Year: 2017

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Gaining Recognition When The Odds Are Stacked Against You

recognition

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

The Background Story

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

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

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

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

Problems With Gaining Recognition In Clinical Education

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

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

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

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

Get What Makes The Evaluator Tick

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

Defy Expectations

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

The Nuclear Option

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

Gaining Recognition For Your Work

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

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The Uncomfortable “Screenostic” Breast Ultrasound Imaging Dilemma

ultrasound

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

Issues Behind The “Screenostic” Ultrasound

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

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

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

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

Call To Arms!

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

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

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

 

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Should I Take A Leave of Absence During Residency?

leave

 

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

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

Truth or Consequences

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

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

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

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

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

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

I Can’t Do My Job

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

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

A Once In A Lifetime Opportunity

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

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

Situations That Do Not Merit A Leave

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

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

Final Thoughts

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

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

 

 

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Patient 0- A Mystery Wrapped In An Engima

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

The Background On Patient 0

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

 

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

 

Panic!!!

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

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

Patient: “No…”

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

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

Physicist: “What was that injection?”

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

Physicist: “Did you eat anything unusual?”

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

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

What would you do next?

Calmer Heads Prevail

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

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

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

What Next?

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

Implications, Politics, And Ethics

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

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

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

Immigration Policy Issues

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

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

Our Ethical Obligations

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

Bottom Line

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

Comments From You

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

 

 

 

 

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How Not To Incriminate A Fellow Radiologist For His Mistakes

 

 

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

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

Contact Your Colleague Immediately

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

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

Don’t Highlight Mistakes On Prior Reports

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

Phone The Clinician Directly To Discuss The Case

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

Use The Words New, Stable If Possible

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

Summary

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

 

 

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A Student/Resident Guide To Research

 

Introduction:

Participating in research is a great way to contribute to medicine. Well-conducted research and literature reviews help advance both scientific understanding and clinical practice. Additionally, it enables you to develop expertise in a topic, while simultaneously showing dedication to your field. Peer-reviewed publication and presentation of your research should ultimately be your goal. Although you may want to get involved in research, you might not know how to go about it. Beginning a project can often present a challenge for residents and students with a limited research background. Here, I offer some advice and recommendations that I would give anyone just starting. Much of this I have learned through trial and error. Learn from my mistakes!

Identifying research mentors:                               

Your choice in mentorship can dictate whether or not a project will be successful, especially when just beginning your research career. Try to identify a project mentor (usually a physician or Ph.D.) with a proven track record of publication. Even better, if you can find someone with institutional or national grant funding, you can be confident that your research will likely be published. These are not essential, but finding the correct mentor can mean the difference between publication and fruitless pursuit.

First of all you should approach attendings, residents, and students. Ask if there are any ongoing or projects in the department. If you identify something that piques your interest, offer to assist in any way! Offer to carry out a literature or chart review. Attendings and residents are busy, so help them with the work that no one wants to do. The more you do, the higher up on the author list you will be. Make sure you show initiative and interest!

Although clinical research in your dedicated field might help you more as an applicant, any well-conducted research can be a great interview discussion topic, as long as you can speak intelligently about it.

Research takes time and patience:

What many don’t realize is that conducting research takes time, and that manuscript preparation and submission can take equally long. When you read a newly published paper, often the presented data is up to a year or two old. In many cases, a you need to submit a publication to several journals before being accepted. Especially true, if an author is seeking publication in a high-impact journal. My advice: start your research early. Students should seek out research from the first day of medical school, and residents should look for research during the intern year (if they can find the time!). Not to say that you cannot accomplish research in a short timeframe. However, you must be realistic about your goals and recognize that you cannot completed all projects if you are limited on time (i.e., close to residency or fellowship applications).

If you budget your time wisely, you will be able to edit thoroughly and compose a more eloquent article with a comprehensive review of the literature.

How to minimize your time for completing projects

Remember you are legally/ethically obligated to submit your paper to one journal at a time. Some review cycles can take several months for the first decision, so look up their average turnaround time if this might be concerning. Also, if you plan to submit to notable journals, there is always the possibility of rejection. Resubmission to another journal will likely require reformatting and an additional wait period. The time between finishing an experiment and publishing can add up. Remain conscious of this reality.

If you are limited on time, but still want to conduct a small project, one option to consider is a conference abstract. Conference abstracts allow you to showcase your research often through a poster presentation. The beautiful thing about conference submissions is that you can submit an abstract with preliminary findings, and later expand upon these in the full poster if accepted. Certain conferences/societies will even publish your work in their journal afterward.

As a bonus, getting an abstract accepted allows you to attend a conference and network with your colleagues. Most large meetings are held in either the spring or the winter. And, abstracts are generally due approximately six months before the conference. Deadlines may vary so identify these times if you have an ideal meeting in mind.

As a side note, the societies that hold conferences often have student/trainee travel scholarships or discounted conference fees. Any young professionals with funding concerns should apply. Again, be aware of scholarship applications deadlines.

Where to publish:

Everyone should strive for publication in high-quality, peer-reviewed journals. Things to consider are impact factor (IF) and indexing in scientific databases. High IFs are in journals like Nature or Science. However, it is essential to realize that a journal’s audience can impact this number. For instance, Nature has an impact factor of approximately 40, while Radiology has an impact factor of around 6-7, and the Journal of Vascular and Interventional Radiology (JVIR) has an impact of about 3.

If each is an example of a high quality-peer reviewed publication, then why the difference in IF? The reason is the audience and journal scope. Nature covers a wide range of disciplines. And therefore, it has a larger audience. On the other hand the other two have smaller audiences. By sheer readership, this means that fewer people read them and cite their articles.

Although everyone might aim for publication in big-name journals, we often have to settle for lesser-known, lower-impact publications. This is ok, as long as you consider several things. Journal reputation, peer-review, and indexing. Ultimately, we want our research to be visible to the scientific community. Therefore, we want our papers indexed in PubMed, Medline, Web of Science, etc.

Why you should consider open access:

Professional scientists often have a “publish or perish” mentality. For a Ph.D. actively conducting full-time research, publication in large name journals can provide major career and funding opportunities. This is especially true for young postdocs. However, the pressure to get published in major journals like Nature, Science, or the New England Journal of Medicine reflects a major flaw in the scientific community. Scientists often delay submitting their findings until a more thorough narrative can be told. This can involve years of additional experiments, and, unfortunately, deceptive and unethical practices in some cases. Additionally, it also prevents experiments from being repeated and perfected, as the drive to submit “novel” findings fuels these major publications. This also discourages the presentation of negative results, or when an experiment or intervention fails. These findings are equally as important for scientific progress.

Although research output is not as essential for becoming a successful practicing physician, a publication can augment your career opportunities, especially at major academic centers. As physician-scientists, this pressure is not felt as strongly, thus we have a unique opportunity to help change the industry and combat these practices.

One movement in response to the publishing business is open access. This model of publishing promotes freely available, online publications with a quick review turnaround time and lower publishing costs. However, certain concerns over the quality of these publications have been raised. Not every open access journal is created equally. There are certain predatory publishers who will publish anything without peer review as long as a fee is paid.

More information about open access:

Be aware of journal quality when you are considering the submission. One great resource, the Directory of Open Access Journals (www.doaj.org), continuously compiles a list of reputable open access publications organized by specialty and database indexing. Another interesting response to the flaws of the publishing industry takes the form of the publisher, Matters (https://www.sciencematters.io/why-matters). Matters takes the stance that those individual findings should be reported. They suggest that observations should again be the basis of good science, not embellished narratives like major journals tend to favor.

Rapid dissemination of new data could provide the missing piece to a colleague’s research on the other side of the world. Knowledge and its access should be easier in the age of information. Give open access a try, and get your data out there!

Know your reviewer and audience:

Before submitting any publication be sure to edit your content for grammar and spelling. It is not uncommon for a great idea to get rejected because of poor presentation! No matter how groundbreaking your findings may be, sloppy grammar, spelling errors, and disorganization will instantly raise red flags among reviewers. “They were not meticulous with their writing, were they meticulous with their research?”, a reviewer might think. Share your paper with anyone willing to read it. A fresh set of eyes always picks up something you might have missed.

Also, always try to write with your reader in mind. In reality, radiology journals will likely be read by radiologists, but try to consider an extended readership. Think of your reader as a scientific/educated person, but from a field different than your own. You should compose a logical and concise piece, with appropriate references for the majority of your statements. Something that might seem intuitive to you or a radiologist, might not be as clear to another professional. Provide the extra detail, or at the very least, a resource if more information is sought.

Be aware of the publication scope and adhere to manuscript formatting requirements:

Every journal has its own formatting and organizational requirements. These are usually clearly stated online. Read these carefully and make sure every item has been accounted for. You don’t want to wait several weeks for a decision only to get a request to re-upload a version with double-spacing and times new roman 12-point font, and then have to wait again! Also, make sure your paper fits within the journal scope. Again, this is usually clearly stated online. Don’t submit a surgery paper to a radiology journal. Don’t submit a case report to a journal that doesn’t’ publish them. Use your common sense! You can always look up what they have published in previous years to get an idea of the style and types of papers that are accepted.

Important items that are often omitted from the discussion section:

  1. Make sure you have a sound basis for why you carried out your study. If you state a fact, technique, or clinical approach, cite the literature. Even if a statement might seem like common knowledge to you, it might not be to a reviewer or reader. Reference everything!
  2. Do not embellish. You should discuss the limitations of your study. Every study has shortcomings. Be upfront about them. Offer solutions to these limitations for future research. This shows maturity and that the scientist has thought about the holes.
  3. State how you think your findings can advance the literature, science, or clinical practice.

Avoid frustration by using a citation manager from the start:

When you’ve finished your project, and are ready to write, be sure to use a citation manager such as Endnote. Often when writing, you will reorganize your thoughts and shift your references. By using a citation manager like Endnote linked to Microsoft Word, you will save yourself hours of frustration trying to organize citations and manually create a bibliography. You can create a free online account on www.myendnoteweb.com and if you purchase or get a copy of Endnote for Mac or PC, you will be able to “cite while you write.” Trust me! This is a HUGE help! Often your institution will provide you with access to a research database, like Web of Science. You can link this account to your endnote account and export references easily. Alternatively, you can download a citation file from PubMed and upload to your citation manager. Either way, you will save time and avoid frustration! How-to guides can be found online and on YouTube.

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The Art And Science Of The Lowly Addendum

addendum

Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most crucial part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the essential parts of our report simultaneously? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.

The Lowdown On The Lowly Addendum

OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…

Addenda And The Legal World

First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation.” Sometimes it is the only documentation in the chart that the radiologist took the time to give the caring physician the report results.

On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the report results on your patient with appendicitis? It is only the supplement that documents this vital information.

When Absence Of An Addendum Is Legally Important

Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write a supplement, a communication never occurred.

How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that they discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told them not to order a leg film to look for a fracture. Since the physician did not request the test at your hospital, it turns out the patient went to another hospital for additional imaging three days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!

Addenda And The Medical Record

Addenda can also be necessary for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate the cause of a disease/illness.

Alternatively, frequently we will issue a supplement as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report.” Placing an addendum, in this case, becomes medically essential. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, they may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).

Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the true history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A lousy history can lead to a denial of care payment for a patient. An addendum as a correction can be a lifesaver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!

Ethical Obligations To The Addendum

We, as physicians, are ethically obliged to abide by our Hippocratic oath to do the best for our patients and do no harm. Based upon some of the examples above, we fulfill a moral and ethical imperative to improve patient care by creating addenda. So even though overlooked by our readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!

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Radiology Jargon That We Would Love To Use But Can’t

radiology jargon

Radiology Jargon Defined

Radiology jargon that we use to describe our findings to our fellow clinicians and radiologists differs widely from what we have to put in our reports. If only we could use these words in the final dictation because these words are so much more picturesque and meaningful. In addition, they can replace a long-winded description with a simple phrase. Life would be so much more fun!!! Ohh, to be truly living the moment. But alas, we can’t do it for legal, moral, and ethical reasons. Perhaps, the words are too flippant. Or maybe, they are not grammatically correct. But what if we could? I’ve come up with an excellent glossary of thirteen words that should be in common usage that we do not dictate or write down for these reasons. So, here we go!

Badness/Pure Evil

Some tumors have such an aggressive configuration; these words apply. Usually, these lesions are over 99% likely to be malignant with a high probability of metastases.

Brain Teaser

When you obtain the final diagnosis, you are dying to put this your dictation by complicated, circuitous logic. However, it is just not allowed!

Cheesy Consistency

You know it when you see it. It is slightly higher density than fluid with small foci of air.

Ditzel

A tiny finding that you see of no significant consequence.

Fecally Challenged

It’s what you say when you can’t mention constipation because that is a clinical diagnosis. But yet there is tons of poop everywhere!

Glom

It is usually a proteinaceous mess within the body. The glom can be contained or free! I would love to use this one. It sounds so right…

Gumba

A gumba is an enormous finding that is of paramount importance.

Nightmare Case

It is the perfect descriptor for that case, with a billion findings on a CT scan, usually with no oral and intravenous contrast. The problem is- who wants to be called a nightmare?

Ring Magnet

A patient who has rings in almost every orifice imaginable. I am waiting for the proper case to use this one!

Screenostic

Screenostics are breast studies ordered as a diagnostic for a callback or finding and include the opposite breast for some unknown reason. Hence, the “Screen” part of the word.

Shpiel

It’s the real story, not the long-winded, boring version. It can be a word or phrase to replace the written history or impression. Direct translation from Yiddish

Sweet Pickup

It’s what you like to say when you make a subtle but significant finding. Unfortunately, there is nowhere you can say it in your dictation! You have to rely on hearing it from others.

White Cow In A Snowstorm

It’s what you see when there is so much noise that the findings are impossible to visualize. Usually, it is present on ultrasound in an obese patient, an underpenetrated film, or a study with tons of artifacts.

 

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Twelve Red Flags At Your First Post Residency Radiology Job

red flags

 

Unfortunately, not all practices are equal out there. Some abuse the junior employees. Others require responsibilities of their employees that the employer does not outline in the contract. And, even others promise partnership with its employees and do not deliver. So how do you know that your first job is going to work out for you? Well, it can be exceedingly difficult to tell for sure. But, I have come up with twelve red flags while employed or interviewing that will enable you to figure out if you need to move on to a new job or interview elsewhere.

No One Tells You Anything

You show up to work one day and discover that the hospital owners changed the location of your reading area within the imaging center without warning. Or, the private practice partners have a partners’ meeting and are unwilling to divulge any information, even non-sensitive information such as compliance issues for the employees. If this pattern of poor communication continues over time, it is a sure sign that the partners either have poor communication skills or do not respect the employees’ work. Be very wary!!!

Constantly Changing Work Responsibilities

You may be a neuroradiologist, but the practice expects you to all of a sudden read mammograms that you have not read for many years. And, the next week, you are responsible for all the arthrograms, even though you have not done one since your residency. If this happens once or twice, it may be related to staffing or temporary issues. On the other hand, when it is a recurring theme, it may be the first signs of an inept management structure unable to either retain its employees or, perhaps, severe practice disorganization. Think twice about staying!!!

Severe Isolation Syndrome

When you come into work, you see all the offices with radiologists with the doors locked. Just like everyone else, you shut your door too. And, you don’t even hear a peep from another radiologist for days at a time. Is this a collaborative environment? Certainly not!!! It doesn’t bode well for a fruitful, enjoyable long career!!!

No Practice Socialization Events

Most practices have some sort of get-together for the members of the group or hospital, whether it be the attendings, technologists, nurses, or other staff. And, there is a good reason for that. It is essential to get to know your colleagues so that you can feel comfortable relying on them as people. If none of these events are available, it sure seems that a lack of trust may be in the cards. Do you want to be part of a practice where you don’t even know your colleagues?

Hallway Brawls

OK. Perhaps, once in a while, a colleague does not get along well with another. However, if you find this a regular occurrence, there is a good possibility that your colleagues have significant personality disorders. Are you willing to deal with this behavior for the rest of your working career?

No Rewards For Good Employees

Sometimes your employees go above and beyond what the employer expects of them. Practices that ignore good employees also tend to overlook each other. How do you reward someone who is adding value to an imaging business? Well, you give them a bonus, extra vacation, or at the very least essential verbal recognition of their excellent work. If your practice can’t see how good you are and are working hard to better the business, consider going elsewhere!!!

Always Being Told You Are Wrong

Perhaps, you are missing a lot of findings or do not communicate well with colleagues and physicians. But, if you find that you are within the bell curve and your employees are constantly criticizing your work, did you ever think that they might just not want you there? Start looking around!!!

Running Around Like A Chicken Without A Head

Living in constant stress with tons of studies and responsibilities without end is not sustainable over the long run. Some practices run continually by having radiologists read too many cases to be safe. They are just in the business to make money for the bottom line of the partners’ pockets. Can you work in this sort of situation for the rest of your working life? Think about finding someplace where you can work over a long, sustainable period!!!

Lack Of Hospital Involvement

You notice that none of your colleagues or future employers is on committees within the hospital staff. If you want to stay relevant to your place of practice, at least someone needs to be involved. Otherwise, if there is no connection to the practice facilities, the ax may fall when you least expect it, and all of you may be out of a job!!!

No QI Committees

Believe it or not, quality is a crucial element of good practice. How do you know how you are doing? Well, there is only one way. You need to have someone that monitors the quality of the practice. Does the imaging business have morbidity and mortality conferences or peer evaluations? If your future coworkers are embarrassed to have their work checked, you may be looking at a practice that doesn’t care how they are doing. Start thinking about finding a practice that cares about the quality of their work!!!

No One Cracks A Smile

I find it a relief to crack a joke or say something nice and get a good response. However, some practices take themselves way too seriously. Do you want to be in a practice where everyone is miserable?

The Almighty Buck Always Rules The Roost

If you have not learned it yet, you will undoubtedly learn it at some point. It is not always about the money. Employers need to value ethics, practicality, and hard work over money at many points to run a genuinely great practice. If there is never a time that your future employer factors these attributes above the almighty buck, consider your alternatives!!!

So There Are Red Flags. Now What?

Not all practices are perfect, and it doesn’t necessarily mean that they are dysfunctional. However, when you catch a pattern of multiple red flags again and again without correction, it may be time to rethink your employment strategy. Keep your eyes wide open and your ear to the ground!!!

 

 

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Is Your Residency Like The Lord of The Flies?

residency leadership

If you have not read The Lord Of The Flies, you are missing out. It is a “must-read” for all professionals and especially for residents and residency leadership. For those of you who have never read the book, the story is about human beings’ “true nature.” A plane crashes on an uninhabited island, and the survivors are children without any adult supervision. The children create a society that slowly devolves into utter chaos. The book uses this as a metaphor for civilization and culture.

Well, how does this relate to radiology residency? Some residency programs over time become “leaderless.” This situation can occur due to a change in program directors, weak, ineffectual leadership, or program leadership in-absentia. When this happens, the residents may take over the “island.” This debacle can sometimes lead to utter chaos since most residents do not have the training to understand what is essential in radiology residency and beyond. Individual programs need residency leadership.

So, what are the signs that your residency program has turned into the Lord of the Flies?

Residents Arrive Late And Leave Early

You know the residents rule the roost when the program has no accountability for the attendance of your fellow resident colleagues. Your fellow resident arrives at noon because they “need to study” and leave at 2 pm for happy hour at the local bar without some form of consequence. Members of a residency “island” cannot survive unless all the participants band together and work to make residency the best it can be!

Residents Not Showing Up On Rotations

Residents miss out on the most crucial residency experiences when they miss their rotations. These rotations are the time to learn how to be a great radiologist and understand the subtleties and context of their future profession. Instead, the radiology residents gather in the library downstairs to read books rather than active cases. It’s just like not showing up to the hunt to get food for the members of your island. How can you survive?

Infighting Amongst Colleagues

When your fellow residents have decided to divide into two factions, constantly trying to throw each other under the bus, you can’t even look at your fellow residents in the eyes without arguing or getting upset. Even giving each member of your residency a conch before speaking does not help!!!

Shirking Responsibilities

You notice that the radiology residents ignore their responsibilities. The attendings are now performing “resident procedures” like sentinel nodes and paracenteses. All members of a “residency island” need to perform their duties. In the book, the responsibilities of the society were to create shelter, forage, and hunt. In a residency program, it is performing procedures, consenting patients, and reading studies. Residents need to perform these duties to receive the training they need to meet the needs of the survivors. Perhaps, the faculty do all the work because they cannot rely on the radiology residents!

No More Evaluations

If the program director and attending staff have not evaluated you over the past year, the program leaders are likely not following up on your training. The leadership has abandoned its post! Each member of the “residency tribe” is now forced to assume that they appropriately perform their duties. Residents learn bad habits that can stick for the rest of their careers without the guidance they require. How can the individual know what to improve when the residency provides no feedback?

Educational Meetings Are Gone!

When the educational committee disappears, the individual resident has no representation in how they learn radiology during the four years of residency education. Just like the book, once the tribe members no longer have a say in the functioning of the island, the “leaders” slowly take over and create an oppressive society. Those who did not comply were tortured and killed! Education needs to be a partnership between the residents and attendings.

Residency Leadership And The Lord of the Flies

All residencies need leadership with the best intentions of the individual resident physicians in mind. Sometimes it means rules and regulations that the program needs to enforce that allow the individuals to maximize learning. Other times, it requires the participation of its constituents so that the program gives the best educational experience possible over the four years. If these institutions are not in place, you are in for a rough ride. Your residency island may not survive!!!