Month: July 2019

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Don’t Forget About The CT Reconstructions!

CT reconstructions

Due to improving CT scanner and software technology, the resolution and detail of reconstructions have dramatically improved over the past ten years. Nowadays, most institutions include these CT reconstructions in their protocols without even an afterthought. However, it wasn’t always like that.  And, like most other images from a CT exam that we add onto PACs, these images exist for a good reason.

But, with the increasing numbers of slices, it has become more common to forget about them. And, that’s understandable. It takes extra time to look at so many additional images. So, let’s go through why it’s worth our time to give them a well-deserved second look and why you should not interpret a case without them.

Some Structures You Can Only See In Another Plane

Ever go through a CT scan and search for the appendix? Especially in folks with a lot of intra-abdominal fat, they pop up in seconds. But, in the typical thin child with lots of contrast filled bowel and not much fat, the abdominal axial images do not help all that much. It is the magic of the coronal plane that often lets you see the appendix in all of its glory.

And, it is not just the appendix. I have seen renal tumors with barely a contour defect at all on the axial images. But, when you look at the coronals, they become readily apparent.

What else? Well, compression fracture deformities magically appear on the sagittal images, sometimes without a hint of abnormality on the axials. So, make sure to use these reconstructions wisely!

Increased Conspicuity

And, it’s not just that you can only see some structures on individual planes. Other times, it just becomes a whole heck of a lot easier to make the findings. Take the bowel, for instance. If you go back to one of my cases from May 25, 2019, you can find a colon cancer that was exceedingly hard to pick up on the original axial images. However, on the coronal images, it becomes a bit more reasonable to find. And, this holds for many other organs as well. Liver lesions, lung nodules, and fractures are other examples of findings that can sometimes be much easier to detect in different planes.

You May Miss The True Consequence Of The Finding

On the axial images alone, you can interpret the findings in the wrong way. Take a look at a typical CT scan. Many times diffuse ground-glass opacities on axial images can look entirely linear on a coronal or sagittal. And, that makes an enormous difference in the final interpretation. Linear opacities on a chest CT are not clinically relevant.  On the other hand, diffuse ground-glass opacities may mean pneumonia, invoking antibiotics and a call to the doctor to return.

Or, you can easily misinterpret disc disease if you look at it in the wrong plane. I can’t tell you how many times I have seen neural foraminal stenosis that disappears once you look at the right sagittal or reconstructed axial planes.  It pays to take another gander at these recons!

CT Reconstructions- Not Just Another Useless Set Of Images!

Unfortunately, reading additional images adds more time to the radiologist’s workday. But, the rewards for reading CT reconstruction series and penalties for missing findings without using them are enormous. So, the next time you see another sequence of reconstructions, do not brush them off as just another set of useless images. Instead, make these reconstructions a regular part of your search pattern for any CT scan study that you read. First of all, you will know to ask for them when they are missing. And finally, you will be glad that you did!

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Should I Address My USMLE Step II Score Drop In My Statement?

score drop

Question:

Hello – I’m actively interested in applying for DR residency, but I was let down yesterday after receiving a Step 2 score which dropped 11 points from my Step 1 (230 –> 219). I’m a DO student, and I’m afraid this will be a red flag that will become detrimental to my application for a radiology residency. I planned to address this score drop in my personal statement, as I’m sure programs will wonder why it happened. I believe my Comlex Level 2 exam went very well. However, I haven’t received that score yet, and I’m not sure PDs even care about it. Do I need to apply to a backup specialty?

A Worried Candidate

 

 

Answer To How To Deal With The Score Drop And More!

I wouldn’t throw in the towel quite yet. You have to remember that there are so many factors other than board scores to add to the equation of getting into a radiology residency. Moreover, many residencies use a cutoff of 220 or higher on the step one exam. So, you will most likely get a decent number of interviews as long as your other application credentials are OK. (not having those I could not tell you where to apply)

Also, you are right about the COMLEX scores. Most programs do not care much for those scores because it is harder to compare to everyone else taking the USMLE examination. So, I don’t believe that it will change your chances of acceptance all that much.

Finally, being a DO does not hurt your application as much as it had in the past. Now, the ACGME and the AOA are one organization, so you are no longer as much of a “second class medical citizen.”

One more critical point about your personal statement that you mentioned: I would not be so keen to address the score drop. (unless there was some major life crisis that could have affected your entire application). It would call more unnecessary attention to your board scores. To begin with, really, your step I score was not so bad. Instead, it shows that you have the potential to pass the core exam. (what most residency directors care about) Your personal statement would better serve you by talking about all the other issues that I discuss in my blog called How To Create A Killer Radiology Residency Personal Statement. Make sure to read or reread it before submitting your residency personal statement.

 

 

Let me know how everything goes,

Barry Julius, MD

 

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The Fellowship Personal Statement- What’s The Deal?

fellowship personal statement

After the popularity of my initial article called How To Write A Killer Radiology Personal Statement, I’ve had multiple requests to write a post on How To Create A Fellowship Personal Statement. Now, I have to admit that there are lots of similarities between the two. And, many of the same writing techniques still hold. So, I would recommend that you click on the link above to remind you of some of the basics. However, you will find a few unique differences that I will share. Let’s have at it!

The Fellowship Personal Statement- Does It Matter?

Well, to start with, even though personal statements tend to be one of the least critical parts of the application, they are a bit more important in fellowship. Why? First and foremost, fellowship directors have fewer data points than residency directors. For instance, applicants may have a Deans letter and USMLE scores, but they are out of date. And, extracurriculars do not play as significant a role in the fellowship application since residents do not have as much time. Moreover, core examination results do not change the equation at all because they come back too late.

So, what’s left? The application, recommendations, interviews, and then, finally, the personal statement. So, by the sheer decreased numbers of relevant items to peruse, you will notice that the personal statement must play a more substantial role in the decision for fellowship.

To balance that out, however, most radiology fellowships, currently, are less competitive than the same application to residencies. Of course, that statement probably does not include some select programs such as the independent interventional radiology fellowships. But for most applications, if you take the higher weighting and the less competitive nature of fellowships, both factors probably cancel themselves out.

Finally, it’s not just my words. Instead, it comes directly from the mouth of several fellowship directors that I know. Most do not put too much stake in the personal statement. (Similar to residency directors!)

So, what’s the take-home point of all this? Well, even though marginally more influential, the personal statement still has little sway on most fellowship applications.

OK. How Should The Fellowship Personal Statement Differ From Residency?

Now that we got that brief introduction out of the way, here is the million-dollar answer to the question. And, it is rather simplistic. In addition to all the general recommendations for a residency personal statement, you need to add why you are specifically interested in this particular fellowship. And, you should also incorporate the reasons and motivations for you to select a fellowship in this area.

Unlike the residency personal statement, you want to rely less on extracurriculars and more upon your experiences in residency, not medical school. And, unless they pertain directly to the fellowship, your statement should not emphasize the motivations that initially led you to go to medical school or residency. Of course, however, if you continued to pursue an impressive extracurricular or motivation that began before residency and is relevant to your fellowship, you can add it.

What should you add to show your interest in your fellowship? It could be a radiofrequency ablation device if you want that fellowship. Maybe, you secretly desire to interview patients and miss close patient contact as a mammographer. Or, it could be your love for untangling wires and hoses as former electrician or plumber (notice the touch of lousy humor- that can be a useful tool!) Whatever you choose, you need to make it specifically known why you have decided upon this career path. And, show not tell why you have made that decision.

Where Does This Information Belong?

If you click on the following template link (Fellowship Personal Statement Template), notice that in the first section, you have the “hook” to reel that program director into your application. (That still counts!) Well, you need to apply the reasons you are interested in radiology to this first paragraph. Makes sense, right? Get to the point!

The Fellowship Personal Statement- Not So Hard Right?

To make a great fellowship personal statement, all it takes is a few steps. First, take a look at my Fellowship Personal Statement Template and the link to How To Write A Killer Radiology Residency Personal Statement. It’s an excellent summary if I say so myself!  Then, make sure to add your specific motivations for fellowship in your first paragraph. And, finally, explain any other extracurriculars or specifics during your residency that may be relevant to your fellowship. There you have it. Now, you have the system that you will need to make that exceleent fellowship personal statement!

 

 

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Are You Getting Burned Out By All The New Articles On Physician Burnout? I Am!

physician burnout

I don’t know about you. But, between JACR, Medscape, Diagnostic Imaging, Radiology, AJR, JAMA, the New England Journal of Medicine, the New York Times, the Wall Street Journal, and a myriad other radiology journals, the numbers of articles about physician burnout have starkly increased. So much so that you cannot go without one week without coming across a new report on the subject.

And, I acknowledge that burnout is a real problem. Yes, physicians that I know tire of reading increasing numbers of studies. They drown in electronic records. Others complain every day about the lack of control they experience in medicine.  Also, I concede that there is a high suicide rate of physicians throughout the field. These are real events and facts that contribute to a harsh environment.

However, that’s not the whole picture of the dissemination of information about physician burnout. Let’s briefly look behind the iron curtain of the media’s interests in presenting information about the subject.  How does the press affect readers’ perception of reality on the topic? Moreover, is this a topic that should receive so much publicity?

Misalignment Of Media Interests

Sometimes the goals of media and the public good align. And, other times they butt heads. It’s not all altruism. And let me explain why.

In general, what is the goal of the media? It is to increase readership. And how does the press increase readership? By addressing emotionally charged issues. And, what can emotionally charge the public more than seeing how your physician is so stressed that she can no longer function appropriately?

Any subject matter that induces an emotional reaction from the reader can sell lots of journals, papers, and all sorts of electronic media consumption. This positive bias from all types of media affects not only the articles they write but also the surveys they create and the interviews they get with physicians. If you are interviewed or surveyed, you are far more likely to say you are experiencing burnout if someone asks you a leading question than if they ask you the same thing in a different way. And, they have every incentive to do so. It’s their livelihood. Now, these facts may be real to an extent. But, they may also overemphasize the problem to a degree beyond the truth.

#Me Too

Not only can the increased emphasis of media on burnout overstate the problems and issues associated with the condition, but it also leads to the #Me Too dilemma. If you see 20 articles on the same topic within any given month, you are more likely to associate the features of burnout with your situation. Now, this may not be your reality. But, the subtle psychological hints of repeated media stimuli can influence your perception of whether you have burnout.

Burnout: A Real Epidemic Or Pure Perception?

Like always, the truth probably lies somewhere in between. I know the condition does exist. And, I am aware that some physicians that I know meet the criteria for burnout. But when you read your next article on burnout, be mindful of the biases that lead the author to make their assessment of the degree of the problem within the physician population. There may be a hint of truth to their views, but it may not be to the extent you assume. That said, I’m feeling a bit of burnout after writing this article. Time to go back to sleep! (Written at 3 am)

 

 

 

 

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Fellowship Quality Training Trumps Name (Most Of The Time)

fellowship quality

Question About Fellowship Quality:

 

Hi Dr. Julius,
I have a follow-up question on fellowship.

My situation is a little tricky. My wife just started a three-year fellowship, as I’m beginning my R4. Having a kid, I would hate to leave my family, and there’s no big-name program where I can do my fellowship within a driving distance. So, I signed up for a body fellowship in an excellent facility. However, it does not have a shiny name. Do you think it makes a big difference in the long run if I did my fellowship now, in this place, vs. after completion of my wife’s fellowship at an Ivy League Program?

Regards,
Confused About Fellowships

 

Answer:

Thanks for the excellent question!
In general, fellowship quality trumps name. Why? It is more important that you feel comfortable in the subspecialty you have chosen and have learned what you need to know to become a well-rounded subspecialist radiologist. However, in a depressed job market or regions with stiff competition for jobs, sometimes name recognition does help. Also, academic places tend to weigh name recognition a bit higher. So, the more critical question is: Where do you ultimately plan to practice? If you plan on staying in a more rural area, it probably does not matter one lick. More so, in today’s market, even on the coasts, name recognition does not carry as much weight as it did five years ago. However, if you plan to practice in academia or Manhattan/San Francisco, it probably does.
Another item to remember, it is always possible to complete a second fellowship later on down the road if you wanted additional experience. (unlike residency)  So, I don’t think it is a bad idea to complete this fellowship now and come back later to do another one if you decided on a career with more stiff competition.
Hope this aids in your quest,
Barry Julius, MD
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Do You Really Want To Go To A “University” Program?

university program

During medical school, commonly, students talk about their goals to get into a “University” program. Moreover, faculty often recommend that residents should receive “University” based training.

But, what does being a “University” program mean? And, how does that compare to a University affiliate or a residency with no University affiliation at all? You may be surprised to learn that there is significant variability in the definition of a “University” program. Also, the “University” training you receive or the residency where you want to enroll may have more features in common with a “Community” program than any other “University” program out there.

So, to figure out what all this nomenclature means, I have lined up some of the features of what you would expect University programs to contain. And, you can decide for yourself if your program of interest is more “Community,” “University,” or somewhere in between.

Resources

You would expect University programs to have large endowments, kind of like what you always hear about Harvard. But in reality, many “University” programs have very few grants or any extra money to spare at all. So, resources can vary widely among institutions. What does your residency receive from the University serving your residency?

Number Of Faculty

Once again, you would expect most University programs to have more faculty, right? Well, that number can vary widely between University and Community programs. Contrary to popular belief, many non-University institutions can have more faculty than their University brethren. Though, they may not have the University reputation that precedes them.

Offhand on my mental radar, I can think of one enormous non-University system in California called Kaiser Permanente, the largest health care employer in the state. And, until 2020, it will not have had an affiliated medical school to go along with it. It has more radiologists than any other system in the state.

More Subspecialists

Along with the faculty numbers, more subspecialists in a given area does not reflect whether an institution is community or University. It is more of a reflection of the size of the program. Go figure!

Support For Research/ Statisticians

As an overall trend, residencies home based in a University tend to have more support for research. However, you will find that some large scale Community programs also may excellent support for research at their institution. Don’t assume just because you attend a University program; you have more chances to participate in studies.

More Stringent Curriculum Requirements

Every institution has program curriculum requirements as mandated by the ACGME. However, you would think that a University program would hold to these standards more stringently than a Community program. Well, that is not so. It all depends on who manages the program and the teaching faculty.

Medical Students/Opportunities To Teach

Some University residencies are so extensive that radiology residents may seldom come across a medical student anywhere. On the other hand, many community hospitals have contracts with non-affiliated medical schools to house residents in their institution. Once again, being a University program does not necessarily afford any additional special

Let The Buyer Beware

Tread carefully when you assume that a University-based residency will meet all your expectations for your residency training. Not all University-based programs are the same. Some will have unlimited resources, enormous numbers of subspecialists and faculty, tons of funds for research, a well-formed curriculum, and lots of medical students to teach. But, others may not have one or more of these features. In a world of numerous residency choices, make your checklists to confirm that the “University” or “Community” program that you want meets your specific needs. Don’t rely on a name!

 

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Informatics Vs IR: Should I Enter Digital Heaven Or Perform Manual Labor?

informatics

Question About Informatics Versus IR:

 

Dear Dr. Julius

Thank you for this amazing blog; there are many useful topics that we don’t cover during our training. As I am finishing my second year of radiology, now is the time to choose the fellowship. I will be happy to hear your opinion as I am debating between two pathways.
I am making some bullet points for each as pro and cons.

1. IR
• ( + )Higher salary, further as it becomes more competitive, I can imagine that it will become more exclusive and the pay will keep rising.
• ( + )Now, with the introduction of the direct IR residency path, it might be the last time to join, and I should seize this opportunity.
• ( + )With all the hypes of artificial intelligence taking over diagnostic in a decade, this seems to be the long term responsible choice.
• ( – )I like from time to time interventions, but I hardly see myself enjoying it for life, especially considering overnight calls when I have a family.

2- Informatics and diagnostics-

• ( + )I am personally fascinated with all the current potential of informatics. Maybe naively thinking that we are still very early in the artificial phase of our profession, I could enjoy diagnostic, perhaps enjoy the creativity phase of this upcoming technology, and maybe also become a leader in this field.
• ( – ) Diagnostic salary will probably decrease in contrast to IR, and there is a chance in a decade that I might be obsolete
• ( – ) 2 years fellowship without any short term financial benefits
The rational choice will probably be to go to IR, but I feel that I should take a chance with informatics,
I will be happy to hear your opinion.

Answer:

Once again, some great questions. I love my audience!!!!
 
Anyway, to answer your specific questions, I am going first to give you my general gestalt about the two fields. Then, I will go through your sentiments for each bullet point (some of which are correct but others are a little off the mark)

 

My Opinions About IR:

 

 

So, when it comes to IR, it is the type of field where you need to invest your life toward that end fully. What do I mean by that? It has more “surgical subspecialty like” qualities than the rest of radiology. If you decide you don’t like to do PICCs and Ports or you determine later on that you are not interested in seeing patients, it can become challenging to extricate yourself from the specialty. And, as you mentioned, it can be hard on the family, not necessarily because of less vacation time (usually interventionalists get more), but instead, you can expect to leave earlier and come home later on a typical workday. Additionally, you may be taking overnight call a bit more often than other areas of radiology. 
 
Furthermore, especially in the beginning, if you decide you want to learn more about informatics independently while doing IR, it will be more challenging to make the time to do so. You need to establish yourself in the Interventional first to become the “go-to” person in the field. That said, anything is possible if you put in the time. It’s just a matter of how much time you want to spend with a family versus work. On the other hand, if you were to decide on another field in radiology, it would be a bit easier to learn more about informatics on top of your regular diagnostic radiology career.

 

My Opinions About Informatics:

 

In terms of informatics, I would recommend you first have some idea about what you might want to pursue within the field before you begin down that rabbit hole. The career options vary more widely than any other subspecialty in radiology. Do you wish eventually to become a CIO of a practice or hospital? Or, maybe you want to become an entrepreneur or work for a private company? Perhaps, you want to be the key “tech” guy within the practice that can fix the PACs systems? I would say before thinking about the specialty as a whole; I would first target a specific area so that you can hone in precisely what you would want from the informatics training before you start. It would be best if you had an idea about what you want before you begin or else the training you receive in informatics may not be as helpful for your career. 
 
As much as I love the specialty of informatics as a career choice, this specialty seems to me to be more like an MBA. It gives you the tools to help you in your career. But, if you don’t know what you are doing, it’s just another title!

 

Addressing The Bullet Points:

 

 
Now for the answers to the bullet points:

 

IR

 

1. IR usually has a higher salary because they work more time, not because they make more per unit worked. The reimbursement for IR procedures is overall worse than many other subspecialties in radiology. Salary is a function of supply and demand. As more people enter the field, you increase the supply and decrease prices.
2. I agree that doing the direct pathway now would save you an extra year of training if you decided to go that route. However, it is more important that you like what you do. So, that would not be my first consideration.
3.  I don’t see AI taking over any subspecialty within radiology during your or my career lifetime. AI is just as likely to take over interventional as any other subspecialty in the field. (you can refer to some of the prior blogs on the topic- especially the one from the RSNA last year)
4. The most valid consideration that you mentioned is the time issue/overnight calls. I agree with that sentiment entirely
 

 

Informatics/diagnostics

 

1. Interest in the field is the most important factor for deciding on a career path. If you enjoy what you do within a radiology subspecialty, you will be successful regardless of the field. Fascination and curiosity are great reasons to enter a field. (especially when you can get paid well for it!)
2. I don’t believe that you will become obsolete in any area within radiology as long as you keep up with the changes. Moreover, it is hard to predict where the salaries will be decreasing the most within radiology. Don’t be so sure that a salary for an interventionalist will be higher in the future than someone who is involved in informatics. It all depends on what you do.
3. From what I have read, you can do a one or two-year fellowship in informatics or any variation in between. Moreover, you can certainly moonlight during the time that you are completing the fellowship to increase your salary for the year or two that you are there.
 
So, there you go. My final summary:  I believe that for interventional radiology, you have to be “all-in.” It needs to be a calling more than any other area in radiology or else you will regret choosing the field. And yes, informatics is only as good as how you choose to use it. Have an idea of precisely what you want before you pick that route.
 
Hope this long-winded summary helps!
Barry Julius, MD