Year: 2018

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Do Video Games Make Better Radiologists?

video games

Let’s face it. For some of us, radiology and video games go together like other classic combinations such as peanut butter and jelly or bread and butter. In the radiology profession, these games have enticed many of us since we were young. And, I think it has something to do with our love for technology. Even I enjoy playing an occasional video game on the Nintendo console we bought for the kids. But do they serve a role for the radiologist in training? What are some of the evidence that they may help with brain function? Finally, do they enhance radiology practice in a radiologist’s career? In today’s piece, I will investigate some of these burning questions.

Video Games And Radiology Learning

So, what evidence can we use video games to learn radiology? Well, let’s look at two articles that I found. One of these articles explicitly gives an example of a specific video game dedicated to radiology learning. The other indirectly provides evidence that we can learn radiology with video games.

In one case, I found an article that showed a video about a game developed at a Spanish university meant to teach radiology to physicians called Medgame. (1) At least from the video, it seems to be an enticing and possible alternative way to learn the basics of radiology. For those who love playing, I imagine a video game like this would be a great way to learn new material and reinforce radiological concepts. (If only I had something like this when I was a resident!) Although I can’t say that I have played the game, I would be interested in getting feedback on it.

More indirectly supporting the average video game player, another article from 2013 in the Journal of Molecular Psychiatry shows that you can alter the structure of your brain by playing video games. They claim several sites of increased gray matter thickness in those that played Super Mario 64. Moreover, they also espouse the potential for the increased gray matter to help with PTSD, Alzheimer’s disease, and schizophrenia. (2) In my mind, the increased gray matter should translate to increased neural complexity and networks, likely related to increased learning.

Video Games And Brain Function

More than just learning, some evidence supports increased brain function in video game users. In one article, I found some interesting information about how video games improve brain function in patients with multiple sclerosis. It describes increased thalamic connectivity in patients that played a particular video game. (3) Another study also showed that manual dexterity improved in more heavy video game users than young adults who did not play and those who played less often. Both of these articles provide some supportive evidence of the power of video games to enhance brain function.

Video Games Improving The Field Of Radiology

And then other articles have shown that technologies created for video games also have been found helpful in radiological applications. Thereby, these applications also have significantly improved patient care. One of these motion sensor technologies from an Xbox specifically reduces radiation dosages in X-rays by assessing motion and thickness. (4) Even back in 2008, Microsoft programmers created 3D technologies for video games that subsequently applied to radiology. (6)

These video game technologies are merely the tip of the iceberg. With so much recent virtual reality development for video game users and the great graphics technologies on current games, I believe the applications will become much more numerous. We will see many other applications from video games that improve patient care.

Are There Any Negatives For Radiologists?

With any discussion of video games, we also have to discuss the downside. I don’t know about you. But, when I get into playing an addictive one, it can interfere with other “life activities.” You want to know what will happen next and can easily sit down for hours at a time, passing the time without realizing you have been playing for so long. So, the individual radiologist video gamer must carefully monitor their gameplay usage. However, this situation may not be so bad if the game provides a significant radiological education benefit.

And then, we also need to confirm that video games created to enhance radiology performance do just that. Sometimes at the beginning, creators of products will tout the benefits of technology without evidence to support whether or not it helps. So, we need to justify that these video games truly enhance performance with an evidence base before making claims that the technology improves radiology and healthcare.

Video Games And The Radiologist

In this whirlwind tour through the world of video games and the potential applications to radiology, I believe the preponderance of evidence supports that they will enhance our lives as radiologists. Some of the takeaways include that they can enhance education, may improve brain function, and will continue to improve radiology practice for years to come. These benefits come with limited downsides that I think we can overcome. Nevertheless, the application of video games to radiology is far-reaching. We only need a bit of imagination and the willingness to adapt to new technologies for the betterment of our field.

 

(1) https://healthmanagement.org/c/imaging/news/mir-2015-learning-radiology-through-computer-games

(2) http://www.nature.com/articles/mp2013120

(3) https://press.rsna.org/timssnet/media/pressReleases/14_pr_target.cfm?ID=1879

(4) https://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=118512

(6) http://www.digitaljournal.com/article/258548

 

 

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Why Radiology Is Better Than Law!

law

For many of you training to become a radiologist (or any physician for that matter), by this point, you may be a bit cranky and tired. When this happens, I often hear residents question their original intentions and ask, “Should I have gone to law school instead?” Typically they follow this question with, “I would have finished my residency and would be rolling in the dough by now if I was an attorney…” But in the website’s style, I will immediately debunk those painful thoughts! So let’s start going through why law school is no replacement for becoming a radiologist!

Attorneys Have Loans, But Are Less Likely To Pay Them Back!

If you think you are alone in your debt, think again. Lawyers also have three years of law school loans that they must pay back. OK… It’s not four years. But, the prospects of having them paid back are more tenuous than yours. Did you know that the median attorney earns 118,160 dollars? (1) You may not be the median lawyer, you may say. Let’s say you are above average. An attorney at the 75th percentile makes 175,580 dollars. More rarely do attorneys bring the astronomical salaries that we hear about as partners in a firm on Wall Street for long periods.

And what is the salary for a radiologist? Hmm… Well, it depends on the survey. But, if you look at the AuntMinnie website, they say that the median compensation is 503,225 dollars. (2) If you don’t like that survey, let’s try another showing a lower average salary. How about Medscape from 2017? (3) We are talking about an average of 396000 dollars. Either way, you split hairs. As a radiologist, you will more likely be making more! And more importantly, even though you may owe a bit more, you are more likely to pay those loans back!!!

Attorneys Have Long Hours Too!

If you think you work many more hours than an equivalent attorney, think again!!! Sure, attorneys spend more time at lunch to make that next deal or to increase connections. However, most hardworking attorneys work until late at night, especially if they want to become a partner in a practice. My former Wall Street attorney friends frequently worked until after 8 pm or even as late as 10 or 11 pm! So, I don’t want to hear that whining!

Attorneys’ Work Is Not As Interesting As Ours

OK… This statement is a bit opinionated. But, in my situation, it is very accurate. I certainly would much prefer to read films or perform procedures than splitting hairs over the definition of a word in court. The prospect of researching cases doesn’t do it for me. And, probably not for you if you have chosen to join the field of radiology!

Radiologists Have More Vacation, Ha!!!

Radiologists are blessed with more vacation time within the field of medicine than most other specialties. On the other hand, I can guarantee that few attorneys have eight or ten weeks off per year. I know we work hard when we are on. But it is sure nice to have those extra weeks of vacation, whether at home or away in Bora Bora!

Radiologist Contributions To Society

I’m not particularly eager to make overarching statements. However, I think this one is mostly true. Most radiologists make essential contributions to society by increasing overall health and well-being. Not to say that attorneys do not contribute to our communities, but I believe a more significant percentage of attorneys make less of a difference to humanity. I’m not sure how much ambulance chasers help the average human being! And many other attorneys serve even less noble purposes. On the other hand, hospitals would falter without the average radiologist working their shifts, and patients would have severe health issues!

Law School Vs. Radiology Training: A New Perspective

If those reasons are not enough to convince you about the benefits of radiology training over law school, maybe you should become an attorney! The grass is always greener on the other side in the throes of residency. But, I have news for you; take a look around. Training to become an attorney is not all that flashy. You are lucky right where you are!!!

 

(1) https://money.usnews.com/careers/best-jobs/lawyer/salary

(2) https://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=117841

(3) https://www.medscape.com/slideshow/compensation-2017-overview-6008547#4

 

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How To Present A Great Case Conference

case conference

During residency, you must choose a case to present to your colleagues or faculty in a formal setting. Many of you will be flying by the seat of your pants without instruction on how to do so. So, how do you select which case from the past week, month, or year? What features make up an excellent case for discussion at a case conference? And what exactly should you discuss during the presentation? These questions and more I will answer as we discuss how to present a great case conference.

Which Case Should I Choose?

On any given day, you will encounter multiple cases that have the potential to become excellent cases for a conference. Some studies may have confounded you or your faculty. Other times, your attending may love a case for some reason. Then, your attending may want a classic case of a particular disease entity. In these situations, how do you pick among all the possibilities?

Typically, I look for cases on a particular theme I want to address. Even better, the study may have addressed several points that created interesting discussions or controversies. Then, I check to see if the case runs through multiple imaging modalities. What do I mean by that? The best cases show a particular diagnosis in many different ways. For instance, say you are interested in showing lung cancers at this specific time. So, a perfect case would be a lung nodule on plain film that the hilum may partially hide. Then in the same study, you have a CT scan showing the mass abutting the hilum with subtle adenopathy within the mediastinum. And perhaps you also have a PET-CT scan demonstrating additional hypermetabolic nodes present on the scan and a hidden osseous hypermetabolic lesion in a vertebral body. Cases that show a finding or related findings in multiple modalities reinforce the subject matter well.

How To Prepare For The Discussion

So, you’ve found this extraordinary case. First, make sure that you can describe the findings appropriately. If you have less experience, you may want to run it by a faculty member or senior resident to confirm that you are conveying the description correctly.

Next, like any good physician, you should read on the topics extensively. In the case I described above, you need to read about lung cancer diagnosis, staging, and treatment basics. Additionally, you should learn how the radiological diagnosis affects the management of the patient. For instance, how does the presence of hypermetabolic nodes and a vertebral body lesion affect the outcome of the patient? Ultimately, you want the listeners to perceive you as the expert on this topic for the presentation.

Moreover, you want to be able to answer almost any question thrown at you. In other words, go to town! By reviewing the topic extensively, in essence, you are not only going to improve the discussion and your ability to answer questions, but also you are studying for the boards at the same time.

What Should You Discuss At The Case Conference?

The lung nodule example above lends itself well to discussing the findings on each of the modalities, the differential diagnosis, the final diagnoses, and the pathophysiology behind the final diagnoses. Furthermore, the topic will lead to basic management principles like how vertebral lesions change treatment.

I would first review the findings similar to the standard logical approach of taking cases. And then, I would discuss the differential diagnosis and the management in that order, just as if you were taking a case during a faculty presentation. If you want to make the case conference a bit more spicy and controversial, you can discuss whether the case met the ACR appropriateness criteria for the symptoms given. Usually, you will get multiple opinions from different attendings if the ordering physician approaches the workup correctly. It would help if you strived to guide the discussion to ensure it follows an appropriate path. With a case like this, the debate can ensue for a while!

Case Conference As A Tool For Learning

You primarily need to remember the end goal whenever you create a conference. In a typical case conference setting, the presenter should want the audience to learn a few essential points by the end of the discussion. Too much information will overload the learner. Likewise, too little information may not reinforce the concepts. So, try to strike a balance after discussing the specific case.

In the end, you should view case conferences as a tool for learning, not as a burden. They are opportunities to learn a topic in great detail and the art of presenting. Moreover, each presentation you perform builds upon the knowledge that you have. I still remember the case conferences I created when I was a resident. Just like I did, if you prepared appropriately, you will use the strategies and information you learned from your case conferences when you become a faculty member yourself many years from now!

 

 

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Vacation During Residency: Not Just A Luxury!

vacation

Have you ever worked in a typical business office setting (like the world of Dilbert(1)!)? Typically, you will see young professionals, some working but others wasting time. They make time to text, check out the internet, meet at the water cooler, or make sure to make time to go out to lunch together. If they forget something or make a mistake, perhaps an order gets delayed. No big deal…

Fortunately or unfortunately (depending on your perspective!), these experiences are foreign to radiology trainees and radiologists. We tend not to have much time for inconsequential social activities in our world. Most days, we spend reading films or performing procedures with real consequences. If we miss a pneumothorax, a patient can die. If we embolize the wrong artery, we can cause a stroke. So, we relegate ourselves to taking everything seriously. And rightfully so. But, all this takes a toll over time.

Have you ever heard the phrase: all work and no play makes Jack a dull boy? (According to Wikipedia(2), it comes from 1659!) Well, this phrase applies just as much to the radiology resident. In fact, with all this talk of burnout, each resident should follow this ancient bit of wisdom. Every person (even radiology residents!) needs some time to play. So, all this banter brings me to today’s blog topic: why vacation should be mandatory for every radiology resident.

Gaining New Perspectives

Often, residents get so caught up in worrying about studying, reading, and taking tests that they forget to appreciate the other important facets of life. Sometimes, you need to step back from the daily grind and spend time with friends/family, by yourself, or accomplish something different. Whether you take a trip to an exotic locale or stay in the comfort of your own home and get some more sleep, a vacation gives you that extra time to accomplish different activities from the usual. What better way to gain a more positive perspective on your work and life?

Improving Concentration And Energy

I don’t know about you. But, after a week or two off, when I return to work, I usually return with renewed vigor. It’s a wonder what an extra little bit of sleep or change of pace can do. And I am not the only one who says so. Study after study (2) has shown that vacation improves productivity when you return. So, don’t feel guilty you are not learning enough. Take that vacation and enjoy!

Remembering What’s Most Important

Yes, the radiology work and studying we do is critical. However, as the old bit of wisdom goes, what do people remember the most at the end of life? It’s not that they wished they could spend an extra day completing an assignment at work. Instead, it tends to be the time that you spent away with your loved ones or friends or the good times you had on vacation. So, don’t fret and take that little extra time off!

Incorporating Different Ideas To Improve Residency Experience

Finally, when you vacation, you see new places, complete projects, or think about life differently. The best ideas often come when you are not at your primary work home. (For me, that’s at 2 AM when I write these articles!) Maybe, you scuba dived in Bora Bora, completed an archeological dig, took the time to finish that extra gardening, or spent more time perusing in bed. Often, you can incorporate these “extraneous” activities into improving the residency experience for yourself when you return.

Vacation And The Radiology Resident

Vacation is not a luxury. Instead, residents especially need to consider vacation as a requirement to recharge and unwind. So, fly far away or stay home. It doesn’t matter. Just take that vacation, and your work life will improve when you return. Let others worry about work when you are on away!

(1) www.dilbert.com

(2) https://en.wikipedia.org/wiki/All_work_and_no_play_makes_Jack_a_dull_boy

 

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The Real Reasons Partnership Track Salary Offers Are Lower (And The Risks You Take!)

salary offers

Now that you are beginning to search for employment opportunities or have plans to start in a few years, you may hear a bit about the employee and partnership track salary for radiologists. Also, you probably have learned that new radiologists on the partnership track earn significantly less. Since you were hoping to become a partner in a practice, are you getting sticker shock about the lower partnership track salary offers? And, why do stark salary differences exist between a partnership track position and an employee anyway? Moreover, what are the pros and cons of taking on this lower starting salary? To answer these questions, we will examine the most critical reasons why starting salary offers differ dramatically. Then we will discuss the risks you take when starting with this lower partnership track salary.

Why The Differences In Salary Offers?

Increased Partnership Income

After all these years, you’ve probably heard the adage: you never get something for nothing. In this case, this aphorism holds. Those who take on a lower starting salary get more significant rewards in the end. When you start on a partnership track, you sacrifice your current income for future increased income. So, that makes a bit of sense.

Buy-ins And Buy-outs

When you start as a partner in private practice, it’s only fair to put some of your money toward buying a share of the practice’s assets. These assets may be accounts receivable, buildings, equipment, and more. No one is going to give that away. So, here is where the buy-in comes to play. Usually, practices will deduct some of this amount from your initial salary during your partnership track to pay for it. We know this amount as “sweat equity,” or the work/money you must put into the imaging business to share in ownership.

Bigger Benefits

Hey buddy, it’s not just about the salary. The fringe benefits of partnership often make a more considerable difference in your lifestyle. In the case of many partnerships, partners get larger pensions, increased malpractice insurance, more extensive life and disability insurance policies, tax-free car write-offs, cell phone and internet usage deductions, and more. These perks can add up over time. So, practices tend to compensate for these more considerable benefits by issuing a lower salary on a partnership track.

Increased Control

Nowadays, it is next to impossible to control almost anything fully in healthcare. However, entering into a partnership allows you to manage your destiny more than working as an employee for a practice. No doubt, the increased control you will eventually obtain from completing a partnership track factors into those first few years of partnership.

What Are You Risking For All Of This?

The Chance You Will Never Make Partner

You take a leap of faith when you begin on a partnership track. Rightfully so, you assume that you will be able to meet the requirements of the practice and eventually become an equal shareholder. But what happens if this is not the case? Well, that can be undoubtedly devastating. You will lose out on years of potentially higher income that you would have made elsewhere. So, you are looking at potentially significant risk when starting a partnership track.

Company Buyout

More commonly than ever, large corporate conglomerates and massive practices buy out smaller “Mom and Pop” firms or even mid-size practices. Let’s say you happen to be on a partnership track at the time of one of these buyouts. In this case, you will have no guarantee that the new owners will add you to the partnership track, issue you any significant benefits, or even compensate you appropriately when the buyout ensues. All your hard work and lower initial starting salary proverbially can be down the drain.

Partnership Will Not Be The Same

You go onto different forums (check out Aunt Minnie!), and you will find many threads on this topic. Let’s say everything goes great, and you eventually become a partner in a practice. Who is to say that the results will pan out? Sometimes, but not often, private partnership salaries can be lower than the salaries that their employees enjoy. Especially for practices that are not well run. Or, maybe, reimbursements for procedures will take a nosedive when you are working on a partnership track. Who knows if the benefits will remain 5 or 10 years down the road?

My Bottom Line

You probably understand why practices issue lower salary offers to employees on the partnership track than their employed colleagues at this point. You are receiving the potential for real future benefits. 

At the same time, however, working on a partnership track involves taking significant risks. What you choose in the end will probably pan out. But, it certainly does not always work out. Therefore, before starting any job, you must do your due diligence and determine if a partnership track or employed position works well for you. Good luck with your search!

 

 

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Artificial Intelligence And Radiology Voice Recognition Technology: What Can We Expect?

Do you get this irony? We hear so much lately about artificial intelligence and how it can potentially affect radiology. But, for all this talk about the application of artificial intelligence, I have heard barely a squeak on anything tangible about applying artificial intelligence to real-world voice recognition technology. Why do I find this so strange? Startup companies espouse artificial intelligence for so many applications, some with questionable benefit. Yet, sitting right in front of everyone’s face is the most obvious work efficiency improvement, the application of artificial intelligence to enhance voice recognition. It is an area that desperately needs attention!

To me, it makes no sense that companies do not pursue this avenue. Unlike other health applications, applying artificial intelligence to voice recognition technology will unlikely result in lawsuits or untoward health effects (unless the AI switches rights with lefts or unwittingly adds a lot of nos to our dictations!) And, voice recognition is exactly the type of technology that fits the paradigm of why developers construct artificial intelligence. Everyone’s voice is different and we all choose different words to express ourselves. So, a technology like artificial intelligence that learns the subtleties of each of our voices and vocabulary should really make a difference in daily work life. So, why don’t we hear about breakthroughs on the voice recognition front? Let’s take a look at what’s out there already…

My Internet Literature Search

Since so much potential exists for the intersection of AI and voice recognition, I started a simple internet search on this topic. And, guess what? This is the first article I found. Microsoft announced a milestone. The company’s most accurate artificial intelligence enhanced software reached an error rate for transcription of conversational speech measuring 5.1%. (1)

Next, I found another article from Inc. that talks about the world’s most accurate voice recognition technologies. The top three are as follows: Baidu, Hound, and Siri. For those of you that do not know these enterprises well, I will briefly discuss each of them.

First of all, Baidu… Baidu is a Chinese company similar to Google but made for China. Why is this needed the most? Well, think about typing in Mandarin and how long it takes to type. In Mandarin, it is much shorter to speak than to write. So, that makes sense. Second, Hound… Honestly, I had never heard of this enterprise prior to writing this article. Apparently, it was a first comer in the voice recognition personal assistant realm and is a fairly accurate digital assistant. And lastly, of course, is Siri by Apple… To say the least from my experience, if this technology is considered to the be one of the world’s most accurate, artificial intelligence voice recognition does not even come close to where it should be. I can’t tell you how many times Siri interprets my language incorrectly! (2)

What’s In Store For Radiology Voice Recognition?

Now, call me crazy… But, none of these technologies sound so great to me. If a speech recognition system gets approximately 1 out of every 20 words wrong as in each of these technologies, that could be a recipe for disaster in the world of radiology reporting. And, this is the best that artificial intelligence offers for voice recognition?

In addition to these “seminal” articles, I did find an interesting merger between the ACR and Nuance Communications to set up a collaborative effort to improve radiology reporting. (3) But, nothing tangible has yet been created to significantly improve voice recognition technology. It’s all in the initial phase. This leads me to believe there is a long way to go.

Final Thoughts

Sorry to break the news but… I don’t see any significant improvement in the quality of our radiology dictation software technology for a long time. So, until artificial intelligence software developers take voice recognition technology seriously and apply their talents to this area, change will not be around the corner. Therefore, continue to check your work many times over and dictate cautiously!

(1) https://techcrunch.com/2017/08/20/microsofts-speech-recognition-system-hits-a-new-accuracy-milestone/

(2) https://www.inc.com/kevin-j-ryan/internet-trends-7-most-accurate-word-recognition-platforms.html

(3) https://www.nuance.com/about-us/newsroom/press-releases/philips-and-nuance-bring-ai-into-radiology-reporting.html

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Creating Great Radiology Teaching Conferences: Think Like A Soloist In A Jazz Ensemble

conferences

Have you ever listened to a great jazz ensemble live? When each soloist takes his turn, he plays in tune with the melody’s key. Also, he stays with the main elements of the general theme. If the soloist deviates from the key and doesn’t maintain some semblance of the original tune, the solo sounds bizarre and out of place. Even though he must play within a particular framework, a soloist also plays a unique melody, creating something new and innovative as he goes along. Sound interesting… But what does this have to do with radiology conferences? Well, let’s get to that next.

What makes a great teaching conference? Great conferences need some general theme, similar to the melody’s key. Maybe, the conference will address adrenal masses. But, if you talk about adrenal lesions and then, on a whim, deviate by discussing brain tumors, the conference will not reinforce essential concepts about the adrenal mass. And, the trainees will not remember the important points.

At the same time, residents or faculty that give great conferences also add some unique flavor that allows the participants to make the experience memorable, just like the unique melody. Perhaps, it is an unconventional thought process or a funny joke that reinforces a concept. Maybe, the direction that the audience moves with unforeseen swerves takes them to new places. The bottom line is that teaching conferences also need spontaneity.

So, let us discuss a few simple principles about how you, too, can create a conference that maintains your audience’s attention. Based on the same principles as a jazz ensemble, we will divide the remainder of the discussion about creating great talks into two parts: how to create a theme and then learn the art of spontaneity.

Creating A General Theme

As we discussed above, the key to aiding retention is to make an overarching theme. So, how do we decide on that? There are many ways to do this. One way, take a specific organ and then divide that subject into individual topics. For example, if you are talking about adrenal masses, introduce each adrenal tumor type and find individual cases to demonstrate the appearance and pathophysiology of each adrenal lesion.

Or, you can find a pathophysiological mechanism and present cases that conform to that diagnosis. In this situation, we can take masses that cause mechanical renal obstruction. Whether you take a general subject area or pathophysiological mechanism, ensure all the cases tie into the theme. This way, you will reinforce the retention of your audience.

Learning The Techniques Of Conference Spontaneity

Just as important as creating a great theme for a lecture topic, residents and faculty all need to learn how to be spontaneous to maintain our audience’s interest. But most of us never learn the art of spontaneity at a conference. So, how can we take our talk to the next level and become more than a droning speaker?

First of all, don’t use PowerPoint as a crutch. Slides are guideposts for an idea, not a source of exactly what to say. I can guarantee that if you read your slides word for word, most of your audience will drift away. (especially residents who had a long call the night before!) Instead, talk about the general ideas behind why you created the slide as if you were conversing with a friend.

Second, let your audience actively participate in the conference. What do I mean by that? Perhaps, you want to have the audience answer multiple-choice questions. Or, have the listeners take cases under your direction. Either way, you will not allow your audience to nod off and feel like they are only passively observing.

Finally, I recommend adding relevant analogies, jokes, or stories to enliven the conference. When you think about some of the best talks, something in the lecture clicked with you to make you remember a concept or theme. Usually, one of these techniques would have helped you to retain the new knowledge.

Creating Great Conferences

Unfortunately, quality varies widely among residents and faculty when giving conferences. Often, it is not the fault of the individual that gives the lecture. Instead, faculty and residents have never learned the basic tenets of providing a great conference. So instead, think like a jazz ensemble and use the basic principles of creating a general theme and utilizing my techniques to become more spontaneous. With these tenets, you will give conferences extra spice to keep the audience engaged and increase retention of the information you present.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Should I Continue With My Fellowship After Years In Private Practice?

years in private practice

Question About Fellowship After Years In Private Practice:

I am an experienced radiologist and decided to join a fellowship after 12 years in private practice. Some people thought I was mad, and some thought I was going through a midlife crisis. I was sick of private practice work and wanted to do something new as I felt I was getting deskilled. So, I joined a fellowship in a tertiary hospital. Two weeks into the fellowship, I think I have become a bit slower and a little out of depth. I expected this change, and I thought it would take a few weeks for me to get up to speed. But now I feel I am very unwelcome because I am an outsider and there is a lot of politics.

I don’t know why I am writing to you, but I thought you might have seen a case like me and could provide some insight into my situation.

A Political Outsider

Response:

Dear Political Outsider,

I admire your tenacity to go back to fellowship. Sacrificing your current life for educating yourself after years in private practice to do something more speaks volumes about your determination and work ethic. Our most incredible residents are ones that have had prior experience. We have had one or two who completed former residencies in their own country before coming to our program.

Unfortunately, it sounds like you have entered a fellowship where education may sometimes take second priority to the whims of the folks who run the program. You have to decide if it is worth it to overlook the politics of your situation to receive the education that you wanted to get initially, Or do the politics of the place prevent you from accomplishing the goals that you had intended to get from the fellowship in the first place? It is often worthwhile to tough it out to get your education. A fellowship is for a relatively short period compared to years in private practice. So, if you can take the pain, it may be worth it. Especially if the tools you are learning will be essential to your future radiology practice.

Regards,

Barry Julius, MD

Question:

Hi Barry

Thank you so much for your feedback. Currently, I am doing the fellowship on my academic drive. It would have been nice if the department’s environment would have been additive.

I had joined the fellowship to gain more training. It appears all scans are done by consultants on weekends as they get paid extra by the department. So they have a vested interest in not letting us fellows report them.

The other day, I was in a meeting, and two radiology consultants mauled me in front of 30 doctors. They kept unsettling me while I was presenting and tried to humiliate me. I still have no clue what was their vested interest.

I want to thank you again for your encouragement.

Regards,

A Political Outsider

Response:

Dear Political Outsider,

Usually, those attendings/radiologists who exhibit bad behavior during a meeting do not reflect your competency. Instead, it measures the insecurity or mean-spiritedness of those who commit the inappropriate behavior. If these radiologists had an issue with you during the meeting, they should have taken you aside and spoken to you privately. Unfortunately, sometimes, in fellowship, you must keep a thick skin and try not to let these episodes derail your excellent work.

Good luck,

Barry Julius, MD

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When To Say No At Nighttime (A Resident Guide)

no at nighttime

Radiology residents can expect disagreement with a nurse, fellow resident, or attending on any given night. Due to lack of sleep, tempers flare, and we magnify minor problems into large ones. Ultimately, we mostly accommodate our colleagues and perform the study they request as we should! Sometimes, however, saying no at nighttime can be one of the most important yet challenging responsibilities of a radiologist on call that we need to learn. We don’t want to offend our colleagues’ sensibilities or upset the attendings of other clinical services. And we want to ensure that we complete studies promptly to increase ER turnover. Yet, there is a time in all radiologists’ careers when the right thing to do is say no.

But, at what point should you say no, I won’t comply with your request? Let’s explore this issue of when to say no at nighttime. We will discuss some of the most common circumstances for the radiologist to refuse a request appropriately. For each case, we will discuss how you should proceed instead.

Studies That Would Cause Undue Patient Risks

Out of all the reasons to refuse a study, most importantly, we must ensure that we comply with the Hippocratic oath, “First do no harm.” This oath is priority number one. For all of us, a time will come when a resident or attending will ask us to perform a study or procedure that can potentially harm the patient. It could be an unnecessary CT scan on a pregnant woman or a biopsy on a patient with an elevated INR. As a physician, we need to prevent these procedures from getting completed. It is our first and foremost responsibility.

So, how do we stop a study when attendings or residents apply crushing pressure to perform the exam? First, we need to elaborate on the data behind why such a study would harm the patient. And then, most importantly, we need to do it in a way that does not demean or upset the physician. This technique is where the art and science of medicine meet in the middle.

Procedures That Would Jeopardize Your Safety

Not only do we have a responsibility to our patients. But also, we have a responsibility to maintain our safety. To take care of others, one must take care of oneself. So, to put yourself in significant danger, simply put, clearly does not meet the sniff test of practicing good medicine. The test could involve putting yourself in harm’s way with a combative patient or exposing yourself to undue radiation. Make sure to think about your situation first before going ahead.

How do you decide if the procedure would affect your safety for you to say no at nighttime? Always think about the potential consequences of a worst-case scenario. If you can think of a situation when you can get seriously injured from a study, it is probably not the best idea to complete the procedure.

Interpretations Or Procedures That Need An Attending

Sometimes we should not complete a test or procedure unless an attending can be present. You may be able to perform the exam adeptly. But, it is not in your best interest to complete the study for legal or ethical reasons.

How do you judge if the study may not qualify as a resident’s domain? If the procedure can result in significant harm unless performed by the appropriate personnel or a protocol establishes that a resident should not complete the study, hold off and call your attending. Let’s give you an example, such as a brain death study. Although easily interpreted by a resident many times, the consequences of “missing” can result in severe harm. Additionally, many programs have protocols for attendings to read this examination.

Inadequate Resources

This one may seem pretty obvious. However, we should not promise to complete a test if we don’t have the capability of finishing it. Often, residents unknowingly will offer a solution to a problem that may not exist in your institution. Or the institution cannot obtain the resources on the night of your call. For instance, you may promise the clinician that you can perform a V/Q scan, not realizing that the agents are in short supply. Unfortunately, this disrupts management, the timing of testing, and the formation of a patient’s final disposition. So, always make sure to check that you can complete a test before you allow the order. And, make sure to let the ordering doc know!

Nondiagnostic Studies

Occasionally, you find an adamant clinician or resident who demands the immediate performance of a test that will not assist in making a diagnosis. In a huff, these folks can propel you down the wrong road. In this situation, it pays to push back a bit. How? Data is your friend. Perhaps, the clinician insists they need a bleeding scan when the patient has a very slow bleed. Calmly, you need to explain why the test would not change the patient’s situation or add any additional significant information. Usually, the ordering physician will comply.

Things That Take Up Too Much of Your Time At the Expense of Patient Care

Often, students, residents, or even faculty will ask for assistance on all sorts of studies they may need help interpreting. However, your time can be minimal. A typical example: A resident asks for a reinterpretation of a cancer workup performed six months ago. Now, it may be essential to perform at some point. But, if you have 20 trauma cases that you still have not read, is it the correct decision to look at this sort of study? Probably not. So, politely tell the resident your situation. Trust me. This physician will go away and let you interpret your STAT cases.

Repeating Similar Previous Studies Without Good Reason

Finally, it is not uncommon to find orders for a repeat CT scan or fluoroscopic study after someone has recently performed it. Clinicians sometimes make errors in unknowingly repeating studies. I can’t tell you how many times this has happened. As radiologists, we are responsible for checking and finding out if these studies are indeed warranted. Again, you must calmly and politely let the ordering clinician know if this is the case.

Final Thoughts About Saying No At Nighttime

Saying no can take real guts when you are not the “authority.” But, when to say no at nighttime needs to be learned by all residents. It can be an art as well as a science. And the lessons stay with you for the rest of your career. So, if the situation arises that you need to say no at nighttime and it can affect patient care, respond gently and with the data to prove your point. The rewards of saying no can be immense.

 

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Top 10 Radiology Anachronisms Today From 1999

radiology anachronisms

Since I started my radiology residency in 1999 (only 23 years ago!), a whirlwind of changes has morphed the field of radiology into something very different from when I first started. It’s amazing how new modalities, technologies, and techniques creep up on us, gradually replacing the old ways. That got me thinking… Since everyone loves lists, what are the top 10 radiology anachronisms from 1999 that would be out of place today? Don’t worry… I’m not going back to the 1950s when pneumoencephalography reigned king because that was not my time. (And most of yours as well!) Instead, let’s start with some of the significant changes for general radiologists from the more recent past (Hopefully after you were born!). I think you might find this enlightening. Enjoy!

Analog Films/Film Panels

When I first started, I hit upon the end of the physical film era. Fortunately, I was one of the last classes to experience the dusk of its usage. Soon after, I graduated residency and never looked back in the world of film. Boy, did that change how we practice radiology!

Pulmonary Arteriograms and Trauma Aortograms

I will lump these two studies into one category because they are invasive diagnostic studies. For those of you that remember, the experts considered pulmonary angiograms for years to be the “gold standard.” Now, we only use chest CTAs. Wow, did that change in a huff with the newer CT technology! And, what about the trauma aortogram? Do you remember getting woken up at 3 AM to rule out aortic rupture? I certainly do!

Misplaced Imaging Studies

For those of you who experienced the film era, you will remember orthopedics taking a good percentage of studies down for surgery, never crossing the path of the radiologist’s eyes. How often does that happen now? Very rarely do films get lost on PACS!

Double Contrast Barium Enemas

In New Jersey, finding the equipment you need to complete a double contrast barium enema is almost impossible. And many residents have never even seen one performed. Incredible isn’t it?! Almost everyone seems to get a colonoscopy or virtual colonoscopy instead. It’s ironic because double-contrast barium enemas played an essential role in cancer screening. No longer!

Written Prelims

Most newer radiologists and residents can’t even picture writing a prelim, let alone writing anything down. That is just how we used to operate in 1999 as residents. We would hang the CT scan boards and then write our impressions on paper in a binder. How passé?

Clinicians in the Radiology Department

I remember when the radiology department bustled with activity from the surgeons and oncologists. Rarely does that happen anymore? Sure, you still get that occasional straggler that enters the room. But, that is more the exception rather than the rule. Too bad, huh?

PET Scanners Without CT

When I started, the debate about whether PET-CT would provide a significant added benefit over a standard PET scanner raged. Well, that debate ended rather quickly! I don’t think I’ve seen a traditional PET scanner around for a while!

Transcriptionists And Cassette Recorders

It’s next to impossible to forget about the changes in dictation technologies over the past 19 years. Granted, I don’t think that the technologies have gone far enough. However, a lot has still changed. I haven’t spoken to a transcriptionist or dictated into a cassette recorder for eons!

IVPs and Ionized Iodinated Contrast

Who can remember having to inject your patients for IVP with iodinated ionized contrast, no less? I do! The pain from an infiltrated dosage was immense. And, I can remember a lot more untoward allergic reactions. Well, fortunately, this is no more!

Absent Hospital CT Techs After Hours

Absent CT techs certainly would not fly at most hospitals anymore. Hospitals expect CT scanners to run at all hours, no matter the case’s urgency. I almost can’t imagine a hospital without 24-hour CT coverage. It makes me miss the old days!

Final Thoughts on Radiology Anachronisms Today From 1999

These radiology anachronisms are probably just the tip of the iceberg. And, I am sure you have your ideas about what would be an anachronism today from 1999. So much has changed! I would love to hear from you to find out what you think are some of the top radiology anachronisms. If you have a good one, please comment below!