Month: September 2017

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Happy One Year Birthday To Radsresident.com!

My Birthday Balloons!

 

Personally, I think it is very important to celebrate momentous occasions. And for me, this is certainly one of those times! I am proud to announce that my blog- radsresident.com has survived to its one-year-old birthday. And, there are lots of folks that I would like to thank. Of course, I would like to appreciate all the authors, commenters, critiquers, email writers, and posters who have added immeasurably to the quality of this website. And most importantly, I give my heartfelt thanks to all my loyal readers who have encouraged me to keep this blog afloat.

For this post, I would like to share with you some of the statistics for the year and recount some of the sentinel events. And, I am also going to mention some of the future plans for the website.

Statistics For The Past Year

I am a lover of statistics and if you are into statistics, writing a blog is heaven. Some of you may be curious as to who reads the website, the most popular blogs, and more. So, I will give you the lowdown as of the blog’s first birthday. Let’s start at the beginning.

Over the past year from September 24, 2016, through September 23, 2017, I have had over 68,700 page views and 34,800 individual visitors arrive at my site. Out of the 68,700 page views, about 60 percent of the hits are from the United States. The other countries in the top 5 to visit my site are India (10%), Canada (2.7%), Pakistan (1.6%), and the United Kingdom (1.4%). Most countries throughout the world are also represented.

How do folks find my site? Well, 34% find my site through search engines, 31 % land on my site through social media, 30% arrive at my website directly, and 6% are referred from other sources such as Aunt Minnie.

In total, we have published 105 separate posts as of the blog’s birthday, not including all the additional pages that we have written. Of all these posts, I have authored 83 unique posts; 14 posts have been interesting questions posed by viewers/commenters in the Ask The Residency Director category; guest authors have written 8 posts.

Ten Most Popular Posts Written By Me:

  1. How Not To Incriminate A Fellow Radiologist For His Mistakes
  2. Radiology Residency And The SOAP Match
  3. What Clinicians Don’t Want From A Radiologist- The 8 Deadly Sins
  4. Top Traits Of Great Radiologists (They Might Not Be What You Expect!)
  5. How To Choose A Radiology Fellowship
  6. Can You Pass The Real Saint Barnabas Residency Precall Quiz?
  7. How To Make A Good Impression As A First Year Radiology Resident
  8. Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?
  9. How To Combat A Difficult Radiology Job Market
  10. Radiology Personal Statement Mythbusters- Five Common Misconceptions About Radiologists

Three Most Popular Ask The Residency Director Posts:

  1. A Common Radiology Applicant USMLE Step 1 Misconception
  2. How To Complete The ABR Alternate Pathway As A Foreign Physician
  3. Is It Still Possible To Become An ABR Certified Radiologist Through The Alternate Pathway?

Three Most Popular Guest Author Posts:

  1. Up To Date Book Reviews For The Core Examination by Danny Nahl, MD
  2. Teleradiology, A Risky Business? by Haley Dezendorf
  3. Has Technology Ruined Your Chance Of Employment In Radiology? by John Chung

Whirlwind Birthday Tour Of The Past Year

Not only did we have a prolific year at radsresident.com but we also were honored to have some of our posts published in some great blogs such as Aunt Minnie, Doximity, and PassiveIncomeMD!

Blogs Published In Aunt Minnie

  1. Taking Oral Radiology Cases- A Lost Art?
  2. Ten Surefire Ways To Destroy Your Radiology Residency Experience (And Your Colleagues’ Too!!!)
  3. Most Common Stereotypical Generational Radiologist Differences
  4. Radiology Call- A Rite Of Passage

Blogs Published In Doximity

  1. Twelve Red Flags At Your First Post Residency Job
  2. Radiology Jargon That We Would Love To Use But Can’t

Blog Published In PassiveInvestorMD

  1. Alternate Careers And Supplemental Income For The Radiologist

Plus, we have survived one full website update and I have written a book called Radsresident: A Guidebook For The Radiology Applicant And Radiology Resident, both on Kindle and paperback. And, we have created new features that have been a great success such as Ask The Residency Director and The Case Of The Week. Of course, I am still experimenting and trying to figure out what interests you, the viewer, and what works on the website well so that I can continue to create interest, entertain, and grow the website audience!

Please Continue To Support The Website

Although our website is growing by leaps and bounds from its humble origins, radsresident.com continues to operate at loss. So, if you like this site, please continue to buy books and items through our affiliate Amazon.com in the books and links section.

Also, if you are interested in completing surveys for money, I am an affiliate of both M3 Global Research and GLG Group. I currently use both companies to complete surveys for extra cash. If interested, I highly recommend joining both organizations to maximize your survey dollars.

And finally, I am also an affiliate of grammarly.com. I use this application on a daily basis to help with correcting grammar for the website and find it exceedingly helpful. If you are interested in writing personal statements, papers, or other documents, I highly recommend utilizing it as a grammar check. Joining up is free for the basic version and you will also support the website. Just click the link in this paragraph.

The Future Of Radsresident.com

For now, I plan to continue to write lots of blogs that I hope will be useful and of interest to you, the reader. (I have 4 articles already written in advance and have lots of ideas for new articles!) In addition, recently, Doximity has asked to publish some of my new articles on its website. So, I am excited to announce that you can also expect that Doximity will highlight my articles in the Doximity op-ed section!

As we go along, I also hope to continue to get great questions from my readers to use for the Ask The Residency Director section of the blog. And, we will continue to publish interesting articles by guest authors as they come through. Of course, if you have any interest to participate in any of these ways, don’t hesitate to contact me at director1@radsresident.com!

Gradually, I also plan to experiment with what works best on this website. But, would be happy to entertain any further suggestions from you, the audience. Over the next year, you may notice changes to the website every once in a while as I add on concepts to the website that may be interesting or take away others that I find to be redundant or do not work as well.  Please, I would love to know what you think!  Thanks for celebrating the blog’s first birthday with me, everyone!

 

 

 

 

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Should Radiologists Ignore The Phone?

phone

All told, on any given day as radiologists, we may receive tens of phone calls from our colleagues, technologists, fellow clinicians, administrators, friends, spouses, and patients. We are constantly bombarded with phone calls. So much so that I always wondered about the rate of interruption in a radiology practice. Well, I found one such paper. Confirming my suspicions, a study from Radiology Business(1) looked at 1000 minutes of radiologist observation and found that radiologists were interrupted 94 times or 2.4 minutes per interruption. That sounds about right! So, we are a specialty with lots of distractions.

Some of these distractions can be very important. Others not so much. Regardless, many of us feel obligated to pick up the phone to answer questions and resolve all sorts of issues. However, at what point does a phone call interfere with our concentration? Do these phone calls hamper our performance at the job? Should we always pick up the phone or just let it ring? Or, maybe is it worth our while to hire someone to pick up the phone for us? Let’s look at some of these issues and see if we can develop some suggestions for you, the radiologist or radiology resident, as we peruse the data.

Literature Review On Interruptions In The Workplace

Let’s start with the most general and go to the most specific. We know from multiple sources that distractions can severely hamper correct interpretations. Here are a few of those studies. The first study (2) looked at 54 students creating essays with a control group (no interruptions) and two experimental wings (interruptions during outlining or writing the paper). The authors found that writers reduced the word number and quality in the groups with interruptions.

Another article (3) looked at workers participating in a simulated submarine tracking program. In this study, the researchers interrupted the participants for 20 seconds with a blank screen. They found that the interruption significantly impacted situation awareness. These participants were significantly slower and less accurate in making decisions.

Next, let’s look at some healthcare studies. This point is where it gets even more relevant. An excellent review paper (4) looked at distractions in the healthcare environment. Two of the most pertinent studies discussed in the report included an article that found that drug dispensing errors increased by 3.42% with interruptions. Then, another article showed a relationship between surgical errors and the number of disruptions.

Most relevant to us, a paper referencing radiology residents looked at the error rate of reads. They correlated the error rate with the number of phone calls in any given hour. This study showed a correlation of an increased error rate of 12 percent with each additional phone call received on call. They concluded that telephone call interruptions might negatively impact on-call radiology resident accuracy (5).

Applicability To The Radiologist

So, how applicable is this information to us, the radiologists? Let’s take these studies to heart. We know based upon the literature above that distractions are not so great for essay writing, situational awareness, drug dispensing errors, surgical errors, and most importantly, film reading. These are activities that have a direct relationship to our daily work. I think, therefore, that these studies are directly applicable to our situation.

What Do We Do About The Phone Calls?

Now, this is the million-dollar question. We know that it is part of our job to take phone calls, interact with people, and deal with sticky situations amid our work. However, with this information in mind and the knowledge that interruptions cause problems, we as radiologists reasonably need to mitigate many distractions in the workplace. What does this mean?

Well, perhaps, we should have systems that allow other employees to field some of the administrative responsibilities. Radiologists should not be triaging phone calls. Administrators should ensure that only the appropriate phone calls get to the radiologist’s desk.

In addition, we need to be mindful of the impact of distractions on our work. And we need to make appropriate adjustments. If the phone is ringing off the hook and we don’t have administrators to take these phone calls, perhaps, we should not be trying to answer the phone when we are reading a case. Instead, we should answer the phone only when we have completed reading a study.

Summary

Based upon our whirlwind tour through the world of phone calls, distractions, and our work, we now know that phone calls are a significant issue in our workplace. Next time the phone rings, think twice before you answer it!

 

(1) http://www.radiologybusiness.com/topics/practice-management/quality/highly-disruptive-interruptions-cause-radiologists-lose-focus-reading-room

(2) http://journals.sagepub.com/doi/abs/10.1177/0018720814531786

(3) https://www.ncbi.nlm.nih.gov/pubmed/26314878

(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3007093/

(5) Acad Radiol. 2014 Dec;21(12):1623-8. doi: 10.1016/j.acra.2014.08.001. Epub 2014 Oct 3

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Ten Disastrous Consequences Of Poor Study Habits

poor study habits

 

Studying for radiology is intense and unlike anything that you have done before. If you think shirking your duties only hurts yourself, you are entirely and utterly wrong. For those of you that don’t yet get it but are willing to listen, here are 10 of some of the disastrous consequences of your poor study habits!

Harming The Patient

First and foremost, you took a Hippocratic oath at the end of medical school, right? Well, by not reading, that certainly goes out the window. Not studying well leaves you more prone to interpretation errors when reading films. Ultimately, this will affect patient care. Who needs unnecessary biopsies and increased morbidity/mortality? You don’t care about that!

Your Colleagues Don’t Take You Seriously

Notice that your colleagues never approach you for consultations on their cases and second opinions. You feel out of place. Why is that? If you read something, you would go over more interesting cases because your colleagues would have a good reason to talk to you. You may become a better film reader. Well, maybe you are not interested in films and consults?

You Go From Practice To Practice

You know this type of individual. Probably, you have seen an attending or two who do not last long at your program. Sometimes you are not quite sure why they left. But many times, they can’t interpret films well. Perhaps, if they had read and studied a bit more…

Can’t Pass The Core Examination

This statement cuts right to the heart of the first through 3rd-year radiology residents. What is a radiology resident’s worst nightmare? That they need to take the core examination twice. Why would you want to do that? Just study!!!

Difficulty Obtaining The Fellowship You Want

Your dream is to go into interventional radiology. Forget about it. You always wanted to do an MSK fellowship. No way. To get into the more competitive specialties, you need recommendations. Who will give you a good one when you have not read a lick and never attempted to change your study habits? Did you think about that?

Your Attending Dreads When You Are On Call

Have you noticed that sigh that seems to emanate from your attending’s mouth when you say you will be on call the night before his CT rotation? Well, you better get used to it! Who wants to be the attending of record after you make all those interpretation errors due to lack of reading?

No Job Connections

Finally, you graduate from your residency program. But, no one seems to let you know when that next great job is available. Why not? It is straightforward. Who would want to recommend you to a position when you don’t have the background to merit it?

Attendings Won’t Let You Perform Procedures

In interventional radiology, you realize that your colleagues are getting to do a whole lot more procedures independently than you get to complete. Why is that? Hmm… Maybe, no one trusts you to touch a patient because you haven’t read about the procedure at all!

Consults Walk By You

Have you ever noticed how any clinical physician that has a questi0n walks right by you to the other guy in the corner of the room? Well, you have established a reputation for yourself because you have not been studying the right way. You are no help to anybody. Maybe this is what you wanted- you now have less work. Congratulations!

Losing Out To The Competition

You are beginning to notice that your patient loads are dropping precipitously? Around the corner, another practice opened up that now reads studies that you don’t feel comfortable reading because you are unwilling to study and learn about the new image modalities in radiology. Your wallet begins to suffer!

Bottom Line For Poor Study Habits

Reading, studying, and continually learning are all part of becoming a great image interpreter. A radiologist cannot exist in today’s climate without these tools as a resident and beyond. Why would you want to destroy your reputation and have to deal with the ten disastrous consequences of poor studying habits!!!

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Gaining Recognition When The Odds Are Stacked Against You

recognition

For medical students and residents, at times, it can be tough to gain recognition for your work. I want to give you a little vignette of one uncomfortable experience with a difficult attending I had as a former medical student. Then we will discuss how to counter a poor evaluation. Although your stories may differ from mine, many of you will experience something similar as you traverse through residency.

The Background Story

I was a fourth-year medical student subintern during a medicine rotation. And my group consisted of myself, a pretty female third-year medical student, an intern, a resident, and a balding senior medicine attending in his late sixties or early seventies. The attending physician assigned us to review compelling cases that presented themselves the prior week. We were then to discuss the medical topics that arose from these cases.

First, the 3rd year medical student began to discuss a patient with severe onset of hypertension. And she went through an appropriate workup of the patient with hypertension and delved into the physiology and management of patients with hypertension. It wasn’t a bad presentation. Unfortunately for me, the attending would not stop affectionately staring at the third medical student. It was a bit creepy.

Next off, it was my turn to present. I had a great case of a patient with Histiocytosis X/eosinophilic granuloma of the spine that I thoroughly researched. I knew the case and the topic cold. Therefore, I rehearsed the presentation many times at home. So, I was excited to present. What could be wrong about presenting a rare, fascinating case I knew well?

So, I began to present the case and then went through the process of coming up with the diagnosis with history and imaging. Again, I noticed the attending continuing to ogle the third-year medical student inappropriately. As soon as I started to discuss the topic, WHAM… He shut me down by saying, “We don’t need to discuss this topic because it rarely occurs, and you will probably never see another case like this in your lifetime. What a waste of everybody’s time!”

Problems With Gaining Recognition In Clinical Education

All too often, something similar to this scenario occurs in clinical medicine, whether you are in radiology or another field. Perhaps, you are a foreign medical student, and the mentor won’t give you the time of day. Or, maybe, you are rough around the edges, and your teacher doesn’t like your personality. In all these situations, favoritism for reasons other than merit and quality often trumps a great job. No matter how you change the grading system to include milestones or different innovative ways of evaluation, bias can interfere with gaining recognition for your work. In the end, the final grade often comes down to the evaluators’ quality. (Don’t take it personally!)

At the same time, there are many positives about the experience of having learned about the topic of eosinophilic granuloma, regardless of my evaluator. First of all, in my line of radiology work, the diagnosis of eosinophilic granuloma has come up in my experience several times. Second, from my studies on the topic, I have used the information from that presentation for the betterment of my patients. And finally, the subject arose on some of my radiology board examinations, and I knew all the answers to the topic cold. So yes, there was something educationally valuable from this experience.

How Can We Align The Evaluator With The Recognition Of A Good Job?

That brings us back to the crux of this post. What can you do to get the attention of your evaluators about your quality work when they don’t want to give you the time of day? I do not claim it is going to be easy. It certainly isn’t. But there are a few workarounds.

Get What Makes The Evaluator Tick

First, ask your evaluator what it is that interests them. Now, I am not asking you to be a brown-noser, but sometimes to garner the attention of our seniors, we have to find out what makes them tick. A person like this is more apt to listen to you when you are on the same wavelength. Admittedly, in my case above, if I had changed my topic, I think it still would have been difficult to change this attending’s opinion of me. But, at least, I would have presented a case that would have been more likely to get his attention.

Defy Expectations

Next, go above and beyond the expectations of the evaluator. For instance, perhaps, I could have begun a quality initiative study to improve the outcomes of patients on his service and put his name on the paper. My story above might not have ended differently, even if I had provided the “ogler” with something distinct and memorable. But, it would have increased my chances of garnering recognition for my work.

The Nuclear Option

And finally, sometimes you need to go to the top. Things can be, on occasion, so bad that you cannot even fathom doing anything that will change the opinion of your senior. But be very careful. Heads of departments will often side with their staff before they side with a resident or medical student. So, if you use the nuclear option, ensure you have objective evidence that this person is unfair to you without trying to get your evaluator into trouble. And, also make sure that the director is willing and able to help. Sometimes, they can pair you up with someone else who can evaluate your work.

Gaining Recognition For Your Work

We all encounter people in positions of authority who may not be “fair” to their subjects. It is part of what we experience in medical school and residency and part of the real world. Most of us are somewhat sheltered from the real world through the beginning of medical school because our teachers’ primary evaluation method is exams. As we enter the clinical years and residency, evaluations become more subjective. So, learning how to successfully interact with difficult attendings who may unfairly evaluate your work is vital. Don’t be another technicality of a poor mentor. Be proactive in your education and obtain the recognition you deserve.

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The Uncomfortable “Screenostic” Breast Ultrasound Imaging Dilemma

ultrasound

For those of you who have completed a mammography rotation or are beginning to practice mammography, you may notice ordering physicians prescribe a diagnostic mammogram along with a diagnostic and screening ultrasound. One example would be the doctor who orders a mammogram for a unilateral breast asymmetry with an accompanying bilateral diagnostic ultrasound. Or other times, the ordering doctor will specify to perform an ultrasound for pain on one breast. Yet they order a bilateral breast ultrasound that the patient expects to get done. One of my former excellent mammographers had called these sorts of situations “screenostic studies.” And I think that is a great descriptive name since these breast ultrasounds encompass both a “diagnostic” and a “screening” component. So, I kind of took to the title, “screenostic.” Now, I use it all the time.

Issues Behind The “Screenostic” Ultrasound

For me, I always find this situation very frustrating. You are never quite sure if the ordering physician means to order the study as a screening ultrasound. Or, did they mean for the case to be diagnostic and accidentally request a bilateral breast ultrasound? Perhaps, they were not thinking about it or did not understand the purpose of the ultrasound. Unfortunately, frequently, you will never know the answer.

So, let me give you an example of what happens when you confront the issue head-on. You call the physician to learn their ordering intentions, taking away precious minutes of your valuable time. Then, when you ask the ordering physician what they wanted, the physician often becomes indignant because it “wastes their time.” On top of this, the patient expects that they will receive a bilateral ultrasound because it is “better” than a one-sided diagnostic ultrasound. Now, they have to wait longer. And if you decide to change the order, you now have to waste additional time to persuade the patient that they need a unilateral breast ultrasound.

Bottom line. All hell breaks loose. It’s ugly. You have a mixture of undecipherable physician expectations. And the patient has unfounded expectations to complete the study. The radiologist is unhappy; the patient is angry, and the ordering physician is upset. It is a lose, lose, lose situation.

So what finally happens? Regardless of the study indication and the true intentions of the ordering physician, the technologist completes the study. It’s just a heck of a lot easier. But, it is all a waste of time and money.

Call To Arms!

I only see two potential ways out of this daily breast imaging mess. First, we need intense education for ordering physicians. In most practices, however, this road is a difficult one. It can be next to impossible to get through to all the referring physicians in a bustling business. And, referrers just want to order and write their scripts without dealing with the implications. It takes too much time to “listen” to the meager radiologist or set up an educational outreach program.

Second (and I may get a lot of backlash for this one), enter clinical decision support systems. If only a system could force the ordering physician to make a clear prescription that makes sense. Clinical decision support systems would do just that.

You may think that I am just whining and complaining. But this issue has real implications for patient well-being and daily workflow. Oh well, in the end, it is just another dilemma that occurs when the clinician controls the ordering of imaging studies instead of the true imaging expert, the radiologist. Let’s take it back!!!

 

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Should I Take A Leave of Absence During Residency?

leave

 

Sometimes events beyond our control interfere with radiology residency. It may be a personal situation, a new business opportunity, mental illness, or severe burnout. I outlined some of these issues in my previous article called The Struggling Resident. And perhaps, one or many of these reasons have you thinking about taking a leave of absence.

But, what does this option entail? Many residents don’t know the details about taking a leave of absence. So, we will talk about the potential consequences of what can happen after a leave of absence and why you need to take the option only as a last resort. Then, we will discuss what situations merit taking a leave of absence, a circumstance where you might want to think about taking a break (but very carefully!), and finally, situations where it is seldom appropriate to take a leave.

Truth or Consequences

What is so serious about deciding to take a leave of absence from residency for some time? Maybe it’s six months, a year, or more. There are so many reasons why it can become a significant issue.

1. It will potentially take you off schedule for getting into a fellowship. Many fellowships will not consider residents who begin in the middle of the year.

2. You will likely have to start paying your health insurance and benefits. Believe it or not, it can cost tens of thousands of dollars for health insurance for a family. You may pay a few hundred dollars out of pocket per month when you are employed, but it can run over a thousand dollars per month when you are not. Can you cover those expenses?

3. You create a reason for future employers not to hire you. Many employers become very concerned when they see a gap in your employment history without an excellent cause.

4. It can cause irreparable harm to your residency program and classmates. You can no longer take call. Additionally, the rest of the class needs to shoulder the responsibilities. It does not set you in the light of a team player.

5. And finally (and perhaps most importantly!), you may be legally required to start paying off your massive debt load. That can be a real bear!

I Can’t Do My Job

So, when should you unconditionally take that leave of absence? It comes down to one situation: you cannot perform your job duties safely. If you can complete your residency duties, radiology residency is a temporary affair (albeit four years). And, believe it or not, many physicians would love to be in your shoes. So, if you are able and healthy, you should put all your efforts into completing your residency.

That said, if you have a mental illness, severe disability, or significant trauma, by all means, take that leave of absence. You took the Hippocratic oath and may not be able to abide by it in these circumstances. So, these conditions necessitate a departure. My advice: If it is some reason that does not involve breaking the oath, do what you can to pursue other endeavors until after your residency. You will have a great field to fall back on.

A Once In A Lifetime Opportunity

A confluence of events occurs from time to time, leading a resident to consider a job opportunity in another field. Perhaps, you just got that call to anchor a TV show. Maybe you created an invention, and a large company wants to buy out your patent for 5 million dollars; that will take a long time/lots of work to seal the deal. Or, you’ve been dancing for years, and a director in Broadway wants you on his show.

As I began brainstorming about what issues may eventually allow a resident to take a leave without regrets, some of these reasons could potentially cause a resident legitimately to rethink a radiology residency. I get it. Just remember, for those of you with significant debt, if you don’t pay your debts, the IRS can garnish your wages for the rest of your life. And these unique situations are not always a means of securing a lifestyle for years to come. (although occasionally it can be) So, those residents in this unusual situation need to think long and hard about taking a leave of absence.

Situations That Do Not Merit A Leave

If you are thinking of starting a business, quitting medicine, or needing some time off to relax and travel the world, this is not the time. You’ve already been through 4 years of college, four years of medical school, and a year of internship. What is four more years or less in the scheme of things to complete a radiology residency?

So what are some other situations that you should not use to take a leave of absence during residency? These would include taking a break to pursue another subspecialty (why can’t you just wait it out to apply, so you don’t have a gap in employment?) Or, maybe you have mild burnout (better off talking to a coach, colleague, or physician.) Perhaps, you want to start a new business (can you wait until after residency?). Attempting to train for the next Ironman triathlon is not a bad idea (you want to jeopardize your future?), and so on.

Final Thoughts

Taking a leave of absence is a huge deal. Many residents may dream of taking a break at one time or another to go for something they never had a chance to do before. However, think twice, my friends. Often, it sounds good in principle, but the practicalities behind it don’t make much sense!

What do you think? If you have any opinions, please leave a comment below!

 

 

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Patient 0- A Mystery Wrapped In An Engima

Today I am going to try something completely new- a case study as a blog. Typically, I have not attempted to make the focus of this blog individual case studies. But, this case touched upon so many interesting medical, ethical, political, and professional issues that I felt that it was worthy of its own post. So, let me give you some background on patient 0 and allow me to explain.

The Background On Patient 0

A fairly young patient arrives at our emergency department after entering the country by plane, 3 days prior to admission. She claims to have worsening right upper quadrant pain exacerbated by eating. In addition, she states that she never had any imaging studies either here in this country or from her home country. After “examining” patient 0, the emergency physician decides to order a hepatobiliary scan to exclude cholecystitis. So, the patient comes to our nuclear medicine department for the study. Initially, we take a prelim scout image prior to injecting the radiopharmaceutical and this is what we see:

 

A technologist looks at the study and determines that maybe there was some contamination and repeats the image again after cleaning the table. Here is the image again!!!

 

Panic!!!

No change… Uh oh, where is this activity coming from? She just flew in from a foreign country and claims to have had no tests after entering the United States. The physicist is subsequently called down to interview the patient. Here are some of the questions and answers:

Physicist: “Are you sure you did not receive any medical tests since arriving in the United States?”

Patient: “No…”

Physicist: “Did you receive any medical tests when you were in your home country?”

Patient: “Yes, I got an injection of something in my arm to relieve my pain.”

Physicist: “What was that injection?”

Patient: “I don’t know. Pain medication?”

Physicist: “Did you eat anything unusual?”

Patient: “I ate a regular light breakfast and lunch.”

So, the physicist calls over the radiology manager of the department and myself, the nuclear medicine physician of the day. Given the absence of a clear history of radiopharmaceutical administration, he becomes concerned that either patient may have ingested radioactivity from a contaminated source or the patient may have had an exposure something that is highly radioactive. Exposure to a dirty bomb??? We all begin to sweat profusely.

What would you do next?

Calmer Heads Prevail

So, the physicist takes at the Geiger counter and notes that the radioactivity coming from the patient is less than 0.1 mR/hr at 1 meter. Whew, at least we know that the patient is not a danger to the personnel in our department.

Now, how would you deal with this situation???

Well, we decided to change the primary photopeaks of the camera to determine the most likely Kev of the gamma rays emanating from the patient. Theoretically, if the radioactivity was from a nuclear plant or other unusual sources, the patient would not have a photopeak coming from the typical photopeaks for medical imaging. So, we tried imaging with photopeaks at I-131 and thallium. Neither of these photopeaks matched the images coming from the camera. (counts were lower and images were blurred) The best photopeak with the most resolution and counts was from the Tc-99m photopeak, shown in the images above. At least, we were now fairly sure that the radioactivity was from a medical source.

What Next?

Given a large amount of uptake in the belly and the discovery that patient 0 was not a medical hazard to staff and patients, we decided to send the patient back to the emergency department. Since there was too much uptake in the abdomen, we could not run a hepatobiliary scan and recommended the patient receive a different test. (Patient ended up getting an MRCP showing numerous stones in  a dilated CBD and had an ERCP to remove the stones).

Implications, Politics, And Ethics

Let’s go back a bit. I stated before that patient 0 reported to have recently traveled from a foreign country. How would it have been possible for patient 0 to get to this country with this amount of gamma rays coming from her abdomen? If the patient truly traveled from her home country several days ago, wouldn’t the radiation have been detected at the airport? Would she really be in this country at this point? Probably not.

But, no detectors are foolproof. Sometimes, a detector could not be functioning properly or can malfunction. But, does that still likely explain the patient’s radioactivity? Unlikely. Why? Since technetium 99m half life is 6 hours, and the patient states she traveled to this country 3 days ago, would she really have this amount radiotracer left in the large bowel? No.

So then, what is really is going on here? Personally, I think that she received a medical dosage of a radiopharmaceutical, possibly for a hepatobiliary scan, after arriving in the United States. And then, she likely left the other facility to come to our hospital, maybe against medical advice. That begs the question. Why?

Immigration Policy Issues

My first thoughts: Could she be here at our hospital because she feared deportation back to her home country? Was she a medical tourist who was hoping to get better treatment in our country? I’m not sure of the real answer to why she was here.

But, the real question in my mind. Are we going to see more of this type of situation in the future? With new and stricter immigration policies, more patients may decide that they cannot tell the truth about their prior imaging because of the real or imagined fears of deportation. I think this has the potential to be the proverbial “tip of the iceberg”. We may see more cases like this in the future.

Our Ethical Obligations

First and foremost, as physicians, we are obliged to serve our medical duty to the public and ensure that we do no harm to others. In this case, we accomplished that once we figured out that the radiation dose and exposures were not harmful to other people.  However, in my mind, many questions still remain about this case, especially what are our ethical obligations if she was exposed to a non-medical radioactive source. How would we have handled that situation? Who would we have notified next? Do we follow the regular channels of just contacting the Radiation Safety Officer. Or do we also get in touch with the patient’s relatives, the police, the nuclear regulatory commission, or the FBI…

Bottom Line

Fortunately for us, we averted a potentially scary situation. But, it really makes you think about all the potential outcomes of a radioactive patient 0 scenario. What about next time?

Comments From You

I would love to hear what you, the reader, think about this case since it makes for a great discussion. Would you have done anything differently? What are your thoughts about a patient such as this that could potentially arrive at your institution?

 

 

 

 

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How Not To Incriminate A Fellow Radiologist For His Mistakes

 

 

One major theme in many of my blogs is that radiology residents and radiologists do make mistakes. We see them all the time in prior reports. We hear them from our fellow radiologists and clinicians. It is just part of the normal ebb and trough of the radiology resident or attending. I still remember one of my attendings from residency sagely saying we slowly get less sensitive over time. Then, we miss a finding and become overly sensitive until we become less sensitive again. And, this process continues throughout our radiological lifetimes, hopefully, as we try to reach perfection. Bottom line. If you are not making mistakes, you have not read enough films and you are not getting better. We acknowledge that. It’s who we are.

More importantly, we as radiologists have to protect each other from our mistakes. It is important that we don’t throw our radiology colleagues “under the bus”. Politically and ethically, treating our fellow colleagues well is just as important as writing good reports. We all need to be team players in order to protect our practice of radiology. So, what are some general rules for protecting our colleagues from their own mistakes? Well, that is the theme for today. A mini-instructional, if you will.

Contact Your Colleague Immediately

Contacting your colleague is probably the most important step in reducing the issues that ensue from a miss. Often times, I will read a bone scan and find the corresponding metastatic lesion on CT scan that can be very hard to detect prospectively. Immediately, I contact the physician who recently dictated the CT scan, usually on the same day. As a courtesy, this step allows this radiologist to create an addendum if warranted and prevents any harm from coming to the patient due to an incorrect report as well as the possibility of a lawsuit.

Sometimes, however, you may detect a miss from a while back, maybe months or years. In this situation, the offending physician can contact the caring physician or patient and/or make an addendum to his/her report to right the mistake. It may not prevent a lawsuit, but it certainly prepares the physician for the possibility. And, it also happens to be good patient care.

Don’t Highlight Mistakes On Prior Reports

This may seem obvious, but radiologists commit this offense one too many times.  When your fellow radiologist misses a finding on a previous report, the last thing that you want to do in any way, shape, or form is to say explicitly that he/she missed the finding. If the patient catches wind of this miss, you will see dark clouds brew and lightning flicker through the air, about to target this unsuspecting radiologist and your practice too. You are asking for a lawsuit to strike down all those involved in the construction of the prior report!

Phone The Clinician Directly To Discuss The Case

Instead of adding the miss directly to the report, another good idea is to pick up the phone and call the clinician. The issues behind a radiologist miss can be better expressed sometimes by mouth than on paper. It allows you to guide the physician toward what he/she has to do next without having to state it officially on a report. Also, the less incrimination on paper, the less likely the radiologist with a miss will have to answer for his/her sins.

Use The Words New, Stable If Possible

Especially in mammography, the kiss of death for a radiologist with a miss on a prior report is to write that a mass has enlarged compared to his priors. In no uncertain terms, what you are really saying is that the radiologist missed the finding. Lawyers love this stuff! Not that you should lie, but many lesions cannot be seen prospectively because they are really too small to catch. So instead, if you can, use the word new. Or, just say a mass is present with a comparison date to the previous study. Even better, if the lesion was present and unchanged, you can safely say the lesion is stable without incriminating anybody. Stability is usually the radiologist’s friend!

Summary

A radiology practice is a team and if you don’t think like a team player, your team will break apart. Incriminating one’s colleagues for mistakes made (that we all make at times) is a selfish act and is one of the most unsporting behaviors out there. So, be a team player and think long and hard about what you will finally place in your report. It potentially can save your colleague from a lawsuit and allow you to earn respect from your practice as a team player!