have a method for studying well. But, that is indeed not the case for many residents. Studying and reading for the radiology resident is different from studying for medical school classes and the boards. Radiology emphasizes pictures. Medical schools emphasize words.

So, if you are genuinely studying for hours at nighttime without meaningful results, try learning differently. I would recommend emphasizing reading the pictures and captions within a book over the general text. Many residents do not realize they need to do this to be a more effective radiology student.

Pictures/Case Series

You may also want to explore case review series over general text reading. Again pictures are the center of the radiologist’s world. I find that a general text helps more when you have experienced a case firsthand during the daytime and want to find out more. On the other hand, a case image with text is more similar to the radiologist’s day-to-day work and will allow many residents to digest the information better.

Discovering Learning Disabilities

There is one last item that I want to bring to light. On occasion, a radiology residency may make a learning disability evident. Because radiology is different from other subspecialties and the methods for studying differ from other areas, some residents have problems with the transition. Some residents have issues looking at a picture and translating it into findings and conclusions. Radiologists do not usually test for this before beginning radiology. If you think that this may be your situation, it behooves these residents to consider psychological testing to find a more effective means of studying. Dollars spent to solve this issue now if you do have a learning disability may pay back itself in spades later on.

Fixing Professionalism

Professional issues and their solutions can vary widely. It may be as simple for the absentee resident as creating and sticking to a schedule to make sure you attend all the important events on time. If you are in constant conflict with your colleagues, you may need to learn to relate to others better, and that may involve sharing more or not taking everything to heart. On the other hand, maybe the conflicts are connected to other pressing issues such as substance abuse or health problems.

The critical thing to remember: there are many sources of help for the radiology resident. Whether it’s your colleagues, attendings, program directors, chairman, the Physician Assistance Program, a psychiatrist, or other individuals, there is someone at your program that can support you. It is crucial to talk to someone if there is a professionalism issue that you need to address. And, there is always help if the situation becomes unbearable.

How to Deal With Attendings and Colleagues If You Are Struggling

OK. So you have identified that you are struggling, and you have created the means to remedy the issues effectively. The next problem is that you may have created an environment where your colleagues’ expectations are so low that it may be challenging to defy their expectations. I like to describe this as the “vicious circle.” Your faculty will now scrutinize everything that you do, much more so than your colleagues. And, even though your performance may improve, they may not recognize the improvement. Unfortunately, they may still perceive you as below par. This “vicious circle” is probably the most challenging part of being an underperforming resident. So, what do you do at this point?

I would recommend continuing with the remediation program at hand. Healing a reputation takes not a few days or months. Instead, it can take years. Eventually, your effort will be recognized, but not without a lot of work and effort. You will have to suffer through some of your attendings and colleagues’ expectations until they realize you are a capable resident. This process takes grit and determination. You are going to have to ignore the expectations of others and create expectations for yourself. Eventually, you will notice a change in how they treat you, but remember, it will not happen overnight.

Summary

Radiology residency is a big transition for most residents, and some may struggle at the beginning academically or professionally. If you are struggling at this time in your life, don’t let these shortcomings define you. The measure of greatness is overcoming obstacles such as completing a radiology residency, a significant achievement. Struggling radiology residents often become radiology attendings with greater empathy for others’ struggles and can become the most successful radiologists!

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Ten Thousand Page Views- The Radsresident Experience

The Radsresident Idea

Sometimes the best ideas come about in the most mundane ways. I remember an uneventful Saturday in the middle of September when I sat down and began to surf the internet. I started to read about financial topics and happened upon a website called the Financial Samurai, a website dedicated to passive income. Most importantly, at the top of the page, there was an article called How To Start Your Own Blog. And so, it got me thinking… I haven’t really seen much organized accurate information on the web dedicated to the day to day issues of the radiology resident. Most sites were dedicated to medical students and board certified radiologists interested in radiology topics, but the radiology resident caught in the middle seemed to be skipped over. That being said, there were a few scattered helpful radiology residency related articles and forums on websites such as Aunt Minnie and Medscape, but it was a really a sparsely covered subject. And much of the information was not always reliable and accurate, not really personalized to the individual radiology resident, and was very technical and dry.

In addition, I always wanted to create a website. And, with all the valuable information I have learned as associate residency director over the past 7 years or so, I thought I could really contribute to the body of knowledge of the unappreciated radiology resident. I would target the day-to-day information that radiology residents, students interested in radiology, and others involved in the radiology residency process need and want to know. So these were the humble origins of this blog/website.

From the beginning of the idea for the radsresident website, I thought it would take a very long time to get viewers to the website and was expecting a long slog. To my surprise, in a little over a month and a half, we have already reached 10000 page views! So, why not write an article about what I have learned about my initial experiences, what I think it means for my loyal viewers, and what are some of the exciting changes to happen in the upcoming months?

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ESIR vs IR integrated

ESIR

 

Question:

Hello,

I am an M3 student, most likely applying to radiology next application cycle. I am interested in IR but do not have enough exposure to be dead set on an integrated IR residency. I was wondering about your opinions of applying to diagnostic radiology, specifically at programs with ESIR, and how feasible it is to knock a year off of the independent residency that we seem to be switching to through this option. Could you break down the ESIR pathway and how to transfer from DR to IR? Would this be the best option for someone not dead set on IR, or should I apply to integrated programs and pure diagnostic and rank them as I see fit when the match comes?

Thanks!

Director’s Response:

So, I am going to start by summarizing the three current pathways for interventional radiology at present:

  1. The “old-fashioned’ way involves a 4-year residency. But instead of needing a 1-year fellowship (as it was formerly), you now will require a 2-year fellowship. They call this the independent pathway.
  2. The ESIR pathway that you referred to. In this pathway, you must complete a full year of interventional-related rotations during your residency. At that point, you can then apply for a 1-year independent interventional fellowship.
  3. The DR/IR integrated pathway is an entirely separate five-year residency program.

The DR/IR program has three years of general radiology and two years of interventional-related rotations.

Specifically, regarding your situation, most residents who initially say that interventional radiology interests them usually find another subspecialty fellowship. So, if you aren’t entirely committed to interventional, chances are, you will do something else.

ESIR

If you apply to a program with ESIR, you must tell your residency director reasonably early that you are interested in the ESIR pathway. The reasons for this: A. Multiple residents may be interested in ESIR. B. The residency may only accommodate one or two people because of scheduling requirements. C. The conditions for ESIR can disrupt the schedule of other residents in your class because of the need for additional dedicated IR time and less time on different rotations.

However, the significant advantage of an ESIR program is two-fold. First, it enables the ESIR resident to take the one-year interventional fellowship instead of the two-year fellowship. And second, it makes the ESIR resident more competitive in the fellowship match because they have some experience under his belt. Also, programs have limited their two-year independent fellowships for those not following the ESIR pathway.

More About IR/DR

If you attend a program that has an IR/DR program or an ESIR program, it is possible to transfer in and out of one program or another. However, IR/DR programs give the resident less flexibility. Remember, the IR/DR program maintains independence from radiology residency with its own program director and scheduling. Its sole goal is to create interventional radiologists. (Although it does happen to share the core exam with the radiology program, however). So, it is possible that if you decide to transfer to the DR portion of the program, you may not have enough rotations available to meet the residency requirements. Although unlikely, you theoretically may need to find a residency slot elsewhere.

If you are not entirely sure that interventional radiology interests you, I recommend finding radiology residencies with an ESIR program rather than an IR/DR program. Why? , an IR/DR program commits to you the process of becoming an interventionalist. If you go to an ESIR program, you will more likely have a little more time to decide upon entering into interventional radiology later. (but you should still make a decision as soon as possible). And the ESIR program fits within the confines of the diagnostic program. This program allows more transfer flexibility.

Remember, if all else fails, you can still complete interventional radiology by attending a standard DR program without ESIR. However, you may have a much harder time getting into the fellowship. That may make more sense than applying to an IR/DR program to find out you don’t like it.

So, those are my two cents. I hope that clarifies things a bit. I wish you good luck in the radiology match process!!!