Month: February 2017

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How To Prepare For Interdisciplinary Conferences As A Radiology Resident

prepare for interdisciplinary conferences

You get the email… There is a urology interdisciplinary conference on Tuesday at 7 AM, and you are responsible for showing 4 cases with multiple radiological studies. You’ve never done this before! How do you know which images to display to prepare for interdisciplinary conferences? Is there a logical order to the pictures? Will I be able to answer the questions posed by the clinicians in the room? Your heart beats a bit faster as you contemplate the issues.

This situation is common for the beginning radiology resident. Frequently, radiology programs thrust first-year radiology residents into their first interdisciplinary conference without much preparation. However, even though initially nerve-racking as an experience, these conferences are an excellent opportunity to get to know your non-radiological colleagues as well as a way for them to find out about how knowledgeable you are! Learning how to prepare for interdisciplinary conferences pays off big time!

Presenting for interdisciplinary conferences is slightly different from preparing for typical conferences. Your audience will be a bit more sensitive to mistakes that the presenter makes because decisions can often directly affect patient care. Therefore, today I will discuss some of the common questions that arise when you encounter your first interdisciplinary conference to make you feel more comfortable. These topics include how to sort through what is essential, what to discuss, and when to ask for additional help to prepare for your first solo interdisciplinary conference as a radiology resident. So let’s get started…

Selecting Cases To Prepare For Interdisciplinary Conferences

When going through a case, clinicians like to have the relevant initial diagnostic images and the subsequent follow-up images. So, it is imperative to get the correct history for the primary diagnosis. When you check the computerized records, make sure to find all studies that support the principal diagnosis. Then, you will need to look for the earliest studies of this sort. If the diagnosis is breast cancer, find the first mammogram and breast MRI present on the record. If the topic is metastatic colon cancer, look for the first CT scan showing the metastatic disease.

Next, you need to find the first post-treatment studies. So, find the next series of relevant images. If the topic is a retroperitoneal bleed, see the first series of post-intervention cases, such as the post embolization ct scan. These will usually be the second from the beginning.

And, then finally, look for the most recent relevant studies. If this was a case of metastatic colon cancer, find the most recent CT scan of the abdomen and pelvis to show the final consequences of treatment or lack of treatment.

Selecting Individual Images

There are two ways to show images during a presentation for interdisciplinary conferences. First of all, you can go to the source images in the PACs system and flip through the pictures directly. Or, you can select individual images and display them on a PowerPoint presentation. I would recommend doing the latter. Why? , You leave less interpretation by the audience, and you will get a lot fewer questions regarding things that you are not sure about during the presentation.

Additionally, the clinician will less likely ask about information and findings that are irrelevant. For instance, you are less likely to get a question about that borderline enlarged node on the corner of the film that was not mentioned but is present on the PACs display. By choosing the PowerPoint format, you have much more control over what is displayed, and it keeps the discussion centered on the essential topics.

Also, there is less chance for technical issues. PACs tend to go down when you most need it since it relies on an internet connection. A PowerPoint presentation is much more reliable since you do not have to rely upon the internet.

Also, when choosing individual images, make sure to look for the relevant information without the fluff. For instance, if it is a metastatic colon cancer patient, take those pictures only of the liver metastasis without the volume averaging artifact. If the case is a retroperitoneal bleed, show only those images containing the bleed without other distracting findings on the film. And so on…

Discussions

When it is your turn to discuss a case, keep the discussion targeted. You want only to start discussing those issues that are relevant to the clinician’s question. If they need to know if the metastatic colon cancer lesion is better, worse, or unchanged, provide the clinician the relevant information such as the measurements. If they want a differential diagnosis, offer it. But do not go off on a tangential vector! If you go off-topic, clinicians tend to get angry because of the limited time you will have during the morning to discuss patient care and other cases. So, please don’t do it!

Also, try to look up relevant information on the topic during your preparations before participating in the conference. If you want to look like a star, gain additional knowledge on the relevant issues so that you can answer those questions intelligently and with authority. Then, you will establish an excellent reputation for yourself during the conference. Imagine how you will sound describing the features of colon cancer metastasis if asked rather than muddling through and stuttering.

When To Ask For Help?

So, you’ve gathered your studies and selected your images. When is appropriate to ask your attending for some assistance? Here are some specific circumstances: You have never rotated through a particular modality, and you are presenting those images during that case. You are not sure that the report description is the same as the information on the images. You do not understand the disease entity issues they will discuss at the conference.

I always like to know about any questions the resident may have before completing preparations for a conference. Better to be safe than sorry!!!

How To Prepare For Interdisciplinary Conferences!

Preparing for your first interdisciplinary conference can be stressful, especially if you do not have much essential guidance. Hopefully, this summary will allow you to make more sense of the necessary preparations involved. Good luck with your next conference!

 

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Technological Essentials For The Radiology Resident

Technological Essentials For The Radiology Resident
By Daniel Choe

 

In an era of exponential technological growth, it is essential that trainees use the latest technology to improve their educational experience. Demands increase every year for the trainee to remain up to date. Moreover, the resident needs to access information seamlessly. So, let’s talk about a few technological essentials that enhance the graduate training experience for the radiology resident. Different from many articles out there, I have no direct financial disclosures about the products I mention in this article.

 

Smart Phone/Tablet

 

It seems like a no-brainer to have a smartphone/Ipad. However, believe it or not, I once had a colleague who started residency with a blackberry!

Regardless, the Ipad or tablet may serve as a surrogate or mobile substitute for a laptop/notebook. However, it has limited storage and computational power. While upgrading them is easy due to its backup/sync features, it often lacks in ease of use for programs that require hardcore graphics rendition or multi-program use. It is ideal for mobile use of editing online documents, viewing online lectures, storing a limited number of pdf files, and running apps for question banks. Several anatomy learning apps are available and extremely useful for a fee. There is a separate section on apps later on.

 

Cloud Services

 

Most users already have cloud services. In fact, that is often the problem – there seem to be too many online storage services. Google, Amazon, Dropbox, OneDrive to name a few. An elegant solution that helps consolidate all of the different clouds you may use is a service such as odrive. It is free, encrypted, and allows you to automatically sync when you copy files to the odrive folder on your computer. The caveat is that to use the sync feature, you must have enough space on your hard drive.

My suggestion is to invest in a cloud service that offers unlimited space and only the folders that you open most frequently. Obtaining a cloud service is essential for the resident who is continually doing research and keeping tabs on what lectures and videos he watches. Alternatively, if you use a pdf reader, it can keep track of which page you were on in one of the many textbooks you will inevitably read.

 

Computer

 

Regardless of whichever camp you fall into, Mac or PC, your home computer or laptop/notebook should be the workhorse for your education and work. I could write an entirely separate article on this topic. Nevertheless, for the sake of simplicity, a home desktop is not essential, but rather a plus. Because cloud services work seamlessly and storage space is a problem of the past, your desktop is a great way to consolidate your work and use programs that require slightly higher computing power and graphics rendition. For example, I use a remote desktop to do a majority of my preparation for tumor board research, presentations, research projects. Moreover, I have my computer permanently connected to my flat screen TV as a secondary monitor so I can multitask.

Also, I can watch lectures on my TV. Watching them on TV affords greater detail and helps when trying to take cases.

Finally, I recommend swapping out your primary hard drive for a solid state drive (SSD). As well, add a secondary storage drive. They are becoming more affordable these days. Keep in mind, much of the work can be accomplished with a laptop, MacBook, or even tablet/PC as well, at the cost of overall computational power and storage.

 

Universal Password Program

 

I use a password and personal information storage program. Using these tools cuts out approximately 50 hours a year in retyping and resetting passwords. For convenience, I have over 200 passwords stored. Moreover, I can routinely change and generate new complex passwords to maintain security. Password programs also allow you to store credit card information and secured notes for passwords and sensitive information. There are many services out there. I would select the one that suits your needs. It is definitely worth the money.

 

Remote Access

 

Most institutions provide remote access for its residents. If not, it behooves you to suggest that the residents have access to remote PACS and EMR. Remote access is critical not only for learning purposes but effective workflow in preparation for interdisciplinary rounds. Your time is better spent working or studying than having to schlep to the department or stay late (unless you are actively trying to avoid home for a particular reason).

 

Shared Network Storage

 

My institution did not initially provide shared in-network storage. However, since its inception, we have been able to provide essential resources for all residents and staff. More importantly, it serves as the institutional memory for a growing and developing residency program by eliminating the possibility of losing critical learning resources. It is also an excellent way to circumvent the elaborate HIPAA clauses in your IRB research protocol.

 

I also include in this topic the necessity of a secured (password protected) USB drive as a conduit for transferring secure data between machines. Your program or IT department may provide one for you. It will serve you well in the long run as it allows you to transfer sensitive documents from your personal computer to a secured hospital network.

 

Apps

 

There are so many great apps available, but I can only mention a few that are technological essentials for the resident. A document reader is critical. Specifically, it should be one that allows you to maintain a “bookmark” for each document you upload. Also, it should open and save highlights and notes you want to review later. This document reader is worth a few dollars because it allows you to carry your library wherever you go, saves highlights directly onto the document, and remembers your page position. I use Goodereader for my Ipad, because it was one of the best at the time, but there may be new readers out there that suit your preferences.

 

Several of my colleagues purchased a group subscription for e-anatomy. This app is a comprehensive anatomy atlas with corresponding radiology images.
Radiology Assistant has recently developed a new app, which is an adaptation to its website. The app allows you to review all the content on their website while offline if the data is pre-downloaded. If you like the website as a resource, it is an even better tool as an app.

 

The different learning apps available can turn your phone into an instant tutor with quiz programs such as Chegg or Anki to name a few. Also, most of the decks relevant to your training probably already exist. I found over 500 premade CORE exams cards. Use at your own risk since you cannot vet them all throughout your review. You can download and edit them as you go if you find the information is not up to date.

 

Conclusions About Technological Essentials

 

The bottom line is that your training experience relies heavily on how you learn. You may get by without some of the technologies mentioned above, so it’s entirely up to you to decide what you need. The items I have mentioned I recommend so that the resident, from day one, can optimize the use of time with relatively cheap resources (or otherwise covered/subsidized by your program). John Stuart Mill wrote, “there are many truths of which the full meaning cannot be realized until personal experience has brought it home.” Hopefully, my experience with these technological essentials serves its purpose to jump-start your journey through residency.

 

 

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Reading Room Background Music- A Hazard For Patient Care?

music

Walk into any radiology reading room, and you may see several radiologists with headphones plugged into iPhone music. Others are constantly shushing other residents, chatting amongst themselves in the reading room. These rads hate the moment that excess noise comes their way. This divergence of opinions on the matter is enormous. So, should we concentrate solely on the findings on the film and ban all music/noise from the reading room? Or, does music help radiologists to notice things they may have not as seen otherwise? Let’s look at several relevant articles and weigh the body of evidence to come up with a conclusion.

Music As Potential Benefactor In The Radiology Department

Mood

As I was combing through the internet, I came across several interesting positive articles on noise and productivity. However, overall, the scientific power of the studies was pretty weak. One particular study emphasized radiologists, and it was an interesting article in Science Daily. It summarized an American Roentgen Ray Society abstract. The study took eight radiologists and looked at how baroque, classical music affects mood, concentration, perceived diagnostic accuracy, and work satisfaction. It concluded that the most statistically significant positive effects were upon mood and work satisfaction. One physician even stated that there was a subjective improvement in concentration and interpretative abilities. However, it had a low number of included participants and didn’t look at the actual performance of the radiologists. So, I’m not sure if the results are that relevant.

Performance

One abstract in the literature with a slightly higher number of participants (26 radiologists) looked at acoustic noise within clinical departments and radiology performance. This study concluded that acoustic noise found in most radiology departments is not a distraction from work. However, this is not a direct study about music and reading films. Although a small study, the paper suggests no harm in listening to music and reading chest images.

Another article went through different types of music that are best for immersive tasks but are not specific to radiology. I think you can extrapolate these genres to radiology because radiology reading rooms are an immersive environment. Interestingly, it listed baroque, classical, electronic, video games, and low-volume ambient music as the most helpful. Nevertheless, the scientific literature did not back it up. 

The Journal of the Acoustical Society of America released a paper stating that natural sounds may “enhance cognitive functioning, ability to concentrate, and increase worker satisfaction.” I didn’t see the data behind the study, but it would be interesting to arrive at a reading room that sounds like a waterfall or a windy day. That could make me a bit more efficient and relaxed… But perhaps a bit sleepy as well!

A Case Report About Music And Performance

Nototallyrad.blogspot.com had an interesting expose on reading ICU chest films where he spoke specifically about his productivity based on different types of music in an unscientific format. He concluded that he was most efficient when listening to Bach instead of Metallica, White Noise, and Red Stick Ramblers! Call me crazy. But, if I listened to Metallica while reading anything, not only would I have a difficult time reading cases, I may come home with a headache!!!

Music As A Disruptor of Radiologist Concentration

Much of the literature regarding noise/music and adverse effects upon performance is not specific to the radiologist. These articles tend to be a bit more powerful but are certainly not complete. We can try to extrapolate from these articles the relevance to the radiologist. Specifically, if you look at the psychological literature, several negative articles reported on the radiologist regarding noise, music, and performance.

Performance Deterioration

The first one, The Impact of Listening to Music on Cognitive Performance, supported that performance scores were higher in silence than in all types of music conditions. That performance deteriorated as the intensity of the music increased. The kind of music did not affect performance, just the intensity of the music. Again, the sample size was not that large. And other biases were present that could alter the applicability of the results.

Another psychologically-based article called The Effect of Background Music and Background Noise on the Task Performance of Introverts and Extroverts looked at 10 participants and the effect of music with high arousal potential and negative affect, music with low arousal potential and positive affect, and everyday noise on cognitive task performance of introverts and extraverts. Similar to the previous study, performance was worse with background noise compared to silence. There was also differing performance among introverts and extraverts (I’m not sure how relevant that part would be toward radiologists!)

Outside of the psychological literature, a sociological study looked at the relationship between multitasking and academic performance. Although not specific to music, it had a significantly higher number of participants (1839 surveys). Moreover, it could potentially be relevant to the radiologist. The result was that multitasking with social media and academics could lead to a lower GPA. Although there is no direct link in this article between listening to music and radiologist performance, one can conclude that music is multitasking and can just as well interfere with radiology performance.

The Lone Radiology Resident Study- A Mixed Result

Finally, there was an article explicitly dedicated to the radiology resident! It specifically looked at resident detection of rib fractures. They divided eight radiology resident readers into two groups- one accustomed to reading in quiet environments and another group that reported to be unaffected by noise. It turned out that the resident’s attitude toward noise affected the detection of rib fractures. Those residents who usually read in silence had improved performance in silence, and those unaffected by noise had improved performance with noise. Again, not such a robust study, but interesting nonetheless.

So What Is The Preponderance Of Evidence?

Although the higher power studies currently lean toward music as an overall detractor of potential radiologist performance, there are no strict guidelines in either direction. You can still make an argument in some cases that music can help some radiologists get through the day in a better mood if nothing else. However, until there is some more substantial evidence that music has no effect or improved effect upon radiology reads, read films with music at your peril!

 

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Can Clinical Decision Support Systems Help To Improve Radiology Resident Education?

During my residency only a little bit more than 14 years ago, I can still remember grabbing a ream of sheets from the bin to check the day’s CT protocols. We would quickly read through each one to make sure that the appropriate test was indicated as was ordered by the referring physician. Somehow, I think this process is currently an anachronism at many radiology residency programs. The pressure to complete studies in rapid fashion have changed the way things are done. It seems almost all the cases come directly from either the emergency room or from the referring physician directly to the scanner. No longer is the resident an intermediary in the process (a potential delay in the system). Instead, there is a corresponding increase in tests with incorrect indications and/or wrong technique, only to increase radiation dosages and the cost to the system. The ordering physicians, not the imaging experts, have hijacked what should be the domain of the radiologist: to decide if imaging examinations are appropriate.

Why do I bring this topic to our attention? First and foremost, of course, patient care suffers. But also, as today’s topic implies, it also affects the education of the radiology resident. So how do we get control back over the reins of imaging from a standpoint of improving resident education? Initially, we have to understand the role of protocols in the education of the radiology resident. And then, I will briefly discuss what imaging clinical decision support systems are and how clinical decision support systems can potentially enhance the education of residents as well as the appropriate use of imaging.

Protocols And Educational Implications For The Radiology Resident

One of the most important roles of radiologist is to be a consultant for the appropriate use of imaging. As I described above, the process of checking protocols significantly enhanced my knowledge on this topic.  What may have seemed at the time as a questionable activity bordering on scut, I now see as invaluable. Related to my prior experience with protocoling CT scan studies, I now understand when contrast should be administered, how certain studies are typically performed, and most importantly, what are good indications for a study to be completed. At many programs, this educational opportunity is no longer available due to financial and political pressures upon radiology departments to get through the system. Any study ordered must get done in a timely fashion, no matter whether the study is indicated or not! It only matters that it was ordered. Correspondingly, resident involvement in this process has significantly decreased over time.

So, how does removing this educational opportunity for radiology residents change the knowledge base of the radiology resident?  First of all, you are taking away important practical knowledge that can reduce the value of new radiologists as a consultant for determining appropriateness of individual imaging studies. Second, new radiologists will be less likely to understand how to tailor individual studies to the indications of the ordering physician. And finally, the potential implications of issues like when to use intravenous contrast can be underestimated, both from a contrast complication and an appropriate indication point of view. So herein lies the potential savior to return the educational opportunities of protocoling back to the radiology resident- The Clinical Decision Support System!

The Clinical Decision Support System

Here is the definition of clinical decision support systems according to the government– “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”

In terms of imaging, the potential implications of a clinical decision support system from a cost and educational standpoint are myriad. No longer are all imaging studies going to be ordered without the approval a computerized system. When can this potentially occur? How would the radiology resident role going to be affected by the implementation of such systems? Let’s talk about both of these questions…

Institution of Clinical Decision Support Systems And The Potential Effect Upon The Radiology Resident

At first, institution of electronic clinical decision support systems were going to be mandatory as January 1, 2017. The date was subsequently changed to January 1, 2018. We will see if this date is going to be the finalized implementation deadline.

But let’s say that a good quality clinical decision support system became mandatory at all institutions for ordering imaging studies at the beginning of 2018. How would that affect the residents? First thing that would you notice, bogus indicated studies would all of a sudden significantly decrease dramatically. The system should theoretically block anything that has a questionable indication from getting through from the clinician order to actual practice. Second, there could potentially be a flood of phone calls. Since any study with a questionable indication or a complex protocol would not be able to get through the system, instead, clinicians would be forced to ask the radiologist what kind of protocol should be implemented for these cases. Not only would this be a boon for patient safety (decreased radiation dosages) and appropriateness of imaging, clinical decision support systems can actually bring the control of image ordering back to the radiologist. More specifically, a good quality clinical decision support system can theoretically allow the radiology resident to protocol examinations appropriately in concert with the ordering physician and tailor examinations to the indication that is needed. Resident protocol education can be restored!!!

Interestingly, a clinical decision support system for imaging was actually one of the few parts of the health care bill that actually had the potential to decrease costs and quality of care in addition to improving resident educational experiences. Ironically of course, it may never be implemented depending upon how the political situation in Washington affects health care.

Clinical Decision Support Systems For Imaging Can Be The Resident Radiologist’s Best Friend

In summary, clinical decision support systems have the potential to be one of the true benefits to the health care system, in terms of costs and quality of care. But, one of the most overlooked implications is actually the potential educational benefits to the radiology resident. No longer would ordering be in the hands of untrained ordering physicians. Instead, control will again lie in the hands of the radiology resident allowing him/her to protocol patients once again appropriately and giving the radiology resident the education he/she needs to become a true imaging expert.

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Radiology Personal Statement Mythbusters- Five Common Misconceptions About Radiologists

Since I started work on my radiology program’s admissions committee in 2009, every year, I notice a significant disconnect between the medical student impression of what radiologists do and the actual day to day work of the radiologist. The radiology personal statement is a shining example of this truth. In this post, I will debunk many of the myths espoused in the personal statement about what we do daily (Just like the real Mythbusters– this is going to be fun!!!). Let us begin…

Where’s Waldo?

Out of the thousands of personal statements I have reviewed, many use the Where’s Waldo analogy in one form or another. If I see another personal essay with a resemblance to Where’s Waldo?, I will scream very loudly!!! All kidding aside (I’m not kidding!): The Where’s Waldo analogy is one part of the radiology job that is not understood by many applicants.

So, what is it that a radiologist does? First and foremost- we read films and lots of them. Film reading heavily leans upon pattern recognition. And that is what we do. We use search patterns and compare our visual databank to the thousands upon thousands of images, we have already seen.

How does that differ from Where’s Waldo? In Where’s Waldo, the scenes typically change on each page, and you are expecting to find the same Waldo character in a sea of miscellaneous extraneous information. For the radiologist, the scene is usually the same, whether it is a chest x-ray or a CT scan or even a Brain MRI. And, the findings can vary widely in any given film. You may find a pneumothorax or a herniated bowel loop or an infarct. However, you are not looking for one specific thing. You are looking for everything. This general search for everything is very different from finding one Waldo, who is always going to have the same appearance. The analogy does not hold very well!

The One Fascinating Case

A personal statement will often talk about one fascinating case and how that led the applicant to the decision of choosing radiology as a career (I am sick of this conclusion!). Why does this point demonstrate so little insight into the day to day practice of radiology? Sure, every once in a while, something is fascinating- perhaps it is a bezoar or a sporadic tumor. And, sure, it is excellent to perseverate on that case. But in reality, although exciting, these cases take up less than .01 percent of the radiologist’s work. You have to expect to pick up thousands of normals, normal variants, and common findings before picking up one of these rare zebras. When I hear that an applicant is choosing radiology for the one fascinating case, it does not show a good understanding of our day to day work!

The Family Member Saved By A Radiology Finding

Sure, every once in a while, the radiologist is the hero. We discover an occult aneurysm, unexpected appendicitis, or early breast cancer. Maybe the radiologist has picked something up in your relative to save the day and has been credited. But in reality, how often does that occur? Not that often! In reality, it is pretty darn unusual. If you want to save lives daily and get the credit, go into trauma surgery!!!

In general, radiologists have to be pretty humble because rarely are we showcased as an example of the medical profession for all to see. Usually, the doctors on display are the surgeons, internists, ob/gynecologists, or almost every other medical specialty. Don’t go into radiology to expect the glory of saving patients. We are usually behind the scenes!!!

The Diagnostic Dilemma

Many personal statements will describe when a radiologist went through a case and came up with an incredible on-target well thought out differential diagnosis. And, the applicant will point out that they want to go into radiology to make incredible interpretations. In reality, I also love a well thought out differential diagnosis in a compelling case. Unfortunately, most studies are not in the category of the intriguing differential diagnosis. Final interpretations are usually mundane and limited. Don’t expect to go into radiology to become the next House, MD, every hour of every day!

The Isolated Radiologist

What is the last thing that we want to hear as radiologists? That we spend an excessive amount of time in an isolated dark room, not speaking to others for hours. Yet, many personal statements assume that we rarely come in contact with others and only plug away at the films. Although there are probably a few radiologists out there like that, it is usually the opposite. I can’t tell you how many days, there is a constant bombardment with technologist questions, physician consults, nursing issues, and more. Please get your facts straight before putting it in writing a personal statement!!!

Busting Myths And The Final Truth About The Personal Statement

The good news: After all these false assumptions in many of these personal statements and the thousands of personal essays that have come across my desk, very rarely does one spur me to change a radiology residency applicant’s disposition on the final rank list. I usually give these personal statements a pass because I understand it isn’t easy to comprehend what a radiologist does without stepping in our shoes.

On the other hand, if I had to give you one piece of advice as one of the leading players in the application process at our institution, make sure you are not one of the chosen few who write a personal statement that influences our final decision. These are the personal statements with bizarre and sometimes scary thought processes and conclusions. The outcome of these weird personal statements is not usually positive! (meaning DO NOT RANK) So, stay away from the impulse to write something too unusual/different. We typically use the personal statement to weed out potentially psychotic behavior, not as a tool to make the final rank list.

So, as long as you don’t write something overly bizarre, I wouldn’t worry about this part of the application too much. Just make sure to avoid the basic grammatical and spelling errors. And, most importantly, don’t try to rock the boat!!!

 

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Step II USMLE- When Is The Best Time to Take It?

Dr. Julius,

I’ve planned to take step 2 between late August and early October this year. I’m doing this as I feel my step 1 score in the high 230’s and I’d rather spend time focusing on an away rotation at one of my target institutions and on getting more quality clinical experiences, and therefore LOR’s for my application. Does this seem like a bad idea to you?

Thanks for your input!

First of all, congratulations! High 230’s is a very respectable score. But more importantly, I would say that if you have done well on Step I USMLE, it shows that you can take a test well. It also turns out that with the new radiology core exam, I think there is a much higher correlation between doing well on the USMLE exams and passing the radiology core examination than there was with the old oral board examination. In our program, when we look back at those people that have had trouble with the radiology core exam, they have not done as well on the step I and II USMLE examinations. It makes sense because the style of testing is very similar (multiple choice, matching, etc.) to the current style of the core radiology examination. I think that may be the subject of whole other article!

Getting back to your question, most programs just want to see that you can take a test. So, if you do well on your Step I examination, it is usually acceptable to wait a bit longer to take your Step II USMLE examination and focus on away rotations, clinical experiences, etc. That being said, there may be some programs out there that use both the Step I and II USMLE examination as a screening criteria for getting initial interviews. You may experience a delay in getting interviews at those programs. Many programs, however, will use whatever is submitted at the time and I believe that 230s is usually acceptable for passing that initial screening barrier at most programs assuming the remainder of your application is reasonable.

In particular, you mentioned that you are doing an away rotation at a target institution. Sounds like you might be interested in going there. So, I think it would’t be unreasonable to ask the program coordinator if they require the Step II USMLE examination as an initial screening criterion. If so, then I would take the Step II boards earlier rather than later. Otherwise, it makes sense to get try to get to know the radiologists at the institution of interest rather than hurrying to take the Step II examination. Just remember that when taking an away rotation at a place where you desire to do residency, it is ultra-important to make a decent impression. In some cases, rotating through a desired residency program can be backfire if you make the wrong impression. I’m sure you’ll do great… But, be careful!

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How To Combat A Difficult Radiology Job Market!

job market

Once again, like in many other economic cycles, the radiology job market has hit a bit of a pause. This time, it is due to Covid-19. Although the job market is not as bad as it was back around 2010, it certainly is not the same as it was at the beginning of this year. And, in many locales, the job market froze up entirely. Competition remains fierce in desirable practices on the east and west coasts. Even with some folks abandoning the cities for the more suburban and rural areas, you will likely find it very difficult to obtain a partnership position in San Fransisco or Manhattan!!!

How do you, as a graduating radiology resident or fellow, begin to approach finding a job in this competitive landscape? We are going to cover the essentials for finding a quality job in these problematic radiology markets. I will divide the essentials into the following sections: networking, diversification of skills, location, recommendations, and research/national organization involvement.

Networking, Networking, Networking!!!

Maintain Relationships At Home

Networking does not only begin when you start looking for a job. The search for the ideal job commences at home. What do I mean by that? The first and most important part of networking is maintaining good relationships with your colleagues and attendings.

Many attendings have their proverbial “ear to the ground.” More often than not, therefore, many can tell you about opportunities in the area. Moreover, they can guide you to those jobs. So, to get access to these high-quality jobs, you need to perform and be a good team player. The resident that has not been “playing nicely in the sandbox” during training will not receive those inside tips. More likely, the poorly behaved resident will need to fend for himself. On the other hand, residents who continuously strive for excellence and relate well to their colleagues will have first dibs on those desirable jobs with connections to your radiology attendings.

Keep In Touch

It also becomes more critical than ever to stay in contact with your colleagues and coworkers. When you are ready to leave your residency to go to your fellowship, keep in touch with your former colleagues, residents, and attendings. You never know when that next job lead is going to pop up. And, most former colleagues will happily give you a tip for a new contact. These connections will be the most likely to help with finding that next great job.

What about social media? Nowadays, professional-based social media groups such as LinkedIn can play a role in getting that next job. Besides, social media can keep you in contact with your former colleagues. And, social media allows you to let others stay aware of your current training and expertise. Therefore, residents should maintain at least one account. But be careful to keep the account relevant and correct. View it as a resume. If it is not updated and contains false information, it can be detrimental to finding that next great job. Otherwise, it can be a great way to contact your former colleagues as well as a way to obtain new leads.

Always Be Nice

Finally, even when you have started on that first job, whether it be a dream job or merely a stepping stone, make sure to be cordial and appropriate to your interviewees. I remember when I was interviewing, I met with a private practice attending who was touting the merits of his work to me. I subsequently found a job with a different practice. However, six months later, that same attending who interviewed me became an interviewee at my current practice. You never know what is going to happen!!!

Diversification of Skills

As a resident and fellow, try to do things in your field slightly out of your comfort zone. What do I mean by that? You never know what practices are going to want. Things change. Sometimes an imaging business may need a cardiothoracic radiologist but also require a radiologist that can also read mammograms. Other times, a practice may need an interventionist that feels comfortable with reading musculoskeletal MRI. To become the most competitive candidate in your class, you need to make sure that you feel comfortable in as many modalities as reasonable. Therefore, you should not just concentrate on your fellowship skills or areas of comfort, but also your weaker procedures/imaging areas.

As a fellow, it also becomes crucial to moonlight to maintain your skills in other general radiology areas, outside of fellowship. It can build your speed and accuracy. So, when you start your first job, you will be able to read studies at a reasonable pace. Moonlighting will allow you to have a higher likelihood of remaining at your first job after training!

Should Location Be The Sacrificial Lamb?

Sometimes the job market in some locations becomes so ultra-competitive that good jobs may not exist in your desired area. In that case, there are times when it makes sense to alter one’s expectations and apply to other locales outside of one’s original intentions. By switching locations, the applicant may significantly increase the job market choices that will allow her to practice her subspecialty or earn more income. However, an applicant should not take this decision lightly because personal or family issues sometimes can trump job selection. But, an applicant should consider all the alternatives before selecting a job.

Recommendations

As a radiology resident or fellow, obtaining a radiology job recommendation differs significantly from asking for one as a medical student. Instead of a formal letter, a radiology resident or fellow should let the attending know to expect a phone call from a radiologist at the practice where he had interviewed. Although informal, this practice gives more information to the radiology practice than a simple letter of recommendation. A radiologist can relay the real personality and information about a candidate on the phone more easily without legal repercussions. In this situation, no paper trail exists.

In the conversation, the caller may informally ask your supervising attending about your work ethic, whether you played well with your team, and more. Other times, a member of the practice may speak with a friend of theirs within your residency program to confirm that you would make a reasonable job candidate. Bottom line: it is good manners to let your attending and program know to expect a phone call!

Research/National Organizations

For those interested in academics, completing research projects can help to snag that first academic job. Although not as crucial for the private practitioner, it also can’t hurt to have completed research projects. As I’ve mentioned in a prior post on research, if practices have a choice between two equal candidates, they may sometimes choose the resident with more research experience. You never know…

Also, getting involved in national organizations, whether it be the ACR, RSNA, or AUR, can be a great way to learn about the politics of radiology as well to meet colleagues and practitioners. Residents should consider participation in these organizations.  It could be a stepping stone to find a great job or to become the next President!

Final Thoughts About The Job Market

If the job market is tight, all is not lost. Even in the most challenging markets, some practices will usually have a few jobs available. To increase your chances of getting one of these popular slots, you may need to work a bit more intelligently and focused so that you can become a desirable candidate. Networking, diversifying your skills, making sure to get great recommendations, finding the correct location, and participating in research and national organizations can help your cause. Ultimately, these practices will choose someone that fits the expected identity of an ideal candidate. If you follow these essentials, you have a much better chance that that person will be you. Good luck!!!

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The Presidential Executive Order And Foreign National Radiology Residents- Will Life Ever Be The Same?

In a medical resident’s life, he or she is so busy that politics rarely influences day to day work and living circumstances in the United States. But, this is no ordinary year and we are not in ordinary times.  A new presidential executive order has been issued. No longer can residents from the following countries: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen travel to the United States without the appropriate documentation. But, it turns out that the implications of the executive order run much deeper than just the inability to return to the United States. Resident physicians lives may be altered for many years to come.

On the surface, the executive order makes some sense. Prevent the bad guys from coming into the country by halting travel for all citizens of the designated countries, countries where there have been incidences of terrorist activities. Dig deeper and you realize that most of the foreign born nationals have already been in the United States for years legally, either with a green card or certain visas. A majority of these residents are not terrorists and are in fact, good people, hard working, and excellent physicians. Additionally, many other countries with histories of harboring terrorists were not included in the executive order.

Effects of the Travel Ban On Residency

So what are the potential effects of this executive order if you happen to have been away in another country? Since some of these residents are already abroad and cannot return to the United States, these physicians in training will have their training delayed by at least 90 days since they need to stay in their country of destination. On the surface, that does not sound so bad. But, it can have profound implications. Training will have to be delayed by over 3 months. This means that the resident cannot graduate from the radiology residency program on time at the end of the 4 years. And, he/she will potentially have a difficulty either beginning their chosen fellowship on time if they are scheduled to start at the end of residency. Others will have to delay finding a fellowship potentially for over a year.

Furthermore, many foreign medical students from these targeted countries have recently interviewed for residency positions. Program directors are either ranking these medical students lower on their rank lists or are being placed in the “do not rank” category due to the uncertainty that these prospective residents may not be able to start at their residency on time or perhaps not at all. This year’s residency selection is already being affected by the executive order. In the fact, the NRMP has already submitted a statement on the executive order recognizing these challenges.  (NRMP Statement on Immigration Executive Order)

Also, on top of the general work related issues, these residents can no longer visit their relatives abroad, for the risk of not being able to return to the country, giving them less of a support system during the time of their residency. Residency is time a time of significant emotional and intellectual stresses. It is also possible that the international travel ban can last longer than has already been stated, potentially making the stressors even greater. So, although well intended, the executive order is severely flawed.

What Needs To Be Done To Make The Executive Order More Effective And Reasonable?

First of all, the current blanket executive order needs to be made more targeted. Most of these foreign residents have already had their green cards for many years and have been working in the United States as productive employees for most of that time. If need be, these residents can be reinterviewed by the government, but should not be banned from travel abroad or from returning to the United States during this period of “vetting”. Why prevent these legal workers from contributing to the United States workforce and potentially causing shortage of labor in residency programs? We are only harming ourselves.

Second, those countries chosen by the executive order to be targeted is a random selection of “terrorist harboring” countries. Other countries that have traditionally harbored many of the terrorists were not included. So, if you are going to make an executive order to restrict travel and reinterview these residents, it does not make sense to only target a few of those countries.

And finally, vetting should be more individualized and reason based. If in fact, the vetting that was done was not so thorough upon the initial interviews when these foreign born residents came into the country, then by all means go ahead and do the appropriate procedures to make sure that they are in the United States legitimately. But, make sure to do it in a reasonable manner instead of targeting everyone without cause.

What Should You Do If You Are Specifically Affected By The Executive Order?

There are two groups of residents and resident applicants affected by the executive order: applicants who are already in the country and those who are abroad. For those residents that are in the country, I would recommend to avoid travel abroad until the situation clears- you may have difficulty getting back into the country if you make this decision.

For both groups of residents, I would also pay close attention to posts on the ACGME website if you are a resident and the NRMP if you are a applicant for residency. They are scheduled to have frequent updates with relevant information. Also, make sure to stay in close contact with the hospital, residency program, and program directors to receive any relevant updates or other helpful practical and legal advice.

Unfortunately, if you happen to be abroad since the executive order, depending on whether you have permanent resident status or not, you may or may not be able to return to the United States. I would recommend seeking the help of an immigration attorney to help with the issue of returning to the country.

Difficult Times For Foreign Nationals From the Targeted Countries

It is unfortunate how the executive order was issued without regard to the specific circumstances of the individuals affected. Regrettably, many excellent well trained and talented foreign national residents and applicants may be at least temporarily prevented from completing their training due to no fault of their own. However, I believe that once the flaws of the executive order have been worked out, order will be restored to the medical training process, most qualified residents will be able to return to their positions, and medical students will be able to reapply. Although it is only 90 days until a more logical system can be sorted out, these residents may be affected for a much longer time due to the unintended consequences of the order. Continued patience and perseverance is in order for these residents. Hopefully, this situation will eventually pass.

 

 

 

 

 

 

 

 

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Can I Be Sued As A Radiology Resident?

lawsuit

As radiology medical school applicants, radiology residents, and full-fledged radiologists, we all dread the possibility of a lawsuit when we begin to practice radiology. Very rarely discussed, however, is the possibility of being sued during radiology residency. The good news: it is very unusual! One article stated that there were only 15 legal cases and 10 law review papers that addressed physicians in training and standards of care on two large legal databases. And, these cases were not necessarily radiology residency specific. The bad news is that although a remote possibility, it has happened several times in the past. 

So, this makes for a relevant topic that is not frequently addressed but is certainly a possibility. In this article, I analyze a few different sources on the web and literature to understand the conditions you need to meet for a patient to sue a radiology resident. More specifically, we will analyze what standards of care a resident needs to breach. Also, we will go through several ways radiology residents can prevent lawsuits in the future.

The Grounds for a Lawsuit

For a lawsuit to be successful against any physician in general, three requirements need to be satisfied. According to a recent article in Diagnostic Imaging, these are breach, causation, and damages. Breach implies that the physician did not satisfy the requirement of the standard of care. Causation means that the breach of duty caused the malpractice. And, damages indicate that the event produced significant harm. 

In today’s article, I will explicitly discuss the issue of breach without discussing causation and damages. Why? Because the concept of breach makes a malpractice case performed by a resident different from a fully trained attending.

Resident Breach For A Successful Lawsuit

Due to the standard of care being different for a resident, the definition of breach for a resident involved in a malpractice event becomes a little more complicated. In fact, over time, the standards of what breach means for the radiology resident have become blurred. I will discuss several cases with different definitions of what the legal system considers “standard of care,” specifically for a resident in training.

Breach For The Intern

Some cases have involved the medical intern. There was one case where an intern failed to identify retained glass fragments and sewed a wound shut. In this case, the court concluded that the criteria for the standard of care should be based upon the standards for the typical intern’s skills. Subsequent lawsuits have demonstrated that the first-year resident needs to fail to do something that a “physician or surgeon of ordinary skill, care and diligence” would typically do to breach the standard of care rule. In other words, the legal system can require a first-year resident without a full license to meet the standards of a general practitioner physician in terms of standard of care.

Breach For The Subspecialist Trainee

For residents in a subspecialty level training program, breach of the standard of care is even more confusing. Some cases imply that the sub-specialized resident should meet the obligations of a general practitioner. Other instances suggest that residents should meet the demands of a more specialized physician. Adding more confusion to the issue, one relevant article’s author reported a radiology resident-specific case of a misread MRI of a newborn. In this case, the court was unable to determine a specific resident standard of care and ruled in favor of the defendant. So, this case did help to define the “standard of care” for this radiology/specialist. (1)

In another case with a radiology resident, an AJR article discussed an incident during radiology moonlighting. The patient sued the resident for missing an abscess and instead called it a bladder diverticulum on a CT scan. The parties eventually settled the lawsuit, but the court determined that the jury would decide the liability before the settlement. This settlement implies that a standard of care was breached at the level of an attending subspecialist/radiologist.

The Main Source of Confusion About Breach

So, according to the literature, the law sometimes considers residents to have lower than the typical standard of care for attendings. Other times they are considered to be at the standard of care of a general practitioner, and at other times the resident has to meet the standard of the attending in his subspecialty. Confusing, huh?

What Does This All Mean?/Primary Take-home Messages to Reduce Liability For A Lawsuit

So, now that all this information confuses you, what does this mean? 

Precept 1: Regardless of the definition of breach for the radiology resident, make sure to get help if you are unsure, and the case can lead to patient morbidity. Getting help can reduce the odds of getting sued for a questionable interpretation and allows your fellow attending to take responsibility for the case.

Precept 2: If moonlighting, make sure you have malpractice insurance. Misses do happen, and the courts may treat you as a fully trained radiologist. So, don’t catch yourself off guard without proper insurance. You need to make sure that your insurance will specifically cover you for moonlighting mishaps.

Finally, Precept 3: Although it is infrequent, lawsuits do happen to radiology residents, and you are certainly not immune from the ravages of the legal system. So, treat each case as if you are the responsible party and always provide your best effort to make the correct findings, diagnosis, and management.

Lawsuits And Residents

Although unlikely, patients can still sue residents for malpractice. Don’t leave yourself susceptible to the possibility of a lawsuit as a resident!

 

References

Clin Orthop Relat Res. 2012 May; 470(5): 1379–1385.

Published online 2012 Jan 26.

Medical Liability of the Physician in Training

Brian Wegman, MD, James P. Stannard, MD, and B. Sonny Bal, MD, JD, MBAcorresponding author

Radiologists, Expect to Get Sued Mar 03, 2016 | RSNA 2015, Practice Management

By Liza Haar

AJR1998;171:565 Malpractice Issues in Radiology: Liability of the Moonlighting Resident By Leonard Berlin