Month: October 2019

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Have A Professionalism Violation: Can I Still Get Into Radiology?

professionalism violation

 

Professionalism Violation Question:

Hi, I don’t want to give too many details, but I’m finishing up my last year at a top 25 med school w/ step 1>240, multiple pubs, and a mix of honors and high passes except family medicine which is a pass. I have a professionalism violation by my school that will appear on my MSPE – how do I deal with this and move forward in the best way? The breach was for missing out on several clinic days without approval from my dean. What are my realistic chances for matching DR?

I’m pretty crushed because it seems like my goals are no longer within reach, so I need some honest advice on how to proceed

Thank you in advance,

Crushed Radiology Dreams

 

Answer:

A professionalism violation can be more difficult to remedy than a lousy grade or mistake that you made with a patient. The only way to increase your chances of acceptance into radiology residency would be to own it. What do I mean by that? The professionalism violation will show up on your application. And, that is the first item that most residency directors look for on the ERAS forms. So, you need to be ready to explain the offense, whether in person or the personal statement.
Additionally, you should be able to show deep-seated remorse. But, most importantly, you need to be able to say why this was a “one-off” event. And, you must convince the faculty why it will not happen again.

Biggest Concerns For The Program Director:

What would be the most significant concerns for most residency directors (from my end)? First, this person will not show up for rotations. Or second, this resident will try to weasel out of his obligations because he doesn’t like them. Most residency directors have had residents like this, and that is the last type of resident that they would want to take. In truth, many residency directors would rather have a resident with some academic deficiencies than a resident with recurrent professionalism violations.

Potential Solutions:

Therefore, you need to reassure your interviewers that you follow through with all the activities that you accomplish. How can you do so? Well, some places in the application that may help would be: comments on your Dean’s letter from your rotations, or other letters of recommendation testifying that the event was atypical for your personality. Regardless, you need to make sure not to cast any further doubts on your application and your character. If the readers of your application sense that you have a recurrent pattern of professionalism violations, you will not receive any interviews or rankings.
Bottom line: you are not going to be able to make the issue magically go away. But, you can mitigate some of the damages. All is not necessarily lost.
Hope that gives you some insight,
Barry Julius, MD
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Do Recommendations Come With An Expiration Date?

recommendations

Do letters of recommendation last forever? Obviously not! But, if someone provided you with a kind word once, shouldn’t it last? It all depends on the type of recommendation and what purpose it serves.  So, let me provide you with a basic outline of the staying power of different sorts of recommendations for radiology residents and radiologists (kind of like the shelf life for foods!)

To organize this into something useful that you can use as a resource that you can come back to many times, I will divide the recommendation categories into both timing and purpose. And, I will begin in the order of training and subdivide the recommendations into subtypes. Let’s start at the beginning, medical school, and end with recommendations for attending radiologists.

Medical Students Applying To Radiology Residency

General Recommendations

Of course, before you even start talking about expiration dates, we need to mention the sorts of recommendations that medical students should obtain. It is not fixed (and dilated!). Instead, it can be fluid. From my experience, I like to see one radiology related reference and a couple of non-radiology recommendations for our program. But, I’ve seen some impressive applications with credentials coming from all radiologists and also all non-radiologists. So, in general, it is essential that the referrer knows you, the applicant well.

Unexceptional Recommendations

Now that we got this general caveat out of the way, how old can the average recommendation be before it begins to get stale? For the average, unexceptional reference, I would say no more than two to three years. Usually, it is best to get these recommendations from physicians with whom you work in your medical school. These recommendations are a general evaluation of your work ethics during this time. So, it shouldn’t be much older than that.

Exceptional Recommendations

Instead, let’s talk about extraordinary recommendations. What do I mean by that? Let’s say you are a former olympian, and your coach gave you an incredible reference and testament to your grit and personality. Or, maybe the President of the United States knew you and wanted to put in a word (for some that may not be so great!). But, I think you get the idea. These sorts of residency recommendations can be used as an adjunct and have a longer shelf life, perhaps indefinite. You can probably afford to put one of these in your application to differentiate your application from the others. And, this recommendation has some staying power. More importantly, it can help the program director to remember your credentials at the time of interview selection and ranking.

Known Entities

And, then, finally, what about the recommendation from a known entity/physician within the radiology residency or someone that the program director knows directly? These recommendations also come with a longer shelf life. These sorts of recommendations last until the referrer is no longer known to the program/program director.  If you are talking about someone that a resident knows within the program, that shelf life only lasts until the resident leaves and no longer has much influence anymore.

Residents Applying To Fellowship

General/Unexceptional Recommendations

For your “Average Joe” recommendation for fellowship, generally, you should ask an attending from your institution to write you a reference. At the bare minimum, it shows that you can interact with your team and garner the appropriate support to apply for fellowships. These recommendations should be no older than the time you have already been within your residency. I would not request references from your former ERAS application for residency. That would show a bit of laziness as well.

Exceptional Recommendations

For Fellowships, the unique/unusual recommendation now has much less meaning. Most importantly, at this stage in your career, you want to show that you are capable of performing the work. Although it would be interesting to get a recommendation from the President, that will not help your program director to figure out if you can perform liver biopsies. Recommendations at this stage should be much more laser-focused on your future specialty. The role of this sort of reference wears off as you advance in your career.

Known Entities

These recommendations become more important than ever. Why? Well, that would be because the fellowship director wants to feel comfortable that he will be working with someone capable. And, for residency, there is no better way to accomplish that than to receive a recommendation from someone that you know. Therefore, the shelf life of one of these recommendations will last much longer. It may last as long as the person recommending you is actively involved with radiology!

Fellows Applying For Radiology Attending Jobs

General/Unexceptional Recommendations

These recommendations are a bare minimum requirement before beginning to look for your first job. Typically, most of these references are no longer actual letters. Instead, they come through direct phone conversations with the referrer. Practices will often place random phone calls to the referrers that you list on your application. So, these recommendations will only last as long as the person that recommends you is at your current institution. If that person leaves, the reference is no longer “kosher.”

Exceptional Recommendations

These sorts of recommendations no longer should play any role in your application for a job. Your future employer is only interested in two things, mostly. Can you function as an attending in your new job? And, can you get along with others. A recommendation from a President or other interesting source cannot tell you the answer to either of those questions.

Known Entities

At this point, these recommendations are the most critical. If the applicant receives a reference from someone that the practice knows, it is like proverbial “gold.” It is most likely a checkmark for you to get the job. Most partnerships take these recommendations the most seriously. Why? Because most other measures do not provide valuable information about the candidate. These recommendations will last as long as the referrer is in practice.

Bottom Line About Recommendations: Different Strokes For Different Folks

Depending on the stage of your training, recommendations do have different shelf lives and impact. Known entities usually have the most significant influence on chances of admission or getting a job, and they tend to have the most extended shelf life. On the other hand, “exceptional” recommendations play a smaller role as you go further in your career training. Additionally, in general, make sure that an average reference should not be older than your medical school or residency training time. Or, if you are trying to get your next job, these recommendations will last as long as your faculty are present and continue to remember you.

Laziness can prevent you from getting into the residency, fellowship, or faculty position of your choice, especially when it comes to references.  Don’t rely on ancient endorsements. Instead, remember these guidelines the next time you ask for your recommendation. Don’t just leave the process on autopilot!

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Should Radiology Residents Be Chronic Overcallers?

overcallers

In an ideal world, radiologists, in particular, would like to get all the cases right all the time. But, in reality, we know that can never happen since radiologists are people. And, we deal with imperfect technologies. Some findings will go undetected, and others misinterpreted. But that is the way of the world.

So what can we control? Well, we can adjust our sensitivities. Increasing our sensitivity allows us to make more findings at the expense of causing all our patients to receive too many additional tests. Subsequently, they would receive elevated doses of radiation and too many biopsies.

Decreasing our sensitivity sets us up for missing findings. These same misses can lead radiologists down the path of patient care issues and lawsuits. So, we continually set our internal thermometers to call cases toward either overcalling or under calling to get to that perfect mean. And, radiology residents must learn to do the same.

How Do We Adjust Our Internal Thresholds?

So, what causes us to change our sensitivities and become overcallers? Well, have you had a recent lawsuit or a bad mistake? You probably will overcall a bit for fear of missing findings. Do you have a large population with healthy hearts and read cardiac nucs. You probably are under calling a patient’s cardiac disease, knowing that most patients have none.

Additionally, we are continually tweaking our internal standards all the time. Should we call that skin fold over the chest as a pneumothorax? Or, is there a trace subarachnoid hemorrhage near the calvarial fracture site? These are the questions that we face daily. And how we choose to answer them affects the patient care we deliver.

What About Radiology Residents Versus Attendings?

Moreover, radiologists and radiology residents practice in two alternative universes. And, their pitfalls differ substantially. To that point, what can dramatically affect an attending’s care can barely impact a resident and vice versa. For instance, chronically overcalling lung nodules on chest films as an attending can anger your referrers. In a worst-case scenario, a practice may even decide to fire overcallers over the issue.

On the other hand, it may be desirable to overcall those same nodules as a resident. Your attending may want you to call the finding to alert them to whether it should make a clinical difference. She can always discard it in the final report if it does not change management.

So, Where Should Residents Lie Within The Spectrum During Residency?

In general, under calling as a resident, can be particularly dangerous for many reasons. First and foremost, residents have a lack of experience upon which to rely. After your 10,000th case of pneumonia, you will have probably have seen enough to almost instinctually know what most types of pneumonia look like on a chest film. Residents don’t have that background on which to make a judgment. So, when you don’t call pneumonia, you are more likely going to miss the signs of one.

Second, the hazards of under calling far outweigh the benefits of overcalling. If you are on an overnight shift and you are not sure whether your patient has a bleed, you can cause much more damage by sending the patient home with a bleed. The consequences of keeping the patient in the hospital with that more sensitive call are much less devastating. This philosophy goes for most serious disease entities.

And then finally, you make your attendings happier when you overcall rather than under call. I would much rather see a resident make all the findings of equivocal tiny nodules and questionable hepatic cysts. Although part of the spectrum as overcallers, these residents make findings that can help me to pick up lesions I may miss as a radiology attending. A pair of second overly sensitive eyes can be an excellent accessory screening tool to ensure that the radiologist does not miss the findings as well.

Chronic Overcalling Can Lead To A Difficult Attending Transition

But, this chronic overcalling can lead to a problem at your first attending gig. You have accustomed yourself to overcalling findings as a resident. Now, as radiology faculty, that same sensitivity point may not work well to allow you to flourish in your career. But, you have worked at this threshold level for a while. Not so easy. Habits die hard. We see this issue all the time with new radiologists.

What’s The Point Of This Conversation About Overcallers?

Well, residents need to be aware of their thresholds for making findings. Yes, it is worth it to start as overcallers based on less experience and the consequences of missing critical diagnoses. But, be wary about maintaining the same thresholds as you move along in your career. Be mindful of slowly trying to increase your limits for detection over time using your increasing experience and knowledge. The goal is to get you closer to the perfect sensitivity in an endless asymptotic curve. So, be ready to adjust your approach as an attending. It may save your career!

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TI-RADS: Is It Just Another Time Sink?

TI-RADS

Almost every time a governing body makes recommendations to institute a new reporting system, the amount of work multiplies. And, the advent of Thyroid Imaging Reporting And Data System (TI-RADS) is no different.  Yes, I believe that the new reporting system has the potential to decrease unnecessary biopsies. And, new software dictation systems will eventually reduce the extra time that we spend on each case. But until that time, radiologists surrender their lives to increasing the verbiage and size of their thyroid dictations.

Imagine a patient with four significant thyroid nodules (not that uncommon). Then, tack on all the TI-RADS descriptors. (Check out the TI-RADS worksheet in this link from the ACR). Add on a final categorization and analysis of each thyroid nodule. Finally, compare the dictation size with the old dictation styles (in the past, you probably just measured the nodule size and consistency.)  You are talking about an order of magnitude change in the radiologist’s time per dictation. And, yes, there are programs online that can calculate the scores for you. But, using these programs also takes additional clicks and time out of your day.

Big Deal Right?

No big deal. I mean, what is an extra 3-5 minutes per thyroid dictation, right? Well, multiply that number times 3, 5, or 10 depending on the number of thyroid ultrasounds you do in a day. That time racks up. It’s no longer that we are talking about 3-5 minutes more. Instead, we are tacking on 15 minutes to 50 minutes more per day. In an age where all the systems are trying to cut budgets, and radiologists need to increase efficiency to the nth degree. This increase in the workday doesn’t cut it.

Moreover, one of the most expensive links in the chain of an imaging center is the time of the radiologist. You are now increasing that time substantially. Fifteen minutes per day (on the low side) times five days per week times 40 weeks per year equals 3000 minutes of our time per year. Or, in other words, we are talking about 50 hours in a year. If you assume that a radiologist makes 300 dollars an hour, that small reporting change is instead costing 15,000 dollars per year per radiologist. Then, think about the costs to all radiologists (multiply that number by five or ten thousand). That’s not an insubstantial amount of dough!

What Is The Point Of This Exercise?

Well, let’s get to the bigger picture. I am trying to make the point that changing the requirements for radiologist reports is not just another inconsequential change. Instead, forcing us to modify the way we report cases for the good of society can substantially increase the costs to the system. So, we need to ask the governing bodies (like the ACR) to consider these points and take action to decrease the time and expense when they institute such a change.

How Can A New Reporting System Like TI-RADS Take Into Account The Radiologist’s Time?

There will be more reporting requirements to improve patient care. And, TI-RADS is only one requirement in a litany of many more to come. That’s fine. But, before initiating a new reporting system, organizations such as the American College of Radiology (ACR) should provide embedded software to compensate for the radiologist’s time. For instance, for those of us that use Powerscribe for dictation, when the ACR rolls out a new reporting system, provide the radiologist templates and artificial intelligence to simplify reporting.

So, in the case of TI-RADS, how can we restore the time of the radiologist? Well, take one of those TI-RADS calculators and embed it into the dictation software.  And, create templates for thyroid ultrasound that will take the extra descriptive verbiage of a thyroid nodule and spit out a final assessment. Or, add a menu of options in a report-like configuration using the TI-RADS features to our dictation software to create a final report. These steps can decrease the costs and the radiologist’s time taken for the new reporting requirements by more than half.

Back To The Real World

Unfortunately, often, we, as radiologists, need to figure it all out on our own. We are left flailing about trying to work out how to decrease the time of reporting when these new change occur. It shouldn’t be this way. If we have to incorporate an entirely new type of report, and for a good clinical reason, the ACR should also take responsibility to help to restore the radiologist’s time. It’s not just decreasing radiologist’s leisure time with the family at stake. It’s also millions of dollars of cost to the system!

 

 

 

 

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DR Versus DR-IR Application Questions

DR-IR application

Question About A DR Versus DR-IR Application Dilemma

Hi! Love reading your blog, you’ve been a great source of information,

I’m a current M3 interested in both DR and IR. I genuinely like both fields, but it seems like there is a growing sentiment in both areas to define themselves as separate. I’m currently working on research in IR with my IR faculty, but I don’t want to lock myself out of DR programs, which is what I’m noticing has happened this cycle for some of my M4 colleagues. Applications IR weighted are not receiving much love from DR programs even if they do quite well for IR programs.

What thoughts do you have about the growing divide between fields, and what advice can you give for a medical student interested in both? Should I also do some DR research? I like the way IR is currently practiced, where IR folks will do a mix of IR and DR, but it seems like most IR leadership and PDs are interested in furthering the distinction.

Thank you!

DR And DR-IR Application Weary

 

DR Versus DR-IR Answers:

How To Apply

Having gone to the recent APDR/AUR meeting, I can tell you that you are right about some of your reported sentiments in some programs. Some programs/program directors take it in stride that many folks will be applying to both IR/DR and DR programs. But, other DR program directors did not have such favorable opinions about those applicants that are applying to both. I believe that if you are not sure about which program to choose at this point (as is normal!), the best bet would be to apply to a DR program that has IR/DR and ESIR slots. Applying to DR programs that also have both will allow you to hedge your bets a bit and give you the most flexibility. In these programs, they can usually flip a DR spot to DR/IR or ESIR or vice versa. Also, it doesn’t lock you into the IR pathway if you are not sure you want it. DR/IR is a big commitment and works if you are sure about it. If not, you can regret your decision because you will have less diagnostic radiology, and it will be a tough slog.
Also, DR research can never hurt an application and can only serve to enhance your chances of getting into a program. It demonstrates an interest in the field. And, it gives you a bit of radiology research experience. Who doesn’t want that?

The Growing Divide Between DR and IR

More and more practices are indeed allowing or requiring the interventionalists to do only interventional. However, some imaging companies still have the model of doing DR and IR work (that’s the way our practice works). It is hard to tell how difficult it will be to find a job in a practice with DR and IR in the future. But, I would imagine there should still be a role for these folks in more rural and smaller less subspecialized practices. But if corporatization of radiology takes root everywhere, that model could become rare. It remains to be seen.
My 2 cents,
Barry Julius, MD
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Do Radiology Resident Retreats Really Work?

resident retreats

Flashback to 2001 or 2002: Our program director at Brown announces that we are going to meet in the fancy dining room in the new wing of our hospital for a resident retreat. One or two days later, we all had a free meal and shared war stories from the hospital with the guidance of our faculty.

Today: I can vaguely remember only the stuffed chicken from this first “retreat.” And, I can barely remember the war stories. Sure, it was nice getting a break from the regular rig-a-ma-roll of hospital activities. But, did it reduce resident burnout and exhaustion? Moreover, did it create a lasting memorable experience that changed me?

Well, the recent article in the Radiology Business Journal claims that resident retreats may directly reduce burnout. And, this conclusion was explicitly based on another piece which issued questionnaires to residents.  (You can click on it at Current Problems in Diagnostic Radiology here).

So,  based on some of the “data,” as well as my experience, I figured I would attempt to tease out whether resident retreats do mitigate resident fatigue. And, we will look into whether this article is anything more than clickbait. Also, is the resident retreat is just another way to get around the real issues that cause residents to be miserable during their residency without directly addressing them? We don’t want to give this article and the Brigham program (as much as I like it) an easy pass!

The Main Conclusion Of The Study: Improved Camaraderie

Yes, many residents bog themselves down in residency and lose the bigger picture. And a day or two of a retreat can reset your general mindset and outlook. However, giving residents an open-ended questionnaire and expecting the answers to reveal some long term decrease in burnout is a big leap of faith. I mean, sure, you will get positive opinions expressed because it is a day off from work. Who doesn’t want a day off to relieve the mundane parts of your job? I would be happy to answer any question positively after a day or two off with a full belly and a few good conversations with my colleagues.  So, I’m not sure if this format truly addresses whether the resident program is mitigating burnout. Sounds nice in theory, though!

What Is Causing Burnout- Does The Retreat Solve That?

Well, take a look at another article from the Radiology Business Journal. You will see a whole list of factors that cause resident burnout. In fact, they list the following: “counterproductive administrative tasks such as procedure logs and training modules, continuous and long clinical shifts, demanding call schedules, technical issues and lack of feedback and social interactions.” And, of course (based on my current resident experiences), I would like to add student loans/high debt to the equation.

So, what exactly does this retreat address then? Merely just one of the myriad factors that cause burnout- lack of social interactions. Is this enough to tip the overall ship to reduce burnout significantly? I’m not so sure about that. And does it deflect from solving most of the other real issues that cause exhaustion in a radiology residency program? Probably! If you think about it, of all the causes of burnout, this residency neglected all the others in the spirit of making the residents temporarily happy by having a day or two of social interaction.

Bottom Line About Resident Retreats

It’s good PR to create a retreat to provide the residents with an opportunity to fraternize with their colleagues. And it’s certainly nice to have some time to commiserate with your brethren. However, it takes more than one resident retreat with a few fleeting smiles to relieve the myriad causes of resident burnout. Based on this method of data collection, the numerous sources of burnout, and my own retreat experiences, the study conclusions overly simplify the real causes and solutions for treating resident burnout. Although it sounds nice in theory, and may temporarily increase residency morale, a solitary retreat is not the answer!