Month: October 2018

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Why A Strong Department Chair Is Critical To Residency

chair

As an associate program director, I work with all the residents and faculty. But, one role, in particular, plays an even more significant role in the quality of the residency than the others. Which one would that be? (Hint: Well, if you have not guessed it by now, you may want to look at the title again! The Chair)

OK. So, the chair is critical to running a great residency. But what is it about a chairperson that makes the role so important? Well, the importance of the position is what we will run through over the following, oh, say, 8oo or so words!

Backbone When The Going Gets Tough

Everyone, once in a while, events conspire to mangle a residency program. Perhaps, a resident decides to leave for another career, and the hospital wants to take away the residency slot forever. Or, the emergency department determines they no longer want residents to give the final dictations at nighttime. In any of these cases, you need a firm chair to prevent these issues from negatively affecting the residency program. Sometimes you need a leader to fight for your department!

Allocation of Resources To The Residency Program

What would happen if you had a chair that decided to commit more resources to non-residency-associated imaging centers at the expense of a hospital-based residency program? Chaos, of course! You may not have enough physical bodies to teach the residents. Or, the chairperson decides to stop giving the program directors administration time to run the residency program. Either way, the chair controls many of these outcomes. And, if she decides to allocate the resources to the outside facilities instead, the residency loses out.

Carrot And The Stick

In any practice, some physicians have more or less interest in teaching. But, what happens if some of the attendings decide that they no longer want to give conferences? Well, the chair has the practice’s long arm to ensure that does not happen. The chairperson can either decide to provide money or non-monetary incentives to make sure that the faculty performs. Or, she can remove incentives from staff members who do not participate. Either way, the chair’s ability to utilize her power directly affects the program’s quality.

Sets The Tone Of The Department

Let’s say your chair runs the department as a dictator. Or, he is always just trying to appease friends instead of doing what is best. What happens to the residency in these cases? In the first case, the residency program runs on fear and misery. And in the second case, nothing ever gets accomplished. Bottom line: the chair sets the quality of interactions in the department and the residency.

Liaison Between The Hospital And The Program Director

Some departments have a chair who does not communicate the critical issues of the institution to the residency. What occurs in these situations? First, residents may lose out on remaining compliant with national requirements such as hospital ACLS training. Or the radiology program may not fulfill its obligations to stay accredited. Poor communication between the hospital, chair, and the program director can become a nidus for a residency to implode!

The Ceremonial Function

Sometimes, a chair may decide not to attend essential residency functions. The chairperson may not participate in the residency graduation or the annual hospital ball. What does this say about the department? Do you think the hospital will look fondly upon the residency program when its leader is remiss? Probably not. In this case, the chairperson and department will be much less likely to receive the resources they need from the hospital. It’s a “give and take” relationship. So, the chair must step up and set an excellent example for the residency and hospital.

Residency Advisor

We, as program directors, often need to get a feel for how the faculty will respond to a change before implementation. And residencies constantly need to institute new requirements. But will the faculty buy-in so we can implement the new development? A strong chairperson who knows his department well can ensure you can fulfill your change. Moreover, she can guide what works and what doesn’t. Without serving this role as a residency advisor, a program director will encounter many more pitfalls during his tenure!

The Chair As Leader

In any medical department, a chairperson plays a critical role in running the specialty service and ensuring the residency moves along smoothly. So, when you decide to look into a residency department, observe the chair. Does he participate in the interview process? Can you get a feel for how he behaves toward the department? All these factors will affect you long after the interview day. A chair reflects the face and culture of the department!

 

 

 

 

 

 

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The Gestalt Versus Segmental Approach For Radiology Residents (Doximity Article)

gestalt

Ever watched an expert radiologist read a CT scan or an MRI? They gaze at a scan, digest the information in one fell swoop, and spit out impressive findings and differentials with the single Gestalt.

If the world’s greatest radiologists can do it this way, why can’t you?

Well, what if I was to tell you to avoid this expert radiologist’s approach? You might think I was crazy, even though it may be hazardous to your career! But this “Gestalt approach” is most likely the wrong one for you.

But why? Why does this Gestalt approach to films, used by expert radiologists, not work well for the neophyte radiologist? To answer this question, we will define Gestalt and explain why this approach can be dangerous for early radiologists. Then, instead, we will tackle why and how radiology residents should read films using the “segmental approach.”

Defining Gestalt

Let’s start by defining the principles of Gestalt. According to Wikipedia, these are “the idea that natural systems and their properties should be viewed as wholes, not as collections of parts.”

Radiologists use the Gestalt approach when they sense the findings and diagnosis without processing the individual steps. I like to think of the Gestalt approach like The Dog Whisperer, Cesar Milan. He can naturally sense the overall picture of a dog that others cannot. With this sixth sense, he can train dogs to do whatever he wants while mere mortals struggle to figure out exactly how to do what he does.

Why Avoid the Gestalt Approach When Starting?

Since you have not been practicing radiology for long, you will miss half the findings in the film. You don’t know what you don’t know. And, if you don’t look for a finding, you won’t mention it or find it. So, if you read a chest film and don’t know to look at the pulmonary arteries, you won’t find that case of pulmonary hypertension. The Gestalt approach does not allow for evaluating each of the individual sectors of the film to ensure you have looked at it.

How long have you been practicing radiology? At most, for residents, three or four years. Rarely is that enough time to build a network in your brain allowing you to look at a film rapidly once and then create a framework for arriving at a final impression of the study. You have not trained your eyes to search everything in the image in a short period. And, therefore, you will not catch everything.

Take it from me; the Gestalt approach is a fast way for a resident to look like a fool. When you review a case with another clinician, they will catch things you missed. What could be more embarrassing?

What Approach Should You Use?

Instead of the Gestalt approach, the beginner radiologist should utilize a segmental approach. What do I mean by that? The segmental system divides the film into individual parts. You then review the entire image until you have completed your search pattern. In essence, it is a glorified checklist.

In addition, the segmental approach can vary for each reader based on personal preference. For some, you may divide the chest film into quadrants. For others, on the chest film, you may look at the technique, the heart, the soft tissues, the bones, and the lungs. Whatever the pattern, it usually doesn’t matter except that you cover all bases. As a beginning radiologist, this approach will prevent you from missing critical findings. And you will look much more intelligent than the new radiologist that uses a Gestalt approach.

The Bottom Line About the Gestalt Versus Segmental Approach

The Gestalt approach does not work well for beginning radiologists unless they have a tremendous gift. Most learners cannot look at the whole to identify the abnormalities in each part. Instead, the new learner is more adept at looking at all the pieces to determine what went wrong with the whole. Therefore, until you have the experience to identify abnormalities with a glance rapidly, the Gestalt approach is a recipe for disaster.

So, create a great, all-inclusive search pattern to avoid missing individual findings. Who knows? Maybe someday you will become that great radiologist who uses that Gestalt approach!

 

 

 

Want to see the original Doximity version? Click on the following link!

Link to the Doximity Website Version

 

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What Might Happen With A Residency Merger?

residency merger

Throughout the country, businesses grow to keep costs down. One of the ways that they accomplish this task is by merging. And, if you think that residencies are any different, you would be wrong! Similar to many businesses, you may have noticed that residencies have grown bigger and bigger over the years. While it was once rare to hold ten residents per year per class 30 years ago, a radiology training program of that size is no longer unusual. So, what happens if you begin a radiology residency program and it merges during your four years? Will the residency approach you like a second-class citizen? Or, would you notice some fringe benefits from the process? We will treat these issues and more as we summarize the benefits and downsides of a residency merger!

Benefits Of A Residency Merger

More Residency Resources

First and foremost, you may notice that soon after a residency merger, you may be able to rotate through new departments. Or, you may have access to a simulation center that you did not have before. Furthermore, you may find new grants for residents to start research projects. And you may have at your fingertips a more extensive staff to choose from as your mentor or research partner. That doesn’t sound too bad.

Increased Prestige Of The Residency Merger

Before the merger, you might be in a small community program without “name recognition.” Now that you are part of a larger entity, you may find that hiring practices that want graduates from high-powered programs may be willing to look at your resume for your first job. There is more to a name than you might think!

Faculty With More Time To Teach

Sometimes, faculty at a hospital may no longer have the responsibilities to run their program as they did before. You may find that the staff can now dedicate more time to teaching and residency responsibilities.

Downsides Of A Residency Merger

Loss of Special Programs

As programs grow, they relook at areas in the budget that they can cut so that the senior administration can save some dollars. Perhaps, your residency may have had different outside rotations that you no longer “need” since the entity provides the same service. Or, you may have had a foreign travel program that the original institution sponsored. You know what they say in business: “Cut the fat!”

One Program Director For Many Sites

No longer, you can go to the same program director in charge of everything at your one site. Now, you have one program director for an entire system. What does that mean for you? The program director may have less time to focus on individual residents. Instead, they have multiple sites to “keep in line.” So, you may find that the director caters less toward you.

More Bureaucracy In The Residency Merger

On that same note, now that you have a more extensive system, you may find it more unwieldy for the Institutional Review Board (IRB) approval for research projects. Or, you may have more difficulty getting reimbursed by the system for expenses. With a larger institution, you exponentially multiply the “red tape.”

Increased Traveling Distances

Now that you have multiple sites within a more extensive system, you will likely need to travel to each location. If you live in the city, you may need to go to work via subway, train, or bus. You may need a new car if you live in the suburbs across from your original hospital. Unfortunately, you have a new budget item!

Some Disgruntled Attendings

At most hospitals, the faculty does not like change. Moving around resident call schedules and increasing the responsibilities of the staff can induce resentment among the mix. So they may be less willing to participate in the residency process. Or depending on how the system arranges coverage, attendings may have less time to teach. No change is perfect!

Less Intimacy

Remember that three-person class you had before when you learned each member’s quirks and foibles? Well, that is no longer the case. Now, you will have to contend with colleagues and attendings you will not get to know during your remaining years of residency. When your program touted a small program feel during your interview, they didn’t meet your expectations!

Dilution Of Resources

You remember what your teacher taught you in kindergarten- you need to learn to share! Perhaps, you had a fantastic faculty teacher on service. Or, your program had a one-of-a-kind pathology rotation within the institution. Now that you have a more significant residency, you may have less opportunity to use these resources because they need to be utilized by a larger body of residents.

Change And Residency Mergers

Change is hard. There is no way around it. And, when you enter a residency, some alterations from a merger are beyond your control. But, as you might initially think, a residency merger is usually not all bad or good. Instead, it will afford you some new opportunities and come with some additional palpable downsides. So, what is my advice? Make the most of a changing situation. Learn about the new lay of the land. You never know. Now that your program has included you in a more extensive system, you need to know it well. And make the most of its new opportunities even though they may have some downsides!

 

 

 

 

 

 

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Do Average RVUs Matter For Private Practice And Academic Radiologists?

average RVUs

Question About Average RVUs:

 

Do you know the average RVUs per shift for radiologists and the differential between private practice and academic radiologists?

 

Thank you,

Wondering About RVUs

 

_____________________________________________________-

Answer:

I have not found a specific breakdown of work RVUs per radiologist regarding academic versus private practice. I can shout out to my audience and see if anyone has this information. Has anyone found any valuable data about this? If so, please write something in the comments section!) However, to figure out the average RVU per shift, you can take the average RVU of 10020 in 2023 (from Lifetrack Medical Systems) and divide that by approximately 200 days per year. (around the average number of days worked per radiologist) That would give you around 50 RVUs per day shift.

However, the question may not matter concerning practicality and potential job search. I know of private practices where they have a “lifestyle” practice and complete very low RVUs. Likewise, I know of academic centers where the radiologists work like dogs and meet ungodly RVUs. So, using this information to determine whether to go into private practice versus academia would be a mistake. You need to approach this issue individually, not on a global academic versus private practice basis. On the other hand, if you are using the information for research purposes, it may have an alternative use.

Assuming that you are using RVU data to look for jobs using this criterion, I would look at the specific RVUs of a group and, even more importantly, remember to also look at your particular role in the academic or private practice. Some “academic” centers do very little research and expect some radiologists to do almost entirely clinical work. Likewise, other private groups have a partial academic bent and are less heavily RVU-oriented.

Good luck with your search!

Director1

 

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Radiology Residency Rank Lists: Are They More Than Just Entertainment?

rank lists

Like many, I enjoy browsing the U.S. News And World Report Medical School rank lists yearly to see which programs are top. (Usually in a line at the supermarket!) Even more so, I enjoy reading the Aunt Minnie and Doximity radiology residency rank lists each year. And I love reading and writing about them as much as the next guy. But, we need to be careful when we rank schools, residencies, and other educational institutions. So, why am I such a “Debbie Downer” when it comes to ranking residencies and educational institutions, and in our case, specifically radiology residency? (And no, it’s not related to my role as an associate residency director at a small radiology residency program). Well, as you guessed, I will give you my reasons for our topic for today!

One Size Does Not Fit All

When you rank multiple programs in one list, you cannot consider all the variables that would make one program great for a particular type of personality and terrible for another. Moreover, looking at the rankings, you will see categories like best teaching, research, and clinical experiences. Some folks learn best on the job, and others retain better in a lecture format. How do you rank that? Or, you want to become a great clinician and don’t take a research interest. Would a Mass General work well for you? It doesn’t do justice to the individual.

A Majority Of Residents Want To Work In Private Practice

Many of the rank lists assume that applicants want the same thing: a high-powered research and teaching program. But, 90% of all radiology residents go into private practice. So, the rank lists usually do not follow the end career results of its participants.

Development of Vicious/Virtuous Circle

Rank lists tend to have a pile-on effect. If a program is ranked highly, it sticks in all the readers’ minds. They will say to their colleagues, “Oh, XYZ school is great.” Likewise, if an article ranks a residency low on the list, that remains in the mind of its readers. I call it a “self-fulfilling proposition,” not based on the truth.

Emphasis On Larger Programs

The larger the program, the more graduates know about it. Therefore, the lists show bias toward bigger residencies just by the sheer numbers. So, if you have a program that contains 20 residents per year, these residents will tend to vote for their programs, right?

Each Site Within A Residency Program Can Be Different

Even within a program, experiences can vary widely. Sometimes, residents barely see each other and do not rotate through all the sites within a system. And one resident may spend more time at the V.A. hospital versus the academic center. So, what may be an excellent experience for one resident may not even resemble the reality for the remainder of the residents within the program.

Residency Experience Is So Dependent On Individual Colleagues/Faculty Members/Mentors

I always like to say the following: if you go to an OK residency program, but like the folks you work with, it will seem excellent. On the other hand, if you attend a program that by all the rankings is fantastic but hate working with all your colleagues, it will become terrible. So, how do you measure one person’s experience versus another when the program’s culture varies widely in any given year?

Do Residency Rank Lists Have Any Merit At All?

Based on these legitimate reasons, residency ranking tends to have very little relevance for the average radiology resident to choose his rank list. Instead, like the U.S. News Report Annual rankings of colleges, it primarily serves as a great way to grab the attention of its readers and create a bit of buzz. Therefore, it performs an essential purpose, but the goal is not necessarily to help out the audience that reads it. So, what is my conclusion based on the evidence? I’m not saying that you shouldn’t read a rank list of the best programs. Instead, take the results with a grain of salt and realize that a “top program” may not be top for you!

 

 

 

 

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How To Switch Gears From Orthopedic Surgery To Radiology As A Medical Student

orthopedic surgery

 

Question About Switching To Radiology From Orthopedic Surgery:

Hi Dr. Julius,

 

I’m a 3rd-yr med student with a growing interest in radiology. I’m in the middle of core clerkships and have come to appreciate how vital radiology is in all fields and how broadly it covers different parts of the body and aspects of medicine.

 My issue is that up till now, I have been pursuing orthopedic surgery, doing research, and making connections exclusively in that field. If I switch to seeking DR (maybe IR), what can I do to improve my ERAS application in the eyes of residency directors when I apply next year?

Background information (in case it helps): BS in engineering, currently at a top 25 med school, Step I – 233

 

 

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Answer:

 

Unfortunately, you can’t change what you’ve already done in orthopedic surgery. However, you still have time to get involved with research opportunities in radiology. Find a radiologist who needs some help with her research. At least, that shows some interest in the field. That is the low-hanging fruit that can help your application a little bit. It will also demonstrate some increased interest in the DR or DR/IR field. Even better, if you are interested in IR, I would find an interventionalist to work with and do research. That way, they could become your “mentor” and give your application even more relevance.

 

 

Suppose you have come from a good school with reasonable grades/Dean’s letter. In that case, you should have an excellent shot at a university program for DR. DR/IR is a little more of a crapshoot since it has become highly competitive. But you should still have a good chance as well. As I’ve mentioned, I highly recommend checking your Dean’s letter for any mistakes or “questionable” references. That is the most likely cause for a surprise for not matching where you want on match day. And it is also straightforward to correct if you can.

 

 

I hope that helps a bit,

 

Barry Julius, MD

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Are Residency-Wide Meetings A Waste Of Time?

meetings

In many radiology residencies, similar to some large private practices, not all residents work at the same site. Perhaps, rarely, if at all, do they remain in the same building simultaneously. Moreover, within the program, individual sites within the residency program may give different lectures to the residents rotating at that particular site. Or maybe, you will have varying experiences in your residency due to the limited spots and rotations. One resident may never even rotate through areas that others do. So, big deal, right? How important can it be to have meetings with all your colleagues in your radiology program? Well, I will convince you today that residency-wide meetings are essential. And we will go through the most critical reasons why!

Uneven Distribution Of Work

For instance, you may work at one location and experience a level I trauma center. At the same time, the colleague you started with spends most of his time in an oncology center. Your fellow resident becomes jealous that he is getting very little on-the-job training in trauma radiology. And, you think that you are not getting enough oncology work. How do you resolve this issue? You may not be able to change the schedule without reaching a consensus. Often, to do that, the only way to address this issue is to meet with your colleagues!

Or, since you are working at a pediatric center with inadequate coverage, you must work night call every 5th night. Meanwhile, your “friend” in the main hospital has plenty of coverage and can work call every two weeks. Now, you can discuss all this with your program director. However, you must lay out the issues first with your fellow residents and faculty at residency meetings so everyone can understand and fix the problem.

Miscommunication

Like the game of telephone, you will likely miss out on the opportunity to communicate on the same wavelength if you do not meet as a whole residency program. Perhaps, separate study groups form, and some residents are not privy to the same information. Or, one group learns a technique for fluoroscopy and never shares it with their colleagues. What happens? The whole residency loses out!

Less Sharing Of Resources Leading To Poor Outcomes

Perhaps, one site has a simulation center for interventional radiology procedures. And the others do not. If the residency does not meet as a whole, how do you know which resources to share? And what happens to those residents that never get a chance to perform procedures on the simulation devices? Well, they lose out on the opportunity to learn interventions. And that is just the tip of the iceberg. Not having regular meetings can lead to poor resident training outcomes!

Lack Of Interresidency Networking

Every person in the residency that you do not know reduces the chances that you will find a great job when you graduate. Why? Maybe, the uncle of one of your fellow residents is a radiologist at a hospital in Walla Walla, Washington. And that is the only place where you want to live. When you lose out on your contacts because you barely meet with colleagues at other sites, you lose another chance to get that next best career opportunity!

Importance Of Residency Meetings

Individual sites cannot remain entirely independent from one another to have a well-functioning residency. Accordingly, resident education will either suffer or, at least, not achieve the best possible outcomes for all its members. Not creating regular meetings for all the residents allows jealousy among residents to fester, uneven work distribution to continue, inadequate sharing of resources, and opportunities lost for resident networking. So, don’t poo-poo the resident meeting. They serve a crucial function!

 

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Blogs And Social Media: Worthwhile For Resident Education?

Today is a unique opportunity to see me live and in action on video. Recently, to help out with faculty development, I created a short video on the hospital website. So, I thought it might be of interest to the radsresident.com audience. In it, you will get see to see me justify this website’s existence! Enjoy my video called Blogs And Social Media: Worthwhile For Resident Education?