Month: March 2019

Posted on by

What Radiology And IR/DR Programs Don’t Tell Applicants About Interventional Radiology!

IR/DR Programs

After all of the hype about the new IR/DR programs, I am not surprised that it has become so attractive for medical students. However, most applicants don’t realize what happens to the typical resident’s desire for interventional radiology after they begin their residency. Of course, these programs don’t tell them that! It’s bad for business. So, I will give you the lowdown.

On the interview trail, at least since when I became a program director, and before the new IR/DR programs existed, a large percentage of medical students have always claimed interventional radiology was their top choice for fellowship. But, as soon as they would arrive at the program, some of these former desires became a wist of memory. And, the other rarified few would make it to their first, second, or third year and then suddenly drop off of the IR bandwagon. Very few who initially wanted interventional would make it to the end of the residency. Why did that happen? Well, I have some theories.

Constant Consents/Too Much Patient Contact

One thing most residents like to complain about (myself included back in the day): scut. And, in the world of interventional radiology, you can find no lack of scut in any corner. Patients need consents. They complain about their symptoms.

Moreover, as a “real” IR doctor, you need to listen. That can become real old quickly if you cannot stand performing these critical patient duties. It’s not why most residents signed up for radiology.

Lifestyle Is Not What They Thought It Would Be

Overall, which radiologist subspecialist awakens the earliest in the morning? Well, that’s easy- the interventionalist. And, who often leaves the latest? The same. Also, some interventionalists may get called in for all hours of the night at any time on their lonesome. Now, radiology may not be the lifestyle specialty that it was years ago in any subsegment of radiology, let alone interventional radiology. Regardless, this sort of long day in interventional does not attract many radiology residents to the field. You may be the only one in your residency!

Risk Of Needlesticks

In any medical field, you will encounter physical dangers. But notably, the interventionalists have a higher likelihood of bodily injury. Most critically, these folks use lots of sharp needles. And, guess what? When you utilize lots of needles, you increase your chances of a needle stick and the good stuff that comes with it- Hepatitis, HIV, and more. Many residents think about this only after they start their residency. And, walla, they make their decision not to enter the field!

You Can Perform Procedures As A DR Graduate

No. Interventionalists are not the only ones that can perform procedures. If you decide to take a rural job or practice as a general radiologist, you will likely be responsible for some of these. I know of many “non-interventionalists” that perform all sorts of biopsies, vascular work, and interventional oncology. So, why bother if you don’t need that extra certificate of qualification?

Not As Glamorous As They First Thought (PICCs and Ports)

Nowadays, most interventionalists perform all sorts of procedures. And, most likely, it will not be many of those stent placements in the neck or embolization of the liver. Most techniques are much more mundane. You will probably have done a lot more PICC lines and Portacaths than any high tech complex procedure out there. Yes, you will be a critical member of the team. But no, you will most likely perform more garden variety interventional procedures than complicated ones.

Heavy Lead

In some “fancy” institutions, they have made sure that each interventionalist needs to wear anti-gravity lead before any procedure. But, more likely than not, you will need to wear a regular lead uniform most of the time. And, unless you maintain yourself in excellent shape, many lead garments tend to cause back and muscle pain. In fact, at a certain age, it is not uncommon for many interventionalists to switch to a DR specialty because of the wear and tear on their bodies. Most new radiology residents do not realize the long term consequences of wearing a heavy uniform until they hear the complaints of their mentors.

 

Bottom Line: What Does This Mean For The Future Of The IR/DR Programs?

After all of these issues, and as much as I like the field of interventional radiology as a profession, I find it fascinating that the IR/DR residency has become one of the most popular and competitive specialties out there. I think many residents have not done their research and have fallen for all the hype.

Now, call me crazy, but I believe that one of two things may happen since residents are signing up early before they get to know the specialty. Either, the attrition rate for these IR/DR residencies may become more significant than the founders realized or the programs will have created lots of disenchanted and unhappy IR/DR clinicians. Only time will tell. I hope I am wrong!

 

 

 

Posted on by

I Didn’t Match In Radiology! What Do I Do?

match

Question:

Thank you for providing great information. I have been utilizing it throughout my residency application process and have found it to be an invaluable resource. Currently, I am in the process of SOAPing (Supplemental Offer And Acceptance Program) to match into a position and was hoping to get your input on applying for research fellowships in radiology as an alternative to SOAPing into an undesirable program/alternative specialty. I am a US MD 4th year with a 230-240 range for both USMLE1&2 and with previous research experience in genetics and interventional radiology.
Thank you for your time and consideration,
A Worried SOAPer

Answer:

Sorry to hear about having to try to SOAP into a position. I would continue to try to get into a slot in radiology if you can. Getting a residency slot in a marginal program is better than not getting anything if radiology is your chosen field. I believe that you can always make the most of your experience regardless of the residency that accepts you.
However, I would imagine that there are not that many empty slots in the SOAP this year. (Only ten programs did not fill as of the time I am publishing this article). So, if you do not match into an opening, I think doing a radiology research program would be a great way to make yourself more desirable the next time you apply. I would probably opt to find a clinical program this year first as well (if you have not done so already), so you have that clinical year that you need under your belt. But, getting a research year afterward would be an excellent way to stay immersed in the field. It is the closest you can get to remain in radiology without completing a residency year.  It will also demonstrate your interest in the programs when/if you reapply.
Good luck with the SOAP,
Barry Julius, MD
Posted on by

Can I Discuss Lifestyle On Interviews?

lifestyle

We all want to know about lifestyle when we interview for residency, fellowship, and beyond. But, many of us are afraid we will offend the sensibility of the interviewer. Will he think I’m lazy? Will she believe I will take too much vacation if I work here? I’m sure at one point, or another, these thoughts have crossed your mind.

So, in what context, can you ask these questions? And, is it ever appropriate to grill your interviewer about the lifestyle that she leads in her job? I mean that likely is one of the reasons why you are taking the position there. Or, at least, you don’t want to let on that is the reason why you are taking the job, right?

Once again I aim to please. Accordingly, I am going to delve into the hornet’s nest of the discussion of lifestyle on an interview. At what point should you avoid it at all costs? When is it appropriate to discuss? And, finally, how should you address it and what should you say?

When To Avoid Discussion Of Lifestyle

In general, unless under special circumstances, you should not broach the topic of lifestyle on that initial outing when you interview for an attending job. Think of the first interview as a “get-to-know-you” session. First and foremost, you want to discover if the place of work matches your expectations for what you want. Typically, once you introduce the subject of lifestyle issue during that first interview, you have opened a can of worms. You are saying; essentially, lifestyle is more critical than the working environment. Most likely, you do not want to relay that message on first sight!

Likewise, as a resident, most often it is inappropriate to ask an attending about lifestyle issues as a resident. First, faculty tend to know less about the day-to-day lifestyle issues of residents. So, it shows poor insight when you ask the attending about how and where they live. Try to direct these questions to a more appropriate source, your future colleagues, the residents within a program.

And finally, sometimes, you discover that you are interviewing with a person who does not seem to want to answer questions about lifestyle. Perhaps, this person is awkward or is a bit off. Is that the sort of person, you want to ask about lifestyle anyway?

When Is It Appropriate?

Of course, as an attending interviewing for a job, you need to find out more information. So, wait a bit. Get a feel for the practice. If you have already had your first interview, then you can start thinking about lifestyle questions. Vacation and call issues become more important once you have established that this place may work for you.

Or, perhaps, you are sitting down at the table at lunch with future resident colleagues. This time would be perfect for broaching the topic of lifestyle. Do residents always eat together? That’s certainly an appropriate question at this point in the day.

And then finally, sometimes the interviewer may ask you a question that can lead you into discussing a lifestyle issue. For instance, he may want to know how you tend to enjoy your vacations. That could appropriately stimulate discussion on the topic since the interviewer essentially permitted you to discuss it.

Best Way To Address The Issue

Once you have established that you think that you will fit in with a residency or practice, it pays to be tactfully forthcoming. At that point, you can ask the interviewer if they receive extra “administration” or half days. Or, you can find out about which days may lead to easier rotations. The information that you collect from this place may further inform your decision down the road to choose where you want to work. Use your best judgment. You have gotten this far!

If you feel less comfortable, you can also always sidle your way into the conversation. A statement like the following For instance, after you see a picture of the radiologist in Bora Bora on the reading desk, the following statement would undoubtedly work- “I see that you like to go away to Bora-Bora. How often do you take that trip?” That would be a non-offensive way of beginning to broach the topic. And, it can lead to more detailed information.

Another non-intrusive question that I like and can work to get a feel for the “corporate culture”: “Do the partners/residents like to go to dinners together?”. This question establishes whether or not the partners get along well enough to host events together.

Bottom Line About Discussing Lifestyle On Interviews

Understanding the corporate lifestyle is a critical piece of data that you need to decide whether the radiology practice or residency works for you. Nevertheless, it can become a sensitive topic. Delivered at the wrong time, it can relay a lousy impression that may prevent you from getting that next great position.  So, be sure that you mention the subject at the appropriate time to the correct individual. And phrase these questions non-offensively. Tread lightly, my friends!

 

 

 

Posted on by

Why Does No One Want To Go Into Mammography?

mammography

Question:

Why Does No One Want To Go Into Mammography?

Hey! Why are so few residents interested in pursuing a breast fellowship? The job market for breast has always been ‘hot’ and the hours and salaries are generally higher than other subspecialty specific jobs. I was an IR resident who dropped to DR because of the discrepancy in lifestyle vs. salary vs. free time. Let me know… thanks!

Answer:

My Four Reasons For Fewer Mammographers Than Expected

Well, I have a few insights for you about the world of breast imaging. Back in the day, eons ago before when I even started practicing, mammography was a no brainer. If you talk to some of the older radiologists, you will be surprised to learn that most will say that they initially felt comfortable reading the films. But, the field slowly became more litigious. And, eventually, the area grew into the most sued specialty in the field of radiology.
However, that is not all. Many radiologists went into the field to “get away” from the day-to-day emotions of the patient encounter. And, what do you do when you work in this field? You work with one of the most touchy subjects known to women, breast cancer. You will serve some crying emotionally charged patients. That is not why many radiologists signed up for radiology.
Additionally, mammography differs from other fields in daily practice themes. Unlike other radiologists, breast imagers mainly work with management issues. Instead, most general radiology practitioners want to solve diagnostic dilemmas rather than management matters. Hence, the name of our field “diagnostic” radiology. That’s very different from the expectations of most radiologists.
Finally, this last thought may be a bit more controversial, but I will stick my head out a bit. Many mammographers tend to work intensely at one time or another just reading one type of study, screening mammograms. You may drown in hundreds of the same sorts of studies all day long. Now, this does not necessarily apply to the radiologists that are consummate all-around breast imagers who do biopsies, read MRIs, and work directly with surgeons. But, some of the older breast imagers do only the straight screening and diagnostic mammography portion of breast imaging. And, for many, this work can become redundant and tiring.

My Final Take On Mammography

Now, taken together, these unique practice issues make a particular sort of person to want to go into mammography. And for that reason, regardless of salary, lifestyle, free time, you will not find as many breast imagers as some of the other specialties in radiology. To each his or her own!
Regards,
Barry Julius, MD
Posted on by

Minimal Effort And Maximal Gain: A Targeted Residency Approach

minimal effort maximal gain

Radiology residents, especially, are under the gun to complete their work efficiently. I mean, to learn what you need to know for the boards you have to read through umpteen books and a gazillion films, right?  So, who has the time to go through the motions of a bland long-winded study routine to get you through all the material? That would take way too long. Therefore, I want to give you some suggestions to guide you efficiently through all the subjects you need for radiology residency. So, here are some the basics you need to get through residency with minimal effort and maximal gain!

Targeted Reading

I can’t remember the number of times that I have talked about targeted reading in my posts. But, I will repeat it for the ten thousandth time. It’s that important. Every resident should read radiology books differently from other subjects. Remember. Pictures first, then captions, and then text. If you start from the text and go to the images, much less information will stick. So, please do yourselves a favor and do this the right way.

And, just as critically, make sure to emphasize case review series in your review process. Radiology without cases is like peanut butter without the jam (sorry for those of you that are allergic to peanut butter!). It just does not feel right!

Reinforced Reading

How do you get information to stick around in your brain? Well, you need to look at the same item from different angles. What do I mean by that? If you find a meningioma on a CT scan at work, first of all, make sure to look it up that night. Then, look at the same case on multiple imaging modalities. Perhaps, check it out on an MRI, a contrast-enhanced CT scan, or even a skull series if available. The more ways that you look at the same findings, the more likely you will recall the case when you need it!

Lots Of Questions

Don’t let the texts that you are reading become merely a bunch of random words. Just like any other time that you had to study for tests, make sure to phrase the text into the form of questions. And, I have some great ideas to help you along your way. My residents reported using several test question bank companies for study, especially around board time. But, it may not be a bad idea to use these question banks at any time during your studies to emphasize the materials.

The two companies that I hear assist the residents with fairly comprehensive question banks are as follows: Board Vitals and Quevlar. Both of these companies give you some great questions for the Core Examination. Now, you need to make sure to have learned the basics before. But, both Board Vitals and Quevlar will enable to get through the material that much quicker to get you where you need to be before the boards.

Group Learning

You certainly need to read a lot independently to learn the material that you need to know. However, you should also utilize your colleagues to maximize your knowledge. Going over questions or cases in groups with your fellow residents adds new perspectives on the same information. And, by golly, here you have another neural pathway to maximize what you retain!

Board Review Courses

I believe in learning from numerous different angles. And, therefore, I need to put a pitch in for Board Review Courses. Not all program directors believe in this approach. However, sometimes, it helps to step out of your familiar residency conference world and to get a fresh perspective. Different instructors and different points of view create distinct neural pathways for information recall. That is the reason I believe a board review course can work. I think it’s not a bad idea to attend one or two.

Minimal Effort And Maximal Gain

Don’t get me wrong. To be a great radiologist, you need to put in the hours. However, make sure that you utilize your time as effectively as possible. Why spend time that you don’t have? So, follow this approach to get through the material logically and efficiently. Who doesn’t like minimal effort for maximal gain?

 

 

Posted on by

You Are Not Right: Radiology Is Less Competitive This Year!

less competitive

Statement From A “Questionable Program Director”

Hi, I saw your post and talking to all the programs in the south this year, radiology was less competitive with our program receiving 60-80 fewer applications than last year. I state this because this year was not more competitive. But if you check the NRMP and look at the numbers instead of writing from your gut, you would not spread false information.

I will take a page from Barry and speak from my gut and say it is getting less competitive in the next few cycles with the horrors of taking candidates with no inclination for radiology via the SOAP to only fail the boards will start again.  In retrospect, I wish that I had interviewed more students because many have already been to 20-30 places with their prepared responses.

Fellow program director

________________________________________________________

Response From A “Real Associate Program Director”

Not quite sure if y0u are a real program director since you did not leave an email or another way to contact you. Most folks that are “real” will put their money where their mouth is. Additionally, the grammar was horrible (so I took the liberty to edit it a bit), and the note was challenging to read. (But that does not disqualify you from being a program director!) Regardless, I thought it would be fun to reply to this email in an ask the residency director format, now that we know our program has matched all four spots.  So, here we go!

Less Competitive This Year?

First of all, the NRMP has not released any of the numbers about the 2019 match. They are not yet available. Can’t say that I know what figures you are talking about from the NRMP. (another red flag regarding the credibility of your post!) However, I find it interesting that you reported having 60-80 fewer applications this year. That statistic flies right in the face of what our program has experienced for this year’s match. And, it also differs from what I have heard other programs saying. But, then again, we will find out the actual numbers of the match statistics when the real NRMP releases the stats for this year.

Second, my article called 2018-2019 More Competitive For Radiology? A Midyear Perspective is just a perspective. I based it on the hard and soft facts of what we saw at our program at the time of the article.  I use pieces of evidence to support the conclusion that this year was more competitive, not gut reactions. But again, we will see if my prediction bears out when we do get the final word from the NRMP.

Next, I want to put a pitch in for those folks that will be matching in the SOAP. What you are implying about the SOAP candidates could not be further from the truth.  Our former residents that matched through this process have been some of the most dedicated and fervent radiology residents that we have ever had. Most residents that match through the SOAP do not fail their boards. To the contrary, these residents perform extraordinarily during their four years and beyond.

And, finally, I am sorry to hear that you wish you should have been interviewing more students. (if you are real!) I think that says more about your program and your region of the country than the state of the radiology match this year.

Too-da-loo,

Barry Julius, MD

Posted on by

Why Residents Should Take Charge Of The Worklist

worklist

By the time you start your first radiology attending job, you should feel comfortable getting through a typical day’s work. So, how do you arrive at this point of comfort? Well, it is not via magic. Most successful starting radiologists will have adopted a formula for getting through a day’s trials and tribulations. Moreover, they know how to manage the worklist. And, the easy way to do so? You should have that experience during your radiology residency.

Now, not all residency programs work the same. Some residents plow through whatever cases the attending tell them to go through. In these sorts of residencies, the attending maintains the responsibility for the worklist. They make sure that either the resident or the attending read through the cases that they need to complete.

And at others, the resident starts the day by gathering the necessary cases together and dictating. Attendings will intermittently arrive at the department to read out the studies with the resident. However, the attending charges the resident with the responsibility of getting through the worklist for the day.

I would argue that the latter programs tend to be more helpful for starting in practice. Let me tell you why.

Most Practices Are Run By Radiologists

First of all, in most practices, who is in charge of the worklist? No, it is not the nurse, the technologist, or the radiology assistant. Instead, usually, the radiologist manages the worklist to determine who he should read first, second, and third. Even though artificial intelligence may one day take over some of this process, radiologists should have the background to feel comfortable owning a worklist.

Teaches You How To Get Help From Others

Let’s say that you start on your worklist and you find a case where you are not sure of the diagnosis. Who do you approach? And, how do you contact that person? Do you call or walk over to the other room? Do you interrupt their train of thought or do you wait until they finish up? Or, do you find a clinician in another specialty? These skills only come when you have to manage cases outside of your purview. And, these cases are much more likely to arrive when you control your worklist.

Learning How To Triage Work

In the same vein, when you have an unsorted worklist, how do you know what needs to be read first, second, and third? Sometimes, you arrive at a decision best when you have had the experience to make that conclusion. It takes time to figure out that you should read certain physician’s cases first or a specific type of STAT indication sooner. What better way than to manage a worklist as a resident?

Time Management Skills

Of course, when you learn to control your worklist, in the beginning, you may not realize how much time you have to complete all the work for the day. Unfortunately, you may find that you had less time than you initially thought. So what is the best way to hone your time management skills? Manage the worklist! You’ll eventually learn the ropes.

Patient And Physician Phone Calls

During the day, you are bound to receive multiple phone calls from both referring physicians and patients alike. How do you deal with them in the confines of a busy day when you have a whole bunch of studies to read? Well, when you manage your worklist, you get to figure that out. Do you spend an inordinate amount of time on the phone or do you hurriedly give them an answer? To determine how you should proceed, take charge of the work for the day!

Taking Charge Of The Worklist

It’s more than just lip service. Owning the worklist allows budding radiologists to hone their skills. Whether it teaches you to work with others, time management, the art of triage, or more, it will enable you to get through the day in a timely fashion. More importantly, when you learn all the skills of managing a worklist, you can hit the ground running at your first job. That’s where you want to be!

Posted on by

Beyond MOC: Should The ABR Scrap The Core Exam And Find A Way To Assess Competency Objectively?

competency

As physicians, we rely heavily upon our boards to verify that members of our profession can competently practice medicine. Nowadays, physicians are questioning whether the requirements for maintenance of certification (MOC)  provide a valid measure of competency to practice radiology. Even in areas like internal medicine and radiology, a few physicians are taking this mission to court. (1)

But that’s just MOC for attending radiologists. What about the initial exam that the academics created to ensure that residents are competent to practice medicine, the core examination? Did the test creators correlate these board exams with minimal practice competency when residents finish training? And, is it even possible to do so? Moreover, what are these exams testing?  Today I am going to provide a voice for the unloved residents that can’t vocalize their concerns about the examination due to the potential for reprisal from their faculty.

In doing so, I am going to investigate some of the biases that board creators such as the American Board of Radiology (ABR) face. And, then I am going to give some ideas our governing board can objectively use to assess minimal competency, not the current more subjective assessment of what the minimum skill sets should be.

Starting From The Beginning: Who Is Making The Exam

If we think about how the ABR makes its core exam, they farm out experienced voluntary member radiologists of the ABR to create questions for the examination, most of which are academics. Herein lies the first problem. Who are the majority of the radiologists in the country? Are they academic radiologists? Simply put, no.

So, when the initial test question creators formulate the exam, they do not base their questions on the basic competency levels of all radiologists. Instead, these test creators may base their test questions on their own academic experience. This experience may include fairly esoteric knowledge that only the academic radiologist may need. For instance, the question creator may be an academic radiologist that works in an esthesioneuroblastoma center of excellence. Therefore, this radiologist may emphasize a rare disease that most radiologists may never experience. And, you might see this question pop up on your examination even though it does not evaluate for minimal competency.

Also, some of the question designers may practice in a highly subspecialized area. These subjects may not apply to the future practice of a majority of the examinees. Do these questions test for minimal competency? Sometimes probably not. The core examination should more objectively test knowledge that addresses skill levels, not random factual or subspecialty competency.

The Problem With Correlation- Are We Correlating To The Correct Metrics?

According to the ABR, a candidate passes a test if she meets the minimum cutoff that the organization deems appropriate. No, they do not base it on a curve. But, the ABR does need to figure out how to base their minimum cutoff. So, with what exactly does the ABR correlate this minimum competency level? Well, they have to base it off something. To answer that problem, the test question makers assume that they know what the minimal level of competency should be. Well, I am not so sure that is an objective standard based on their different skills compared to the average Joe Radiologist.

Potential Objective Competency Standards For The Core Examination

So, what are some objective standards to which questions should correlate? Well, I can think of a few. Peer review in practice may be one such metric. If the radiologist is entirely off the curve and has passed the board exam, this would indicate that perhaps the examination was faulty. We can correlate the test to that.

What else might be an appropriate metric? Radiologists that cannot hold a job and has been fired by more than one practice. Think about it. If practices continue to let a radiologist go because he does not meet the standards, that is probably a useful measure. Why not use this as a way to correlate the appropriateness of the core exam questions?

Another measurement could be surveying physicians in other subspecialties to assess the competency of the practicing radiologist. If the preponderance of surveys shows poor clinical insight, I believe that would be another useful measure for determining competency.

And finally, perhaps you could use a metric such as multiple lawsuits far about the mean in a particular subspecialty. If a radiologist has been sued five times and the average in her specialty is one or two, that would be a red flag. You can see if the test questions correlate with this endpoint.

These are all potential valid endpoints that the ABR can use to correlation the test that would lend a sense of objectivity. Right now, I am only aware of the subjective criteria of a biased individual examiner of what a passing physician should know. Perhaps, we need to change this concept 180 degrees to assess true competency with objectivity.

Summary: Assessing The Correct Metrics?

Currently, the subjective determined minimum standard of the ABR core examination is not good enough. If we want to create a test that genuinely tests minimum competency, we have to create one with a basis of more objective criteria that associate with the quality of practicing general radiologists that have completed the exam. It will take time and maybe a difficult chore. But it may be well worth it to develop a test that we can rely on to make sure that residents who pass the exam have the minimal competency to practice radiology, instead of being an expert in test taking itself.

(1) https://www.radiologybusiness.com/topics/healthcare-economics/lawsuit-american-board-radiology-antitrust-moc