Month: July 2017

Posted on by — 5 Comments

How to Choose a Radiology Fellowship

radiology fellowship

For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!

So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.

Personality:

You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.

I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.

Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology

Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology

Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology

Jack of all trades- Body Imaging, MRI, Nuclear Medicine

Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging

Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology

Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine

And so on…

Lifestyle:

So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.

Body Imaging/MRI-

Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.

Cardiothoracic Imaging-

Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.

Informatics-

Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty

Interventional Radiology-

Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours

Musculoskeletal Imaging-

Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic

Neurointerventional Radiology-

Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.

Neuroradiology-

Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty

Nuclear Medicine-

Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.

Pediatric Radiology-

More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty

Trauma/ER radiology-

Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.

Women’s Imaging/Mammography-

Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.

Money:

Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.

Location:

Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.

Application Competitiveness:

Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.

Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.

Trends/Countertrends:

So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.

Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.

Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.

On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.

Summary About Choosing A Radiology Fellowship:

Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!

Posted on by

Expectations vs Reality Upon Graduating Radiology Residency (I Hate To Burst Your Bubble!)

expectations

During residency, most physician trainees are studying and working so hard that they vaguely realize what is in store for them when they finish their training and begin their first job. What they often expect differs dramatically from reality. So, I thought this would be the post to give you the lowdown on some expectations versus reality when you start as an attending. We will cover six employment topics: money, job performance expectations, the importance of the bottom line, teamwork, case sign-off, and feedback.

Money Issues

Scenario

You begin residency and see these large salaries that come across in your email from recruiters. And, you hear stories of friends doing well at their first job, making tons of money that they don’t even know what to do with.

The Reality:

Many residents consume themselves thinking about the relatively “large salaries” they will earn once they finish their residency. You may think, well, if I can do that for ten years, I will be out of debt and rich. However, every large salary comes with a price. Either you will be working like the proverbial “dog,” or you may be located in a place very far from your friends and family.

Other new attendings also do not realize the costs that accrue from debts, buying a house, and maintaining a luxury lifestyle. Often, these folks go into further debt, funding a lifestyle that they cannot afford. Don’t let that be you!

Job Performance Expectations

Scenario:

You have just graduated as a neuroradiologist, and you are ready to take your first job. The job post said you would be performing 50 percent neuroradiology and no mammography while on a partnership track. You are excited as can be not to have to read any mammography!!!

The Reality

As soon as you start, one of the partners asks you to help out reading mammography by taking a course and over reading one of the other radiologists’ mammograms. Since one of their mammographers left, they need the help until they can hire another.

This situation is commonplace in the world of private practice. Sometimes, undue circumstances arrive beyond the practice’s control, and your expectations for your work will not precisely align with reality. If you cannot be somewhat flexible, you may not become a partner in the practice!

Importance of the Bottom Line

Scenario:

Your academic nuclear medicine position at a high-powered center of excellence is about to begin in a few days. Since it is a large academic center, you figure you will have lots of administrative time to pursue your research interests. I can’t wait!

The Reality:

After a few days of working in your position, the institution issues rules regulating administrative time. If you cannot obtain a grant to support the institution, you will have very little administrative time.

Don’t assume that a large academic institution does not care about how much money it earns. It needs radiologists to financially support the institution by reading films just as a private practice needs to perform procedures and interpret enough films to stay solvent. An academic institution does not mean lots of free time!!!

Teamwork Expectations

Scenario

You are about to begin your first private practice job, and they told you that they treat all employees and partners equally. So, you are very excited to start a career with an equal footing to everyone else.

The Reality:

In your first week of work, a partner asks if you could help him out with reading some extra films because he and his wife want to go to a concert. You tell him that you had early dinner plans with your wife, but he continues to insist. You feel you have to stay to complete the work because he is an influential partner in the practice. Bottom line… Everyone is equal, but partners are often more equal than others!!!!

Case Sign-off

Scenario:

You are sick of waiting for your attending radiologist to sign off the reports you dictated a few hours ago. When you finish residency, now you will be able to complete your dictations whenever you are ready!

The Reality:

Now that you are the final reader and the buck stops with you, you become unsure of the findings and want to ask your colleagues before completing some of your more complex reports during your first days of work. Well, now you don’t have to wait for someone else to sign off your reports. Instead, you may need someone else to look at the cases for a second opinion before completing the study!!!

Feedback

Scenario:

The practice partners state that you will get immediate feedback about your progress after six months. Furthermore, they say that they can even tell who will be partnership material by the first year.

The Reality:

Six months roll around, and no one lets you know about your progress. You think you are doing well, but you are not sure. The patients and the clinicians seem to like you. After one year, no one lets you know if you will make a partnership after the three years they promised you. Unlike residency, feedback can be much more challenging to obtain since it is not designated. There is no guarantee!!!

Expectations For The New Attending!

Becoming a radiology attending is not like entering Shangri-La. There will be new challenges that you do not expect. Along with the added respect, you will have many additional responsibilities. So remember, as a radiology resident, try to prepare yourself for the reality of becoming a radiology attending. So, you will not be surprised about what to expect when you begin!!!

 

Posted on by — 2 Comments

Dictating- Tips for the Radiology Resident

dictating

dictating

Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.

Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.

Resident Versus Seasoned Dictating

So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.

Residents Need More Formalized Guidelines To Learn Dictating

To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.

Templates:

When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.

In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.

Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)

Important Pitfall

However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.

Histories/Priors:

Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.

One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.

Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.

Technique:

I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.

Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!

Comparisons:

The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.

Comments:

If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.

One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.

Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!

Impressions:

The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.

In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.

Beware Of Technical Jargon

Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!

Stick To The Answers

Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely. MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.

If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.

What terms are most frowned upon in the impression?

Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.

But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.

Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!

In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!

Structured Reporting Dictating Versus Prose Dictating

Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.

I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!

Dictating Tips: A Final Conclusion

You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!

 

 

Posted on by

How To Create A Killer Radiology Personal Statement

radiology personal statement

 

Personal statements in the radiology field are the least effective way to bolster your application. (1) Rarely, do they help an applicant. Occasionally, they hurt the applicant’s case. Regardless, I am aware that the personal statement will often become essential to many viewers of this article who apply to radiology regardless of whatever I say.  Therefore, I am creating this blog for anyone that is applying for a radiology related job to learn to create that killer radiology personal statement. And, today I am going to recount some of the basics for creating one. Specifically, I am going to start by explaining the parts of a great radiology personal statement and then give you some general tips that I have learned over the years from blogging and reading many personal statements.

First Paragraph:

The Hook

After having rummaged through thousands of radiology personal statements and writing lots of blogs, I can definitely say that the key paragraph for the reader begins at the beginning. If it is average/boring, I have almost zero desire to read the rest of the statement, especially when you have another 10 more to read that day. Something in the few first few sentences needs to draw the reader in quickly. You are not writing a short story or novel where you can slowly develop your characters and plot. Rather, you need to write using a technique that I like to call the hook. Reel that program director in.

There are several techniques that I have seen over the years. Let’s start by using the writing technique of irony. Notice the irony I chose in the first paragraph of this article. I started by saying personal statements are the least effective way to bolster your application. Whoa, wait a minute! The title of the article is How To Create A Killer Personal Statement. That’s somewhat interesting. The dissonance in that first paragraph draws the reader in.

So, what other techniques can you use to maintain the interest of the reader? Sometimes quotes can certainly help. Once in a while, I come across a quote that really interests me. I tend to like quotes from Albert Einstein. They tend to be witty and have double meanings. But, there are certainly millions to choose from. A good quote can set the tone for the rest of the personal statement.

Finally, you can write about an interesting theatrical description of a life-altering event that caused you to want to go into radiology. Use descriptive novel-like adjectives and adverbs. Go to town. However, be careful. Don’t choose the same events as everyone else. Read my other blog called Radiology Personal Statement Mythbusters to give you some other ideas about what not to choose!

Tell Why You Are Interested In Radiology

The first paragraph is also an important place to tell the reader why you are interested in radiology. Many times I will read a radiology personal statement and say to myself that was kind of interesting, but why does this person want to go into the radiology field? He/she never quite answers the question and I am left feeling that this person does not know why they want to enter the field. Don’t let that be you!

Second Paragraph:

Explain Any Problems/Issues

I like the applicant to be upfront with the reader rather quickly if there was an issue that may cause a program director or resident to discard an application. It could be addressing something as serious as a former conviction for drunk driving when you were young and stupid. Or, it could be something milder like a questionable quotation from a mentor that you found in your Deans Letter. Either way, you need to explain yourself. Otherwise, the problem/issue can declare itself as a red flag. Subsequently, it can prevent you from getting the interview that you really want.

Second and Third Paragraphs

Expand Upon Your Application

Let’s say you don’t really have any red flags in your application. Well then, now you can write about some of the things that you accomplished that you want to bring to the attention of your reader. Typically, these may be items in your application that are partially explained in the experience or research sections of the ERAS application but really deserve further emphasis or explanation.

Show Not Tell

In addition, the meat of any personal statement should contain information about what you did. Do not, instead, describe all the characteristics you had to allow you to do it. This is a cardinal mistake I often see in many personal statements. What do I mean by that? If you have been working at NASA on the Webb Space Telescope, you don’t want to say I was a hard worker and was well liked by everybody. Rather you would want to say I spent 1000 hours building the mirror for the telescope constantly correcting for mistakes to such a fine degree that the engineering societies considered it to be almost perfect. And to show you were well liked by everybody, you can say when you were done completing the telescope, NASA held a ticker tape parade for me!!! (Well, that’s probably not the case. But, hopefully, you get the idea.)

Final Paragraph

Time to Sum Up

This can be the most difficult part of writing a personal statement (and blog too!) How do you tie everything together into a tight knot so that everything comes together and makes sense? Well, one thing you can write about is what you will bring to the table if your residency program selects you based on what you have stated in your radiology personal statement. Back to the Webb telescope example: Given my experience with my successful quest for perfection by creating an almost perfect telescope mirror, similarly, I plan to hone my skills to become an incredible radiologist by always learning from others and my fellow clinicians to get as close to perfection as possible. Bottom line. You want to make sure to apply your experiences to the job that you want to get.

General Issues With Editing

1. I have learned a few things about writing over the past years, whether it is blogs, personal statements, letters, or whatever else you need to write. However, the most important is the obsessive need to review and re-review whatever you are writing for editing. It may take 100 edits to get it right!!!

2. Have a friend or a relative read your personal statement to catch errors you may not see. Your brain is trained to already know what you have written. Many times the only way to catch your own mistakes is to have another person read your writings.

3. Also, make sure to the read the personal statement out loud. Sometimes you can only detect errors by listening to what you have actually written. It happened many times when I edited my book Radsresident: A Guidebook For The Radiology Applicant And Radiology Resident

4. Finally, I recommend the use of grammar correcting programs. The one that I would like to bring to your attention is the program called Grammarly. I am an affiliate of Grammarly. However, that is only because I use the program myself for my blogs all the time. It has saved me from really stupid mistakes. One version is for free and corrects simple critical errors. The other uses more complex grammatical corrections and is a paid service. Regardless, either version will assist you in catching those silly errors. In addition, I usually paste my blogs into the Microsoft Word program to correct any other possible errors. I have found both programs to be complementary.

Other Useful Tidbits

Avoid Too Many I Words

When writing a radiology personal statement, try to reduce the usage of the word I for multiple reasons. First, it begins to sound very redundant. Second, you appear selfish. (It’s always about you, isn’t it?) And finally, you want to create the impression that you are going to be a team player, not in the field of radiology just for yourself.

Active Not Passive Tense

If you want a passage to sound great, make sure to almost always use the active tense, not the passive variety. When using the passive form, the reader has more work to do because he/she has to figure out who is doing the activity. In addition, the environment appears to control you rather than you controlling the environment. And finally, sentences sound more verbose when using the passive tense. Think about the following phrases: The job of creating a computer algorithm was completed over the course of 10 years vs. My colleagues and I created a computer algorithm over the course of 10 years. Which sounds better to you?

Use Sentence Transitions

If you want your personal statement to sound smooth, I find words other than the subject at the beginning of the sentence help to diversify the sound of the individual sentence. Also (notice this transition word!), it allows for a change of idea without being so abrupt.

Don’t Use The Same Word At The Beginning Of Each Sentence

In that same train of thought, try not to use the same word to begin a sentence over and over again. It’s a surefire way to bore the reader!!!

Creating That Perfect Radiology Personal Statement

Now you know some of the rules I would utilize to create an interesting radiology personal statement. Some of these are general rules that I apply to my blog on a weekly basis that I also see in the best personal statements. Therefore, I know that they work well. So, go forth and write that killer radiology personal statement. You now have all the tools you need!!!

Posted on by

Cracking the Radiology Residency Application Code

application

Most medical students and residents do not have an insider’s insight into radiology residency and fellowship application and interview processes. Even worse, misleading advice and rumors cloud the process. One needs only to look at the average student or residency forum to see numerous conflicting stories and statements.

Only someone actively involved in the process can understand what you need to know when applying for a radiology residency. So, thankfully, you have come to the right post. I have looked at thousands of applications and interviewed hundreds of residents for positions in our program as associate program director. So, I will help you out by delving into the depths of the radiology residency application process. This article will give you the basics of what you need to know.

The Application

We could go through the application in one of many ways. But, I think the best way is to go through the different parts of the application from most to least important. This way, you will not squander your energy on the small stuff!

The Dean’s Letter

Few sections of the application genuinely differentiate one applicant from another. Dean’s letters happen to be one of those items. The reason for that: you will receive comments from attendings, residents, nurses, technologists, and secretaries that may say something negative. I can’t tell you how often we have parsed an entire application with glowing positives until we arrive at the Dean’s letter. And, then we receive coded messages in the letter, such as: was very shy during the rotation, but did see some improvement. Or, this resident was very independent. However, he did not seek help when presented with a challenging patient care issue. And so forth.

Additionally, the Dean’s letter is the only document (other than the boards) that compares the applicants to their classmates. Most medical schools have buzzwords indicating the residents’ rank in their class. Each one is different, but typically it allows insight into which quartile the resident resides.

Can You Do Anything About The Dean’s Letter?

Ok, so you have your Dean’s letter written in “stone.” And, at some institutions, you may hear that administrators say you cannot change the Dean’s letter. But usually, at the bare minimum, you can check the Dean’s letter. All medical students applying for a residency should scan their Dean’s Letter before sending out the application. I have seen Dean’s letters sent on behalf of medical schools with the wrong applicant’s information!

At other institutions, you can look at your letter before application time and potentially modify the document. If that is the case, you should undoubtedly check it for any hostile or questionable comments. And then, if possible, confront the department/person that wrote the statement. Ask if they could redact or modify it. If the writer is truthful, the person may decide to leave it there. But an attempt should be made, as this one negative comment can make the difference between high, low, or no ranking on a program’s rank list. Not infrequently, the admissions committees will obsess over one questionable comment. They will often spend countless painful hours perseverating over these “minor details.”

The institution may not allow you to look at the Dean’s letter at a few medical schools. But the school may allow your mentor or a faculty member to look at the document and possibly edit it for corrections. I can’t emphasize enough how important it is to increase your odds of being accepted to the residency of your choice.

The Boards/USMLE

Why are the boards important? Well, the boards/USMLE assess the ability of a future resident to pass the radiology certification examinations. We have noticed a strong correlation between lower board scores and difficulty passing the new core exam in our program. So, similar to our program, most programs take the USMLE score very seriously.

In addition, programs use board scores more as a baseline cutoff. Once you score higher than that baseline, it doesn’t factor much into the ranking equations. On the other hand, unless extenuating circumstances exist, failing and low scores usually place the application in the deny pile.

What About COMLEX?

For those of you that are D.O. medical school applicants, I recommend that you take the USMLE in addition to the COMLEX examination. Many radiology programs are unsure of the significance of COMLEX scores and don’t know how to factor the scores into the ranking equations/cutoffs. Applications with COMLEX scores alone may get thrown out of the interview pile entirely.

Gamesmanship

Even with all these factors, you can use some gamesmanship when it comes to the boards. If you have done very well in the step 1 boards, often, you may be able to get away with just sending those scores alone. You may want to delay taking step 2 USMLE. With high USMLE Step 1 scores, USMLE step 2 scores can only hurt you if they are lower. Of course, all this gamesmanship will disappear when the scores no longer exist on Step 1. At that point, Step 2 scores will most likely replace the outcomes on Step 1.

Finally, most programs look for/expect improvement from step 1 to step 2, especially with borderline step 1 scores. So be careful and take the step 2 boards very seriously. Invest in a review course if you need to.

Research

Nowadays, research can become a significant factor in getting an interview in a residency program. What is the reason for that? ACGME guidelines mandate that accredited radiology residencies have specific radiology research requirements for residents before graduating. Knowing that a resident has completed multiple quality research projects means that a resident can work more independently completing research projects. This knowledge of research reduces the burdens upon the department.

Furthermore, radiology research may demonstrate significant interest in the field. And, it provides an avenue for discussion during interviews later on in the process. We often look at an application, saying it’s pretty good, but the resident hasn’t completed any research. That may take the application down a few rungs.

Bottom line, though. It won’t take you entirely out of the running for getting a spot. However, it can be a significant asset in some situations.

Extracurricular activities

We look for two big red flags to avoid on this section of your application: those applicants that emphasize that they have participated in every extracurricular activity under the sun and those applicants who write down almost nothing. A resident who participates in everything suggests that he lacks focus, never investigating or accomplishing tasks in depth. On the other hand, a resident that engages in nothing but school tends not to be well rounded. These residents may not have outlets to disperse their frustrations during their four years of training. A residency director does not like having frustrated residents!

Impressive Extracurriculars

So what are some activities that impress the admission committee? : Interesting extracurriculars that show leadership potential, activities that demonstrate a depth of involvement, and activities that offer an ability to handle stressful situations and function independently. Some of the special extracurriculars that stand out in my mind that meet these criteria would be a student that started a Subway franchise successfully from scratch and made it into a big business, a student that participated in the Olympics, and a student that lobbied for Congress. These are people that tend to climb the rank list higher because their extracurriculars were memorable.

Not So Memorable Extracurriculars

What are some extracurriculars that don’t add much to the application? Those activities that everyone else does and do not suggest leadership potential. In radiology, those would include participating in a radiology club (Big deal!), participating in health fairs (Every medical student does it), and teaching inner-city kids (We see it all the time as part of medical school curricula!) Not that these activities are harmful, but they don’t add much at all to your application. My recommendation to you: find something you enjoy, hopefully, something unique, and stick with it during your four years of medical school training!

Recommendations

Admissions committees like to make a big deal about recommendations. You’ll undoubtedly hear that you need an excellent letter to get into a great program. But honestly, if you ask someone for a recommendation, it is unusual to find someone who will write you a nasty one. Students are going to ask attending physicians that like them. On the other hand, although rare, we see a “bad” recommendation as a significant red flag. It often means the resident that obtained the letter has a poor emotional intelligence quotient. Or she couldn’t find one attending that liked them- both significant issues!!!

Like the rare bad recommendation, great recommendations that raise the application within the pile to a higher rank are also unusual. For the most part, this type of recommendation stems from well-known entities that want the person in their program. Or perhaps, it comes from a close colleague that the radiology admissions committee implicitly trusts.

Recommendations rank relatively low in the application influence equation given the rare ability to change the application disposition.

The Personal Statement

Finally, I would like to talk about the item that medical students often perseverate on the most: the personal statement. The personal statement seldom helps an applicant and can occasionally hurt an applicant. After having read over a thousand of them, there are very few standouts. And, almost all of those that stood out were somewhat disturbing. I still remember an essay that emphasized a dead rabbit. It did not have any correlation to radiology whatsoever. I was concerned about mental illness in that student. We terminated the possibility of acceptance to our program immediately!

If I had to say one thing, I would advise you to be cohesive and relevant to your future career as a radiologist. Also, watch out for typos because typos suggest an inattentive personality, not a characteristic you want in a radiologist. Other than that, don’t fret too much about this part of the application.

Summary

Application for radiology is an arduous process with multiple pitfalls. Make sure you concentrate on those items that give you the most “bang for your buck” to send your application higher on the rank list. In particular, put particular emphasis on the Dean’s letter. Check it if you can. Correct it if need be.

And finally, don’t be that student with marginal board scores, no research, dull or no extracurriculars, poor recommendations, and a personal statement that stands out too much. If you follow my suggestions and try not to rock the boat, you should get into a great residency!

 

 

 


Posted on by

Maintenance of Certification (MOC)- A Controversial Necessity?

MOC

A groundswell of controversy about maintenance of certification (MOC) has been building slowly for the past decade. In truth, no quality evidence-based study has shown a link between quality of care and MOC. Therefore, multiple entities in the United States are abuzz, attempting to create anti-MOC legislation to prevent boards from gaining a legal foothold in states requiring MOC for practicing medicine. Some of you may hear about these issues in the press. (1,2) These issues are not just unique to radiology.

But before we discuss the individual controversies, we need to delve into MOC a bit further, especially for those just starting. What exactly is the maintenance of certification once you complete your residency in the United States? What do you have to do to satisfy the requirements? Why do you need to meet the requirements for MOC? And when do the requirements for maintenance of certification begin? Some of the answers to these questions are not so obvious. So, these are some of the questions I hope to answer in this post.

What is MOC?

According to the “experts,” maintenance of certification is a way to show that you are continuing to keep up with the educational demands of your specialty. Theoretically, it should ensure continued minimal competency to practice medicine. The American Board of Radiology and your state of practice require specific essential documentation for diagnostic radiology. For instance, the ABR requires 25 hours of continuing education credits (CME) per year, passing a test every ten years or completing online email questions correctly to certify competency, verification of state licensure, and quality improvement projects or leadership roles.

Individual states also require their primary means of determining competency to maintain licensure. When I first obtained my license in New Jersey, I had to take a required orientation course. Every year, I need to submit 50 CME credits each year. In addition, the state requires me to satisfy an end-of-life care course requirement every three years. Each state can significantly differ in what is needed to keep a license. Go to the site called mycme.com for more information on your particular state.

How Do I Get CME Credits?

Typically, radiologists can get continuing medical education credits in one of many ways. First, many online radiology society websites, such as RSNA and ARRS, develop education portals for radiologists to complete either articles or lectures. The radiologist then takes a short quiz they must pass at the end of the episode to document that he has completed the task.

Second, you can attend conferences at many locations throughout the country and then collect the CME credits at the end of the course. Usually, the conference presents the physician with a certificate of completed CME at the end of the meeting.

And then, internally within your hospital or practice, you can participate in tumor boards, conferences, etc. Subsequently, you can obtain the CME credits after documenting what you have experienced as long as the creators of the conference have applied for CME.

What Happens If I Don’t Participate In MOC?

Unfortunately, for most radiologists, it is not an option to forgo MOC. Most hospitals require certification by the ABR and state licensure bodies to maintain staff privileges. And individual practices often stipulate that you need MOC to remain in practice.

But, you may hear about other specialty physicians in the news who have not renewed their certification. Many of these folks are leading political and internal movements to eliminate the MOC requirements. Individuals and organizations are suing certification boards who are teaming up with insurance companies and hospitals. Some of these boards aim to make MOC a requirement for radiologists to get reimbursed for the interpretation of images. Usually, the physicians not participating in MOC have been practicing for a while, so they have the clout to abandon the MOC process.

When Do I Need To Start With The MOC Process?

Over time, the ABR requirements about when to start MOC have changed. The MOC process begins on day one since the ABR now considers MOC to be continuous. According to the ABR, you need 75 CME credits over three years of practice to maintain certification. That means you could theoretically begin CME on the first day of practice or wait a bit to start.

On the other hand, each state has different requirements for when to begin MOC. You should look up your state online to determine which rules are correct. Again, refer to the site called mycme.com, which outlines the specific requirements for each state. For the state of New Jersey (my state of practice), they give you a grace period of two years to begin CME after the first renewal of your state licensure.

Former Actions Against MOC

According to a Medscape article from 2017 (1), many state organizations have been banding together to prevent the overreach of MOC. This article documents many of the individual state medical society activities. I thought these activities were particularly fascinating.

To summarize some of the activities in this article, multiple state medical societies have attempted to pass anti-MOC bills in their states. Most of these attempts are in process or have been temporarily tabled. One state, Georgia, became the only state to pass a bill that prevents using MOC as a condition of licensure, employment, reimbursement, or malpractice insurance at certain hospitals.

At the time of the writing of the Medscape article, several states have initially failed in their attempts to pass MOC legislation. Three state medical societies (Arizona, Kentucky, and Michigan) created stipulations stating state medical boards “may not require a specialty certification or maintenance of a specialty certification as a condition of licensure.” However, legislatures did not pass the bills. Oklahoma became the first state to attempt to enact legislation to remove MOC as a requirement for physicians to obtain a license, get hired and paid, or secure hospital admitting privileges. However, at the last minute, the bill failed after significant lobbying by ABMS (American Board of Medical Specialties).

Other state medical associations are in the throes of creating anti-MOC bills. Both Tennessee and the Florida Medical Associations aimed to create bills to defeat efforts by the ABMS and FSMB to impose MOC as conditions for reimbursements and licensure. Finally, numerous other states, including Maryland, Missouri, North Carolina, Texas, Alaska, California, Maine, Massachusetts, New York, and Rhode Island, are trying to enact anti-MOC bills.

More Recent Defeat Against The Anti-MOC Movement

Most recently, in 2021, the federal court of appeals affirmed the dismissal of physicians’ claims against the American Board of Internal Medicine claims that challenged the MOC process. However, other litigation is still ongoing. 

Summary

Regardless of your stance on MOC, it is integral to most radiologists’ practice. It will be present in some form or another for a long time, perhaps in a more weakened state. Follow the current rules when starting, and you will get to practice radiology. Be a revolutionary against the system, and you may have difficulties. Either way, the final decision is up to you!!!

(1) Chesanow, N (6/21/2017) The War Over MOC Heats Up. Retrieved from http://www.medscape.com/viewarticle/881274

(2) Reese, N. (8/3/2016) MOC Exam: Take It Or Not? Retrieved from http://www.medscape.com/viewarticle/864922

 

Posted on by — 1 Comment

Radiology Call- A Rite of Passage

call

Every year around the beginning of July, I see some of the most haunted radiology resident faces, right around 10:00 pm, just after the attending evening shift ends and the resident night shift begins. It is almost always a second-year radiology resident who happens to be starting their first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And most importantly, will I kill someone?

The resident only unlocks the answers to these burning questions on the first night. Only after this event does the resident and the program director know whether or not they can handle the burdens of a radiologist. Everything in the first year leads to this point: the precall quiz, the intense reading, the conferences, and the studying. It’s crunch time.

Just before the first night of the dreaded call, my famous last words are: you begin the night as a kid, and you will end the night as an adult. Why do I say that? Because I think the truth lies embedded in that statement. You can never become a full-fledged radiologist until you are responsible for independently making patient decisions. It’s like all those ancient traditions in all religions/cultures, like hunting that first wild boar, the confirmation, the bar mitzvah, etc. The residency now allows you to function as an independent, freethinking human being who can make decisions on your own. Until then, you are merely an observer, not an active participant.

Since taking night coverage is such an intense and essential experience, you must follow certain tenets to make it valuable and safe. I will enumerate eight simple golden rules of call I wish I had known before beginning those fated first nights to come. I urge that you follow all of them to enrich your education safely. Do not stir the wrath of your fellow staff members and program directors in the morning by breaching these rules!

Look at every film with these primary thoughts- what will kill the patient, and what is common?

I can guarantee that if you look at every film with these thoughts at the forefront of your brain and have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. If you see a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think of acute appendicitis. And so forth. Thinking about badness will prevent undiscovered horribleness in the morning.

Likewise, when you look at films, always think about the most common diagnoses first, and you will be right much more often than wrong. For instance: Opacity on a chest film- pneumonia, not Hampton’s hump. Restricted diffusion on a brain MRI- infarct, not ependymoma. Abnormality on a GI bleeding scan, think primary GI bleed, not Meckel’s diverticulum with bleeding gastric remnant. I can guarantee your attending faculty will look at you funny if you come up with too many zebras!

Always, always, always maintain your search pattern in every study.

In the radiology world, one of the main ways to miss something is not to look for it. Sometimes in the middle of the night, the pressure will seem impossible, and you must deliver an answer at that second. Perhaps, a team of 4 angry surgeons comes down and asks, “What is going on with the film?” and needs to know now! Or, an inpatient resident shoves a chest film in front of your face and says, “What’s going on here?” Maybe, the emergency medicine doctor calls incessantly to get a read on that CT chest for dissection.

In each of these cases, I don’t care how emergent and immediate they need the answer, always step back and go through your search pattern. Everyone makes this cardinal error at one time or another. Avoid it! Step back and say give me a moment. Go through each organ or region rigorously. You will look much less stupid than blurting a diagnosis/finding out only later to realize it was wrong because you haven’t thoroughly analyzed the study. One of the worst feelings is finding the doctor who just left your department with the wrong answer, who is getting ready to begin an unnecessary surgery on a patient, or a doctor who will discharge a patient that needs to stay in the hospital!!

If there is no harm to the patient, it is easier to do the study than to fight it.

Most residents take a while to learn this one piece of sage advice. At nighttime, you will have limited time for everything. Interruptions will pull you in fourteen different directions at once. You will receive calls from the emergency department, the floors, the surgeons, etc. And often, these events tend to happen all at once. So, I urge you that if a study is reasonable, do it.

You will spend more time and energy preventing a study from getting done than just completing it. Of course, if it significantly harms a patient, then obviously avoid it. But that is the exception rather than the rule. That fluoroscopy study to rule out a foreign body that you try to block after the resident ordered it: I can guarantee it will come back hours later when you are either exhausted or have lots of things going on at once. So, just do the study!!!

Don’t let your temper get the best of you. You will hear about it in the morning!

Every resident encounters a curt gynecologist, a rude surgeon, a loud, demanding resident, and so on at some point. You are likely going to be grumpy and tired as well. It may seem like a good idea to talk back to that person similarly rudely and unprofessionally. Or, you may want to take a swing at one of these annoying chaps. But don’t do it. One of the most common complaints at nighttime is a letter written by an attending or a resident colleague saying this radiology resident was unprofessional and handled the situation poorly under pressure. This complaint will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident’s file/record. Don’t let that be you!!!

Residents best handle resident matters. Attending matters are best handled by attendings.

At nighttime, many times, a clinician may need an attending radiologist. So, make sure you don’t go in over your head. Call your attending when necessary. The worst thing you can do in the morning is to perform a procedure that your attending should have done or make a phone call that really should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town in the department, not in a good way. An attending should always read a brain scan because of litigation issues. A faculty radiologist should always be present for an intussusception reduction. And so on. Don’t go over your head!

On the other hand, if you have a resident issue at nighttime, try to handle it yourself. If the Emergency Department asks you whether to give the contrast, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the more minor decisions by playing the role of a radiology resident.

Ask for help if you can’t handle something at nighttime.

Sometimes, the job may be too much to bear for one person. (A disaster happened with every patient getting a total body CT scan) Perhaps, it is a question that an expert needs to answer. (A subtle abnormality on an emergent Neuro CTA) And, other times, administrative issues that only your chair or program director can handle. (The MRI broke – should we recommend sending patients to another hospital?) If such problems arise at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it is a patient question that you are not sure about, ask your chief resident. Then, if they can’t answer the question, you may want to ask the assigned attending on-call. And, up the chain, it goes.

If you decide to handle everything yourself and it is inappropriate for your level, you can almost be sure that repercussions will occur in the morning. So please, ask for help when it is needed and appropriate!!

Always answer your beeper/phone/pager.

Occasionally, we hear about a resident sleeping and not answering their pager at nighttime. Unfortunately, those residents will often get written up in the morning for lack of timely dictation. So, jack up the sound on your beeper/phone/pager. And, take all calls!!!

Look at the films. Don’t rely on the ER or Nighthawk reads.

Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. So, do not repeat a dictation or reading that is already present. You should do everything de novo/from scratch, although you should look at their reads afterward. It also seems silly when the resident’s dictation matches the Nighthawk dictation verbatim and hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes that a resident used to check the cases even though others have looked at the study. And, it is not infrequent that our residents catch essential findings that the nighthawk didn’t notice. So please, do your independent reads/dictations!!!

Summary statement

Call is a challenging but integral part of raising a radiology resident right. It is a time of trials and tribulations. You can and will make it through this harrowing trial if you follow the golden rules. Good luck!

——————————————————-

Need some help with what you need to learn before taking call? Check out the following books on Amazon!

Emergency Radiology Case Review Series

Core Radiology

 

———————————————————-

This article is featured on auntminnie.com!!! Click here for the Aunt Minnie version of the article. 

 

Posted on by

Transferring From Another Specialty to Radiology: Will I Be Competitive?

radiology

Question:

Dear Barry,

I will be finishing my categorical surgery intern year. I have decided to reapply this year for radiology, with a strong interest in IR. I am aware of the competitiveness of IR and DR in general. I am leaving in good standing. Also, I have good scores and achieved AOA. My radiology mentors in my hospital have encouraged me and feel I am competitive. I don’t have any published research, but I am working on projects. In terms of gauging my competitiveness and having realistic goals, how may I improve my application before September 2017?

———————-

Answer:

Get To Know The Radiology Program Director

In the past several years, several surgical interns have transferred to our department. Both residents came to speak to me about their interests while they were surgical residents (one was a SOAP match candidate, and the other stopped during the year to ask about interviews). I think speaking to the program directors increased their chances of getting into our program. It shows initiative! So, if I were in your shoes, one of the first things I would do would be to get to know the program director for radiology if there is a radiology training program in your hospital.

Also, sometimes spots can open up before the year begins, and showing interest in the radiology program can’t hurt. Therefore, it would make sense to talk to the program director about applications for this year. The biggest problem is that you probably will have to wait another year to secure a spot in a radiology residency program since applications are not for 2018-2019 but for 2019-2020. But you never know; a position can open up for the 2018-2019 R1 year.

Finally, it would allow you to get a feel for the quality of your application at your institution. The program directors will usually have insight into your chances of admission.

Get on The Radiology Bandwagon Now

If you have the fortitude to go through another surgical year and wait for a 2019-2020 spot after interviewing this year in the regular match, that would be the most likely way to secure a radiology spot. As you said, if you are a categorical surgical resident, you will likely be a competitive applicant for a radiology residency (even though the specialties of radiology and DR/IR have been getting slightly more competitive over the past year or two). Nevertheless, I would certainly get on the application bandwagon now because if you wait another year, you are less likely to be able to get government funding for a radiology resident spot. You snooze, you lose!!!

Is No Radiology Research An Issue?

Regarding research, it certainly can’t hurt to have completed a project or two. If you are interested in academic radiology, that will add to your application. In a clinical program, it probably doesn’t matter as much. In either case, most residency programs do not require research before entering. But, it does confirm interest in our specialty. Regardless of whether you have completed a research project, I think most program directors (especially IR/DR PDs) like to take surgical residents who have performed well at their institution and demonstrate an interest in radiology. Surgical residents who serve well can handle stress!!!

Make Sure to Apply To The Correct Programs

Also, since you are interested in IR, I would send out applications to residencies that are DR programs with an ESIR program and the new DR/IR program. Applying to both programs maximizes the probability of getting into a residency that allows you to complete IR without having to do a 2-year independent fellowship.

Let me know if you have any other questions.

Barry

 

 

 

Posted on by — 13 Comments

How to Make a Good Impression as a First Year Radiology Resident

impression

It may be your first day, your first month, or maybe you started residency several months ago. Perhaps, you want to make that great first impression on your program director. Or, maybe things are not going as well as you might have liked during your first year. Having worked with numerous first-year residents rotating in our residency and having completed a full four years of residency, I have learned the ingredients you need to become a great first-year resident. As a former resident, I wish I had a list of tips on how to start my radiology resident experience on the best footing possible.

Well, now it’s here. I have a list of 12 ways to improve your radiology residency experience starting in the first year of your diagnostic radiology residency program. Also, I will give you examples of what not to do (these scenarios are real!). Then, I will explain how to make the best of each piece of advice. To all- ENJOY AND HEED THIS ADVICE!!!

Be Enthusiastic

On your first day of radiology residency, you walk into the reading room for the first time, and you are nervous and hesitant. You begin to yawn, mouth wide open. An attending sits in the corner about to read films. You slink back and worm your way into a corner. You don’t introduce yourself for fear of disturbing the attending radiologist. Instead, you start talking to your resident colleagues. Is that a way to start your career? By all means, NO!!!!

My words of advice:

Always make sure to put on your best face forward toward your staff. What does that mean? Well, it’s pretty much common sense. Always introduce yourself. Always ask how you can help. And, always volunteer to participate in a readout or procedure. You have only one chance to learn the things you need to know before practicing as an attending, and that way is RADIOLOGY RESIDENCY. Make it the best learning experience you can, and that involves going that extra mile to show your enthusiasm/interest.

Be On-Time

You wander into the reading room, and it’s 10 AM. When you see your attending radiologist reading out films, he pauses for a moment. You decide to say, “When can we start reading out together?” The attending looks at you with a confused quizzical face. Was I supposed to have a resident today?

My words of advice:

When you arrive in the morning, always let your attending know that you are today’s resident. If you have to step out for a few moments, let him know that you need to leave. It is a sign of respect to let your attending see that you are going to be around to help out, learn, dictate, and ask questions. It will go a long way to establishing a rapport between yourself and your residency staff!

Be Nice to Everyone

It’s your first day, and you walk into the residency coordinator’s office. You sit in her chair, never having seen or met her. And then, you start playing games on her computer. The coordinator walks into the office and stares at you and is thinking: who the heck is this guy?

My words of advice:

Make sure when you are beginning that you are kind to everyone!!! I don’t care if it is the residency coordinator, janitor, technologist, attending, senior resident, or nurse. We are all part of the same team. Moreover, we always hear about our resident’s behavior, good or bad. As residency director, we receive 360-degree evaluations, reviews of the residents from potentially all these sources, and more. I can tell you that if you want to destroy your reputation as a resident, the worst thing you can do is misbehave with your team members, especially the residency coordinator!!!!

Dress Appropriately

You are upstairs on the floors in a t-shirt and ripped jeans. Your ID badge sits in your back pocket with the list of patients to consent. In your morning haze, you stumble up to the door of the 3rd patient with informed consent in hand. You introduce yourself to the patient, and she gives you that look- who are you really, and what are you doing here? You go through your pat explanation of the procedure, the risks, and the alternatives. The patient warily signs the consent form. Great! The last consent of the morning.

Later that afternoon, the program director calls you into the office. It turns out, the patient was the wife of a hospital executive and called the emergency hotline. The program director now has two complaints about this resident, one from the patient’s husband and another from the doctor in the hallway. Both are furious because they did not know who you were and felt uncomfortable confronting you. The program director states, “Go home and change immediately!”

My words of advice:

Always make sure you look and play the part of a physician. Some patients and physicians are easily offended by an inappropriate appearance/uniform. In our world, radiology is a service-oriented profession. Furthermore, appearances fortunately or unfortunately lend credence to your skills, personality, and the department. Please make sure to represent your department in the best light!

Play the Role of An Attending From Day One- Take Responsibility for Your Patients and Department

You roll on into the nuclear medicine department and arrive at the department early. Briefly, you look at the list of patients in the computer. A bone scan and a gallium scan lies waiting as unread. You think to yourself, I know those topics well. I also know it would be much more productive to read a nuclear medicine book on a new subject. As you are waiting for your attending to arrive, you pull out your text and learn about nuclear medicine. The attending walks through the door a few minutes after you started to read and says, “Have you looked at the cases from last night?” You reply, “I was hoping to get my reading done for the day. Didn’t get a chance to look at the cases.”

My words of advice:

When you are on any service, good learners become great radiologists by reading lots of cases. You may know a given topic well, but you can only learn normal from abnormal by reading thousands of cases in different contexts. Unfortunately, you cannot learn this from merely reading a book. The only way to get that experience is to look at lots of cases every day. Take an active role as if you are an “attending.” Radiology is not a spectator sport!

Be Knowledgeable

You are in the second week of your first CT rotation. So, you sit down with the CT attending to go over the day’s work. The attending goes through each of the cases slowly. Finally, she happens upon an abdominal CT scan. You stare at the images, and she asks you about an ovoid cystic density structure just inferior to the liver. You blurt out, oh, that’s easy. It’s an aorta!!! Your attending begins to shake her head slowly and becomes silent. She doesn’t say much for the rest of the day.

My words of advice:

There’s an old radiology adage. The difference between a bad, OK, good, and great radiology resident is the amount you read every night. A bad resident doesn’t read. An OK resident reads 1 hour a night. A good resident reads 2 hours a night. And, a great radiology resident reads 3 hours a night. Don’t be that bad radiology resident! When you start, I encourage you to read a lot, especially emphasizing the basics and anatomy!

Read a Lot, but Make Sure to Study the Images

It is your first day on the new chest film rotation. You have just finished reading an entire textbook on chest radiology. As you start looking at the cases with your attending, you figure that you will try to impress him with your in-depth knowledge of the findings associated with sarcoidosis. So, you start going through a small presentation about your newfound knowledge based on the textual information. After your serenade, he begins to look at the first few cases of the day. Then, he pauses as he starts on the third case of the day.

He asks, “What do you think about this chest film in front of you?” You stay silent as you search the film up and down, left and right. Nothing seems to register as abnormal ton the film. Your attending points out a significant opacity obliterating the vessels behind the heart and obscuring the left hemidiaphragm. He then asks, “Where is the opacity located?” You realize that you have read tons of information on pneumonia but never looked at the pictures. Uh oh! You cannot identify the location based on a mental reference point. Your heart sinks as you realize you have more reading to do…

My words of advice:

Reading a radiology text differs dramatically from reading an internal medicine book, a novel, or other sorts of written information. The most important features of a radiology textbook are usually the pictures and captions below the pictures. So, it behooves the resident to concentrate on these films, often more than the text itself. Of course, you need to understand and remember the disease entities, but radiology is most often about the images!

If a Radiology Attending Asks You a Question, Always Look Up the Answer

So, it’s the end of the day, and you are sitting with your favorite attending. For the few days that you have worked with her, she has a habit of teaching interesting topics while taking cases. It feels like you just read an entire book without even touching a page. She enthusiastically asks you a question about a patient with breast cancer. She says, “I wonder what a sclerotic metastasis would look like on a PET-FDG scan? Maybe you can look it up, and we will go over it tomorrow.”

You go home exhausted and fall asleep slumped over your computer, without even getting a chance to read a word about the topic. You get up in the morning and realize you are running late. Hurriedly, you grab your stuff and arrive barely on time. Sweating profusely, you run into the reading room. Your attending almost sits down at her workstation. And she says, “Did you look that topic up for me?” Unfortunately, you don’t have a satisfactory answer. For the rest of the day and weeks afterward, she barely spends time on her cases with you. You’ve lost many opportunities to learn with your mentor.

My words of advice:

You sow what you reap! When someone, specifically a radiology attending, takes the time out of the day to teach. And, she goes over cases with you out of his/her own free will, it is essential to pay back that person with attention, diligence, and care. By under-appreciating the attending’s time, you change the willingness of a teacher to teach. Remember, most hospitals do not pay radiologists stipends for their time with their residents. Teaching emanates from the goodwill of the staff!

Always get a good history

It is late in the day, and you are about to read the last hepatobiliary scan of the day. But you have to do it quickly because you need to get home to your family. Instead of entering into the electronic health records, you promptly peruse the one-word order on the top of the dictation page. It says pain. So you start reading and dictating the case promptly for the attending with that one-word history. In a few minutes, you finish the dictation.

You walk back to the reading room and begin to go over the case with your attending. Subsequently, he opens the case, looks at your history/dictation, and begins to look at it as the surgical team walks by to get the radiologist’s interpretation. The surgeon asks, “What do you think?” The radiologist says, “With a history of pain, it looks like the gallbladder fills nicely without findings suggesting cholecystitis.” The surgeon responds curtly, “We just took out the gallbladder!!”

My words of advice:

Always take the time to get a great history. As a resident, you should take the time to gather all the information. Without a good history, trust me, you will get burned. So, avoid the inevitable, take your time, and always get all the necessary information!!!

Establish a search pattern for all modalities

The day’s attending sends you out of the room to read a new CT scan of the abdomen. The patient has right lower quadrant pain, and the emergency doctor wants you to rule out appendicitis. So you look through the CT scan quickly and ramble into the Dictaphone about the case. Your eyes move here and there without any specific pattern. Finally, you see some terminal ileum wall thickening and put in your impression- findings suspicious for terminal ileitis/inflammatory bowel disease. Happily, you trot back to your radiology attending to go over the case. Within 10 seconds, your attending says, “You missed the 4 mm obstructive stone in the right ureter!”

My words of advice:

Believe it or not, almost every experienced radiologist has a rigorous search pattern and mental checklist in every case. With this checklist, they don’t miss any findings that may be relevant to patient care. You might not know they have a search pattern/checklist because they have been doing it for so long. And, they rapidly read the cases. But, I can guarantee you will miss plenty of significant findings if you do not go through an organized approach to looking at a film. It happens all the time!!!

Always check for priors

The radiology attending just left the service for the day. You are now on call for the night. The emergency department continues to call the nuclear medicine department every 10 minutes to get the result. Annoying, isn’t it? It is time to give a STAT interpretation of a pulmonary V/Q scan. So, you look at the scan and the associated chest film. And, you see three large mismatches without corresponding findings on the chest film. You call the ER and tell them the scan is positive for pulmonary embolus. You feel good because you think you made the right call for sure.

The next morning at the readout, your attending starts to look at the case. He notices that you didn’t compare to the prior scan. It seems the same. His interpretation- no findings to suggest new pulmonary embolus. He says, “Call the ER right now to make sure the patient doesn’t get more anticoagulants.” You feel like an idiot for missing the correct diagnosis!

My words of advice:

I can’t emphasize enough how important it is to compare priors. Priors will bail you out many times. And, comparing with them makes the difference between shoddy and outstanding patient care. If you want to become a resident star, always make a concerted effort to check for prior studies!

Learn about things that can kill a patient or are common first. Zebras can usually stay at the zoo!

You are taking your first independent call and start to look at your first ultrasound of the evening. It is a 2-year-old pediatric patient with right lower quadrant pain. Looking through the ultrasound images, you see a target like structure in the right upper quadrant. You recently read a large text and saw a case of Henoch Schonlein Purpura affecting the bowel. It happened to look just like it. Your differential reads Bowel thickening from Henoch Schonlein Purpura before anything else. Ten minutes later, the pediatric surgery team trots up the stairs toward your workstation and says, “What are you talking about? We were looking for a large bowel intussusception!”

My words of advice:

Stick to the most common two or three items within the differential diagnosis. You will often be right more than not. As I said, zebras can usually stay at the zoo!!

Making A Good Impression

I’m sure almost all of you want to make your best impression on the staff that you are going to work with for four years. One or two mistakes toward the beginning of your stay can make your life very difficult for the rest of your radiology training. Unfortunately, it is effortless to leave the wrong impression on the staff, but it is harder to correct. To avoid these blunders, I highly recommend you follow these rules. Don’t be the brunt of your residency’s jokes!