Month: August 2019

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Off Cycle And Need Funding: Can I Get A Fellowship I Want?

off cycle

Question About Off Cycle Fellowships And Funding:

Hello Dr. Julius,
I hope all is well. Thanks very much for creating this site. It shares a lot
of very valuable, helpful information that is difficult to find elsewhere.
I have a few questions I was hoping you could answer for me.
I matched into a categorical Internal Medicine residency last year, during
which I realized I wanted to pursue radiology because it better aligns
with my interests, strengths, and personality. I discussed this with my
program director, who fully supported my decision. I completed my
internship a few months ago and left the program on good terms, receiving
strong references. I am now involved in radiology research at an
academic medical center. I recently became aware of an unexpected PGY-2/R1
residency opening for this year, which would start shortly, as
an off-cycle position.
1. Does completing an off-cycle residency limit fellowship opportunities?
Would fellowship directors be less interested in a candidate if he or
she finishes residency training after July, thus complicating the schedule
for incorporating a new fellow into the schedule at later point?
2. Since I matched into a 3-year Internal Medicine program, do the
remaining two years of my funding follow me to the next residency?
3. Is it possible to have more than one source of funding for a single
resident? For example, could one theoretically have funding remaining from
the first match and then also have partial funding through the military
or a foreign government? I’ve noticed there are positions on ERAS
dedicated for external financing through the military or international
sponsors. I am just curious if sources of funding can be combined.
Thank you very much for your time! I appreciate it.
Best Regards,
The Off-Cycle Resident

Answers:

You posed some interesting questions about particular issues that residents of mine have encountered in the past. So, I can help you based on my experiences.

Off-Cycle Issues

Let’s start with the problem of being off-cycle. Yes, most program directors would rather have a resident that is on-cycle. But, life happens, and it does not always work. For personal reasons, we had one resident who started residency three months later than the typical July 1 beginning. In his case, we were able to get a dispensation from the ABR to allow him to start his fellowship on time. On the other hand, if you are way off-cycle, you may not be allowed to do so. In that situation, it would make it a bit more challenging to find a fellowship position that can conform to the timing that you need.

That said, since the market for fellowship now favors the applicants, many programs would be willing to create a spot that allows you to start a fellowship soon after finishing. Right now, I know of many 6-month fellowship positions that would be happy to take an off-cycle resident at almost any time. It might be a bit more difficult if you were interested in a more competitive fellowship like interventional radiology.

Funding Issues

In terms of the funding for residency, typically, the government bases it on the amount of time completed in residency, not the expected time in a residency. So, if you only have completed a year or two of a three-year categorical spot, you will still have as many options as those that did a one or two-year preliminary program.

For those that have completed more than two years of a government-funded residency, you can also get foreign or military funding to supplement the rest, if available. And finally, some spots I know are entirely privately funded, so it does not matter how many years have been supported by Medicare.

Most programs, however, will utilize the government Medicare program for funding. So, if you are in a residency and have used up government Medicare resources, the program can rely on other sources of financing afterward, if your residency can find it and if it is available.

Thanks for the great questions,

Barry Julius, MD

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What The Core Exam Low Pass Rate Does Not Tell Us About This Year’s Test Takers!

low pass rate

In residency programs throughout the country, you don’t need to go far before you hear some chatter about the low pass rate on the core exam and the change from years before. And, then, you take a look at the article on Aunt Minnie, with headlines stating, the ‘fail’ rate is rising. Or, you check out a forum or two or social media, as they rail against the exam and the test takers. It’s no wonder that many residents are on edge. I know that at my residency, the buzz is palpable.

Similar to other years, I have seen sketchy opinions about this year’s exam and misguided words about the residents who took the exam this year. But, given the increased failure rate, these statements weigh more on the residents who have taken the exam. And, unfortunately, many of the assumptions and statements made about this class of residents taking the exam and the test itself are entirely off-base. So, I aim to dispel any misconceptions by telling you what you should not assume about this group of test-takers and the core exam. Here are some of the more common ones!

This Group Of Test Takers Are Not As Smart

I know many residents who took the exam this year. And, although more residents had trouble passing the boards this year, these residents are just as intelligent as others. Perhaps, many are not great test-takers (reflected in the USMLE board scores used for admission to residency). But, by no means, are they going to make radiologists that are inferior to any other year.

Moreover, residents throughout the country in this class practice radiology competently as judged by faculty, chairman, and program directors. This judgment is in spite of the board score results. So, instead, I am forced to fault the exam itself, and some of the reported esoterica and minutia tested, not the folks taking the exam.

They Are Lazy

The residents of the class who just took these boards have worked very hard, if not harder than in years past. In my program,  some of these residents are the best since I started. Indeed, they have studied very hard for the board examination. But, by no means, should anyone call them lazy!

They Have Been Targeted To Fail The Boards

No, no, and again no. The ABR does not seek to fail more of any particular class in general; however, misguided any exam may be. Instead, I believe they have created a test that does not measure what it claims, minimum competency to practice radiology. The ABR did not specifically target this residency class taking this particular test.

There is No Way To Predict Who Will Pass The Boards

Interestingly enough, the Radexam pre-core exam did predict the outcome of the core exam results very well. Percentages on our pre-core Radexam mirrored the real exam almost perfectly. At least in my residency, it turns out that this test is far superior to the old in-service examination. I would love to hear the experience of other institutions as well since the Radexam is so new. Based on our experience, we will continue to take it more seriously. We will do so to make sure that residents have studied enough (and the right way) to pass the core examination.

Low Pass Rate And The Residents Taking The Exam

An exam is only as good as the material it tests. And, competent residents who perform well in my residency tell me about the many esoteric questions and minutia on it. Therefore, I squarely place the blame of the low pass rate on the core exam, and not the residents taking the examination. As I’ve written before, it’s time to start reworking the test and its questions. We need to change the material tested so that residents will remember useful content for years to come, not just spit empty facts on an examination and quickly forget.

And just as importantly, let’s stop putting all the blame on the residents taking the exam. Based on the judgments of our faculty, we already know that they are competent and will make great radiologists. We do not need a faulty test to tell us otherwise!

 

 

 

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Final Results From The Radiology Call Pain Points Poll!

pain points

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Radiology Pain Points Survey Results

The results of the radiology pain points survey are finally in. And, I bet that many of you would like to know if your colleagues have the same feelings of dread about overnights as you do. So, let’s get right down to the nitty-gritty.

Of all the most dreaded parts of the overnight call, a majority of the respondents stated that they dreaded missing findings the most (51%). And, that makes sense given that everyone has the potential to miss something critical in the wee hours. In second place (30%), you guys selected lack of sleep. Again, not surprising because most of us hate the feeling of nausea and dizziness that sets in at 4 AM. Our bodies and mind abhor lack of sleep! In a distant third (8%), you had selected the fear of injuring patients as the most dreaded aspect of overnights. I had expected this fear to be a little bit higher. But, missing findings often lead to patient injury. So, perhaps this is the proximate cause for this response. And, therefore, you picked this response less frequently.

And finally, there was a smattering of other responses, including a confrontation with colleagues, and some great comments like -dealing with phone calls, contrast reactions, and the isolation of overnights.

Take-Home Message

So, what is the final take-home message from this poll? Well, for one, we need to come up with better ways for you to deal with some of the most significant issues that you will face on overnight call. I don’t believe many residencies have addressed these issues well. For example, we talk about sleep deprivation, and most residencies give you some lectures at the beginning of the academic year. But, what are some real-world radiology specific techniques that we can utilize to mitigate its effects? And, how can we ensure that you have the tools to make the necessary findings at nighttime? Are a precall quiz and a first-year introducti0n to call enough? Perhaps, residencies and the regulating bodies need to do more. Just some food for thought!

 

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What Kind Of Technology Background Is Critical For The Radiology Resident?

technology background

Ever been frustrated watching your nuclear medicine attendings use their proprietary software adeptly, while you do not understand how they manipulate the images? Or, do you notice that some of your faculty can look at a whole series with a slice by slice comparison by setting them with a point, but you can’t? Although hospital and corporate information technology should create systems easy and intuitive for every radiologist to use, in the real world, it is not the case. And, even though you may know your radiology and anatomy cold, there are serious ramifications if you do not know what I like to call technology background or “buttonology” knowledge to operate the systems.

So, first, I am going to elucidate why “buttonology” and some radiology technology background can become so critical to your skills and practices. And, then I will tell you what computer features you should expect to learn during your residency and why.

Reasons For Learning “Buttonology” And Getting A Technology Background

Helps Us With Our Job

In general, most of the technology that we use make our lives easier. It may not seem so at the beginning. But, when you do get to know how to manipulate images and information the right way, it can increase efficiency. Heck, what was life like before Picture Archiving And Communication Systems (PACs)? We read half the amount of films in double the time!

Can’t Function Without It!

I cannot even imagine how I would function without knowing how to make measurements or to get to the next case on the queue. So, it requires us to make time for learning at least the bare minimum of what we need to know to get us through the day whether we like it or not!

May Use It After You Leave Residency!

Believe it or not, yes, life exists after residency. And, many of the same hated technologies that you use during your residency, you will likely need to know later as well. I can still remember learning Penrad (a mammo text-based dictation system) that I could not stand during my residency. It took hours to learn how to use it properly. And, I thought it was a waste of time. But, you know what? It has become a regular part of my day as an attending who reads some mammography. You never know what you will need to grasp after you finish.

Clinicians May Ask For It

In our practice, clinicians ask for the use of specific technologies and documentation in our reports. So, it behooves us to learn them to stay in business. Yes, it took some time to learn how to use the DATquant software to determine the likelihood of Parkinson’s disease in patients. But, now we have cornered the market. It was well worth the effort!

Technological Features You Need To Know

OK. We need to learn these technologies even though it is a time sink and may seem distasteful. So, what are the tools that we need to look out for and take time to learn? We will go through some of the basics here.

Tools To Function Daily

This first category would be the most obvious. It would be the technology background that you need to get through the day as a radiology resident. So, which are the essential tools that residents should take time to learn? You should acquire mastery of measurement tools (distance, Hounsfield units, angles, etc.) Each resident should also be able to scroll, pan, window, link cases, and perform necessary reconstructions in a pinch.

You also need to operate any computer system that you will need to make it through a night of call. These include the general nuclear medicine imaging readers, CT perfusion technologies, and so on.

And then finally, you need to know some of the other functions that if you do not remember, you cannot read the cases. These technologies would include the dictation software and sending images to the correct workstation or software.

Tools You May Need After Residency

In your hospital and departments, you will most likely not need to know all of the technologies available. However, you may find some of them will pay off in spades later on when you begin your first job. You never know. RIS systems, complex nuclear medicine applications, mammography software, etc. are only some of the technologies that you may encounter. You may not “need” them now, but it may be worth it to put the time in upfront to learn them if you think there is a chance you may use them. If possible, you do not want to learn them at your first job where you will waste a lot more time. And, more importantly, you will seem a lot less efficient when you begin as an attending.

“Buttonology” And Your Technology Background Can Make Or Break You

Knowing the “buttonology” of radiology systems can be critical for your professional development and future career. Without the tools that you will need, at best, you may make yourself inefficient. And, at worst, you may not last at your first or second job. So, during residency, take the time to learn the basics of PACs functionality and hospital systems. Think of it as an investment in your future. I promise that it will pay off big time!

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How Do I Know Which Cases To Discuss With My Attending In The Morning?

You’ve made it through a typical night of call and the attending for the day is about to arrive. Your mind begins to meltdown from the exhaustion of it all. And, there are too many cases to discuss with your morning radiologist. It’s just going to take too long.

Moreover, you don’t want to waste your attending’s time with the obvious. On the other hand, you are not sure about what you are going to have missed during your shift. And, you want to make sure that you address all the critical issues. So, how do you go about deciding which cases to discuss with your morning attending? And what can you ignore? To increase your efficiency, let’s go over some of the basic guidelines.

All Cases That Can Significantly Change Patient Medical Management

Remember, in the end, every case that you sign off at nighttime, also will have your attending’s name on it too. By default, therefore, you should show every situation to your attending that will significantly change medical management. Now, what exactly does that mean? If your patient has gone to surgery based on your findings for any reason, that would certainly qualify. Or, if the patient needs to stay overnight because of your call, that would be eligible too.

In essence, I would have a low threshold for what constitutes a change in patient management. And, if it meets that criteria, well then, you must show it!

Equivocal Findings

It’s those cases that you hem and haw over. These are the best learning tools. So, make the most of them. Even it’s not the most clinically significant case; I would highly recommend that you try to discuss it with your morning attending. It’s one way that you may never discover that finding to be equivocal again. Think about all that time over your career that you will waste that you could have figured out immediately by just asking your attendings in the morning. Why wouldn’t you bother to do that?

Discrepant Reports With The Nighthawk

If you want to get burned, the best way to do it: Don’t go over discrepant nighthawk reports with your attending. I have been on the receiving end of one or two of these unmitigated disasters. And, the resident could have avoided it by simply telling me about it.

Moreover, even if the resident gets it right, and the nighthawk misses the case, it can still become a problem. Medically, the emergency physician can administer the wrong medication based on the nighthawk read. Or even potentially worse, she may not administer treatment based on his final report. Therefore, please let your attending know about these cases, especially if you made the critical finding, and the nighthawk reader missed the obvious!

Discrepant Reports With The Emergency Physician

Just as often as nighthawk discrepancies, if you forget to go over those cases where your opinion differs from the ED physician, you are potentially asking for trouble. Immediately, these cases should be some of the first that you must discuss in the morning. In addition to increasing the work burden on your morning reader, your attending will likely have to make a whole bunch of unnecessary phone calls if he doesn’t know that there was a discrepancy.  Your goal should be to reduce the amount of work your attending needs to complete, not increase it!

Any Other Cases With Questions

Sometimes, cases bring up fascinating points or other medical management questions. And, what better time to ask questions to reinforce what you have learned at nighttime? After residency, you will not have these opportune moments again. So, take advantage of making inquiries with experts while you can!

Whew, That’s A Lot Of Cases To Discuss!

Well, not necessarily. It sounds like a lot more than it is.  Often, these cases are the minority of what you will experience at nighttime. And, fortunately, most nights, you will encounter many normals and garden variety cases that don’t need to take up a lot of your time in the morning. However, regardless of the number of cases, it always pays to go over those cases that need extra attention and care, whether it’s for medical management issues, equivocal findings, discrepancies, or simple questions. It’s a fantastic tool for learning, and more critically, a moral duty for excellent patient care!

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Should I Waste Time Looking For Tiny Lung Nodules At Nighttime?

lung nodules

One of my former residency mentors said the following as he proudly scrolled through the electric film panel reader without stopping as he dictated, “You can miss em’ fast, or you can miss em’ slow!”

And, the life of a resident works non-stop, just like this former radiologist, especially on a busy night of call during residency. At least at our institution, we can easily have a night of 40-50 CT scans, 10 MRIs, 20 ultrasounds, multiple plain films, and fluoroscopy consults. Even though it’s tough, we expect our residents to churn through all these images and more! Then finally, in addition to all of this, we require them to dictate the cases that they’ve previewed.

So, with all this work that the typical resident needs to complete on an average night, does it make sense to worry about every little detail? I mean, how bad can it be to miss a 2 mm lung nodule or a 3 mm hepatic cyst or hemangioma? Well, I don’t like to be dogmatic about what’s right before I review the evidence. So, let’s consider the pros and cons of what it means to skip the imaging details.

Pros Of Missing The Tiny Lung Nodules

So, let’s start with talking about why we can forgive our residents for missing a few lung nodules here and there. Well, who cares if the resident flies past a few nodules at nighttime, as long as she has picked up the big stuff, yes? If you pick up a pseudoaneurysm of the common femoral artery and you miss a renal cyst, you’ve done your job. You’ve prevented severe harm and injury to the patient. What more could a residency director ask?

Moreover, the attending usually picks up the other findings in the morning that the resident misses. Regardless of whatever the covering radiologist does, she can always count on the backup of another set of eyes.

Also, if you are so busy at nighttime searching for nodules and cysts, how will you have time to look through all the other cases as well. Indeed, it is not critical to find that next nodule, when you need to get to that next case that can potentially have free air and pneumatosis.

And lastly, what is the harm to the patient of missing the incidental small lung nodule? Well, that is also close to zero, right?

Cons About Skipping The Small Stuff

But wait, is that all? Can we miss these nodules with impunity? Stop there.

Do you want to become a fully-trained radiologist? A well-heeled radiologist will never skip looking for any of the potentially relevant findings. They will always look for all the nodules and cysts on a CT scan. By practicing forgetting to search for these nodules, you are encouraging yourself to miss the same findings when you complete your residency. If you want to become a great radiologist, you need to act one early on.

Additionally, not all small stuff is harmless. Occasionally, those 3 mm nodules turn into that 4 cm mass which happens to be lung cancer. I’ve seen that happen with my own two eyes frequently, having interpreted multiple rare cases for a contract research organization that had us read cases for numerous drug trials. The risks are real, albeit small.

And, finally, not all the nodules and cysts are picked up by the morning radiologist. Just like anyone else in any profession, we cannot be perfect. If you did not make these findings at nighttime, how do you know that the morning radiologist has also picked it up as well?

For And Against- Where Should You Lie?

Both camps have some excellent points to make. And, stepping back from the fray, they can both make some sense. However, I would argue that you need to make your judgments about what to do.

Of course, if you are having an insane night with busloads of patients getting scanned, you need to triage your reads. Getting through all the cases trumps the potential for missing a lung nodule.

On the other hand, on a reasonable night, why not look for all the findings? You are doing an extra service to the patient and the morning’s radiologist. And, just as critically, you are augmenting your radiological skills.

Nodules or no nodules, one of the essential skills a resident should pick up from their residency is learning the art of sound judgment. We should leave this task to you to help you grow as a radiologist. Every time we allow, you, the resident, to make up your mind, and see the consequences, you learn a bit more. And, that’s the point of nighttime call for a radiology resident, to decide to look for tiny nodules or not.  Let’s not forget that!

 

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Radiology Fellowship Interviews: What’s The Difference?

radiology fellowship interviews

Question About Radiology Fellowship Interviews:

Hi Dr. Julius,

Thanks so much for the great piece about writing a fellowship personal statement. I recently went through the process myself and can appreciate the truth behind the points you stated.

As a follow-up, do you have any tips when preparing for the fellowship interview, after being shortlisted?

Thanks once again for all the high-quality posts. 🙂

Yours sincerely,
A Concerned Fellowship Applicant

Answer:

 

Thanks for the excellent question. It turns out that I have never delved into the differences between residency and fellowship interviews. And, there are a few significant differences between the two that I should mention. So, I thought that in addition to answering your question, it would make an excellent post.

To begin with, I highly recommend that you take a look at my original posts on residency interviews called How Important Is The Interview, Really? and Ten Ways To Sabotage Your Radiology Residency Interview. These rules still apply. And, once you have gone through some of this essential advice, take a look at some of the other specifics below about what you should look out for on your fellowship interview trail.

Radiology Fellowship Interviews: What’s The Diffference?

First of all, you will notice that different from a residency interview, most fellowship interviews tend to be more intimate. Most of the time you will be the only candidate at the site at this time. So, you will get to know the few interviewers much better than on a typical residency interview day because you will no longer be just another one of ten candidates. In that sense, it will often be a bit less nerve-racking. However, the general rules for interviewing still apply!

Next, the interviewer will expect you to have a background and a specific interest in the fellowship field of choice. So, you cannot have makeshift answers to why you are choosing to train in the field of radiology in general. Instead, you need to get down to brass tacks and come up with specific reasons for choosing this area of specialty.

Moreover, you will need to know more about the individual program to which you are applying. It is not enough to say that this will be a well-rounded program for your radiology training. No. You need to say why this particular fellowship would be an excellent fit for you. So, you should verse yourself in the specific equipment and unique training that this program has.

Also, make sure that you can talk about specific areas of research that may interest you. Fellowships, more so than residencies, tend to expect that you will perform research. So, talk intelligently about some projects that might interest you in this specific facility.

Other than that, it comes down to the same rules for interviewing in general. Be enthusiastic, conversational, well-dressed and groomed, etc.

So there you have it: some additional rules of the road for the residency interview. Let me know how it all goes.

Regards,

Barry Julius, MD