Year: 2017

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The Isolated Specialist

isolated

No, this is not another article about physician burnout. Instead, today we will talk about why isolated specialists can lead to poor patient outcomes. So, why do I find this interesting? In my own experience, I have encountered multiple instances when I see isolated specialists as the cause of deficient patient care. Let me give you an example.

A radiologist will encounter a non-radiologist physician demanding that his patient receive unwarranted intravenous contrast for his CT scans every once in a while. What is the big deal about administering unwarranted intravenous contrast on CT scans? Well, say you perform a contrast-enhanced CT scan for a pulmonary nodule. Or perhaps, you decide to approve a contrast-enhanced CT scan of the abdomen to check for a retroperitoneal bleed with contrast while on Coumadin. The patient risks returning home with a “present”- acute renal failure in both situations.

Meanwhile, both CT scans would give you the same result regardless of whether we administer intravenous contrast. And both of these cases of acute renal failure are entirely preventable. If you perform the study as directed by the physician, you have complied with the order as the radiologist. Unfortunately, these cases can lead to a lawsuit that you have no hope of winning.

Poor Communication And The Isolated Specialist

So, what does this all have to do with the isolated specialist? The ordering physicians decided to order CT scans on their patients without consulting with the radiologist in both cases. Sometimes these orders can go through the system without the OK of the radiologist. And in both situations, communication with the radiologist could have prevented unnecessary contrast administration. Or in other words, lack of communication/isolation between the ordering specialist and the radiologist was the proximate cause of a bad patient outcome.

All this brings me to discuss the topic of today- the isolated specialist. I will divide it into two different sections: What are the effects of operating “in a bubble” isolated from our colleagues? And how can we prevent physicians from working in isolation from one another?

Effects Of Operating “In A Bubble”

Untoward Side Effects

Witnessed in the examples above, two patients that should have had a non-contrast scan instead had their scan “upgraded” to an intravenous contrast-enhanced CT scan. Instead, a simple phone call from the physician could have prevented the possibility of a bad outcome. And these examples are just the tip of the iceberg. Many other cases exist where the clinician could have communicated with the physician and prevented a bad outcome.

Increased Expense

Imagine how much expense inappropriate imaging costs both the insurance company and the out-of-pocket expenses to the patient. It’s not just the additional unnecessary contrast. Instead, it is the additional weeks spent in the hospital, blood draws, nurses, physicians, and on and on. The physician could have avoided all of that with a simple discussion with the radiologist.

Prolonging Workups And Hospital Stays

In our example above, it is not just the untoward patient side effects and unmanageable expenses incurred. Instead, it is also the increased time the patient may need to stay in the hospital to figure out the patient’s disease entity. Very few patients say, “I have renal failure.” Patients may experience fatigue and other nonspecific symptoms. And a physician has to work up the clinical situation. Imagine the loss of time from work or other productive activities incurred by the patient and doctor.

Also, this is just one example. Lack of communication between radiologists and specialist cause all sorts of problems. Ridiculous unnecessary workups often ensue, wasting everyone’s time.

Radiologist Lawsuits

Don’t forget about the potential for lawsuits. All the factors from the above situation meet the criteria to allow a legitimate case. These would be breach, causation, and damages:

  1. The radiologist administered intravenous contrast inappropriately, breaching the standard of care.
  2. Contrast administration is the proximate cause of the patient’s renal failure.
  3. The patient suffered damages, including renal injury and a hospital stay.

A simple discussion between the physicians could have prevented a lawsuit.

Remaining Ignorant About Alternative Diagnoses and Treatments

Frequently, I learn about many of the most up-to-date patient diagnostic tests and treatments when I pick up the phone and discuss a case with a clinical colleague. In the situation above, a simple question about contrast could have avoided causing harm to a patient. This example is one where the ordering doctor remained ignorant about alternative methods of diagnosis (a non-contrast CT scan) when no communication ensued. Isolating oneself from phone calls with the specialist often prevents the best possible patient outcomes.

How Do We Prevent The Specialist Isolation?

Make It Easier To Contact Physicians

I think we have to blame both the ordering physician and the radiologist in these situations. Many physicians make it next to impossible to contact them by phone. Likewise, I know many radiologists who shun the phone under all circumstances. We have to make a conscious effort to make ourselves more available. Perhaps, it is a simple answering service that can solve the problem. Or, a radiology assistant may do the trick to improve communication.

Remember We Don’t Know Everything

Sometimes, we need to remind ourselves that each of our own experiences by ourselves is extremely limited. Only our interaction with others can allow us to understand patient issues best and give our patients the best care possible. We need to remain humble and ask for help from the radiologist and the ordering physician.

Computer Guidance

I hate to say it. But, clinical decision support systems have the potential to increase communications between clinicians and radiologists. When the computer detects the potential for a wrong imaging study order, it will force the clinician to interact with the radiologist. Potentially, this can relieve some of the issues of specialist isolation.

Attend Physician Friendly Events (Staff Meetings, Golf Outings)

Finally, many say that interdepartmental physician functions are unnecessary. But, I cannot disagree more. Making ourselves feel more comfortable with our colleagues allows physicians to be more likely to pick up the phone with a colleague who can become a friend. What better way to decrease isolation than sharing fun events with our colleagues?

Final Thoughts About The Isolated Specialist

Radiologists and specialists need to treat specialist isolation as a severe barrier to good patient care. And unfortunately, isolation is all too common. So, we need to make inroads to break down these barriers. Reducing specialist isolation will prevent patient side effects, reduce hospital stays, lessen patient expenses, decrease lawsuits, and increase diagnostic and treatment options. As specialist physicians, let’s all make a concerted effort to solve this critical problem together.

 

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Addressing Referrer Psychology In The Radiology Report

psychology

What are the most important differences between most resident and attending reports? Residents’ dictations tend to be one size fits all. On the other hand, the attending will usually look at the referrer’s name and specialty before starting with a dictation. Then, he integrates referrer psychology into the report. And finally, seasoned attendings will approach a dictation as a solution to the specific clinician’s problem.

Why is it important to address these differences? The primary reason for radiology’s existence is to provide solutions for our fellow physicians to come back for more. So, we must satisfy our referrers’ needs in our reports before anything else. And therefore, we need to individualize these solutions in every dictation we complete. For today, I aim to teach how residents and even junior radiologists can change their “one size fits all” reports into a report with a laser-like focus that answers the referrers’ questions. Let’s do just that!

Addressing Pertinent Positives And Negatives

Take a look at a great radiologist’s dictation. If the patient has a history of an abdominal aortic aneurysm, you will see statements about dissection, rupture, mural thickening, or ulceration. Or, if the patient has prostate cancer, the dictation will detail the sclerotic osseous lesions, iliac and inguinal nodes, liver lesions, the prostatic bed, and pulmonary nodules. You are much less likely to observe these relevant findings in the resident’s dictation. It is more likely to be a bland checklist. Addressing the pertinent information goes a long way to addressing the psychology of the ordering clinician.

Keep In Mind What The Referrer Wants To Know

Typically, the first paragraph of the findings should answer the clinician’s question. Logically, this makes sense. The clinician most likely analyzes only the first part of the findings and impression, if any. In addition, make sure to start with those items that contain the most critical information—then run down the findings in order of importance. For the clinician reading the report, the priority order clarifies what is most important. Dissimilar to the typical resident dictation, its goal remains clear, to answer the clinician’s question appropriately.

Give Some Leeway To The Referring Clinician

A clinician does not like to be hemmed in by the requirements of the report. So, make sure to give the clinician that leeway. Do not lock in on one diagnosis, forcing her to pursue that avenue. What do I mean by that? I will give you two examples.

First, give all the relevant likely diagnoses. If you start talking about something in-depth that is unlikely to be the cause of the patient’s illness, in essence, you may force the hand of the clinician to pursue the wrong diagnosis to the cost of poor patient care and expense to the system.

Second, you can legally bind the clinician to perform an unneeded procedure if you recommend a biopsy without an alternative. If for some reason, something goes awry and the doctor does not pursue that avenue, legal consequences can follow. So, be careful what you say!

Don’t Leave The Referrer Hanging

I like to call this waffling. Instead of giving many differentials, make sure to come down on those most likely to be the diagnosis. Always attempt to attach probabilities to the different possibilities. This process makes it much easier for the physician to provide appropriate testing and quality care.

Ask For More History

You may think the clinician will get annoyed if you ask him for more information. But, it is usually the opposite psychology. It shows you are taking the initiative. And, you are more likely to create a relevant report that will be helpful to the patient and the clinician. Rarely does a good history ruin a report!

Communicate The Results More Effectively

After you complete the report, check it over multiple times. Few things bother the referrer more than reports with incomplete, unintelligible sentences. Perhaps unwillingly, you leave out the word “no” somewhere in your dictation. Believe it or not, this can be crucial to the clinician’s treatment plan. Most of the time, the unnecessary phone calls I receive are for the occasional grammatical or incidental mistake in the dictation. It happens to everyone. But, try to minimize this effect by checking your work!

Summary On Addressing Referrer Psychology

To create a sound report that helps the clinician, you need to get into the mind of the ordering doctor. So, think like a clinician. Put all the relevant information into the dictation without the fluff, always keep in mind the goal of the ordering doctor, make sure to give some leeway to the physician, get an appropriate history, and make sure you look over your report so that it makes sense. Not only will the referrer appreciate your dictations more, but your patients will receive better care too!

 

 

 

 

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The Program Director Interview Welcome Presentation: More Than Meets The Eye?

welcome presentation

 

 

As part of the radiology residency interview trail, most interviews begin with a welcome presentation delivered by the program directors. I know. Your eyes may start to glaze over as you think about these presentations. All of them blur together by the time you have reached your second or third interview.

But wait… Maybe there is more to these conferences than meets the eye. Although sometimes painful, these presentations are chock full of information that will become very important once you begin the radiology residency. And, believe it or not, the initial program director lecture content usually does summarize the residency programs well. So, try your best to maintain awareness instead of falling asleep in that comfy chair in a warm room with the program director droning on about the program. Listen very carefully and take notes. Your future career is on the line. Ignore it at your peril!

To summarize for today, my goal is to cue you on what you should tune into when you hear these lectures. Most quality presentations contain wide-ranging information, from residency rotations to information about ancillary staff and even imaging equipment. But what do you need to get out of the production? I’ve divided some of the most important themes you may not find elsewhere with the following subheadings: program theme, staff availability, teaching methods, program stability, and fellowship connections. We will go into all of these in more detail.

Program Theme

Every program has a general theme. Some programs are academic. Others produce community radiologists. And even others gear themselves to the interventional radiologist. Usually, the presentation develops one or more of these general themes. Most of the time, you will not find this information on the website or paper. For instance, I can tell you that when I gave the welcome presentation, I emphasized how our program runs as a private practice in an academic community setting. It doesn’t say that anywhere on the website or in the packets we give the applicants. You will be hard-pressed to find this information elsewhere. So, you need to take notes and write down the kind of program you are interviewing.

Staff Availability

Often, the welcome lecture summarizes how open the program is to input from the residents. Can you ask the attending a question on the fly? Or do you have to make an appointment month in advance to get the program director’s ear? You can derive a sense of the general communication between the residents and the attendings from the interaction with the program director and residents during the welcome session. Again, you won’t receive this information quickly from other sources.

Teaching Methods

Most presentations mention the styles that attendings utilize to teach the residents. Does the program emphasize multiple-choice questions at conferences? Do they like to use the Socratic method of teaching how to read films? Or maybe, the residents are taught chiefly by total immersion in the rotation. For some residents, this may be a crucial determiner of the effectiveness of their learning over four years. I’m unsure how you begin to find this information unless you know the other residents or the program director well.

Program Stability

If you listen carefully, the program director may talk about the attending staff at the institution. Are they all young? (Usually, that means there has been a recent collapse of the residency program) Or, as I like to say, do all the staff members stay around until they are in a “proverbial box.” The average age of the staff is 70. (If you see a residency program like this, maybe they churn their young attendings) This information can also be hard to come by using other means.

Fellowship Connections

Usually, you can find out where the former residents went to their fellowships after residency online. However, the program director may drop hints about getting their residents into these fellowships. That is just as important. Do the attendings have deep seeded connections at other institutions? Or rather, the program director may not talk about staff connections at all (A red flag!). Typically, the welcome presentation will divulge some additional information about these connections.

The Welcome Presentation- More Than Meets The Eye

As you can see, a welcome presentation is more than just a summary of all the information everyone already knows about the program. Typically, it summarizes facts about a residency program that you may not be able to find easily elsewhere. So, I recommend listening (as dull as some of them may be!). You may learn a thing or two that will help you decide where you want to match!

 

 

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Should I Attend The Radiology Department Holiday Party?

holiday party

 

It’s almost that time of the year. And if you have not received an invitation yet, it will probably arrive in your email or mailbox soon. Yep… It’s time for the annual radiology department holiday party.

Our department has hosted a party every year since I started as an attending in my practice. (over 17 years ago!) Faculty expect most of our residents to attend the festivities since it is such a deep-seated tradition at our organization. And most do.

But what if you are on the fence? Maybe you have other obligations or are not the party-goer type. Whatever the case may be, you need to decide whether to attend or not. Well, I am here to help you with that decision! Let’s go through six reasons you should try to make that holiday party if possible.

Esprit De Corps

You are not just a radiologist but also a team member. Showing up displays your pride in the organization and lets everyone else know you care about the department. Now, all the others will understand that you are a team player, too!

Befriending Your Colleagues

What better opportunity to get to know your colleagues? Not just your fellow residents but the technologist who works down the hall and the nurse who cares for your patients. You can finally see these people not just as hospital employees but also as living human beings. You can even dance the Macarena on the dance floor with them, too!

Get To Know Your Attendings

It can be hard to get to know your bosses when they are involved in patient care and running a residency, telling you what to do. You may feel uncomfortable with the party because you now must sit down with them and chat. Now, you can spend time with your “difficult attendings” in an environment unrelated to your primary occupations. Who knows? Maybe it will lead to an excellent recommendation!

To Be Polite

You know… Someone had to shell out the money for the party. And the radiology department invited you to enjoy a party with them. Is it nice to skip out on an event created just for the benefit of all to enjoy? Not really!

Getting Involved

You can’t always study. Sometimes, you have to get out there and get involved. Getting involved can be as simple as showing up early to work up your patients. But it can also mean attending a party. You’ve signed up for this residency. So, show up for the events!

Find Out What Really Happens In The Department

Few better opportunities arise that allow the resident to see what happens in the radiology department. When the attendings “let their hair loose” and have a few drinks, you know who plays with whom. And, you get the real low down about what goes on. You can’t learn everything from a book!

Is It That Important to Attend The Holiday Party?

Yes!!! We struggle all year to work hard to learn and improve patient care. It’s now time to take some time aside to get to know our department. Let us enjoy the fruits of our labor together!

 

 

 

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Paid Surveys For Radiologists Revisited

Completing paid surveys is probably one of the easiest methods of earning some extra cash on the side. And as we know, when you have hundreds of thousands of dollars in debt, every little bit helps. In addition to the extra cash, surveys have enabled me to learn more about some of the newest radiology technology and products that I may not have learned about otherwise.

In the past, I have briefly addressed opportunities for completing paid surveys in my prior post called Alternative Careers And Supplemental Income For The Radiologist. But today, I thought I would go into some more detail about surveys since I regularly participate. So, let’s start by talking about the general rules for deciding when it makes sense to complete a survey, go through the different types of surveys, and then finally delve into some of the opportunities that are available out there based on my own experiences.

My General Rules For Deciding If A Survey Is Worth The Effort

You will find that surveys vary widely in the amount of time and effort for a given amount of cash. Unless you really enjoying completing surveys for free, survey companies should compensate you well for your knowledge and time. Remember, even medical students usually have more education than the folks giving out the surveys. And, education comes at a price. So, I would recommend to not allow the survey companies to take advantage of your goodwill.

In fact, let me give you my rule of thumb. A survey company should compensate you at a rate similar to or greater than what you would earn by moonlighting. What do I mean by that? If you are a resident and you can make 100 dollars per hours by working an extra shift, then you should work at a rate no less than 100 dollars per hour. That means if you work on a survey for 15 minutes, you should get paid no less than 0.25×100 dollars or 25 dollars for your time.

Also, make sure not fall for the sweepstakes entry reward for completing a survey. Usually, there is no guarantee you will win. And, you are essentially providing a free consultation.  You are worth much more than that!

Finally, if you need to travel to complete the survey, make sure you calculate the amount it costs to get to the survey. Deduct that amount from the survey fees to come up with a final total to decide if the survey is worth your time. Or even better, have the survey company reimburse you for the travel expenses.

The One Exception To My Rules

But, of course, I have one exception to the rules. (Just like there always is!) If you have nothing else to do at the time, then I permit you to consider completing a survey for less. Why do I think that is a reasonable exception? Well, getting paid for doing something is always better than doing nothing, even if you are not getting paid what you are worth. Hell, you have lots of bills to pay for your medical school training!

What Are The Different Types Of Surveys?

Surveys opportunities vary widely. These include the standard online questionnaire, participation in a phone interview, a direct interview with a survey manager, and sitting on an expert panel. Out of the different varieties, I find the online questionnaire to be the least thought-provoking and energy draining. Other forms of surveys require more active participation. You need to be awake to answer the questions!

In addition, survey companies attend national conferences and offer opportunities for radiologists. Take advantage of these opportunities when they avail themselves. Often times, these opportunities can be the most lucrative.

Overall Best Survey Companies For Radiologists

Over the years, I have found that at any given time, the best survey companies change. Depending upon your specialty, the best radiology survey company may vary. Presently, the following companies still give me the most opportunity to complete paid radiology related surveys at the highest rates: GLG Group and M3 Research. In fact, I remain an affiliate of both of these companies since I complete these companies’ surveys regularly. Of course, other survey companies every once in a while ask for my opinions. On the whole, GLG Group and M3 Research still give me the most opportunities.

Final Thoughts

Although no magic bullet exists for getting rid of student debt, survey opportunities can give a significant boost to your bottom line. Try to avail yourselves of the opportunities when they arise. Who knows? You may even learn or thing or two!

 

 

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When A Disaster Strikes- A Radiology Resident’s Role

disaster

 

 

It’s ironic. A while back, I started to write about disasters and radiology residency in the evening, only to wake up the following day with Las Vegas headlines screaming about a disaster with mass casualties, gunshot wounds, and severe injuries to over 500 people from a crazed gunman. Unfortunately, these poor victims needed immediate care. And we, as radiologists, were in the trenches. It is only a matter of time before we may encounter a horrible situation such as this.

Perhaps, you are on call at the time. Or maybe, you are the only radiologist in the hospital covering this affected population. Again, we are not discussing a bus collision with a few victims. No. I’m talking about a mass casualty such as this one where hundreds or perhaps, thousands get injured at a time—a dirty bomb, a World Trade Tower-like incident. What should you do first? Who would you contact to help? How would you cope? Where would you go? Let’s sort through some general rules and think through these issues together.

Make Sure You Are Safe To Perform Your Duties

It goes without saying. For you to perform your duties as a radiologist, first and foremost, you must ensure that you are safe. Is there an active shooter in the building? Get out. Are you in a place of radioactive fallout? Move further from the epicenter. You cannot do your job unless you are alive and healthy. So, be aware of your surroundings.

OK. So, you feel reasonably safe at your post. But, you are not done with maintaining your safety. Be aware of the mass casualty situation. Is it chemical exposure or radioactive contamination? Perhaps, an airborne illness. Follow the rules to avoid further exposure to provide the most help to the maximum number of victims.

Does Your Department Have Electricity?

This question might sound a bit silly. But, unique to radiologists, we rely almost entirely on the ability of the facility to generate electricity—no electricity and no x-rays, MRIs, CTs, and so forth. If there is no power, you will unlikely be able to help as much as a radiologist. (except for battery-powered ultrasounds) Instead, you may be only able to help as a treating clinical physician.

Take The Time To Call For Backup

Next… When hundreds or thousands of victims require acute medical care, and you have electricity at your facility, one lone radiologist is unlikely to be able to provide imaging services for everyone. Call the covering attending radiologist in a mass casualty such as this one. Now, you can decide if you need more coverage to interpret or perform all these studies rapidly.

Triage, Triage, Triage

Unlike standard operations, you no longer have the luxury of providing any study to anyone. In this situation, all the hospital’s imaging resources will run out. So, you are in a position to ensure that the appropriate victims receive the correct studies (the art of triage!).

The treating physicians are not experts in imaging. You are. So, you need to monitor appropriateness criteria like a hawk. You want to save the most lives. Only the sickest and most needy patients should receive imaging first. And, of course, they need the correct study.

Read Where Help Is Needed

Perhaps, you are dealing with lots of inhalation injuries. Well, then, concentrate on the chest X-rays. Or maybe, tons of gunshot wounds. Read the CT scans. You should read what is most needed.

Assess What Happened And Create An Action Plan

So, you’ve run through all the initial steps of our disaster protocol recommendations. And you’ve made it through the disaster scenario. What do you do next? It’s simple: Assess the disaster situation and create an action plan.

Creating a radiology action plan becomes essential so that if disaster strikes twice, you know the best ways to handle it. Your hospital should have a radiology emergency protocol even before the disaster. (Not all hospitals do!) So, now is your opportunity to contribute to or create your own hospital’s disaster committee. Make the plan as efficient and as practical to implement as possible.

Disaster Management Summary

No matter how you slice it, as a radiologist and a physician, a disaster scenario can be complicated. So, you need to follow some of these general rules to make running a disaster protocol as efficient and safe as possible for you, the radiologist, and the patient. Be safe, call for backup, triage, and use appropriate resources. Finally, remember that assessing the situation is crucial and developing an action plan (hopefully before the incident!). Next time, if it happens, you will be ready as you can be!

 

 

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How Much Work Is Too Much For A Radiologist? (Think RVUs!)

RVUs

You are excited to start your career as a radiologist. And, you are interviewing, hoping to find a job where you can make the most money and pay off your student debt. There is much more to find the correct position than just assessing the income. Of course, you should consider the location and job profile. Just as importantly, however, you also need to figure into your calculations the workload and relative value units (RVUs) you need to complete to reach that income.

Avoid the following situation: an insurmountable daily imaging workload with a queue of patient studies that never ends. A job like this is bound to end badly. But, what is an unsafe workload for you, the radiologist? Or, more accurately, when looking for a job, how many studies are too much to read daily? Let’s investigate these issues together by examining some of the markers of workload and then get to some more specifics about the appropriate RVUs for an individual radiologist.

The Lowly RVU

Before we conclude how much work is too much, we first have to define a unit of work. The essential measurement of work is the RVU or relative value unit. According to an excellent presentation on the history of insurance, the first “RVU” came out in 1992 (1). It defined a relative value unit as three different components- physician work, practice expense, and malpractice. Most of the cost/workload of the RVU relates to physician work and practice expenses.

So, who decides the cost of an RVU? The American Medical Association defined a committee called the AMA Specialty Society Relative Value Update Committee (the RUC). It consists of an expert panel of an individual from the 21 major national specialty societies, two IM specialists, one primary care practitioner, one specialist, and six additional committee members. They assign explicitly what the Medicare costs are for each procedure. (1)

Why Is The Average RVUs Per Radiologist Is Important? (And Why It’s Not!)

OK. So, we have defined what makes an RVU and who creates an RVU for any given procedure. The following important question: What is the median number of RVUs per radiologist throughout the country. Well, I found a relatively recent article in The Reading Room that reports just that. (2) To summarize, it says that the average radiologist performed 10,020 RVUs in a 2020 survey. Now that we know the average RVUs per radiologist, it’s a relatively simple step to ask the average number of RVUs per radiologist per year in any given practice. Usually, the business or practice manager can obtain the number if you ask. If you find that the number deviates significantly from the mean, perhaps, you are looking at too few or too many studies.

But wait… There’s more to the equation! Let’s say you are a neuroradiologist that reads almost exclusively high-value RVU MRIs. Perhaps, you may read them significantly quicker than a general radiologist. Then, you can probably handle more RVUs than the average radiologist. Or, let’s say you just started and have not yet picked up speed with dictating. In that case, you will likely read lower amounts of RVUs. Therefore, you have to put in your weighted factor to determine how much work is reasonable.

Why Are Daily RVUs Even More Important?

Finally, we have developed your individual optimal yearly RVU number where you should lie within a reasonable spectrum. But, it is impossible to conform to that number precisely every day in any given practice. Some days you will have more studies and others less.

To add even more variation, in some practices, the radiologists may take 16 weeks of vacation, leaving only 36 weeks to complete all the work. To make the appropriate calculation of RVUs in this sort of practice, you would need to take the individual practice’s annual RVU number and divide it by the number of days per year worked. In actuality, that yearly average total RVU number does not measure the amount of daily work. A more appropriate calculation would be the daily RVU number. Therefore, a practice with a seemingly ordinary yearly RVU number can have an exceedingly high daily RVU number.

The RVU Tipping Point

What happens when a radiologist reaches the daily RVU tipping point beyond which they are comfortable? Well, most practicing radiologists have had bad days like this at some point. (Hopefully not every day!) You cut corners; your mind drifts elsewhere; burnout ensues; eye strain develops. Not only is it a wrong place for you, but it is also terrible for patient care. Let’s try to avoid that situation as much as possible.

How Much Is Too Much?

Back to the original question again. Too much work can vary widely for any individual. But at least, you now have a feel for calculating how much is too much. So, go forth and ask about the RVU number when you interview for a job, calculate the daily RVU value and compare it with your comfortable RVU numbers. That way, you are much more likely to find appropriate work for you!

(1) http://www.rsna.org

(2) https://thereadingroom.mrionline.com/2020/11/radiologist-alary-update-2020-show-me-the-money/

 

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Reading Imaging Studies On Our Clinical Colleagues

colleague

The Scenario

A clinical colleague walks up to you, and the following conversation ensues.

Clinician: Can you take a look at my chest film? I have had a cough for several weeks that won’t go away.

Radiologist: Sure. Let me take a look at the image.

The name of the clinician is on the computer, and the scan pops up on the screen

Clinician: Well, what do you think?

The radiologist stares intensely at the screen. Beads of sweat begin to form on his forehead as he sees a spiculated 6 cm left perihilar mass with adjacent interstitial changes and pulmonary nodules in the opposite lung. The clinician stares at the radiologist in front of the desk.

Radiologist: Well… Ummm…

Clinician: Well, what do you see?

By far, reading your fellow clinical colleague’s imaging studies has the potential to be one of the most stressful clinical situations as a radiologist. (as witnessed above) Even worse, the physician-patient may stand directly in front of you while looking at the films for the first time. God forbid we find something potentially lethal or unexpectedly harmful.

Over the years, similar scenarios have played themselves out several times. And, it’s not just me. It happens to most radiologists at some point in their careers, probably you as well. So, what do we do in these situations? Well, you guessed it. That is the theme for today’s post. Let me try to give you a few pieces of sage advice.

Take Time To Read The Study And Call The Clinical Colleague Later

Like I previously advised in prior posts such as Radiology Call- A Rite Of Passage, you are better off taking your time and going through your search pattern rather than being interrupted and making the wrong diagnosis. When a physician-patient stands right in front of you and stares at the screen, you direct your attention toward your emotions, leading to poor discrimination and interpretations. You are not doing justice to good clinical care.

I know. It is challenging to say to the physician-patient, “I can’t look at your images while in the room.” Instead, just say, ” I will look at your images later when I can make my best interpretation.” Most of the time, your clinical colleague will comply (But not always!). It indeed allows you, the interpreting physician, to have time to think about the films and diagnosis appropriately.

Don’t Beat Around The Bush

Your colleagues are physicians and generally know a bit about imaging/radiology. They will see if you are holding back a finding. So, regardless of whether you are on the phone or in person, you just need to tell them what you see. In radiology, however, most findings and impressions (even malignant-looking ones) can have numerous outcomes. In this situation, it is reasonable to say I think it may be x (a malignant diagnosis), but I have seen when it turns out to be y (a benign diagnosis). Of course, you don’t want to give false hope. But we, as radiologists, are rarely 100 percent correct! That gives you a little bit of an out.

Never Farm-Out This Responsibility To Another Radiologist!

Generally, there is a reason why this physician-patient comes to you to read their study. Maybe, they like your skills as a radiologist. Or perhaps, she sees you as a confidant and friend. But for whatever reason, this person came to trust you to read his film. It is never appropriate to shirk your responsibility to talk to the physician-patient by doling the obligation to another physician. It is part of your responsibility as a colleague and physician. Not to say, you cannot get help with the interpretation if complicated. But, you need to be the one that directly speaks to the physician-patient.

Be There As A Friend/Colleague

Finally, as radiologists and physicians, we are all interconnected to our fellow clinicians through the shared medical experience. It is essential to remain present as a friend and colleague to the physician-patient you diagnosed. Give the physician-patient your number to call if they have any additional questions. Commiserate over the diagnosis. Treat this person as you would any friend.

Treat A Colleague As We Would Want To Be Treated!

Our most demanding jobs as radiologists and clinicians are not the day-to-day interpretations of films and coming up with differential diagnoses. But instead, they are the problematic interactions that we may need to have at some point with our colleagues and friends. We need to relay the information to them about their images in an appropriate, correct, and thoughtful way. Even though there is no perfect way to do so, we must treat our colleagues as we want to be treated ourselves.

 

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Halloween Tales From The Radiology Residency Crypt

crypt

 

In honor of the up and coming Halloween holiday, here is a collection of two of my own homemade nightmarish radiology residency stories. (written expressly for your amusement!!!) Beware of ghouls, ghosts, and program directors!

Story 1 – End Of Days

The noise of the resident’s footsteps battles the endless quiet of the hospital corridor but to no avail. A faint silent breeze blows through the hallway with a subtle smell of disinfectants, used to mask the horrid smells of sick patients that have rolled through the hallway. Doorways to physician offices and patient rooms are already locked and closed as the resident’s digital watch approaches 5 o’clock on Halloween, the hospital witching hour when everyone seems to leave. But, there is one door 30 feet down the hallway that is slightly ajar with light peeking through. It is his final destination.

He thinks about how it was only just an hour ago when the hospital was active and buzzing. The program director took him aside to tell him to meet at 5 o’clock, speaking curtly. Yet, it almost felt like an eternity. No sign of anything he could have wanted. But the time has now almost arrived. He is almost here.

Turning his attention back to the slightly ajar door, his stomach begins to knot up. Heart paces more quickly. Thump, thump, thump… he can hear and feel his chest almost explode. Barely can he muster the energy to knock on the door. But, he does. And, he hears the faint serious tone of the program director’s deep voice, “Come in…”

As he peers into the office, ancient films line the edges of the walls with glowing light panels underneath them. Diseased skull images, x-rays of horribly broken bones, and bizarre abdominal series with a variety of different foreign bodies all sit tucked into their appropriate places on these walls. Perhaps, the program director found them amusing. Nonetheless, they are entirely inappropriate and bone-chilling. And there, behind a large messy wooden desk sits the program director watching and waiting for him to sit down…

Resident: Gulp… “Uh, sir, why I am here?”

Program Director: “Well… I spoke to the technologists and they said great things about you. I wanted to relay the information that you had done a great job with your patients in interventional radiology.”

Resident: “That’s good news, right? Well then, I will get out of your hair”

Rapidly, the resident gets up out of the hard seat and makes a beeline for the cold door. But, he stops short just before arriving there.

Program Director: “Well, there is one more thing I need to tell you.” He clears his throat with a loud, “Ahem…”

Turning back toward the director, he notices his eyes become a bit glossy and sees a lump form at the back of his throat. He endlessly waits for another word to leave from his mouth, but it doesn’t seem to come.

Resident: “OK… What is it?”

His eyes point to a box across from his door that he must have missed when he entered the room, so nervous for this encounter. The resident looks closely at the side of the box and notices his own name. Pictures line the edges of the box. They look familiar. He notices they are pictures of him and his family. Wait a second… They were just on his desk in the resident room yesterday. At the base of his box lies a thick binder. His learning portfolio.

Resident: “Uh sir. What does this mean? Why is all my stuff from my desk in this box?”

Progam Director: “Well, I guess I didn’t tell you. I thought you knew. The hospital ran out of money for your residency spot. You were chosen out of a hat. We have to let you go. You have to find a residency slot somewhere else.”

Resident: “Noooooo!!!!”

Moohaahaahaa!!!!

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Story 2: The Halloween Reading Room Of Hell

It’s 5:00 PM on Halloween evening and the resident begins his shift. He remembers hearing how the other residents say they were “killed” by the number of cases on call on Halloween night. Even so, like many other nights, he enters the reading room.

Although the room only contains a few PACS monitors, a cramped desk, and a hard wooden chair, his reading room is so small that there is barely any space to move about and there is no wired phone. The walls and door are thick and lead lined. All these factors together, make physicians that enter the room feel like the walls are about to cave in. The walls rapidly muffle the voices from within. Noise from outside the door does not penetrate through the heavy doors and walls to allow the radiologist to dictate cases uninterrupted.

The room begins to bustle with activity as clinical attendings and residents walk in and out viewing CT scans of a group of Halloween pranksters caught by the police with altered mental status after their pursuers beat them silly. And, others were interested to see the scans of some kids with stomach aches from eating too much treats/candy, of course, to rule out appendicitis.

The workload is nonstop. His cell phone rings off the hook. And, clinicians stop into the cramped room by the dozens. Hours go by.

It’s now about 10 pm during the heart of Halloween eve. Clinicians continue to bombard the poor resident throughout the evening. A final large bolus of clinicians stops by to see another imaging study. They finally leave. After all this activity, the resident didn’t have a moment to himself to dictate any of the cases on the PACS system.

Now that everyone left the room, he thinks he has the time he needs to get all the dictations out for the morning’s attending. He can’t take another interruption. Suddenly, with frustration peaking, he slams the door and yells, “I can’t take it anymore!” There are a loud bang and a click. The room falls silent.

Rushing through the next ten CT scans in the cramped room, he notices something unusual. No one comes in or out the door. He dismisses the issue and continues to run through the next ten CT scans. Still not a peep. It’s just his voice and the computer dictaphone.

Exhausted from dictating so many CT scans, he rises from his chair to stretch his legs. He realizes that he wants a breath of fresh air. Slowly, he attempts to turn the doorknob and pull the door. Nothing happens. He tries again. No movement.

No big deal. He decides to get out his cell phone to call security to get him out of the reading room. As he attempts to turn the iPhone on with his fingerprint, nothing happens. The battery must have run out after being in his pocket for all these hours in a lead-lined room and all the phone calls he had to make.

Now he begins to furiously bang on the door. No response. Nothing. How can anyone hear him in this lead-lined tiny room?

He begins to feel hot as the air is stagnant. There is no temperature control. Now sweating like a banshee, beads drip onto the floor from his forehead. Claustrophobia sets in. Feels like a coffin. He can’t breathe. Eyes roll to the back of his head as he slumps down in the seat. Everything appears blurry. The room is moving back and forth. He finally settles down, now unconscious.

Floating upward, he is looking at his body slumped in his seat not breathing. The rest of the night’s CT scans not dictated. Clock on the wall says 8 AM. The door is finally jiggling. A security guard opens the door, not even taken aback by the ghastly sight of the dead resident. He begins to wrap up the body in a plastic bag and thinks  Another resident killed by Halloween call. No one will know the difference. Just like the other residents always say- residents are “killed” on call. It happens every year!

Moohaahaahaa!!!

 

 

 

 

 

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Should Artificial Intelligence Be Feared Or Welcomed?

artificial intelligence

Question:

Hello!

My name is Yasmin Amer, and I’m a producer for WBUR in Boston. I’m working on a segment about machine learning and medicine, and, of course, radiology is part of that discussion. I spoke to a local doctor and machine learning specialist who says artificial intelligence will make the field more exciting. Is this the attitude of many med students and residents interested in radiology? Are they primarily excited about tech in radiology, or is there any nervousness there? I’m happy I came across this blog – I would love your input.

thank you,

Yasmin Ameren

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Answer To The Artificial Intelligence Question:

Yasmin,

Speaking to my residents about the topic, several of them fear the onset of artificial intelligence and its effect on radiology. Therefore, some residents have decided to go into “hands-on” fields like interventional radiology and breast imaging.

However, most others have responded they don’t see how a machine can synthesize the context of a case, the images, and all the patient-related factors to arrive at a final impression that tailors itself directly to a patient. Let me give you an example in the next paragraph.

Sometimes, two similar ultrasound findings can lead to entirely different management scenarios on breast ultrasound. An MRI may be the most appropriate for a noncompliant patient with multiple slightly complex cysts instead of serial follow-up ultrasounds. On the other hand, in a low-risk patient with the same cysts, the most appropriate conclusion may be to follow them every six months. These are slightly different patients with the same images. How would the artificial intelligence judge who is noncompliant? So, it takes more than just pattern recognition to process the information and arrive at a viable conclusion for an individual patient. I don’t think we are quite there yet.

Then, legal barriers prevent easy entry into the independent practice of radiology. Are large companies going to take responsibility if the machines make mistakes? Billions of dollars of losses are potentially at stake.

It is also interesting that applications to the radiology field have dramatically increased over the past few years. Improvement of the job market right now likely contributes to the increasing desirability of radiology. But that cannot be all. If applicants thought artificial intelligence would rob residents of their future 25-30-year radiology careers, we would not receive so many applications for radiological residency programs.

Long story short. Some fears of the unknown consequences of artificial intelligence exist. Overwhelmingly, however, I believe most resident concerns of artificial intelligence encroaching upon the radiologist’s work are less than the expected barriers to independent widespread implementation without supervision by a radiologist.

I hope that helps,

Barry Julius, MD