Year: 2017

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Reading Room Background Music- A Hazard For Patient Care?

music

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

Music As Potential Benefactor In The Radiology Department

Mood

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

Performance

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

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

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

A Case Report About Music And Performance

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

Music As A Disruptor of Radiologist Concentration

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

Performance Deterioration

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

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

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

The Lone Radiology Resident Study- A Mixed Result

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

So What Is The Preponderance Of Evidence?

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

 

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

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

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

Protocols And Educational Implications For The Radiology Resident

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

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

The Clinical Decision Support System

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

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

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

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

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

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

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

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

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Radiology Personal Statement Mythbusters- Five Common Misconceptions About Radiologists

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

Where’s Waldo?

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

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

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

The One Fascinating Case

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

The Family Member Saved By A Radiology Finding

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

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

The Diagnostic Dilemma

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

The Isolated Radiologist

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

Busting Myths And The Final Truth About The Personal Statement

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

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

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

 

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

Dr. Julius,

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

Thanks for your input!

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

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

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

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How To Combat A Difficult Radiology Job Market!

job market

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

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

Networking, Networking, Networking!!!

Maintain Relationships At Home

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

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

Keep In Touch

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

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

Always Be Nice

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

Diversification of Skills

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

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

Should Location Be The Sacrificial Lamb?

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

Recommendations

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

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

Research/National Organizations

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

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

Final Thoughts About The Job Market

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

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

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

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

Effects of the Travel Ban On Residency

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

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

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

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

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

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

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

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

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

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

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

Difficult Times For Foreign Nationals From the Targeted Countries

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

 

 

 

 

 

 

 

 

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Can I Be Sued As A Radiology Resident?

lawsuit

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

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

The Grounds for a Lawsuit

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

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

Resident Breach For A Successful Lawsuit

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

Breach For The Intern

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

Breach For The Subspecialist Trainee

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

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

The Main Source of Confusion About Breach

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

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

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

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

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

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

Lawsuits And Residents

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

 

References

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

Published online 2012 Jan 26.

Medical Liability of the Physician in Training

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

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

By Liza Haar

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

 

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Tackling Research- Basic Issues and Considerations for the Radiology Resident

research

Put an academic radiologist and a general community radiologist in the same room and start a conversation on research and radiology residency. How do you think that conversation would go? I bet there would be bitter debate and sharp words. It would likely be next to impossible to get them both to agree on the merits of radiology research.

The academic radiologist would point out the necessity of research to allow the resident to understand how to delve deeply into an area within radiology, understand the mechanics of making discoveries, and create and advance new areas of knowledge within our specialty. He would espouse the importance of statistically analyzing false positive and negative rates, ROC curves, sensitivities, and specificities, tools invaluable to becoming a good radiologist. Additionally, they would also likely say that without an understanding of the mechanics of the research process, companies can easily mislead you by marketing headlines for new software, contrast agents, radiology hardware, etc., that may, at best, marginally display the truth of an imaging process or at worst can be entirely incorrect.

On the other hand, the community radiologist would say that if you understand the fundamentals, can read films well, and know how to manage patients appropriately, what is the point of doing research? Let others develop new ways of interpreting films, creating protocols, or creating new contrast agents. Or in other words, “leave the research to the academics.” The community radiologist would also utter in the same breath that research is too time-consuming, costly, and incompatible with the day-to-day running of a revenue-generating practice. Why bother?

To What Extent Should You Pursue A Project?

So, given these diametrically opposite points of view, the big question becomes: to what extent should the radiology resident pursue research during residency? Should you make it into an all-consuming process or relegate research to satisfying your residency program’s requirements? Given the potential difficulties of making this decision for some residents, I will go through how to figure out for yourself whether you should follow the advice of the academic or community radiologist. In addition, if you go down the research pathway, I will give some sage advice about how to find a research mentor and what makes the best research projects.

How Much Research Should I Pursue?

Maslow’s Hierarchy of Needs

Ever read about Maslow’s Hierarchy of Needs? If not, I highly recommend you click on the previous Wikipedia link. Instead of Maslow’s Hierarchy of Needs, now picture the Radiology Residency Hierarchy of Needs. You might have to dictate films, study radiology material, and attend lectures at the base. At the apex, you would have radiology research. This point is so important: your own basic needs of a radiology residency must be satisfied before you tackle the research requirement. Therefore, you must answer some questions before starting a research project: Have you been studying enough, attending lectures, and learning the basics of radiology concepts? Are you performing well on your rotations? Do you have to concentrate on other issues, such as the USMLE? In other words, the resident must first focus on becoming a good radiologist and then their research. 

The entire pyramid will collapse without the essential elements of good radiology residency preparation. Why do I make this statement? Suppose the resident concentrates so heavily on research instead of learning all the imaging modalities and vital skills during their residency program. In that case, they will find it very difficult to perform well during residency. You want to ensure that you know the general skills of the radiologist first and foremost. Furthermore, too much emphasis on research can lead the resident to lose focus on other issues, such as passing the core examination. So, make sure not to forget about the main reason you are doing your residency: to become a radiologist.

The Rewards

On the other hand, if you can dedicate time to research because you can comfortably divide your time appropriately, by all means, go for it. The rewards are numerous from both a practical as well as academic standpoint. Significant research becomes essential if you are interested in academic radiology, love to come up with innovative ideas and enjoy writing publications. Publishing several papers and abstracts during residency and fellowship can help you get that first job if you want to pursue an academic career.

Even in private practice, performing research during your residency shows that you are interested in radiology. From a radiology job market perspective (although the community radiologist may not want to admit it!), if you have two equal candidates, one who has accomplished much research and the other who has done none, I believe most practices would choose to hire the former.

The bottom line- yes, research can be rewarding but make sure that it doesn’t interfere with your fundamental mission of becoming a radiologist!

How Do I Find A Research Mentor?

Most radiology programs have some attendings that are almost exclusively clinical and others that are more academic. I recommend you seek out mentors/attending with a decent amount of research experience. Although these clinical-based attendings can be great teachers and mentors for learning radiology, they will likely not be as valuable for understanding how to do research. They may express interest in helping you with research, but they cannot instruct you on completing a project. So, unless you have already had a lot of experience with radiology research, a more clinically based radiologist may not be the best choice for a radiology research mentor. There are a lot of radiology attendings out there that don’t have a clue how to structure a research project. (not that it makes them bad radiologists!)

Although not always possible, depending on the size and structure of your residency program, try to find a mentor in an area/subspecialty of radiology that interests you. It will more likely help you later in your career when you complete a project in your area of interest.

Finally, try to find a mentor that meshes with your personality. In addition to the grunt work of research, part of the research process involves bouncing ideas off one another and brainstorming. Exciting research can begin to seem more of a chore than a genuine passion if you feel you are not an equal participant. It shouldn’t be that way. Personality can become a significant issue.

What Makes The Best Projects?

My favorite research projects are those issues and problems that have constantly nagged at me or annoyed me over the years of practice that you have the itch to solve. In addition, I love research projects in an area of actual interest. These tend to be the best and most satisfying projects. I find that esoteric projects without relevance do not provide that spark to take the research to the next level. It also may dissuade the resident from pursuing other projects down the line.

I recommend that when you are involved in the day-to-day readouts, try to take notice of the issues that bother the attendings or questions that occur in the areas of interest you love. There are few things more satisfying than coming up with a question you thought about and then figuring out how to solve it.

Final Thoughts

Radiology research is an excellent avenue for understanding the mechanics of what we do as radiologists. We take many presumed facts for granted, whereas these facts may not be based on the best evidence available. Performing your projects allows the radiology resident to understand how to determine what information is genuinely facts and what information does not have a basis in science. This process helps the resident to read and interpret studies and critically define the accuracy of the information we use to analyze images daily.

Furthermore, delving into research by completing a project can be a very satisfying professional endeavor and become a capstone on top of our radiology residency training. Few things are more satisfying than answering your question, for which the body of literature did not provide an answer.

However, it is essential to remember that as a radiology resident, you must satisfy the basics of radiology residency first and foremost. Before deciding whether or not to become involved in a project, consider if you have the time and energy to pursue the project to its end. If a research project is very complicated and time-consuming, think twice about the project because your priority should be to become a well-trained radiologist. Radiology research can be rewarding, but only to the extent that you first satisfy the basic requirements of radiology residency training.

 

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The Post Interview Second Look – Is It Worth My Time?

second look

Every year after interview season ends, there is a brief interlude until the rank selection list is submitted. And now, during the life and times of covid, it may be more challenging to arrange a second look. However, with vaccines available to health care team members, students, and attendings alike, you may be able to schedule one. 

So, you may wonder at this time- Does it make sense to go back to a radiology program to take a second look? It may be a complicated decision and can depend on numerous factors. Therefore, I am going to take a look at this issue from a program director’s perspective. We will approach the problem by tackling a series of questions that will help you make this critical decision. Hopefully, it will be of some benefit to those of you that are involved in this process.

Who Is Most Likely To Benefit From a Second Look?

From a residency director’s perspective, the ideal candidate for a second look at a residency program is a student that has already interviewed, for which the admissions committee was unsure of its final disposition. For example, every once in a while, an application/prospective resident interview causes a stir among the committee. The interview may have gone well, but the application quality didn’t sync with the interview. Or, the application was excellent, but the applicant’s personality was questionable on interview day. Usually, it is some conflict in the committee evaluation process. These applicants can benefit the most from a second look because it may sway the admissions committee one way or another after the candidate returns.

Second, the marginal/below average candidate that has been ranked but did not have many interviews would also be an ideal candidate to return for a second look. Some programs will rank their returning applicants slightly higher for just showing interest by returning to the program. Usually, candidates don’t return unless they are earnest about a program. A slight increase in the rank list can make the difference between matching and not matching.

Finally, the other ideal candidate would be the interviewee who felt he/she didn’t get the best impression of a program and wants to make a more informed decision on the day he/she will submit the rank list. Maybe the program director was absent. Perhaps you have a spouse that wants to remain in the area, and you didn’t get the best impression on the interview, but the location would be ideal. Or, maybe you like the people you met, but you felt you didn’t meet the residency program’s key players on the day you interviewed. Whatever the case may be, the second look can help to reinforce that decision.

How Do You Know You Should Come For a Second Look?

Let’s first begin by stating: The worst situation for the residency applicant and the program is to have an applicant that has already been placed into the “Do Not Rank” pile return for a second look. It wastes the applicant’s time and money and the resources of the program director and staff. Also, it may not make sense for the individual applicant to return depending upon other applicant factors. So, here are some criteria that may help you to decide if you are in either of these situations:

  1. Did the interviewer suggest you come back for a second look? The program director will usually recommend to return for a second look if he/she is potentially interested in a candidate and think it may be of some benefit.
  2. Did you get the cold shoulder during the interview process? Some interviews don’t go well for multiple reasons. That will happen from time to time. Your instinct is probably correct if you feel that is the case. In this situation, it is perhaps not worthwhile to return for the second look.
  3. How far down is the program on your rank list? If the program is very low on the order of your rank list and you are a reliable candidate, it is probably not worth the effort to return for the second look.
  4. Is it reasonable to travel to the interview site? Some candidates live very far away from the prospective residency program. Suppose it will be disruptive to return to the program due to travel costs or significant inconvenience (maybe you are amid your medicine sub-internship and can’t miss a few days). In that case, it is probably not worth your effort.

 

How Should You Behave/Present Yourself On The Day Of The Second Look?

The program director or interviewer that asks you to return for a second look will often tell the candidate, “we would love to have you return for an informal second look.” It is important to remember that there is no such thing as an “informal” second look. A second look is a second interview day, and you need to treat it as such. Wear your best interview clothes as you would have worn for your first interview. Be on your best behavior and be friendly to all staff members, just as you would have done for the initial interview. Remember, you still have not been admitted to the program, and you are certainly not yet “one of the residents.”

What Should You Tell The Program Director Before You Leave?

Certain buzz words have significance to the program director when meeting at the end of the second look day. The program directors and admissions committees take these words very seriously. So, be careful what you say. If you say the wrong thing, it may cause a different result than intended.

If you are genuinely interested in the program, you can say, “I will rank the program first.” This phrase is specific and demonstrates your genuine intention to the interviewers. The program can verify this fact on match day when you either match the program or do not match it. So, your action will back up the facts. This truth will follow you from this point forward. If you ever decide you want to return to the community as an attending and you did not abide by your word, the program can blacklist you!!!

On the other hand, the phrase “I will rank your program highly” is a buzzword that means your program is nowhere near their first choice, and you will probably match elsewhere. Some applicants do not realize this. So, be careful!

If you are still not sure after the interview day, it is appropriate to say, “I really enjoyed my second look at the program, but I am still considering my decisions.” The program director/interviewer will usually understand. When/if you decide to rank the program first, you can always contact the program and let them know.

Final Thoughts About The Second Look

The second look can be an essential part of the residency interview process. It can provide a slight edge to your candidacy and may be worthwhile if approached the right way. On the other hand, it may not be the right move for all applicants. So, weigh the facts and make a final decision. The interview process will be over before you know it!!!

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The Informatics Fellowship- Bulletproof Your Radiological Future

Concerned about artificial intelligence taking over our jobs? Worried about the economic cyclicality of each of the radiological subspecialties? Do you fear the instability of your future radiology attending career due to corporate takeovers and mergers? Well, I have a solution for you (and no, I am not an infomercial!!!)… Welcome to the new fellowship called Informatics!!!

Why am I writing about the informatics fellowship and skipping all the other subspecialties? Well… the informatics fellowship warrants an independent post because it is truly the only radiology subspecialty that is in a permanent secular growth trend. It is also the only fellowship that has relatively little information published on the subject matter. In fact, once several of my residents and students heard about the existence of the fellowship program and understood its potential benefits, they began to salivate!!!

So, this article is dedicated to the topic of the informatics fellowship. Specifically, we will discuss the definition of informatics, what the fellowship entails, requirements for the fellowship, how to find where to complete the fellowship, and what job opportunities are available for graduates of these programs. I think once you understand the potential benefits of this fellowship program, you might consider it yourself!!!

Discussion of Definition and Importance of Informatics

So, what is the definition of informatics? According to Merriam Webster, it is as follows- “the collection, classification, storage, retrieval, and dissemination of recorded knowledge”. Prior to several years ago, I have to admit that I had never heard of the term or definition of informatics. In fact, I think I am probably not alone. It is only since the terms “the cloud” and “big data” have arrived into the mainstream, that I think the word informatics has been used more widely.

Why all of a sudden is this body of knowledge so important? In our age of electronic interconnectedness, large swaths of data are created and processed every day. Particularly in the radiology realm, there are numerous electronic/digital images and reams of clinical/health information. Someone has to both understand and manage all this information. Although computer engineers presently manage a lot of this information, they tend not to understand how to manage the data for physicians, administrators, and patients to understand. Herein lies the niche of the radiology informaticist, translating the imaging and clinical data from the computer engineer to the clinical realm.

What Do These Informatics Fellowships Teach?

Fortuitously, the same day that I started to write about informatics, I received a letter from the APDR explaining that there would be a new initiative to create a summary online 1 week course in informatics for residents. Some of the topics covered by the course as listed in the letter include Standards; Computers and Networking; PACS and Archives; Security; Life Cycle of a Radiology Exam, Data and Data Plumbing; Algorithms for Image and Nonimage Analytics; and the Business of Informatics. This course contained many of the topics that some informatics fellowship programs teach. But, the curricula of many of the informatics fellowships differed significantly from this course and were more expansive.

To add a bit more confusion, each individual fellowship program also covers differing topics from one another and varies the emphasis of each of these subjects.  Some of the topics that these fellowships include: RIS systems, Image Compression, Teleradiology, Quality Improvement, Operations, Clinical Engineering, HL7, Regulations, DICOM, Critical Results Reporting, Decision Support Systems, Radiation Dose Tracking, Mobile Health Applications, Image Segmentation, Imaging Room Ergonomics, 3D Printing, Natural Language Processing, Informatics Funding, Biostatistics, Health Policy, and Experimental Design. There was some overlap between the different programs. But coverage varied widely. I will also refer you to the ACGME formal program requirements in Clinical Informatics for a more formal explanation of all the areas of teaching required at all fellowships.

What are the Requirements To Become An Informatics Fellow?

The prerequisite requirements vary from program to program. Of the programs I visited on the web, most but not all, had a requirement to be board eligible in a specialty (not necessarily radiology), to be a graduate from an American Medical School, and to have an interest in the discipline of informatics. Most fellowships did not have a specific requirement for formal training in computer science. According to the ACGME, the program length was 1 or 2 years to graduate from a radiology program.

Where to Find the Fellowships?

I found several ways to find the informatics fellowships that are offered for diagnostic radiology program graduates. If you happen to be a member of the AMA, you can look up the fellowships on the FREIDA database. (It turns out I am not a member!) Alternatively, you can do a web search on informatics fellowships and many of the large institutions  describe their own programs. And finally, you can go to the ACGME website and look up informatics fellowships there.

Job Opportunities for the Informatics Fellowship Graduate

This is where things get really interesting… Job opportunities are endless. You want to be part of a large private practice or maybe a teleradiology practice?  Interested in becoming a practice leader?- It’s all yours! Not many employers can replace the only radiologist that can fix a PACS or RIS system and can also actually read films.

You want to become an entrepreneur and start your own company? You will have access to all the tools and methods to create a technological niche for yourself whether it be an app, a PACS addon, a new piece of software, or other countless unimaginable outlets.

You want to go into academics? The world is yours. Academics are desperate to have rads translate their IT department workings into something that is useful and efficient for clinicians. Think about the possibility of chairman or CIO.

You want to work for big business? Think Apple, Google, Cerner, and more! Large organizations are contstantly on the lookout for good talent that can translate the engineering esoteric data into clinical reality. You will be able to develop needed applications, improve health and radiology related products to get more clientele, and more:

Think about it… you will be at the forefront and crossroads of technology and clinical medicine- a job that only a few can currently fill. It will be very difficult to replace you.

Diagnostic readers can be outsourced to India. Robotics can replace human procedures. But humans will always be needed to rule the machines (unless our future is to be the same as The Terminator!)

Final Thoughts

Of course in the end, like anything else, you need to like what you are doing in order to be good at it. And, informatics is certainly not for everyone. But, if you have a remote interest in the intersection of computers and radiology, really consider this subspecialty. The possibilities are endless, job opportunities abound, and you have the ability to be in charge of your own destiny, potentially not subject to the whims of government or even private industry.  You can be your own captain!!!