Month: June 2017

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Is The New DR-NM Pathway Worthwhile?

DR-NM pathway

Message For The Director
Hi,
Can you kindly comment on the ABR/ABNM 16-month dual pathway? Is it worth it? Can one get a job without another extra year of fellowship?

Interested Resident

 

 

 

 

 

I would love to talk about the DR-NM pathway. I am an ABR and ABNM certified radiologist, so I am interested in this matter.

Reasons To Not Participate In DR-NM Pathway

If you are going into the DR-NM pathway, you may find a job after the 16-month program during your residency. However, for most people, I would probably opt for the more traditional route for several reasons. First, you will have much less training in general radiology. For most radiologists coming out of residency, you want to maximize your experiences in general radiology so that you feel comfortable in most modalities. You are replacing 12 months of general radiology with almost exclusively nucs. If you have less general radiology, you are less likely to be comfortable with modalities other than nuclear medicine when you work as an attending in general practice. Most radiology residents work for private practices, with some general radiology.

Second, it may be slightly less desirable for most private practice employers to hire someone with less “radiology” experience. Since this DR/NM pathway is so new and there is less general radiology training, employers may recognize this pathway as a second tier.

And finally, you are pigeonholing yourself into nuclear medicine from the beginning. Most programs will want to know that you will complete the DR/NM program as early as possible (perhaps even from day one of residency!) since scheduling mandates that you need a specific set of rotations. Unfortunately, most trainees have no idea what they want to do at the start of residency.

One Reason To Participate In DR-NM Pathway

So, who would be suitable for this program? The individual that has known for a very long time that they want to specifically subspecialize in the nuclear medicine field. Also, this person should be interested in a primarily academic job (I think that would be the one area where employers would find candidates completing this pathway most enticing).

Final Thought

I’m not quite sure where you stand. However, I would generally recommend the standard one-year nuclear medicine fellowship for most trainees.

I hope that helps!

Director1

 

Click here for more information on the DR/NM program.

  

 

 

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What To Look For In A Radiology Residency?

residency

No perfect radiology residency program exists for radiology residency applicants, and no one size fits all. Each candidate has their own needs, wants, and learning style. And each program has its positives and negatives. Therefore, each applicant should strive to match with the appropriate residency. In doing so, the positives of the program should fit well with the applicant’s needs. And, the negatives should be minor and not detract from the overall radiology resident experience.

My goal for today is to discuss the essential ingredients for choosing a radiology residency. Most online overviews do not address many of these crucial factors to look for in a radiology residency program. So, I thought it was critical to include them. Included in my discussion will be of the highest importance to most minor importance: residency culture/hierarchy, location/proximity to family/friends, intimate insider knowledge of a program, rotations/equipment/procedure volume, university vs. community programs, private vs. academic run departments, graduating resident fellowships, conferences, research, mentorship programs, and board passage rates.

In the end, the overall residency experience will allow you to become a great radiologist. So, I will put it all together at the conclusion to help you to make a final decision. To do this, I have assigned an individual point score for each factor. It would help if you recorded for each residency you are considering for ranking. In the end, add up the points. And then, compare to the other residencies on your rank list. When you finish, rank each accordingly.

Residency culture (5 points)

Residency culture is probably one of the most critical factors to think about when choosing a residency. However, it is also one of the most difficult to define. The difference between happiness and misery in a program first and foremost often lies with the colleagues that you have. No matter how excellent the overall “experiences” of a residency program, you will not want to come to work if you hate the people you work with. On the other hand, if the residency is marginal, but the people you work with are fantastic, the four years of residency will not be so bad.

What To Look For

The problem with using this factor for choosing a residency is that it is a moving target. From year to year, residencies accept new residents, and old ones leave. So, the residency culture today may not be present tomorrow. However, the attending, technologist, and coordinator support structures of the residency often remain relatively similar. So, it would help if you got to know the residents and the leaders and purveyors of the program.

In addition to getting a sense of the “happiness” of the residents, you should determine the residency leadership style. Some programs prescribe processes for everything that happens in the program. Other programs have a more laissez-faire attitude. Some programs have one or two leaders at the top that act as “benevolent dictators.” Others have each of the attendings with equal say over residency issues.

No one structure is “correct.”. If you are the type of person that needs a well-defined structure, the hierarchical culture would fit better. On the other hand, if you like to create your path and define your schedule, you may prefer a program with an equal footing.

Location and Proximity to Friends/Relatives (4 points)

Over my years as an associate program director, I have found how important it is for residents to have a social outlet. Although not a “resident related experience” per se, this factor can be just as important. Being near loved ones can make the difference between a terrible residency experience and a great one. A support structure can be just as crucial as the residency program itself. I find that the best residents have a healthy support structure outside of residency. Therefore, the location and proximity to loved ones can be essential factors, just as the residency quality. For instance, who would want to be in Manhattan if your children/spouse are in California? If asked by medical students, I will usually mention that they need to consider location seriously.

Insider/Intimate Knowledge of a Program (4 Points)

As a medical student, it helps to rotate through the radiology residency program you may want to attend. Suppose you know the residents and attendings before starting a program. In that case, you already know the residency program’s upsides and downsides and where “the skeletons are hidden.” Knowledge can be worth its weight in gold. It can be challenging to tell what the true nature of a residency program is like before starting a program. Therefore, having insider knowledge can help you when you begin your residency because “you know what you are getting into.” These residents often are some of the most successful because they have a distinct advantage of knowing the attendings, residents, and the hospital system, even before beginning their residency. Do not dismiss insider knowledge as a factor for making this big decision.

Rotations/Equipment/Procedure Volumes (4 points)

I am lumping these factors into one conglomerate. Why? Naturally, the residency must have all the resources you will need to be comfortable with to practice radiology. If you are in a program where the diversity of patients and patient volumes are sorely lacking, you will be at a loss when you are out in practice and have not seen those cases in your area of practice. Likewise, if the faculty does not perform procedures such as arthrograms or your program doesn’t have a 64 or 256 multidetector CT scanner for the interpretation of cardiac CTAs, you will certainly not feel comfortable performing these procedures when you are an attending.

So, you must make sure to search for a program that has all the necessary resources to allow you to learn all the imaging and procedure skills you will need to become a competent radiologist. Furthermore, as summarized in another post, Best Radiology Electives for the Senior Resident, it is imperative that you can rotate in areas of weakness or interest during your residency. Why? Because hiring practices are looking for residents who can do a subspecialty and are competent in most areas of general radiology practice. So when you are in interviews or looking up information on the web, make sure to look into these factors. Once you have started a residency program without all the crucial resources to make a great radiology resident, there is no going back!!!

Community vs. University Programs (3 points)

Incoming medical students tend to put more weight on attending a “university program” rather than a “community” program. However, both programs give distinct advantages that applicants do not realize before choosing a residency program. A sizeable academic university program does not fit everyone’s career path. So, what are the advantages and disadvantages of each?

Depth Of Resources

Large academic university programs tend to have resources in specific subspecialties and have several attendings that practice in a particular subspecialty. On the other hand, the smaller community programs tend to have more general radiologists that cross cover multiple specialty areas. So, as a resident attending a university program, you will get a more in-depth experience focusing on individual subspecialties. As a community program resident, you will get a more private practice and “real world” hands-on experience. So these programs should attract different types of radiology residents.

Beauracracy

Also, at community programs, you tend to have more accessibility to your attendings and will more likely work one-on-one with that individual. Also, if you have a specific need, it is more likely to be addressed personally without having to go through “bureaucracy” to get there.

At a sizeable university program, more physicians will intercede with direct attending teachings such as senior residents, visiting fellows, fellows, and junior attendings. You may also need to get through bureaucracies to obtain specific resources within your program. However, some electives and rotations may not be available in a smaller community program, such as connections for abroad electives or other opportunities.

Summary

So, this factor should play a role in your decision. But, it depends on the type of practice you want when you leave the system. One is not better than the other for all.

Private vs. Academic Run Departments (3 points)

This factor is often not mentioned or included as a factor in making a residency program decision. But having worked at private, hybrid, and academic programs, I think it should be essential.

I completed my residency in the private/academic hybrid model, and I found some real advantages to this sort of residency program. We had to get through a specific number of cases each day to meet the appropriate caseload. It was a more “real world” experience that allowed me to hit the ground running when I started my first job. I was dictating loads of cases from the beginning and had tons of experience by the time I graduated. My experience was very different from some of my more academic-run department-trained colleagues that I knew. Some of them had more difficulty getting through lots of cases during the day and felt a bit more uncomfortable at their first community radiology job. It made a difference in the long run for me, as it allowed me to become a more efficient general radiologist.

Academic run departments with attendings hired by the hospital emphasize different qualities. These departments may have more resources dedicated to teaching daily. For the resident interest in a purely academic job, it may be heaven!!! But, they may not simulate the real world. They can perseverate on a few cases for an extended period. So, for the radiology resident interested in private practice, a residency such as this may not be the right fit.

Conferences (3 points)

The ACGME theoretically requires all residencies to have at least a daily conference. But, not all are created equal. Some programs have additional morning conferences, while others have the resident prepare for and present at interdisciplinary conferences. And, even others have residents prepare medical student teaching conferences. The styles and types of meetings can vary widely at each program.

Additionally, you should ask if the attendings regularly show up to give their conferences. Please beware of the program with many on paper, but in reality, it does not have the number they suggest.

The importance of the number and type of conference depends on the individual resident. Some residents learn better with didactic sessions, and others benefit from hands-on direct radiology experience. So, the importance of this factor will vary with the individual applying.

Graduating Resident Fellowships (3 points)

It is critical to check where the former residents have gone to fellowships. Are the residents not able to get into competitive subspecialties? Are they going to “no-name” programs? Do the attendings at the institution have connections and networks with other fellowship programs throughout the country? These are questions that you should ask when you get to your residency interview. Or, you should check online for this information. Knowing where prior residents have attended can show you if they get into competitive subspecialties and fellowships.

Research (2 points)

For the academically oriented, research can be an essential factor in selecting a radiology residency. For the community-oriented, it is less so. But, when you look for jobs, having done some research implies an interest in and commitment to radiology. So, it is essential to have had some experience on your resume to get both the academic and private practice job. Therefore, research within an institution should play some role in your decision.

To make this assessment, it helps to get a list of the resident research output over the past five years. You can see what kinds of studies the current residents have completed. Are there retrospective studies, case reports, or large prospective trials? Is each resident finishing lots of projects? And, does the program have research conferences to support the resident? These findings should help you decide if the residency has a curriculum that encourages residency research.

Mentorship Programs (2 points)

Some residency programs have a dedicated teaching program that helps out first-year residents and gives didactic lectures. Others assign an attending mentor to the resident that is the “go to” person for all issues during their four years of residency. When added to the other factors, applicants can use these perks to help make a final decision.

Board Passage Rates (1 point)

I will include board pass rates last because I believe that studying for the new core exam is more of an individual’s responsibility. Of course, you need to pass your boards. But, I think that the overall residency experience becomes more critical in making you into a great radiologist than the board passage statistics. On the other hand, a radiology residency program should have primary resources for residents to pass the exam. They should have learning materials and books as well as board reviews. Great residencies have had lower board pass rates, large academic institutions, and small programs over the past few years. In the end, the examination is very different from the practice of radiology, but it is another hurdle to overcome.

Putting It All Together

No one factor should make or break your decision to go to a specific program. But instead, the different factors should be weighed based on the individual applicant’s needs and wants. So, add up the numerical point totals for each program next to each section and develop a final score to create a final rank list for every residency program.

To summarize, though, for most residents, I sincerely believe that you need to take the residency culture to be one of the most critical conditions for ranking a program in the residency match. And, location can have a significant effect on your happiness or misery during those four years. But, a quality residency culture and a suitable place without adequate training resources would not be enough. So, be careful when you factor each into consideration.

A great radiologist is the sum of one’s experiences that often stems from radiology residency as the initial building block. Ensure that the foundation will provide you with the training you need to become the best you can be. It can be a difficult choice, but I hope I have provided you with the tools you need to make that decision. Good luck with the match!!!

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Can You Pass The Real Saint Barnabas Diagnostic Residency Precall Quiz?

Today you are in for a treat. Our first-year residents at Saint Barnabas have all passed my homemade Precall Quiz with flying colors. So I was thinking why not publish the same 10 cases with images/videos below so you can test yourselves? (Don’t forget to look at the links to the videos for questions 2,3,5,6,8, and 10 that are either after the images or are on their own!) I also gave each resident up to 5 minutes to come up with a final diagnosis and they had to get at least 80% correct to pass. Can you do the same? Check out the answers at the bottom of this page to see h0w you did. If you pass, you are ready to take call!!! Let’s begin!!!

One…

 

Two…

 

Case 2 movie

 

Three…

 

 

Case 3 movie

 

Four…

 

 

Five…

 

Case 5 movie

 

Six…

 

Case 6 movie

 

Seven…

 

 

Eight…

 

Case 8 movie

 

Nine..

 

April 4, 2016

 

 

April 4, 2015

 

 

April 4. 2015

 

Ten…

 

Case 10 movie

 

1. Free air and air tracking adjacent to the ascending colon.

2. Acute appendicitis

3. Type A Aortic Dissection- Call Vascular Surgery!!!

4. T10-11 Disc Herniation with acute cord compression and possible early cord edema.

5. Normal/ nonspecific mesenteric subcentimeter nodes- ? mesenteric adenitis

6. Right-sided UVJ stone with right-sided hydroureter and hydronephrosis.

7. Left MCA distribution acute infarct with MCA thrombus. Evolving right frontal infarct.

8. Bilateral pulmonary emboli and right pleural effusion/air space disease

9. Probable old trochanteric avulsion fracture- Key point- it is chronic (lesson- look at priors!!!)

10. Proximal sigmoid mass, probably subserosal with findings suggestive of large bowel obstruction. Additional mesenteric adenopathy.

 

 

 

 

 

 

 

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How To Artfully Communicate Uncertainty

uncertainty

Many of you know the oldest radiology joke in the book: What is the national plant of radiology? The Hedge! In truth, we as radiologists have to face more uncertainty in our profession than most. Diagnoses of 100 percent certainty are rare. And, we need to communicate this information to our fellow clinicians reasonably. So, how do radiologists do this without infuriating our clinical colleagues? To investigate how, I will divide this post into multiple sections, each one with a meaningful discussion to help you decrease uncertainty for the clinician. Welcome to my world!!!

Don’t Beat Around The Bush

Say what you mean and mean what you say. Don’t hem and haw about your insecurities. Even though we cannot come up with a final diagnosis at times, it is important to say just that. Make sure not to put in too many caveats and extra words. If you see a liver lesion and it could be an atypical hemangioma or hypervascular metastases, don’t use flowery language or multiple qualifiers like the words: however, compelling, of course, and so on. Just say the differential diagnosis includes hemangioma or hypervascular metastasis.

Excommunicate Cannot Be Excluded

One of my most hated phrases in radiology is (drum roll please…) “cannot be excluded.” But, it is not just my least favorite phrase; it is also the clinicians’. Why? It has the potential to force a clinician to investigate further an unlikely diagnosis. 

If you think that a renal lesion is most likely a hemorrhagic cyst, you should say the renal lesion is most likely a hemorrhagic cyst. Suppose the possibility of a renal cell carcinoma is slight. In that case, you can say that the features are not characteristic for a renal cell carcinoma and the likelihood of the lesion to be a renal cell carcinoma is exceedingly rare. On the other hand, if you use the term renal cell carcinoma cannot be excluded; you give the clinician no sense of the actual probability of renal cell carcinoma. The phrase cannot be excluded often causes the unintended consequence of additional unnecessary workups related to your dictation.

Correlate Clinically

Another way to reduce uncertainty is to find additional clinical information on the patient. If you are not sure, look up the laboratories, the prior studies, the actual clinical history, the vital signs, or the accurate ER report to add more certainty to your report. Think of it this way. You have one report that says: chest film shows right lower lobe pulmonary parenchyma disease, possibly pneumonia, atelectasis, or pulmonary edema. On the other hand, you have another report stating the following: Given the elevated white count of 20 and the patient’s elevated temperature of 106 degrees, the right lower lobe pulmonary parenchymal air space disease is most likely pneumonia. You can see that the increased certainty of diagnosis in the second report is significantly more helpful to the clinician that ordered the study.

Specify Probabilities

If you are not sure of the diagnosis, why not just say the probability of the diagnosis? At least, this will help the physician on the other end of the report know how far to work up the patient for other possibilities. Giving a laundry list of diagnoses x versus y versus z helps no one. But, if you know the chance of x is much greater than y, which is greater than z, that opens up a whole new way for the clinician to proceed next with the patient.

Describe The Findings Well

Finally, if you are unsure of the final disposition, make sure you describe the findings well. For instance, if you see bulky adenopathy in the right hilum, make sure to say the size and shape, whether it narrows the mainstem bronchus, and if it causes post-obstructive atelectasis or pneumonia. You may not know the diagnosis. But, the clinician can now decide whether they can get to the abnormal lymph node by bronchoscopy or proceed to the next step. By describing the findings well, you ensure that the physician will work up the patient appropriately.

Communicating Uncertainty Well!

Our specialty is fraught with uncertainty. That is OK. It’s just the way it is. More importantly, good skills to communicate uncertainty can save your reputation and the reputation of the specialty. Suppose you follow my advice about directly saying what you mean. In that case, avoiding cannot be excluded; looking up clinical information while incorporating it into your report; specifying probabilities, and describing the findings well, you can at least drive the clinical physician to the appropriate next step. See. Uncertainty is not that bad!!! Just like always, it is all about good quality communication.

 

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Most Common Stereotypical Generation Radiologist Differences

generation

 

Millennial
Generation X
Baby Boomer

 

 

 

 

 

 

Although not every radiologist fits the particular stereotype for their generation, some generational stereotypes ring true. On the whole, the baby boomers, Generation X, and Millennials perform better and worse in some parts of the radiology workforce and have their own particular needs. When you work with these individuals, it is vital to keep this in mind. Sometimes, we need to change the way we operate to accommodate these differences. So, today I would like to go through some areas where radiologist generations differ, arranged by different topics. I hope you enjoy it!

PACS And Social Media

Baby Boomers: These folks tend to be less comfortable with PACS system changes. So, beware of the PACS upgrade! It can wreak havoc on their lives. Social media can be somewhat foreign to these radiologists. Many of these radiologists do not have Facebook, Linkedin, or Instagram accounts. So, sending out messages via these media may be a waste of your time.

Generation X: For these radiologists, PACS utility issues tend to be a mixed bag. Some of the less tech-savvy radiologists fall into a similar category as a Baby Boomer. Others are more adept with PACS systems. On the other hand, social media outlets are generally much more native to the Generation X radiologist with broader and more frequent use. Although not all of these radiologists use social media, you will be more likely to find these folks more comfortable.

Millennials: On the whole, these radiologists cope well with PACS updates and changes as long as the network runs correctly. Their technology knowledge enables these individuals to learn quickly and grasp the most efficient ways to learn PACS. Social media is not just a tool for many of these individuals; it can be a way of life. Their online persona can become just as important as their offline interactions. They tend to engross themselves in the online world.

Barium Work/General X-rays

Baby Boomers: This group of individuals has, by far, the most expansive repertoire of experiences with both barium work and plain films. Since it was the mainstay of radiology initially, they often pick things up that their more junior colleagues will miss. They can work wonders with barium and grasp the nuances of a good barium examination.

Generation X: They can read plain films rather adeptly and efficiently. Although not as seasoned as a Baby Boomer, they can read an x-ray reasonably well and are comfortable with most barium work. During residency, they have had lots of experience with films and barium slinging.

Millennials: Since they spend a lot more time with CT and MRI than plain film work during the residency, overall, they are less comfortable with plain film interpretation. As residents, hardcore barium studies experience such as barium enemas can be minimal. So, the performance and interpretation of these studies can be a bit more challenging.

MRI

Baby Boomers: It is much less likely for the Baby Boomer to feel comfortable in this modality since they may have completed MRI training after their residency. Most Baby Boomers will avoid MRI if possible.

Generation X: Plus or minus. Depending on the experiences during residency, some feel very comfortable with general MRI work and others less so.

Millennials: Most Millenials are comfortable with all MRI since it has become “bread and butter” radiology, just as standard as all the other modalities out there. I would certainly put a lot of faith in their excellent reads!

Vacation Time

Baby Boomers: This generation believes in the adage “live to work.” Overall, they tend to take less vacation than given (although they get more vacation time than the rest of the generations!)

Generation X: They have a similar work ethic to the Baby Boomers than Millenials, although they can straddle both sides. Vacation time is essential, and they fully take advantage of their time off the job.

Millennials: Everyone needs to work around the Millennials’ schedule. Their motto is “work to live, not live to work.” They like flexibility in their schedule and will do whatever they can to get to the lifestyle they want. Every day a practice gives vacation time, these radiologists will take the day. They do not spare a moment that they can use to bolster their lifestyle.

Money

Baby Boomers: For the most part, these radiologists sit on a large nest egg, having worked through radiology during its most lucrative years. Debt load tends to be nonexistent. They have the most flexibility and can leave the workforce whenever they want. Many of these radiologists perform their job solely for the “love.”

Generation X: Most of these radiologists have paid off their debts and have done relatively well in their specialty. Money is still important to these folks because they still do not have enough to retire. But, they have good jobs and will do well overall since they have been working during the “good years.”

Millennials: Severe student debt weighs down these radiologists and can limit their opportunities to places and jobs that this generation does not want. It almost runs counter to their ideal lifestyle philosophy. These radiologists also started to work in the field during lean radiology years and are more likely to have had less opportunity to make money. Hence, there is some bitterness when it comes to discussing the topic of money!

Interpersonal Relationships

Baby Boomers: Overall, this group develops solid interpersonal relationships with their colleagues and staff. They never had the opportunity to rely on social media or other forms of technological communication, so they deal well with others. In addition, they have the least need for external approval.

Generation X: These radiologists probably have more in common with the Baby Boomers than the Millenials since they grew up in a world without social media. They were allowed to fail just like the Baby Boomers but were more protected than them. But, they do develop strong interpersonal relationships with their colleagues.

Millennials: Since many of these folks were not allowed to fail growing up, they need to be outwardly appreciated by their colleagues much more than the other generation. They spend a lot of time on their mobile devices, garnering relationships with others. Since online life can be just as important as their offline persona, some can seem outwardly unfriendly because of the time they spend on their devices.

Teaching Expectations:

Baby Boomers: They love a great lecturer and taking cases. However, after completing a teaching episode, the Baby Boomer will research and read the topic to reinforce learning. Overall, the Baby Boomer does not care about electronic media, but some will use it. Old-fashioned books instead of ebooks work better for the Baby Boomer.

Generation X: The typical generation Xer fits somewhere between the Baby Boomer and the Millenial. They will do their research and not expect the lecturer to tell them everything they need to know but understand the practicalities of ebooks and electronic resources.

Millennials: They traditionally have been spoon-fed information in lectures. And, they expect everything to be spelled out for them when others teach them. Overall, they expect the teacher to know everything about a topic and point them toward all the resources they need to read. Most Millennials use ebooks exclusively and will utilize electronic media to reinforce all learning.

Summary

I repeat, “These stereotypes certainly do not apply to all radiologists out there!” However, I think there is an overall tendency for individuals of each generation to fit some of the stereotypes. Knowing the strengths and weaknesses of each generation allows us to schedule accordingly, allocate appropriate resources, and understand what each generation needs. For instance, since the Millennial tends to have a higher debt load, allow for more moonlighting opportunities or extra work. Or, make sure to incorporate additional training with new electronic PACS system upgrades for the Baby Boomer. Bottom line- it pays to understand each generation!!!

 

Featured on Aunt Minnie.com!!! Click here for the Aunt Minnie version.

 

 

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Ten Of The Most Frustrating Radiologist Phone Calls

phone calls

As radiologists, we speak with ornery physicians, upset patients, uninformed technologists, and headstrong nurses on the phone. Daily, the phone calls we take are not all peaches and cream. Sometimes these phone calls can get the best of us. So, I thought this would be an educational opportunity for those just beginning their residency or considering a career as a radiologist to understand what goes on in daily practice. Here is a list of some of the most distasteful and frustrating phone calls you may encounter when working as a radiologist. It’s part of our life. Expect the worst but hope for the best!!!

Missing The Diagnosis

You’ve been going through films and feel like you are accomplishing significant work today. For the 3rd time today, you hear the phone ring loudly. As you pick up this phone call after a decent day… WHAM… everything changes, your heart sinks. That patient with pancreatitis has pyelonephritis, and you can hear the physician’s upset but pleasant tone. Can things get worse?

Any Call For Barium Study After 12 AM

Your eyes are watery, and you are barely staying awake in the reading room. Suddenly, the phone rings. “We need a barium swallow to look for a stuck chicken bone in my patient’s throat.” Now I’m never going to get any shuteye. Ugh, the pain won’t stop!

Bad Timing

You have a patient with unsuspected metastases on a thoracic spine MRI, and you attempt to reach out to the physician who ordered the study. “Hi. Is this Dr.______?” Next thing you know, he starts yelling at you, “How dare you to call me while I am at my father’s funeral!!!” He bluntly hangs up the phone. So much for good physician communication!

Contrast Stupidity

You arrive at your workstation and receive a requisition for an abdomen and pelvic CT scan with contrast for a patient with symptoms of flank pain and urinary tract stones. So, you call up the physician and tell her, “I think that you made a mistake with the order. You meant without contrast, right?” The next thing you know, she is arguing with you how contrast studies are better for patients to diagnose an obstructive stone. The conversation goes on for what seems like hours. It’s like talking to a piece of cheese. Oh, My God!!!!

Fellow Physician With Positive Findings

A physician friend comes down from his department and asks you to give him a call when you get a chance to look at his chest x-ray. He has a mild cough. So you oblige and say, “OK.” Ten minutes later… You look at his film, and he has sclerotic bone lesions and pulmonary nodules everywhere. Looks like mets. Gulp. You pick up the phone, not quite sure what to say. Finally, your voice cracks, “Can you come down here. I need to speak to you in person.” Poor guy. How am I going to break the news to him?

Misplaced Anger

As part of your typical protocol, you call in the results of a normal V/Q scan. Suddenly you hear a booming voice on the other end, “HOW DARE YOU CALL ME FOR A NORMAL STUDY DURING REGULAR BUSINESS HOURS!!!!!!!!” You hear a loud click. So much for congeniality…

Demand For Incorrect Protocols

You are going through a knee MRI and notice that the tech did not include the coronal images even though they are essential to evaluate the collateral ligaments. So, you call the technologist to determine why the MRI does not include the appropriate imaging after the patient recently had a motor vehicle accident. The technologist says smugly, “Oh, we didn’t need these images because the clinician said they don’t need the coronal images.” What?

Clinicians That Expect You To Make Their Clinical Decisions

On the queue, a film pops up, and you look at the images. At the left base, overlying the cardiac silhouette, there is an airspace opacity obscuring the diaphragm. So, you decide to call the Emergency Department, and you get through to the Nurse Practitioner. You tell her, “The patient has a left lower lobe pneumonia.” Surprisingly, she asks you, “How do I treat this patient? What kind of antibiotics should I administer?” Listen, buddy- this is above my pay grade. That’s your job!!!

Request For Stats But No One Is Home

At the outpatient center, you see an abdominal and pelvic CT scan with a prescription that says STAT, needs a prompt phone call to the doctor. So, you look at the study at 4 PM and find mild diverticulitis of the sigmoid colon. So, you call the number and receive a message prompt; please dial _______ number to get through to the doctor. Next, you call the number and talk to the secretary. She casually says, “The doctor is not around and there is no one covering.” But, you respond, “But it says STAT!”. She then retorts, “But no one his here.” The phone hangs up abruptly with deafening silence…

The Need To Call The Patient Directly

The patient has abdominal free air on a random CT scan of the chest for pneumonia. So, you call the clinician for the 3rd time after leaving multiple messages with the answering service. No response. The only next available option is to contact the patient directly to come into the emergency room to get checked out. So, you find the number and speak to the husband of the patient, who is 90 years old. He says, “What are you talking about? You need to call my doctor. I don’t understand why my wife has to go to the emergency room.” You spend about 45 minutes on the phone trying to convince him to get her wife to the hospital because you can’t get through to the doctor. Finally, you get the husband to take her wife to the emergency room. Fifteen minutes later, after this long-winded conversation, you get a phone call from the patient’s doctor. What a waste of time!

Phone Calls Can Be Painful!

Although many phone calls are positive and rewarding, these are just some of the phone calls that will frustrate you as a radiologist. So be prepared to have some pretty painful phone conversations with your fellow clinicians, colleagues, and friends. It’s part of the job!!!

 

 

 

 

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USMLE Step III- An Impediment For Radiologists?

Over the past few years, we have been witnessing a new phenomenon that I don’t think is unique to our diagnostic radiology residency program. Incoming residents are either delaying or failing their USMLE Step III examinations. Some of this new reality may be related to the decreased competitiveness of radiology. However, what is interesting is that some of the residents that fail or delay the examination are not toward the bottom of their respective classes but rather are high performing residents with a good fund of background knowledge in radiology. That got me thinking. What is going on with the new USMLE Step III examination? And, should the examination be a prequalifying factor for obtaining medical licensure prior to becoming a radiologist?

According to the USMLE Step III website, “Step 3 content reflects a data-based model of generalist medical practice in the United States. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated, physician might encounter within the context of a specific setting. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care.”

If you actually take apart the content of this summary statement of the Step III boards, you will see that the goal of the examination is in no way applicable to the intellectual goals/medical knowledge necessary for being a good radiologist. Based on the responses of many of my residents that have already taken the test, the questions, and content of the test have limited applicability to the practice of radiology. Very few questions are radiology related and have clinical scenarios that would ever be useful background information for a radiology resident/radiologist. So, is it really warranted to have radiology residents pass such an exam in order to practice their specialty? What is its utility?

Furthermore, the concept of having an intern that trains for one year and practices independent medicine is outdated, to say the least. Almost no hospital or clinic would ever hire a physician without some sort of complete residency training in a specialty whether it be internal medicine, psychiatry, or radiation oncology, let alone radiology. The liability of a hiring physician without this training would be enormous. I, for one, would never let any of my family members see a physician with one year of internship training who had merely passed the Step III USMLE examination.

More relevant to us, radiologists and other subspecialists never practice independent general medical care. The clinical situations that undifferentiated physicians encounter is very different from the needs of subspecialist radiologists. So, why prepare a physician for an end goal that he or she is never going to realize?

All these issues, bring me to this final conclusion. Maybe we consider creating a new examination that is actually going to be relevant to the goals of the subspecialist and not the general practitioner. Perhaps, we should create two separate exams, one with a general pathway and the other with the subspecialty pathway in mind. At least, you would create a test with increased relevancy and with a practical end goal for the individual subspecialist that would help with their future career requirements.

It is time to rethink the requirements for resident physicians obtaining medical licensure since the present concept of practicing independent care as a physician after one year is outdated and dangerous. And, subspecialists have different needs from general practitioners. With that, the Step III examination should change accordingly.

 

 

 

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Should I Sell Out To The Legal Profession?

legal

Often radiologists deliberately take advantage of the opportunity to do legal consultation work for a fee. These services include expert witness work and legal brief consultations. Their colleagues deride some of these radiologists. Other physicians call this “selling out” to the lawyers. But is it? Today I will discuss why I think that radiologists who perform legal work provide some benefit not only to their financial well-being but also contribute to their own clinical and professional skills as a radiologist.

Better Understanding Of Radiology Malpractice

Nowadays, in the United States, radiologists encounter so many pitfalls that can potentially envelop them in a lawsuit. Sometimes the only way to avoid one is to observe others’ mistakes. Participating in legal work provides this window to see other radiologists’ errors and to understand how to prevent these hazards. We are only a hair’s width away from being involved in a lawsuit for our actions and vocabulary daily. Why not work to distance yourself from being the next lawsuit victim?

Improved Reports

Contrary to popular belief, involving oneself in legal work improves the readability of most radiologists’ reports instead of detracting from them. Those who do legal work are much less likely to leave grammar errors, typos, and other blunders in their reports. They tend to take the radiology report’s structure and final appearance much more seriously. Since they understand the ramifications of an unclear dictation, they are much less likely to confound their fellow clinicians with poor dictation.

Physicians participating in legal work are also more likely to know the jargon to not place in a report. Sometimes the wrong word choice can increase the chance of a lawsuit. Why not decrease the likelihood of it happening to you?

In addition, these radiologists tend to create differentials that consider the clinical situation because they know that subtleties can vastly change the outcomes of the patient’s management based on the malpractice outcomes of other radiologists. The final impression is more likely to consider these clinical issues, providing more benefit to the ordering clinicians.

More Thorough Documentation

Some radiologists do not take the documentation of conversations with clinicians seriously. Understanding the mechanics of malpractice increases the likelihood that a radiologist will document the critical findings and discussions with other doctors and patients. This information is vital not just for the attorneys but also crucial for the timeline of the medical record to allow for better treatment and an understanding of the events during a patient’s clinical stay.

Improved Communication With Fellow Physicians

Knowing what has happened in other malpractice situations also forces us to be more careful to communicate the results of a report on the phone or “in person” with other clinicians. Those that have completed malpractice work have a much lower threshold to trigger a phone call to their colleagues so that the report and the patient do not “slip through the cracks.” This understanding is only to the final benefit of patient care.

Is Legal Work Selling Out?

Based upon these tangible benefits of malpractice work, I think I make a case that participating in legal consultation is not “selling out.” Of course, some physicians abuse the legal system to make a quick buck and never learn from the mistakes of other radiologists. However, most radiologists that work with attorneys genuinely want to help their radiology colleagues and improve their clinical and professional skills as a radiologist. Maybe we should all consider doing some malpractice work at one time or another!

 

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Radiology Residency Chain of Command

radiology residency

No, we are not the military, but there is a radiology residency chain of command! Lots of different entities in radiology residency are responsible for your day-to-day activities and training. It is more than your faculty and program directors. It is a whole hierarchy. And, it is was not until later on in my career that I understood the roles that each of these entities played in managing a residency program. But, it would have been nice to understand it all from the very beginning and know who to address for each radiology residency issue. To that end, in today’s post, I am going to define each of the different titles and offices in charge of your radiology residency training and describe the parts that they play. For fun, each role I will associate with a military position! Let’s start at the bottom and work our way up.

Radiology Resident (Private)

A radiology resident is the “lowest” but the most integral part of the chain of command. It is his/her responsibility to be trained in the art and science of diagnostic radiology during the four years of residency. To become a member of this club, he/she needs to graduate from medical school and complete one year of clinical training. After that, he/she answers to all the other “higher” positions listed next!

Radiology Chief Resident (Corporal)

Typically selected by the residents and program directors, this person is the first rung in the ladder of the radiology residency command (also previously discussed in a prior post). When there is a fundamental residency level issue or problem, he/she rises to the occasion. The chief resident is often responsible for scheduling, board reviews, interclass conflict, drinks with peers, performance issues, and noon conferences. In addition, any residency program issue that does not need to go to the attending is under the purview of the chief resident. And, the chief resident is also responsible for communicating faculty-related issues to the residents.

Radiology Residency Coordinator (2nd Lieutenant)

He or she is responsible for the day-to-day running of a residency program but is typically an administrator and not a physician. Most residency coordinators make phone calls, transcribe letters of recommendation, report issues to the faculty, send out evaluations, deal with class conflicts, ensure that the learning portfolios are complete, arrange end-of-the-year parties, and more. Some play a significant role in admissions committee screening. And, the coordinator is often the first-line resource for radiology residents when they have issues with colleagues or attendings. The radiology residency coordinator is an integral part of a radiology residency. (I think of this person like the Class Mom/Dad)

Radiology Faculty (Captain)

Full-time faculty members are responsible for the direct and indirect supervision of residents. The ACGME guidelines require all faculty members to teach. In addition, there are specific minimum numbers of faculty members that are necessary to run a residency program. Teaching involvement, however, varies widely by each faculty member. Residency programs expect all residents to follow the faculty lead when it comes to reading, procedures, and training in any of its forms.

Radiology Section Chiefs (Major)

This designation can be a bit technical. Theoretically, the radiology section chief for a radiology residency program can be different from the head of the section in a department. However, these individuals run the individual subspecialty rotations for a radiology residency. Individual faculty members answer to their respective section chiefs in one of many academic areas. The section chief may also perform many other duties such as setting up protocols for technologists, introducing new procedures, signing off on resident competencies and curriculums, ensuring that the subspecialty curriculum is appropriate, and more.

Associate Program Director (Colonel)

Although not an official designation by the ACGME, the Associate Program Director is the second in command for running the residency program. Suppose there are issues that the radiology chief resident, faculty, coordinator, or section chief cannot take care of. In that case, these problems fall into the lap of the Associate Program Director. He/she is also responsible for curriculum planning, enforcement of residency rules and regulations, maintaining education quality, dealing with residency conflicts, answering both the program director and the residents, and more. The Associate Program Director shares these responsibilities with the Program Director.

Program Director (1 Star General)

The ACGME designates this individual as director in charge of the residency program. He/she is ultimately responsible for most issues that occur during a radiology residency. In addition, the radiology Residency Program Director signs off on each resident that he/she is competent to practice diagnostic radiology after graduation. Clinical activity for this individual varies widely depending upon the program’s size, but most have some clinical duties. However, all Program Directors are responsible for monitoring the clinical teaching in the residency program and administering the radiology residency. So, this person is ultimately accountable for a radiology resident’s training.

Radiology Department Chairman (2 Star General)

The Radiology Department Chairman is the head of the entire radiology department. This person is responsible for dealing with all faculty issues and indirectly will usually help with radiology residency administration issues. When there are complaints about individual faculty members, new radiologists to hire, budgeting, and high-level resident problems, this person steps in to help manage the situation. Frequently, the program directors will consult with the chairman before making important decisions. The chairman sometimes holds the purse strings for some residency programs.

Designated Institutional Official (DIO) And The Graduate Educational Committee (GME) (4 Star General)

The DIO is the head of the hospital GME Committee. The radiology residency program director answers to the DIO for program-level issues and high-level resident issues. The types of problems that a DIO will often work with include accrediting residency programs, monitoring pass rates for programs, dealing with probation and suspension of individual residents, checking residency action plans, adding complements to residency programs, and more. In addition, he/she often gets involved in legal residency issues. And, this is just the tip of the iceberg. Typically, this is a full-time administrative position that is very busy! Individual programs bring many of these issues to the DIO’s attention, and they are subsequently voted upon by the GME Committee for approval.

American Board of Radiology (ABR) (Military Service Chiefs)

The ABR is a private organization in charge of testing for minimum competency for the individual radiology resident. All radiology residents need to pass the boards administered by the ABR to become board-certified radiologists. Although they are not directly in charge of residency issues, they play an essential role in determining the curriculum for the individual radiology residency program since they create the board exams (the core and certifying examinations more specifically).

Accreditation Council For Graduate Medical Education (ACGME) (Chairman of the Joint Chiefs of Staff)

Now we are talking high-level!!! The ACGME is a governmental-run body that is the watchdog of residency programs, a diagnostic radiology residency program. This organization accredits each radiology residency program. They have the power to put a residency on probation or suspension. As part of the ACGME, other committees, such as the Radiology Review Committee (RRC), are responsible for setting up the individual radiology residency guidelines and requirements. They are responsible for making the maximum duty hours, faculty requirements, and more. Overall, most residents do not have direct contact with this organization. However, it is crucial to follow the ACGME rules for the individual radiology resident to graduate from an accredited residency.

Now You Know The Hierarchy

That just about covers the basics of the different levels of responsible parties for a radiology residency program. Even though some institutions have additional positions that also play a role in managing a radiology residency, the ones I described are usually the most important. (Just don’t tell that to the research manager or the radiology liaison!) Of course, additional levels can get quite complicated. But at least you have the basics of who to turn to when you have a specific issue or question. So now you know your ABCs of the chain of the radiology residency command!!!