If you haven’t had a discrepancy with the covering morning radiologist as a resident on call, then one of you encountered one of three outcomes. You either haven’t read enough cases. Two, you are the long-lost great-great-grandson of William Roentgen; Or finally, perhaps your name is Watson, the artificial intelligence computer, and you work for IBM!!!
The truth that very few attendings seem to admit is that everyone, including themselves, will miss something every once in a while. One study reported radiologists clinically miss something important between 2-20% of the time. (1) From my experience, that number looks pretty high, but the rate is significant enough. So, when, and notice, I don’t say if you miss something and have a discrepancy at night, you are an ordinary radiology resident. I would even go as far as to say that you are fortunate, in a sense, because you didn’t miss the finding as a full-fledged attending. You have someone to back you up, and hopefully, you will never forget that finding again.
Accepting The Inevitable Discrepancy!
The first step, of course, is to prevent major misses. The cases you need to study leading up to taking calls are the cases that are common and lead to significant morbidity and mortality. You want to view hundreds of different types of appendicitis, aortic ruptures, pulmonary emboli, and so forth so that when the time comes for you to take a call, the chance of missing the critical finding is significantly lower. Unfortunately, however, we can’t prevent all the inevitable misses, and frankly, we have to admit to ourselves first and foremost that this will be the case.
So, what do you do when you have a significant miss? Maybe you sent a patient home with acute appendicitis or a patient with a ruptured ectopic pregnancy. Perhaps you missed an early retroperitoneal bleed. There are specific keys to making the discrepancy in any of these cases, not just another horrible encounter, but rather a learning experience that is valuable for the remainder of your career. We will go through a few rules that you need to follow in the rest of this chapter.
Don’t Perseverate Over The Discrepancy
The first important point is how you emotionally react to the discrepancy. It is also a life lesson. We can’t undo what you did. You need to move on… Perseverating on a miss is counterproductive at best and, even worse, can cause future misses. Remember, just because you made a significant miss does not mean you are or will be a horrible radiologist. So, you need to get over it. The same rules apply to questions on written exams, future failures, etc. One miss does not a radiologist make!
Make Sure To Follow-up The Patient In The Morning
When you find out about the bad news, it is inappropriate to leave the department sulking, not attempting to make good on the miss you made. Try to do what you can to make sure that the physicians in the emergency room know there was a discrepancy. Or, you may need to call the patient back yourself, if need be. Bottom line… You need to make an effort to clean up your mess. It is partially your responsibility.
Read All You Can About the Miss To Not Make the Mistake Again
Reading about the disease, reviewing the films, looking at other similar cases: These are all the things you should be doing soon after the miss. This miss is a real opportunity to understand and fix the incomplete knowledge you had on the subject before, and, of course, to never make the same mistake again.
Teach Others
One of the most rewarding ways of compensating for the discrepancy is to make your fellow residents and junior residents aware of the miss. Teaching your colleagues protects them from making the same mistake that you have made. And, even better, it reinforces the knowledge you have, thereby making it much less likely that you will repeat the same mistake. Just like lightning, it rarely strikes twice!!!
Learning From Midnight Discrepancies
Midnight discrepancies are part of the everyday learning ritual for a radiology resident. It is not the discrepancy itself that is a problem. That is expected and is part of the typical routine residency learning experience. But instead, the issue is how you as a radiology resident learn and grow from the experience. Make the best of a challenging situation!!!
I read your article on the struggling radiology resident, and it prompted me to contact you. I am an R1 and just finished my first week on Body CT. After this week, I feel panicked and have been attempting to study almost every chance I get, including all day during the weekend. Still, I think I cannot possibly learn all this information (just the anatomy base I need has worried me). I know it is still early, but my colleagues are way more relaxed and comfortable in their current roles than I am. I would greatly appreciate any suggestions you have for me.
Thank you so much for this article and your help,
A Concerned Resident
Answer:
Detailing The Problem
To begin, I want to stress that your colleagues who appear as if they are more relaxed and comfortable may be putting on their best face, but they may be panicking too. It can be challenging to tell how another resident or colleague feels. Regardless of how they appear, it would help if you didn’t worry about them. Instead, you must ensure you are doing your best instead of panicking.
I don’t care what anyone says. The first weeks of the first year of radiology are some of the toughest. Anyone who doesn’t think so is in for a big surprise later. It’s good to have a little bit of fear at the beginning. It can motivate a new resident to become great. Excessive fear, however, is no good. You certainly don’t want a fight or flight response!!! Or, you can burn yourself out before you’ve even started. That will make you make you sick.
Also, I think body CT can be one of the more difficult rotations to feel comfortable with, especially at the beginning. Some of the personalities can often be difficult in that field. And, there is more anatomy to know than you may have imagined. This large amount of anatomical information is more so than other subspecialties like nuclear medicine. Plus, you have to start to get to know the pathologies on top of that. So, I know you are in a tough spot.
Solving The Panicking Problem
But alas, there is a solution. I find that the best way to deal with a challenging situation, like the beginning of the first year of radiology, is to establish a reasonable plan of attack. You and I know you cannot know everything. Albeit, many of your attendings may make you feel that way. (you have to try to tune that nonsense out.) However, you can learn what you need to know to become a trusted first-year resident. The key here is to study smartly. Certain books are geared to the first-year resident. For instance, the Webb Body CT book is a great and short resource to learn the basics of body CT scans. You need to concentrate on these.
In addition, the reading style in radiology differs significantly from what you have been learning. Make sure to read the pictures first, the captions next, and then the text last. This strategy will give you the most bang for your buck when reading radiology. Once you have the basics down of a modality within the first week or two, I would also emphasize reading the case review series. Radiology is about pictures. So, why would you not want to emphasize the images? Memorizing lists is daunting and usually not very fruitful without context. Looking at a bunch of pictures makes a list more relevant and memorable. This technique will leave you less prone to panicking. Try to study in this manner.
Also, I would recommend you look at my article on taking oral cases. Handling cases with oral technique is readily transferable to your day-to-day radiology activities. If you can do that well, your colleagues and attendings will appreciate your intelligent assessments more.
In any case, let me know if there is anything else I can help you with. With a bit of change in the study method and trying not to worry about how others look compared to you during your first year (which can make you crazy), I think you can do just fine.
Thank you so much for reaching out to me with your advice. I am doing my best to stay positive and study hard. I will let you know how it goes. Thank you!!!
Best wishes,
A Concerned Resident
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It takes some time to get into the routine. Good luck with it!!!
As radiology attendings, we need to sit next to our radiology residents for hours at a time. We get to know your quirks, mannerisms, and other personality features for better or for worse. (Kind of like a marriage!) Interviews are a time to let that personality shine through. We want to make sure that you are a living, breathing person with a soul. Can you speak understandably? Can you hold a conversation? Are you funny/witty? What’s your hygiene?
A radiology residency interview can also confirm that you are the person you say you are in the application. Can this person be trusted? Is this person going to lie to his attending about a procedure or history? For these reasons, significant weight is placed on the interview even though the process is imperfect. Furthermore, it does not always weed out the bad from the good.
Even knowing the importance of the radiology residency interview process, many prospective radiology residents enter the interview unprepared and have the perceived emotional/situational IQ of a tomato. If that were you, I recommend you practice your advertising pitch numerous times before beginning the interviews. If you want that residency job, you need to be the greatest of actors/actresses during the interview process. Show us that you can handle the demands of radiology residency!!!
Throughout my interview experience, I have seen all sorts of applicant disasters during the radiology residency interview process, usually related to unprepared applicants. Most can prevent these catastrophes with attention and practice. I am going to go through 10 real interview characters that have sabotaged their application. I hope these scenarios will be instructive in the art of the radiology residency interview. DON’T LET ONE OF THESE CHARACTERS BE YOU!!!
The Liar
Our third radiology residency interview candidate of the day walks into the room and shakes my hand firmly as we sit down to talk. He seems very focused, and I enjoy talking with him. He starts talking about how he developed an organization that hires famous CEO guest speakers to come to his medical school and lecture on business in medicine. Wow, very impressive! The interview ran smoothly, so I preliminarily gave him high marks.
After the interview session, the selection committee convenes to review each of the applicants. It turns out, the application and the other interviewer had different stories. Upon review of the application, it says he was just a member of the organization’s club. The other interviewer said he would only chauffeur the CEO to the meeting. Out of concern for the applicant’s integrity, we put him in the do not rank pile.
Bottom line: Make sure to get your story straight. Your oral presentation and written information should all be aligned. The interviewers regularly reconcile everything together. You need to tell the truth and stick with the same story!!
Smelly Guy At The Radiology Residency Interview
Before the formal interview procedure, we have a social interaction period with the residents to get to know the applicants. After most of the residents leave the room, we begin to hear some grumbling from the residents. So, I walk into the room, and as I walk toward a particular applicant, a stench becomes stronger and stronger. Oh my God!! It smells pungent, and I can almost taste it in my mouth. My impulse is to run, but I have to be cordial due to the circumstances. I am dreading the one on one interview process.
Bottom line: Make sure your hygiene is appropriate before starting your interviews. Appearances and “smells” are essential!!
The Sleepy Man
My introductory lecture to our residency program starts, and the lights begin to dim. I typically look at all the applicants in the room to keep the interest level high. But after 5 minutes of lecturing, I hear a loud freight train-like noise emanating from the back row in the form of an applicant in a suit. My assumption is he is not interested in the residency program: suitable applicant but low-interest level. We rank him toward the bottom of the list.
Bottom line: It is imperative to get a good sleep the night before the interviews. Even if the applicant was only tired but interested in our program, sleeping during the interview shows a lack of interest and respect.
Ms. Robot
I warmly introduce myself to an applicant as she enters the room for the formal interview. Entirely devoid of emotion and empathy, she responds, “Hi” quickly. We sit down, and the applicant immediately launches into this speech about herself without any voice inflection or changes in tone or speed. I have the sense she has done this a thousand times before. There is no “conversation-like” tone to her speech. No interactive quality. Is this the way she will behave when I have to sit with her for hours at a time? Even though her application was excellent, the applicant committee decided to give her a do not rank assessment.
Bottom line: Practice interviewing with others. Pretend you are having a conversation and interacting with your interviewer. Perceived personality is vital!
Shy Radiology Residency Interview Guy
The applicant walks into my interview room and introduces himself, but I can barely hear what he says. He stretches out to shake my hand. His hand feels cold, limp, clammy, and weak. The interview starts, and I try to get him to respond to my questions, but it’s like “pulling teeth.” The answers last 10 seconds at most. I asked the residents sitting next to him in the conference room about the candidate, and they said he didn’t speak a word. No one was able to figure out his personality. Even though his application was OK, we felt we could not put him on the rank list.
Bottom line: You need to get over your fears and act and speak with confidence. It may involve practice, coaching, and psychological evaluation. If we can’t figure out who you are during your interview, we are not sure if we want to sit next to you as a resident!!!
Mrs. Bizarro
Across from me in the interview area sits a pleasant-looking woman dressed appropriately. Everything seems fine until our conversation begins. Her eyes start to bulge out. Smiles and giggles burst out inappropriately in the middle and end of sentences. Even though she answers my questions mostly appropriately, something is off.
After the interview, we meet with the selection committee, and the first thing I ask is: what’s with Mrs. Bizarro? All the committee members look at me and say, “We were thinking the same thing!!!” We quickly took her off the rank list.
Bottom line: Practice your interviewing skills in front of a mirror or tape yourself on an iPhone. You need to know that your expressions are appropriate for the interview context. This lady may have been an excellent radiologist, but we sure would not feel comfortable having her sit next to us!!!
Not Quite Right, Joe
Toward the end of the interview, we start to talk about extracurricular activities and hobbies. The applicant proceeds to say that he was into cow-tipping as a college student. And one time, the college dean reprimanded him for the activity. Automatically, mental bells start ringing. Who would mention something like that in an interview setting? Why would someone want to do that to a cow? Off the rank list, he goes!
Bottom line: We are not your friends in the interview setting. Do not release any information that could jeopardize your application and make you appear strange. We do not want any issues during residency that could cause probation, suspension, or worse!
The Guy all the Residents Hate At The Radiology Residency Interview
I am having a great conversation with one of the applicants. He tells me about some of his exciting research projects and hobbies. He seems to be a straight shooter and is very witty. We end the conversation on a high note with expectations that we will rank the candidate highly.
After our interview, we met with the rest of the admissions committee. The admissions committee consists of the residency director, associate residency director (myself), chief resident, and several other senior residents. We begin to discuss the candidate at hand. Every single resident states something negative like: “This guy was obnoxious”; ‘He was chauvinistic,”; “Really bitingly sarcastic.” The directors are dumbfounded. We place the applicant in the do not rank pile.
Bottom line: You need to play nice with all members of the staff, especially the residents. They have essential input in the residency application process and interviews. The wrong statement can get you kicked off the rank list!!!
The Cell Phone Gal
I started giving the introductory talk to the applicants about the program. Every minute or two, I notice a woman looking down at her lap. Oh well… I continued with my lecture.
An hour later, we meet for an interview, and we shake hands. We sit down, and I start asking questions. The applicant seems a little bit distracted. Again her eyes continue to float down toward her lap every few minutes. All of a sudden, I hear a ring. She picks up the cell phone and says to me, “I need to get this.” She is not interested in our program.
Bottom line: Shut off your cell phone. You are here to interview for a job. It is a sign of disrespect to use your cell phone at any time during the interview process!
Opaque Sam
We parse through an applicant’s resume and ERAS transcript. The package states that the resident had a DUI arrest when he was a college student. So, the interview begins after some ice-breaking small talk. Naturally, a DUI arrest is a big deal. It signifies that the applicant has the potential to be an alcoholic and engage in risky behaviors. So, I anxiously pop the question: Tell me about what happened with your DUI arrest when you were in college? The applicant bluntly states, “It happened. It’s over. I don’t really want to talk about it further…” A moment of silence ensues.
Flash forward to the selection committee meeting. All the interviewers received the same response from the applicant. There was no response of remorse. No explanation for the event. Nothing. Our committee put the applicant in the do not rank pile.
Bottom line: Candidates should address any adverse events upfront, or else an admissions committee may perceive the applicant as hiding something significant, whether true or not. Don’t be like Opaque Sam!!
Sabotaging Your Radiology Residency Interview!
Interviewing is often about what not to do as much as it is what you should say. Make sure you prepare for the interview day. And, don’t be like our ten catastrophic characters!!!
Good evening, I am an MS3 just starting to discover the excitement of radiology on my radiology selective. I am contemplating radiology as a career, but I have low Step 1 score (227) and I am also an international student requiring H1B visa for residency (I attend a top 40 US allopathic school and am not Canadian). Is radiology still an option realistic to consider given my circumstances (I hope to match into a university program)? What can I do now as I start my third year going forward to increase my competitiveness? Thank you for all your help!
Adele
Hi, Adele!
H1B And J1 Visa Issue
The answer to the question of your chance for getting into a program may hinge on the next few questions I am going to ask you. Why is it that you require an H1B vs. a J1 for getting a residency? What kind of visa do you currently have? This may make a big difference because universities are much less likely to support a resident with an H1B visa since it costs the university a lot of legal fees and time to support a candidate to obtain the H1B visa. Also, the federal government limits the numbers of H1B visas. Therefore, you significantly limit the playing field of choices of programs to apply.
Some of the larger academic university programs may allow applicants with an H1B visa. But, many smaller programs like ours do not take applicants with H1B visas for the reasons I mentioned (with a few rare exceptions). When applying, if you can’t get a J1 visa, I would definitely call the individual programs to see which ones would take an H1B visa.
Biggest Positives In Your Application
So, what do you have going for you? First, the fact that you are graduating from an American medical school will help your situation immensely. We, as program directors, selfishly like to get applications from American medical schools. At least we can vouch for the quality of the institution and compare to other applicants. Second, your scores are not bad. Many programs have cutoffs around 220 or 225. So, it should allow you to meet that requirement at many programs.
Other Recommendations
In addition to the recommendations above, I would also consider taking the next USMLE early, studying hard, and perhaps completing a USMLE Step II course so that you can show improvement from your 1st USMLE examination to the next one. Program directors like to see improving scores going in the right direction.
Thanks for the great question. I would be specifically interested in why you need an H1B. Let me know if there is any other information that you think I can help you with. I will post it on the website at some point because I think it would be useful for other applicants in your situation as well.
Regards,
Barry Julius, MD
Dear Dr. Julius,
Thank you for your reply and great advice.
I am currently on an F1 student visa and was advised against a J1 visa by my immigration attorney because of the requirement to return to my home country for 2 years. I am Singaporean and have been looking into the H1B1 visa for Singaporeans. It is similar to H1B, but has its own cap that has never been filled historically, can be obtained anytime throughout the year, and only requires the employer to file LCA (I-129 is not needed).
I am under the impression that it would be easier to approach programs that offer H1B already to ask about sponsoring for H1B1 visa, than programs that offer J1, since they may not be familiar with the H type visa. Is this likely to be true?
Also, how and when would you advise me to contact programs and discuss visa-specific issues/requests. Should this be done before I submit my residency application?
Thank you for all your help.
Best regards,
Adele
Thanks for the additional information. That allows me to understand the issues that you have and why you need an H1B1.
I would definitely make sure to contact the residency programs and the Graduate Medical Education (GME) office prior to applying because many of the programs will not even look at a candidate who has to get an H1B or H1B1 visa for a residency slot. Most programs are set up for the J1 visa. If you need an H1B or H1B1 visa to get into a program, it puts you into a different application pool.
You certainly don’t want to waste your time and money applying to those programs that only take J1s and not H1Bs. It makes sense to contact each of the individual radiology programs and the GME office prior to applying to save you a headache. Typically, the person to speak with would be one of the folks in the GME office who handles visa issues. And, you probably want to speak to the residency coordinator because occasionally the individual program policy can potentially differ from the GME office. ( the program may not take a resident with a visa issue, but the GME office may say it is OK) At our institution, this person is a secretary and is very knowledgeable about all things visa related since she has been doing it for a long time.
Hope that gives you a little bit more insight about when to contact the program and who to contact.
For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!
So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.
Personality:
You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.
I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.
Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology
Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology
Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology
Jack of all trades- Body Imaging, MRI, Nuclear Medicine
Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging
Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology
Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine
And so on…
Lifestyle:
So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.
Body Imaging/MRI-
Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.
Cardiothoracic Imaging-
Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.
Informatics-
Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty
Interventional Radiology-
Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours
Musculoskeletal Imaging-
Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic
Neurointerventional Radiology-
Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.
Neuroradiology-
Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty
Nuclear Medicine-
Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.
Pediatric Radiology-
More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty
Trauma/ER radiology-
Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.
Women’s Imaging/Mammography-
Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.
Money:
Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.
Location:
Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.
Application Competitiveness:
Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.
Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.
Trends/Countertrends:
So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.
Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.
Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.
On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.
Summary About Choosing A Radiology Fellowship:
Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!
During residency, most physician trainees are studying and working so hard that they vaguely realize what is in store for them when they finish their training and begin their first job. What they often expect differs dramatically from reality. So, I thought this would be the post to give you the lowdown on some expectations versus reality when you start as an attending. We will cover six employment topics: money, job performance expectations, the importance of the bottom line, teamwork, case sign-off, and feedback.
Money Issues
Scenario
You begin residency and see these large salaries that come across in your email from recruiters. And, you hear stories of friends doing well at their first job, making tons of money that they don’t even know what to do with.
The Reality:
Many residents consume themselves thinking about the relatively “large salaries” they will earn once they finish their residency. You may think, well, if I can do that for ten years, I will be out of debt and rich. However, every large salary comes with a price. Either you will be working like the proverbial “dog,” or you may be located in a place very far from your friends and family.
Other new attendings also do not realize the costs that accrue from debts, buying a house, and maintaining a luxury lifestyle. Often, these folks go into further debt, funding a lifestyle that they cannot afford. Don’t let that be you!
Job Performance Expectations
Scenario:
You have just graduated as a neuroradiologist, and you are ready to take your first job. The job post said you would be performing 50 percent neuroradiology and no mammography while on a partnership track. You are excited as can be not to have to read any mammography!!!
The Reality
As soon as you start, one of the partners asks you to help out reading mammography by taking a course and over reading one of the other radiologists’ mammograms. Since one of their mammographers left, they need the help until they can hire another.
This situation is commonplace in the world of private practice. Sometimes, undue circumstances arrive beyond the practice’s control, and your expectations for your work will not precisely align with reality. If you cannot be somewhat flexible, you may not become a partner in the practice!
Importance of the Bottom Line
Scenario:
Your academic nuclear medicine position at a high-powered center of excellence is about to begin in a few days. Since it is a large academic center, you figure you will have lots of administrative time to pursue your research interests. I can’t wait!
The Reality:
After a few days of working in your position, the institution issues rules regulating administrative time. If you cannot obtain a grant to support the institution, you will have very little administrative time.
Don’t assume that a large academic institution does not care about how much money it earns. It needs radiologists to financially support the institution by reading films just as a private practice needs to perform procedures and interpret enough films to stay solvent. An academic institution does not mean lots of free time!!!
Teamwork Expectations
Scenario
You are about to begin your first private practice job, and they told you that they treat all employees and partners equally. So, you are very excited to start a career with an equal footing to everyone else.
The Reality:
In your first week of work, a partner asks if you could help him out with reading some extra films because he and his wife want to go to a concert. You tell him that you had early dinner plans with your wife, but he continues to insist. You feel you have to stay to complete the work because he is an influential partner in the practice. Bottom line… Everyone is equal, but partners are often more equal than others!!!!
Case Sign-off
Scenario:
You are sick of waiting for your attending radiologist to sign off the reports you dictated a few hours ago. When you finish residency, now you will be able to complete your dictations whenever you are ready!
The Reality:
Now that you are the final reader and the buck stops with you, you become unsure of the findings and want to ask your colleagues before completing some of your more complex reports during your first days of work. Well, now you don’t have to wait for someone else to sign off your reports. Instead, you may need someone else to look at the cases for a second opinion before completing the study!!!
Feedback
Scenario:
The practice partners state that you will get immediate feedback about your progress after six months. Furthermore, they say that they can even tell who will be partnership material by the first year.
The Reality:
Six months roll around, and no one lets you know about your progress. You think you are doing well, but you are not sure. The patients and the clinicians seem to like you. After one year, no one lets you know if you will make a partnership after the three years they promised you. Unlike residency, feedback can be much more challenging to obtain since it is not designated. There is no guarantee!!!
Expectations For The New Attending!
Becoming a radiology attending is not like entering Shangri-La. There will be new challenges that you do not expect. Along with the added respect, you will have many additional responsibilities. So remember, as a radiology resident, try to prepare yourself for the reality of becoming a radiology attending. So, you will not be surprised about what to expect when you begin!!!
Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.
Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.
Resident Versus Seasoned Dictating
So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.
Residents Need More Formalized Guidelines To Learn Dictating
To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.
Templates:
When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.
In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.
Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)
Important Pitfall
However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.
Histories/Priors:
Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.
One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.
Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.
Technique:
I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.
Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!
Comparisons:
The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.
Comments:
If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.
One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.
Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!
Impressions:
The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.
In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.
Beware Of Technical Jargon
Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!
Stick To The Answers
Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely.MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.
If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.
What terms are most frowned upon in the impression?
Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.
But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.
Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!
In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!
Structured Reporting Dictating Versus Prose Dictating
Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.
I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!
Dictating Tips: A Final Conclusion
You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!
Personal statements in the radiology field are the least effective way to bolster your application. (1) Rarely, do they help an applicant. Occasionally, they hurt the applicant’s case. Regardless, I am aware that the personal statement will often become essential to many viewers of this article who apply to radiology regardless of whatever I say. Therefore, I am creating this blog for anyone that is applying for a radiology related job to learn to create that killer radiology personal statement. And, today I am going to recount some of the basics for creating one. Specifically, I am going to start by explaining the parts of a great radiology personal statement and then give you some general tips that I have learned over the years from blogging and reading many personal statements.
First Paragraph:
The Hook
After having rummaged through thousands of radiology personal statements and writing lots of blogs, I can definitely say that the key paragraph for the reader begins at the beginning. If it is average/boring, I have almost zero desire to read the rest of the statement, especially when you have another 10 more to read that day. Something in the few first few sentences needs to draw the reader in quickly. You are not writing a short story or novel where you can slowly develop your characters and plot. Rather, you need to write using a technique that I like to call the hook. Reel that program director in.
There are several techniques that I have seen over the years. Let’s start by using the writing technique of irony. Notice the irony I chose in the first paragraph of this article. I started by saying personal statements are the least effective way to bolster your application. Whoa, wait a minute! The title of the article is How To Create A Killer Personal Statement. That’s somewhat interesting. The dissonance in that first paragraph draws the reader in.
So, what other techniques can you use to maintain the interest of the reader? Sometimes quotes can certainly help. Once in a while, I come across a quote that really interests me. I tend to like quotes from Albert Einstein. They tend to be witty and have double meanings. But, there are certainly millions to choose from. A good quote can set the tone for the rest of the personal statement.
Finally, you can write about an interesting theatrical description of a life-altering event that caused you to want to go into radiology. Use descriptive novel-like adjectives and adverbs. Go to town. However, be careful. Don’t choose the same events as everyone else. Read my other blog called Radiology Personal Statement Mythbusters to give you some other ideas about what not to choose!
Tell Why You Are Interested In Radiology
The first paragraph is also an important place to tell the reader why you are interested in radiology. Many times I will read a radiology personal statement and say to myself that was kind of interesting, but why does this person want to go into the radiology field? He/she never quite answers the question and I am left feeling that this person does not know why they want to enter the field. Don’t let that be you!
Second Paragraph:
Explain Any Problems/Issues
I like the applicant to be upfront with the reader rather quickly if there was an issue that may cause a program director or resident to discard an application. It could be addressing something as serious as a former conviction for drunk driving when you were young and stupid. Or, it could be something milder like a questionable quotation from a mentor that you found in your Deans Letter. Either way, you need to explain yourself. Otherwise, the problem/issue can declare itself as a red flag. Subsequently, it can prevent you from getting the interview that you really want.
Second and Third Paragraphs
Expand Upon Your Application
Let’s say you don’t really have any red flags in your application. Well then, now you can write about some of the things that you accomplished that you want to bring to the attention of your reader. Typically, these may be items in your application that are partially explained in the experience or research sections of the ERAS application but really deserve further emphasis or explanation.
Show Not Tell
In addition, the meat of any personal statement should contain information about what you did. Do not, instead, describe all the characteristics you had to allow you to do it. This is a cardinal mistake I often see in many personal statements. What do I mean by that? If you have been working at NASA on the Webb Space Telescope, you don’t want to say I was a hard worker and was well liked by everybody. Rather you would want to say I spent 1000 hours building the mirror for the telescope constantly correcting for mistakes to such a fine degree that the engineering societies considered it to be almost perfect. And to show you were well liked by everybody, you can say when you were done completing the telescope, NASA held a ticker tape parade for me!!! (Well, that’s probably not the case. But, hopefully, you get the idea.)
Final Paragraph
Time to Sum Up
This can be the most difficult part of writing a personal statement (and blog too!) How do you tie everything together into a tight knot so that everything comes together and makes sense? Well, one thing you can write about is what you will bring to the table if your residency program selects you based on what you have stated in your radiology personal statement. Back to the Webb telescope example: Given my experience with my successful quest for perfection by creating an almost perfect telescope mirror, similarly, I plan to hone my skills to become an incredible radiologist by always learning from others and my fellow clinicians to get as close to perfection as possible. Bottom line. You want to make sure to apply your experiences to the job that you want to get.
General Issues With Editing
1. I have learned a few things about writing over the past years, whether it is blogs, personal statements, letters, or whatever else you need to write. However, the most important is the obsessive need to review and re-review whatever you are writing for editing. It may take 100 edits to get it right!!!
2. Have a friend or a relative read your personal statement to catch errors you may not see. Your brain is trained to already know what you have written. Many times the only way to catch your own mistakes is to have another person read your writings.
3. Also, make sure to the read the personal statement out loud. Sometimes you can only detect errors by listening to what you have actually written. It happened many times when I edited my book Radsresident: A Guidebook For The Radiology Applicant And Radiology Resident
4. Finally, I recommend the use of grammar correcting programs. The one that I would like to bring to your attention is the program called Grammarly. I am an affiliate of Grammarly. However, that is only because I use the program myself for my blogs all the time. It has saved me from really stupid mistakes. One version is for free and corrects simple critical errors. The other uses more complex grammatical corrections and is a paid service. Regardless, either version will assist you in catching those silly errors. In addition, I usually paste my blogs into the Microsoft Word program to correct any other possible errors. I have found both programs to be complementary.
Other Useful Tidbits
Avoid Too Many I Words
When writing a radiology personal statement, try to reduce the usage of the word I for multiple reasons. First, it begins to sound very redundant. Second, you appear selfish. (It’s always about you, isn’t it?) And finally, you want to create the impression that you are going to be a team player, not in the field of radiology just for yourself.
Active Not Passive Tense
If you want a passage to sound great, make sure to almost always use the active tense, not the passive variety. When using the passive form, the reader has more work to do because he/she has to figure out who is doing the activity. In addition, the environment appears to control you rather than you controlling the environment. And finally, sentences sound more verbose when using the passive tense. Think about the following phrases: The job of creating a computer algorithm was completed over the course of 10 years vs. My colleagues and I created a computer algorithm over the course of 10 years. Which sounds better to you?
Use Sentence Transitions
If you want your personal statement to sound smooth, I find words other than the subject at the beginning of the sentence help to diversify the sound of the individual sentence. Also (notice this transition word!), it allows for a change of idea without being so abrupt.
Don’t Use The Same Word At The Beginning Of Each Sentence
In that same train of thought, try not to use the same word to begin a sentence over and over again. It’s a surefire way to bore the reader!!!
Creating That Perfect Radiology Personal Statement
Now you know some of the rules I would utilize to create an interesting radiology personal statement. Some of these are general rules that I apply to my blog on a weekly basis that I also see in the best personal statements. Therefore, I know that they work well. So, go forth and write that killer radiology personal statement. You now have all the tools you need!!!
Most medical students and residents do not have an insider’s insight into radiology residency and fellowship application and interview processes. Even worse, misleading advice and rumors cloud the process. One needs only to look at the average student or residency forum to see numerous conflicting stories and statements.
Only someone actively involved in the process can understand what you need to know when applying for a radiology residency. So, thankfully, you have come to the right post. I have looked at thousands of applications and interviewed hundreds of residents for positions in our program as associate program director. So, I will help you out by delving into the depths of the radiology residency application process. This article will give you the basics of what you need to know.
The Application
We could go through the application in one of many ways. But, I think the best way is to go through the different parts of the application from most to least important. This way, you will not squander your energy on the small stuff!
The Dean’s Letter
Few sections of the application genuinely differentiate one applicant from another. Dean’s letters happen to be one of those items. The reason for that: you will receive comments from attendings, residents, nurses, technologists, and secretaries that may say something negative. I can’t tell you how often we have parsed an entire application with glowing positives until we arrive at the Dean’s letter. And, then we receive coded messages in the letter, such as: was very shy during the rotation, but did see some improvement. Or, this resident was very independent. However, he did not seek help when presented with a challenging patient care issue. And so forth.
Additionally, the Dean’s letter is the only document (other than the boards) that compares the applicants to their classmates. Most medical schools have buzzwords indicating the residents’ rank in their class. Each one is different, but typically it allows insight into which quartile the resident resides.
Can You Do Anything About The Dean’s Letter?
Ok, so you have your Dean’s letter written in “stone.” And, at some institutions, you may hear that administrators say you cannot change the Dean’s letter. But usually, at the bare minimum, you can check the Dean’s letter. All medical students applying for a residency should scan their Dean’s Letter before sending out the application. I have seen Dean’s letters sent on behalf of medical schools with the wrong applicant’s information!
At other institutions, you can look at your letter before application time and potentially modify the document. If that is the case, you should undoubtedly check it for any hostile or questionable comments. And then, if possible, confront the department/person that wrote the statement. Ask if they could redact or modify it. If the writer is truthful, the person may decide to leave it there. But an attempt should be made, as this one negative comment can make the difference between high, low, or no ranking on a program’s rank list. Not infrequently, the admissions committees will obsess over one questionable comment. They will often spend countless painful hours perseverating over these “minor details.”
The institution may not allow you to look at the Dean’s letter at a few medical schools. But the school may allow your mentor or a faculty member to look at the document and possibly edit it for corrections. I can’t emphasize enough how important it is to increase your odds of being accepted to the residency of your choice.
The Boards/USMLE
Why are the boards important? Well, the boards/USMLE assess the ability of a future resident to pass the radiology certification examinations. We have noticed a strong correlation between lower board scores and difficulty passing the new core exam in our program. So, similar to our program, most programs take the USMLE score very seriously.
In addition, programs use board scores more as a baseline cutoff. Once you score higher than that baseline, it doesn’t factor much into the ranking equations. On the other hand, unless extenuating circumstances exist, failing and low scores usually place the application in the deny pile.
What About COMLEX?
For those of you that are D.O. medical school applicants, I recommend that you take the USMLE in addition to the COMLEX examination. Many radiology programs are unsure of the significance of COMLEX scores and don’t know how to factor the scores into the ranking equations/cutoffs. Applications with COMLEX scores alone may get thrown out of the interview pile entirely.
Gamesmanship
Even with all these factors, you can use some gamesmanship when it comes to the boards. If you have done very well in the step 1 boards, often, you may be able to get away with just sending those scores alone. You may want to delay taking step 2 USMLE. With high USMLE Step 1 scores, USMLE step 2 scores can only hurt you if they are lower. Of course, all this gamesmanship will disappear when the scores no longer exist on Step 1. At that point, Step 2 scores will most likely replace the outcomes on Step 1.
Finally, most programs look for/expect improvement from step 1 to step 2, especially with borderline step 1 scores. So be careful and take the step 2 boards very seriously. Invest in a review course if you need to.
Research
Nowadays, research can become a significant factor in getting an interview in a residency program. What is the reason for that? ACGME guidelines mandate that accredited radiology residencies have specific radiology research requirements for residents before graduating. Knowing that a resident has completed multiple quality research projects means that a resident can work more independently completing research projects. This knowledge of research reduces the burdens upon the department.
Furthermore, radiology research may demonstrate significant interest in the field. And, it provides an avenue for discussion during interviews later on in the process. We often look at an application, saying it’s pretty good, but the resident hasn’t completed any research. That may take the application down a few rungs.
Bottom line, though. It won’t take you entirely out of the running for getting a spot. However, it can be a significant asset in some situations.
Extracurricular activities
We look for two big red flags to avoid on this section of your application: those applicants that emphasize that they have participated in every extracurricular activity under the sun and those applicants who write down almost nothing. A resident who participates in everything suggests that he lacks focus, never investigating or accomplishing tasks in depth. On the other hand, a resident that engages in nothing but school tends not to be well rounded. These residents may not have outlets to disperse their frustrations during their four years of training. A residency director does not like having frustrated residents!
Impressive Extracurriculars
So what are some activities that impress the admission committee? : Interesting extracurriculars that show leadership potential, activities that demonstrate a depth of involvement, and activities that offer an ability to handle stressful situations and function independently. Some of the special extracurriculars that stand out in my mind that meet these criteria would be a student that started a Subway franchise successfully from scratch and made it into a big business, a student that participated in the Olympics, and a student that lobbied for Congress. These are people that tend to climb the rank list higher because their extracurriculars were memorable.
Not So Memorable Extracurriculars
What are some extracurriculars that don’t add much to the application? Those activities that everyone else does and do not suggest leadership potential. In radiology, those would include participating in a radiology club (Big deal!), participating in health fairs (Every medical student does it), and teaching inner-city kids (We see it all the time as part of medical school curricula!) Not that these activities are harmful, but they don’t add much at all to your application. My recommendation to you: find something you enjoy, hopefully, something unique, and stick with it during your four years of medical school training!
Recommendations
Admissions committees like to make a big deal about recommendations. You’ll undoubtedly hear that you need an excellent letter to get into a great program. But honestly, if you ask someone for a recommendation, it is unusual to find someone who will write you a nasty one. Students are going to ask attending physicians that like them. On the other hand, although rare, we see a “bad” recommendation as a significant red flag. It often means the resident that obtained the letter has a poor emotional intelligence quotient. Or she couldn’t find one attending that liked them- both significant issues!!!
Like the rare bad recommendation, great recommendations that raise the application within the pile to a higher rank are also unusual. For the most part, this type of recommendation stems from well-known entities that want the person in their program. Or perhaps, it comes from a close colleague that the radiology admissions committee implicitly trusts.
Recommendations rank relatively low in the application influence equation given the rare ability to change the application disposition.
The Personal Statement
Finally, I would like to talk about the item that medical students often perseverate on the most: the personal statement. The personal statement seldom helps an applicant and can occasionally hurt an applicant. After having read over a thousand of them, there are very few standouts. And, almost all of those that stood out were somewhat disturbing. I still remember an essay that emphasized a dead rabbit. It did not have any correlation to radiology whatsoever. I was concerned about mental illness in that student. We terminated the possibility of acceptance to our program immediately!
If I had to say one thing, I would advise you to be cohesive and relevant to your future career as a radiologist. Also, watch out for typos because typos suggest an inattentive personality, not a characteristic you want in a radiologist. Other than that, don’t fret too much about this part of the application.
Summary
Application for radiology is an arduous process with multiple pitfalls. Make sure you concentrate on those items that give you the most “bang for your buck” to send your application higher on the rank list. In particular, put particular emphasis on the Dean’s letter. Check it if you can. Correct it if need be.
And finally, don’t be that student with marginal board scores, no research, dull or no extracurriculars, poor recommendations, and a personal statement that stands out too much. If you follow my suggestions and try not to rock the boat, you should get into a great residency!
A groundswell of controversy about maintenance of certification (MOC) has been building slowly for the past decade. In truth, no quality evidence-based study has shown a link between quality of care and MOC. Therefore, multiple entities in the United States are abuzz, attempting to create anti-MOC legislation to prevent boards from gaining a legal foothold in states requiring MOC for practicing medicine. Some of you may hear about these issues in the press. (1,2) These issues are not just unique to radiology.
But before we discuss the individual controversies, we need to delve into MOC a bit further, especially for those just starting. What exactly is the maintenance of certification once you complete your residency in the United States? What do you have to do to satisfy the requirements? Why do you need to meet the requirements for MOC? And when do the requirements for maintenance of certification begin? Some of the answers to these questions are not so obvious. So, these are some of the questions I hope to answer in this post.
What is MOC?
According to the “experts,” maintenance of certification is a way to show that you are continuing to keep up with the educational demands of your specialty. Theoretically, it should ensure continued minimal competency to practice medicine. The American Board of Radiology and your state of practice require specific essential documentation for diagnostic radiology. For instance, the ABR requires 25 hours of continuing education credits (CME) per year, passing a test every ten years or completing online email questions correctly to certify competency, verification of state licensure, and quality improvement projects or leadership roles.
Individual states also require their primary means of determining competency to maintain licensure. When I first obtained my license in New Jersey, I had to take a required orientation course. Every year, I need to submit 50 CME credits each year. In addition, the state requires me to satisfy an end-of-life care course requirement every three years. Each state can significantly differ in what is needed to keep a license. Go to the site called mycme.com for more information on your particular state.
How Do I Get CME Credits?
Typically, radiologists can get continuing medical education credits in one of many ways. First, many online radiology society websites, such as RSNA and ARRS, develop education portals for radiologists to complete either articles or lectures. The radiologist then takes a short quiz they must pass at the end of the episode to document that he has completed the task.
Second, you can attend conferences at many locations throughout the country and then collect the CME credits at the end of the course. Usually, the conference presents the physician with a certificate of completed CME at the end of the meeting.
And then, internally within your hospital or practice, you can participate in tumor boards, conferences, etc. Subsequently, you can obtain the CME credits after documenting what you have experienced as long as the creators of the conference have applied for CME.
What Happens If I Don’t Participate In MOC?
Unfortunately, for most radiologists, it is not an option to forgo MOC. Most hospitals require certification by the ABR and state licensure bodies to maintain staff privileges. And individual practices often stipulate that you need MOC to remain in practice.
But, you may hear about other specialty physicians in the news who have not renewed their certification. Many of these folks are leading political and internal movements to eliminate the MOC requirements. Individuals and organizations are suing certification boards who are teaming up with insurance companies and hospitals. Some of these boards aim to make MOC a requirement for radiologists to get reimbursed for the interpretation of images. Usually, the physicians not participating in MOC have been practicing for a while, so they have the clout to abandon the MOC process.
When Do I Need To Start With The MOC Process?
Over time, the ABR requirements about when to start MOC have changed. The MOC process begins on day one since the ABR now considers MOC to be continuous. According to the ABR, you need 75 CME credits over three years of practice to maintain certification. That means you could theoretically begin CME on the first day of practice or wait a bit to start.
On the other hand, each state has different requirements for when to begin MOC. You should look up your state online to determine which rules are correct. Again, refer to the site called mycme.com, which outlines the specific requirements for each state. For the state of New Jersey (my state of practice), they give you a grace period of two years to begin CME after the first renewal of your state licensure.
Former Actions Against MOC
According to a Medscape article from 2017 (1), many state organizations have been banding together to prevent the overreach of MOC. This article documents many of the individual state medical society activities. I thought these activities were particularly fascinating.
To summarize some of the activities in this article, multiple state medical societies have attempted to pass anti-MOC bills in their states. Most of these attempts are in process or have been temporarily tabled. One state, Georgia, became the only state to pass a bill that prevents using MOC as a condition of licensure, employment, reimbursement, or malpractice insurance at certain hospitals.
At the time of the writing of the Medscape article, several states have initially failed in their attempts to pass MOC legislation. Three state medical societies (Arizona, Kentucky, and Michigan) created stipulations stating state medical boards “may not require a specialty certification or maintenance of a specialty certification as a condition of licensure.” However, legislatures did not pass the bills. Oklahoma became the first state to attempt to enact legislation to remove MOC as a requirement for physicians to obtain a license, get hired and paid, or secure hospital admitting privileges. However, at the last minute, the bill failed after significant lobbying by ABMS (American Board of Medical Specialties).
Other state medical associations are in the throes of creating anti-MOC bills. Both Tennessee and the Florida Medical Associations aimed to create bills to defeat efforts by the ABMS and FSMB to impose MOC as conditions for reimbursements and licensure. Finally, numerous other states, including Maryland, Missouri, North Carolina, Texas, Alaska, California, Maine, Massachusetts, New York, and Rhode Island, are trying to enact anti-MOC bills.
More Recent Defeat Against The Anti-MOC Movement
Most recently, in 2021, the federal court of appeals affirmed the dismissal of physicians’ claims against the American Board of Internal Medicine claims that challenged the MOC process. However, other litigation is still ongoing.
Summary
Regardless of your stance on MOC, it is integral to most radiologists’ practice. It will be present in some form or another for a long time, perhaps in a more weakened state. Follow the current rules when starting, and you will get to practice radiology. Be a revolutionary against the system, and you may have difficulties. Either way, the final decision is up to you!!!
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