Month: November 2019

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How Do I Choose My Prelim Year? So Many Options!

prelim year

In 1997, I applied for radiology. At the time, I was not quite sure about my future radiology residency career. So, I decided on the best back up plan if I was to bail on radiology. Logically, therefore, I decided to complete a one-year internship at Beth Israel Medical Center in Manhattan in Preliminary Medicine. I considered that at least if I decided to forego the radiology residency, I still had the opportunity to utilize that year as a time that would count toward an internal medicine residency program. In hindsight, it may not have been the best decision for a future radiologist such as myself (although it was an excellent program!). But, it worked for me at the time based on my circumstances back then. Hell, most critically, I got to spend a year in Manhattan!

So, how should you decide on which internship to complete?  Even though I had made a decision one way, and perhaps not the best way, I will give you a few basic concepts that you can use to make that decision. Some of the factors should depend on your goals and desired location. As usual, I will slice and dice the categories to help you, in particular, make the correct decision for your situation.  I will divide it up as follows:

1. Rules for the budding radiologist who is not sure of their future specialty,

2. Guidelines for the future interventional radiologist

3. Advice for the subspecialist radiology.

Additionally, click on this ACGME link for the list of approved PGY-1 years for radiology. (You can’t use pathology to satisfy the requirements anymore!)

What Type Of Internship Should I Chose?

General Radiology (Not Sure What You Want To Do!)

Contrary to what everyone says when they want to start radiology during the interview season, everyone does not want to do interventional radiology. Instead, most folks have no idea what they want to pursue. And that is more “normal” than anything else. So, what is usually the best internship in this situation for the budding radiologist?

Typically, the majority of these folks would benefit the most from a transitional year. Why? It allows you to survey multiple areas within all of medicine. And as most of you already know, radiology also encompasses a good chunk of most medical specialties. So, to see lots of clinical scenarios in different specialties makes the most sense for the average new resident. Plus, these residencies tend not to be as intensive as others (but not always!) Remember, your goal is not to become a practicing internal medicine physician. Instead, you want an excellent overview of the world of medicine.

Interventional Radiology

For those of you that have their heart set on interventional radiology or you think that you will eventually pursue this avenue, I would recommend you to consider a preliminary surgical internship. This internship tends to be the most hours (but not always!). But, it is also the most procedural. And guess what? So is interventional radiology. Therefore, I believe that a surgical internship does prepare you the best for this eventuality. Consider it even though you may need to power through this internship!

Subspecialty Radiology

OK. For the rarer medical student, some of you may have your heart set on pediatric radiology, women’s imaging, or neuroradiology. Well, I can still make a case for the transitional year because of the variety of specialties that will reinforce your radiological education. However, for many of these folks, I believe you could consider a specific prelim year that will support your radiology practice later on in life. For instance, a neurology internship could help with neuroradiology later on. And, ob-gyn could provide a boost to your clinical knowledge if you decide to go into women’s imaging. That’s something to think about if you choose to take this route, and you are sure which subspecialty that you will practice.

Which Location?

As an intern, I will categorize the different sorts of interns into two types — the young and the restless and those that already have a family. And I will advise both.

Young And Restless

For this sort of individual, you should think about not just the type of internship. But also, consider a place where you have can pursue an active lifestyle. Do you want a good dating scene or do you like to go ice climbing in the winter? Try to pick a place where you will have things to do outside the realm of an internship. The prelim year is a nidus for burnout with long hours and occasional irrelevance to a future career in radiology. So, make sure to choose a location where you have a convenient choice of activities to do when you leave work!

Family Oriented

Then, some already have an established family. For these sorts, think about picking a location that would cause you and your significant others to be the happiest during the tough year of internship. Whether it’s excellent schools or finding a place to reduce your chances of repeatedly moving from prelim year to radiology residency, these considerations tend to be different from the “young and the restless”!

Which Should Win Out For Internship- Type Versus Location?

Well, this is the million-dollar question. Often, you can’t have it all. Perhaps, where you want to be where there is no transitional year? Or, the neurology internship is only in specific locales? So, in these more unusual situations, you will make the best of it. You need to make that final decision about what is most important to you in your own life. For me, being in Manhattan was a critical decision for that internship year. But, I can see how the sort of residency could sometimes trump location. It all depends on your life stage and situation.

What Happens If You Make The Wrong Choice?

I have some good news. If you do make the wrong choice, it’s not the end. Remember, it’s only one year (although it can seem like an eternity at the time!). So, if you decide to complete a prelim surgical internship and you choose to work as a diagnostic radiologist instead of an interventionalist, the world will not explode. You will still learn things that you will take into whatever specialty you decide to pursue.

The Prelim Year- All The Options!

So, there you have it, my take on the choices that you should consider for your prelim year. Regardless of what path you select, you will begin anew when you first start radiology. And, eventually, that internship year will become a distant memory. But, at least, you now have the basic guidelines to make the best-informed choice!

 

 

 

 

 

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Are Two Fellowships Too Many? Probably Most Of The Time!

two fellowships

Since most job seekers look for new jobs for only a few years and the majority of those job seekers are fellows, the collective consciousness of the radiology job market at any given time rapidly fades away. And, when the job market changes, we often forget about what new radiology residents had to deal with only a few years ago. But, talk to radiologists that graduated around 5 or 6 years ago. You will find that many of these folks had experienced a 180 degree opposite job market of today’s when they started to look. Moreover, if you ask them which fellowships they have completed, you shouldn’t be shocked to hear that they finished two of them. In all likelihood, that may have been the norm!

So, the question I pose for today, is there still a role for completing two fellowships? Are there any economic advantages to finishing two advanced subspecialty programs? And, what circumstances should lead a new resident to achieve more than one? You should find this discussion enlightening!

Why Should Anyone Complete Two Fellowships?

OK. From a monetary standpoint, it no longer makes much sense. Most folks can receive the same pay regardless of whether they have completed one or two, let alone none! And, indeed, the job prospects don’t change all that much nowadays if you have finished one or two. So, let’s scratch that reason off the list.

What about future job security? Well, again, I believe that folks that fellows that have completed two fellowships are just as likely to get canned as those have finished one. If you are an excellent radiologist, it should not matter much. And, you can be a lousy radiologist regardless of if you have one or two fellowships. Additionally, I can make the argument that some less competent radiologists have completed two advanced programs because they did not feel comfortable initially starting in the job market with just one. So. let’s nix that reason as well.

How about allowing you to do what you want in practice? No, most jobs have a niche that they need to fill. And, they will meet the demand regardless of the number of fellowships you complete. Sure, you may find a job that advertises for someone that could perform two specialties competently. But, by no means in most cases, do you need to complete two fellowships to fill the position. Those positions tend to be more general. And, it probably does not matter if you have graduated from two subspecialty programs.

So, When May Two Fellowships Come In Handy?

Honestly, I could come up with three main reasons for completing two different fellowships in the market in general. And, one reason specifically for economic reasons.

So, let’s start with the economic reason. (Does not apply for the current market!) When the job market is terrible, you may need two fellowships to stand out from the crowd. And, precisely, that situation happened five or six years ago. It was not uncommon to find these applicants at that time.

Next, some folks choose the wrong fellowship from the get-go. I know of one interventionalist that never really liked it much. And, this person practiced for years and years with the hope that one day she would grow into it. It never happened. So, she chose to start from scratch at a different fellowship. That could make some sense in certain situations.

What else? Say you want to bolster your academic credentials. Well, in the game of academics, numbers of papers, lectures, abstracts, and even degrees matter. And, yes, having an additional fellowship is like having an extra degree. It has the potential to boost your academic prospects in that sort of venue. (A bit different from my world!)

Is More Than One Fellowship Too Many?

Based on our short discussion, the answer is sometimes. And, for most people today, that want to set out into the world of radiology, two fellowships is most likely overkill. But, there is a time and a place for the second fellowship. The question is: is it yours?

 

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What Are Some Valuable Tech Skills To Have As A Radiologist?

valuable tech skills

Valuable Tech Skills Question:

Hello,

I am a 3rd-year medical student interested in radiology (especially the tech side of the industry). I’ve heard that 4th year allows for some more free time, and I’d like to put some of that time towards learning a new technology-related skill (like coding, software design, etc.) In that vein, what are some tech-related skills/hobbies that you think would be valuable to focus on as someone interested in radiology? I’d love to bring a unique skill set to my future residency/career.

Any advice is much appreciated! Thank you.

Answer:

Great question about valuable tech skills! If I were a medical student today, I would become well versed in the world of PACS and EHR. I would want to know how they work, the programming languages they use, and all the information tech related to it. Even though not directly a reason for hiring a new candidate, I think it would be extraordinarily useful to know. Why? It would be great to help out your future practices to choose which of these systems to use. But also, you would be able to customize the packages to the needs of your site of work.
What else? Well, I would get to know all the physics and mechanics of the hardware that we utilize in radiology. This hardware entails the CT scanners, the MRIs, the ultrasounds, and the fluoroscopy equipment. Again, if you want to be the “go-to” guy for choosing these pieces of equipment, it would be better than relying upon a sales representative that sells the same things. It would even be better than relying on a physicist because you would know the direct needs of the radiology practice better.
You could also concentrate on the website and social media production. Do you want to be able to help your private practice to create an excellent website, “on-the-cheap”? Well, that could be incredible cost savings for the practice. Plus, it is always helpful to have someone computer and internet savvy to fix it. That would involve learning HTML, WordPress, etc. Also, you would know how to attract customers to your practice.
However, all of this depends on what you want to do when you get out there. Do you want primarily to work in IT, or do you want to be more clinical? Regardless of the decision, you will have a lot of clinical tasks before getting to these points since radiology residency, even at the most academic places, is primarily clinical. So, don’t forget to learn your clinical basics as a medical student!
Regards,
Barry Julius, MD

 

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Why Breast Ultrasound Should Only Be Performed In The Breast Imaging Department!

breast ultrasound

How often have you heard the following from an outside clinician, “My patient has a breast lump? Maybe, while they are in the emergency department for abdominal pain, she can go ahead and get a breast ultrasound to take a look.” And, as a new radiologist yourself, you may wonder why, out of convenience, you should not say yes. I mean, what’s the big deal, right? How hard can it be to do an ultrasound of the breast while the ED docs are taking care of the patient for something else? It’s a two-minute procedure!

Well, there is a lot more to that simple breast ultrasound than you might think at first glance. And, believe it or not, you may be doing a lot more patient harm than you think if you are using an ultrasound machine in the emergency department.  So, let’s talk about some of the factors, more specifically, that you should consider before making that decision to allow breast imaging outside of the breast department!

Wasted Health Care Dollars

If you scan a patient for a lump in the emergency department, what are the chances you are going to need to do it again? Close to 100%! Why? Breast ultrasound techs have a particular skill set that is unique to their specialty. Plus, the Sonosite is not the same as the hardcore breast ultrasounds used for breast imaging. Who wants to pay for both a wholly inadequate test and an additional appropriate exam in the breast department the following day?

Inferior Equipment

Now, for the next point. Most Emergency Departments don’t stock themselves with the latest and greatest equipment for imaging of the breast. How many times do inferior machines create masses when there are none? A lot! And how many lesions are missed due to poor penetration of the tissue or lower resolution? A ton! It pays to wait.

Technologist Performing Cases Without Experience

Most technologists in the breast department have been performing breast ultrasound for years. It’s not quite the same when you ask a technologist without this experience (which you might have at nighttime!) to complete the case. It is very easy to under call  and overcall a breast ultrasound without the appropriate qualifications.

Radiologists Interpreting Cases Without Breast Experience

What are the chances that you will get a radiologist with a ton of breast experience on call? Maybe 50-50 at best? In truth, most of the die-hard mammographers don’t even take emergency calls. And, now you are asking a second rate breast radiologist to do your exam. It makes no sense!

Additional Procedures With Untoward Harm

Inferior equipment and inexperienced ultrasound users lead to further tests that the radiologist or imager will recommend. More importantly, however, inferior exams are not harmless. Quickly, an inadequate breast ultrasound can lead to an unnecessary biopsy or aspiration with potential complications such as bleeding and infection. Or even worse, a pneumothorax (I’ve seen it before!)

No Knowledge of BI-RADS/Patient Letters

Nowadays, the government heavily legislates breast imaging, and they regulate the process down to the result letters that you send. What are the chances that the radiologist uses the appropriate lexicon for the exam? And, is the ED radiologist prepared to create the proper letter to the patient when he completes the test? Probably not! You may not be following the letter of the law!

Are There Any Exceptions?

OK. For every rule, there is an exception. And, I can think of one condition off-hand that may “qualify” as a “breast emergency.” That diagnosis would be a breast abscess. But, even this exception is debatable. Some radiologists would say you can sometimes drain it the next day in the breast imaging center as an outpatient.

Breast Ultrasound Is Generally Not An Emergency Procedure- Don’t Perform It Outside The Breast Department!

For the most part, however, there are many ramifications to performing breast ultrasound outside the breast center. And, you don’t want to contribute to poor patient care. So, please, I implore you. If you are ever pushed to complete a breast ultrasound outside the breast imaging department for a lump, tell your colleagues why it doesn’t make sense!

 

 

 

 

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Can Trauma Radiology Help You In Your Career?

trauma radiology

I have to admit. When I was a radiology resident, I used to dread the “traumaramas” that would arrive at our level one trauma center in Rhode Island. Because of our unique location, we would receive tons of vehicle accidents. And motorcycle accidents were the worst. Limbs would hang on by a thread. Road burns, covering more than half the body, shearing off half of the patient’s skin. And, horrible head injuries would be part of the norm (especially in those riders without a helmet!). Subsequently, we would image almost every body part imaginable! Squadrons of surgeons and surgical residents would stop by to check the films. Trauma radiology was an enormous time drain.

In the past, I did talk about trauma radiology a bit (check out How Important Is Level One Trauma To My Radiology Training?).  But, recently, with our residency merger marching onward and new potential opportunities for our residents to rotate through trauma at other sites, I began thinking again about the highlights and pitfalls of a trauma rotation again from a new perspective. Did all this extreme level I trauma help me to become a better radiologist? What about it do I still utilize today? And, most importantly, the question that you would be afraid to ask… what about the experience may not add anything at all to your radiology training experiences? These are some of the issues that I will tackle (like a 400-pound linebacker!)

The Good

Organizational Skills

First and foremost, since you have these trauma patients that come in with a gazillion injuries and bazillion imaging studies, you have to keep your wits about you. You cannot afford to forget about any of the search patterns you have learned and miss any of the studies that the ED performs. Of course, if you do, Murphy’s law says that it will be the one with the critical findings!

Having a trauma rotation forces you to keep your priorities straight and organize your work. And, it’s critical for getting through the night. But, these same skills will aid you immensely when you start your first radiology job.

Working Under Pressure

Pressure creates diamonds. Sometimes we all new need a bit of pressure to be at our best. Unfortunately, our work is not all beds of roses and teddy bears. We need to think on our feet and give appropriate advice. And, that also applies to the real world. Doctors expect their reports on time without mistakes. And patients want excellent patient care. Working in an active trauma rotation allows you to build these critical skills that will find you in good stead later on.

Trauma Findings

And then, of course, you will not look at studies the same way after completing a trauma rotation. Instead, you will read every image with an eye toward trauma. Liver lacerations, bowel injury, renal pedicle avulsions, and more will become part of your search pattern for all-time. In the real world, sometimes, but not often, we still see the same trauma that you will learn about during your residency.

Just as critically, it can help to prepare you for the boards. If you have seen a bit of trauma, it that much less you need to study. You have lived it!

The Not So Good

Trauma- Can Be Overly Repetitive

I’ve mentioned it before in my other blog on the topic, but I will re-emphasize again. Trauma radiology is a bit more repetitive than other areas in radiology. The patterns remain the same with a more limited repertoire of findings. There is only so much that we need to enhance our skills.

Learning Checklist Radiology- Not So Great!

I hate cookbook medicine. And, unfortunately, trauma radiology can be the epitome of the proverbial cookbook. Emergency doctors and surgeons expect particular views and types of studies for every given trauma patient and situation. And, we need to oblige as their radiologist. They will assume that we do things their way, whether required or not. It is just part of the trauma formula. I like a bit more flexibility!

The Hours

For multiple reasons, traumas tend to roll in late at night when you are at your peak of exhaustion. Additionally, they tend to occur all at once. It’s just a fact. So, you will have to power through the tough nights when you will not get an ounce of shuteye (Not that you were getting any on other call rotations anyway!)

Trauma Radiology- The Final Verdict

Learning trauma radiology is critical for the boards. And though it may or may not be central to your practice of radiology, and can drain you at times, it can reinforce some good habits that you need to become an excellent radiologist. Whether it is organizational skills, working in tough situations, or knowing the critical elements of trauma, these are some of the skills that you will need later on in your career. So, take it all in stride!

 

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How To Be Happy In Your Radiology Career: Internalize Rewards!

internalize rewards

If you were to ask me about the most critical part of my radiology residency and practice experience, my answer would not be what you might think. Yes, the medical knowledge that I learned was important. And, the communication skills I obtained were invaluable as well. But, those experiences are not to which I am referring. Even perhaps more significant than anything else, I learned the ability to internalize rewards from the practice of radiology.

What do I mean by this? For me, the most significant rewards of practice don’t come from the administration or my colleagues’ lathering praise onto my work. And, it does not come from a massive monetary bonus. (although it can’t hurt!) Instead, I do what I do because I take an interest in the science, art, and practice of radiology. And I derive joy from giving patients quality care.

For new folks coming out, this may not make much sense. Programs have given them evaluations and recommendations, giving them tons of external feedback. And, they continue to thrive on words from others. Additionally, they hear about more significant attending radiology salaries and look forward to getting their own. But that is all fluff. Only when you can internalize the rewards of practice, you will find happiness in your career.

Why Do I Mention All This?

Many new graduates (but not all) expect the applause of others to continue in their job, whether it be your bosses, colleagues, or patients. And then, one day, a clinician criticizes your work, or your colleagues say you are missing findings. Or, maybe at the beginning, you didn’t quite receive the salary you may have initially expected. Then, at the drop of a hat, you want to pack it all in and then quit. Why is that? Well, I believe part of it has to do with the inability to internalize rewards, expecting all the rewards to come from others. And, I have a few theories for this issue! Let’s call them the Millenial Mentality, too much feedback, and lack of experience/grit. I will go into each of them individually.

Causes For Inability To Internalize Rewards

Millennial Mentality

I am sure I will get blowback from this one. But, I think there are unique parenting differences between the millennial generation and the ones before. Of course, these differences don’t apply to all of the parents of the Millenials.

One of the most significant differences is the overemphasis on the reward rather than the process. You can see that represented by all the trophies that children receive for just participating in an activity. Nowadays everybody gets a prize. It never used to be like that. Only the best or the winner would receive the reward. So, if you came in fourth place, you wouldn’t get a badge of honor. And, you had to learn to deal with losing. Learning sometimes to lose enables kids to learn to love to emphasize the competition (or the process) and not the reward (the trophy).

Let’s now fast forward years ahead to your first job. No longer are you receiving the reward, the adulation of your faculty colleagues or the feedback you were expecting? It’s not what you are accustomed to. And, it becomes much harder to appreciate the work that you do.

Too Much External Feedback

Residencies nowadays are on feedback overload. Between milestones and monthly evaluations from attendings and colleagues, semi-annual assessments by the program director, and daily feedback from your faculty, it doesn’t end. And, this was just the tip of the iceberg. Formerly you would receive tons of forced feedback in medical school and college as well in the form of tests and evaluations. And, this is what graduates continue to expect.

However, this is not the way most practices and businesses work. You cannot expect to receive constant attention from your bosses. They may be very busy and have to attend to lots of other issues. Now, this is not to say that you can’t expect some feedback. However, it can make a new radiologist very uncomfortable when all this feedback suddenly stops at her first job.

Lack Of Experience/Grit

And, then finally, many new radiologists have never held a regular job before going to medical school. In truth, being a radiologist may be their first leap into the real world.  Yet, many times, it is only by experiencing the realities of an average job that many folks learn to appreciate the ups and downs of your career and let some of it roll off your back.

It’s those times that a customer yells at you for not getting their drinks on time. Or, the occasion that you had to deal with a fight between you and your manager. You learn to deal with these untidy situations. And, you apply them to your career. It allows you to brush off the criticism you may take and move on. You learn not to take everything to heart.

Internalizing Rewards: A Key To Success?

With all this baggage upon many new radiologists, it is possible to shed the luggage one by one. Be mindful of some of these learned behaviors and the historical context through which you have lived. And, don’t expect your colleagues, superiors, and employees to kowtow to your greatness. Learn to love what you do and not just the external trappings of success. You will be much more happy in your career!