Month: December 2019

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Diagnostic Certainty: Can We Ever Get It Just Right?

certainty

How confusing is this? You speak to one attending who tells you that you should come down hard on a diagnosis in your impression. No differential, please. (usually a more senior attending) And, then, the next one tells you to make sure to put all the diagnostic possibilities in your dictation with impunity. (most likely the attending that has been sued several times!) Well, if you are a resident, this situation most likely applies to you. Why? Because every attending sets their threshold for certainty. And, each does it based on their experience and insight. So, where do you set your limits for diagnostic confidence as a radiology resident?

How I Developed My Level Of Certainty (A Bit Of Back And Forth)

In my residency program, the faculty and program director emphasized saying what you mean and meaning what you say. If a study appeared normal, call it normal. Or, if you had a patient with all the findings of an adrenal adenoma, call it such. End of story.

But, as I went along in my training, I began to realize that most normals are not exactly “normal.” And, even the most “certain” diagnoses are not indeed “certain.” Now, in these situations, you will be right 99.9% of the time. However, in that 0.1%, you will discover something different. In essence, by following the philosophy of my residency program, I resigned myself to automatically missing some of those rare zebras. These two discrepant themes played itself over and over, conflicting with my initial training.

So, how did I resolve this conflict? First, I recognized that I would have to be wrong a tiny but real percentage of the time to make the right recommendation for the referring physician. Moreover, I realized if I left some of those rare birds in the dictation, I would lead my referrers astray in most situations. In essence, I would increase costs to the patients and the health care system as a whole. So, calling something normal when you think it is normal did begin to make some sense again. I began to approach my dications from that angle.

But wait, what happened if that Haversian canal was that fracture that you thought unlikely since there was no adjacent soft tissue swelling? Or, what transpired when that stoolball stuck in the middle of the colon turned out to be a massive polyp? Was I setting myself up for massive lawsuits? Herein lies the rub. Over time, I realized I could not be too sure in any report.

How I Resolved (Some) Of The Certainty Conflict

I’d love to say that you can conquer this fight between certainty and uncertainty in one fell swoop. But, to say so would be naive and even worse, outright dangerous. All I could do is to mitigate the potential pitfalls. It has been a slow process to figure it all out.

So, how did I begin to tamp down this conflict to a much lower level? Well, it’s all about probability. I made sure to give a measured response in my dictations about the likelihood of my primary diagnosis versus the most reasonable zebras. That worked 99 percent of the time. It reduced the probability of zebra misses. Likewise, most physicians will use your primary diagnosis and follow the recommendations.

Why Giving Probablilities Does Not Always Work

Here’s the real issue, however. Your audience could be a physician assistant, a nurse practitioner, or a physician. Some may have more or less experience. And, this provider may practice patient care based on your unlikely diagnosis of a zebra instead of the more probable outcome. So, no matter how hard I try to steer the referrer in my preferred direction, that clinician may not use the probabilities in any report as I have intended. We must accept this fact. And, that is a tough pill to swallow.

Feeling Comfortable With Your Level Of Certainty

But, knowing that we cannot control for rogue clinicians, we can only do our best to relay our probabilistic approach without making the misses that can endanger our livelihood. It’s a sacrifice we must make to practice our specialty.  And, we should do it in a manner that will lead the majority of clinicians to the most appropriate patient care as well as mitigate the potential for lawsuits. Remember. We are not here to control the flow of patient care in every patient, but rather to guide it. I can take some comfort in that notion!

 

 

 

 

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What Exactly Is The Specialty Of Body Imaging?

body imaging

Body Imaging Question:

Greetings and salutations,

Thanks so much for your educative content. I have benefited immensely. Please, what is body imaging (Radiology sub-specialty)? What exactly does it mean/entail? How is it different from Abdominal Radiology and Gastrointestinal Radiology subspecialties? And, are body imaging specialists privileged to carry out interventional radiology (vascular and non-vascular) procedures involving the part(s) of the body in which they specialize?

Thanks so much,

Possible future body imager

 

Answer:

 

It’s a great series of questions that you have asked because it is more complicated than what you might think at first glance. First of all, let’s talk about body imaging. Body imaging covers many different areas. To that point, some folks say that practicing this specialty is like saying you will practice all of radiology. That is because radiology covers the whole body!

Defining Body Imaging

But, if you look at most of these fellowships, they cover at least some of the following areas- gastrointestinal, abdominal, MSK, thoracic, cardiac, genitourinary, and breast. Because of this variability, there is no MQSA for these sorts of fellowships. And, if you look under this category or do a google search and see what they include, any one of them may emphasize any of these subspecialties within radiology. So, if you are interested in “body imaging,” you need to look at the fine print. Then, check out what the fellowship covers.
Moreover, a common approach for these advanced specialty programs is to cover six months in one of these areas and another six months in a different subspecialty. Or, it can emphasize more interventional biopsy type of training. Regardless, the topics can vary widely, and what you should look for depends on your interests for practice. As to your other question, abdominal and gastrointestinal radiology are just some of the areas that a fellowship can teach.
To answer your third question, yes, lots of body imagers do perform interventional procedures. And, no, you do not need to be an IR doctor or even a body image trained specialist to do many interventional sorts of procedures. Just make sure you have excellent training during your residency or body imaging fellowship, and that should be adequate for practice!
I hope that helps with your questions!
Barry Julius, MD

 

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Radiology Sign On Bonuses: A Marker Of An Imploding Practice Or A Booming Market?

sign on bonuses

Nowadays, checking out any of the job websites or even the ACR career center, it’s like window shopping at a candy store. So many great opportunities. High salaries, suitable locations, and even sign-on bonuses. But, are these jobs with sign-on bonuses all that they are cracked up to be? I mean, how bad can it be, begin with an extra twenty grand before you have even started to work! Well, of course, there is more to the sign-on bonus than what you would realize at first glance. So, let’s go through some of the conditions and circumstances for that first sign-on bonus. And, let me even disappoint you some more when you find out the strings that may be attached!

The Clawback

First and foremost, when you sign on to that job with the bonus, take a look at the fine print. Often, the money will come with the assumption that you will be working there for a certain amount of time. It could be one, two, three years, or more. And, the firm will have the right to take a portion or all of it back if you have not met all the specified conditions.

Look At The Specifics

Sometimes, this signing bonus can be not exactly what you think you are signing up for. Take a look at all the stipulations. It could depend on the number of films that you have read. Or, the practice may only release the money on the condition that you have read mammograms or another specialty that does not interest you. Again, the devil is in the details!

Issues With The Practice Itself

Then, you need to ask yourself, why is the practice offering this extra money? Can’t this imaging center find great people because they are a known entity in town where all the radiologists want to work? Take a second look if they are offering you a bonus. Sometimes these entities provide these excellent bonuses because they can’t retain their employees currently. Is this “gift” just an act of desperation to find a warm body to read the films? Well, maybe yes or maybe no!

Market-Related Factors

And then finally, the most likely reason for sign-on bonuses, the market itself. Is the demand for radiologists at the moment so competitive that it forces them to compete with additional incentives? Is the location not that desirable? Is there truly a severe shortage of radiologists that they would have to make such an offer? Any or all these reasons may be at play. A practice can be an excellent place to work. But, market forces can sometimes create a situation for you to gain from their loss. And, for the end of 2019, these situations are all too common.

My Final Two Cents (A Bit Less Than Some Sign-On Bonuses!)

Really, the case for a sign-on bonus depends on many circumstances, some practice-related and others that rely wholly on the market. In any case, make sure to look at the fine print before you “sign-on” to a job with a sign-on bonus. It may not be what you had initially thought!

 

tomatoes

 

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Active Administrative Management: The Key For A Successful Training Program?

active administrative management

As many of you know, residency reputation and quality throughout the country vary widely. Sure, the Radiology Residency Committee (RRC) and the American College of Graduate Medical Education (ACGME) has set out specific guidelines for all radiology residencies to follow. However, over the years, I have discovered these instructions are merely a tool for individual programs to interpret as they will. As much as these organizations would like to have you believe, the current product is not standardized at all.  So, how can a hospital or system convert a program into the best it can be? It’s straightforward. Treat it like any other significant patient care initiative, whether it be a renal transplant program or oncology center of excellence. And what do they all have in common? Active administrative management!

How Successful Programs Model Their Residencies

Take a look at the most successful programs, ones that are rated highly on Doximity and Aunt Minnie. First of all, management takes residency education seriously. Unlike many administrations who only pay lip service, saying that they take residency education as their prime mission, these few do. They treat a residency like a renal transplant program or a multiple sclerosis center of excellence. They build a program with an initial plan to provide the best training possible.

The Plan

So, how do they do all this? First of all, they communicate with all the stakeholders, not just a few select administrators and high-up faculty onto themselves. They involve medical students, residents, fellows, section chiefs, chairs, residency coordinators, engineers, physicists, program directors, c-suite executives, managers, and more. Everyone plays a role, and everyone is aware of their educational role within the mission. They structure meetings with clear goals. Everyone knows the names of those folks in charge. It should not be that murky person with a cigarette in tow pulling all the strings like the nameless, faceless ones in charge of the government in the X-Files!

Second, these hospitals provide the resources that programs need to succeed. A renal transplant team cannot function without technical support from the surgical technologist or nurse. Nor could they survive without the highest quality equipment and tools for surgical intervention. Likewise, an excellent program cannot exist without the educational tools, numbers of involved faculty, and equipment.

And then finally, they establish buy-in from all members. And, I mean all members. Whether it is the CEO of the hospital or the janitors who need to take of the department, all are active participants. When a hospital establishes any other quality initiative, they all feed into a joint mission, and everyone wants it to succeed because they know their role within the system. That is how an organization does it!

An All-Too-Common Residency Model That Doesn’t Work

Unfortunately, this model contrasts markedly with the other all-too-common model. Many of you have seen these residencies on your interview trail or in your own experience. In this situation, orders arrive from a vague administrator whose command is to save money for a hospital or a system. These bureaucrats tell all the affected parties that they are going to have a great program. But, they establish no buy-in from the involved parties. And, they muzzle or fire individuals who seek to improve the system. This model would never work with a broad patient care initiative.

Moreover, these administrators do not communicate an effective mission statement to any of the players. In effect, they say they want an “Ivy League” program, but they do not provide any organization or structure to those that are on the front lines. They manage the world from thirty thousand feet in the air, hands-off, never uttering a word about their plans. And, then they cut the resources that a program would need to improve the education of its residents instead of facilitating improvements. These “saved” funds go back into the system to pad the pockets of the administration, instead of improving the education of what should be its targeted goal, the residents, and the residency program.

The Upshot Of Poor Planning In The Health Care System

Now, imagine the same happened to a formerly successful oncology program. It would have a short half-life. Eventually, it would dissolve due to the best oncologists, surgeons, primary care docs, nurses, and others wanting to leave the program for other better health care programs and facilities.

In this model of health care education, where entities want to save a buck or two,  administrators reap most of the rewards. However, in the long run, it is a losing formula for the residency and the hospital system. Education does not improve. And the residency/health care system deteriorates over time.

What Are The Returns Of Doing It The Right Way?

When you approach a radiology program the right way, first and foremost, you elevate the quality of the residents that graduate. These are the sorts of folks that you would eventually want to hire in your practice. And, they stick around long after they graduate.

Next, you stimulate more dollars to come back into the system. How do you do that? First, the quality of care increases because you have provided an excellent education. And, these are the folks that take care of patients. Then, more patients come to your facility because they are aware of the quality. It first happens locally, then nationally, and then internationally.

And finally, you receive more support. It may be from research dollars from grants for doing incredible research. Or, it may come in the form of additional donations to the cause of education. Regardless, the program has established a virtuous cycle, a continuing formula that supports the hospital and residency throughout the ages. Administrators and all healthcare-related staff win.

The Sad Truth About Residency Program Management

Not all administrations are created equal. And, not all have the primary goal of establishing residency education as a primary mission as much as they like to imply. And, there are many factors involved, whether it be poor planning, greed, declining reimbursements, and more. But, in the end, it is only those administrators that have the foresight to make education priority number one that will create training programs that will stand the test of time. So, when you decide on your residency, choose carefully. Management matters!

 

 

 

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USMLE Scores, Fellowship, And Prestige: Are They Linked?

usmle scores

Questions About USMLE Scores, Fellowship, And Prestige:

Hi Dr. Julius,

Thank you so much for making this website and posting all this valuable information to help out medical students/residents in the radiology community. I’ve been following your website for a long time now, and you have no idea how much I’ve learned from your posts.

I’m currently at a university DR program, and I did undergrad and med school at this same university (both undergrad and med school ranked top 20, DR program ranked around 30 by Doximity). I’m between neuro and breast fellowship, haven’t decided which one, but they are both considered pretty good programs at my university. However, I always feel like I could have gone to a better residency program and couldn’t stop wondering what would it be like if I went to a better fellowship. However, my USMLE scores are on the lower side. I do have excellent evaluations from radiology attendings; some of them even wrote “one of the best residents in the class, if not the best.”

My first question is, how vital are USMLE scores in fellowship application? I do have several research projects and have been going to several conferences each year (either with leadership positions or abstract presentations). I’m hoping to submit two research papers early next year (currently PGY3). I’ve also been involved in med student teaching, as well.

The second question is, should I go somewhere else for fellowship, knowing I may not get into a better program than my home program? I admit the number one reason I want to go somewhere else is for my ego. I want to go somewhere even better and well known. For my career path, I think I want to do private practice first then retire to academics later in life. But if I could find a good academic job that pays well, I might go directly into academics (indeed not my program as new attendings are very poorly paid here)- looking forward to your reply.

From the resident who probably overthinks,

Thank you.

 

Answer:

USMLE Scores And Fellowship

To answer your first question, every time you move up another level, test scores become less and less relevant. That said, the fellowship programs would most like to see that you have passed your core exam. Why? Because it will interfere with the year of the fellowship. And, just as critically, the fellowship program is partly responsible for your passing or failure of the exams you take during the time that you are there. Luckily for you, most fellowships don’t know your core exam results because the match is before you take them! So, that is one positive.
Also, most programs will take your USMLE score with a grain of salt (unlike residency) because you have already made it to the level of a resident. Residencies use USMLE scores as a way to discriminate between institutions because it is an equalizer. It allows the programs to figure out if someone coming from a less competitive school has the abilities that someone coming from a more competitive school does. You are pretty much past that point as a radiology resident. You’ve already made it!
On the other hand, over time, recommendations become more and more crucial. The right one will get you a spot in almost any fellowship program. The same for a residency or medical school usually does not have any near as much power.

My Philosophy About Fellowship

Just as an aside, let me give you my philosophy about any training program. Residencies, fellowships, etc. are what you make of it. Better, in regards to a training program, is exceedingly difficult to evaluate. Unless, of course, one is missing the critical equipment, faculty, or resources to teach the subspecialty. But, that is rarely the case. Most fellowships have to meet stringent criteria so that they can teach fellows. A good fellow will be a good fellow at almost any reasonable program.

Fellowship, Prestige, And The Job Market

For the next question, should you go somewhere else for a fellowship? Many residency directors have a different take on this. But this is mine. I believe that the reason to go to another institution has very little to do with prestige. Instead, the best reason to work at another institution is to see how they do things differently in another place. I find that learning multiple distinct approaches to radiology is critical for succeeding as a fully trained radiologist. And, one of the best ways to get that experience is to have worked at multiple institutions.
Prestige plays a more significant role if you want to become a chairman of an academic radiology department. Believe it or not, becoming a chair at a private practice can be not only less competitive but often undesirable because it means a lot of extra work for minimal reward. You have to go to all the hospital meetings and field all the complaints about the department. It can be a thankless job! (Although some like it).
Moreover, in today’s market, the prestige of the training program has little to do with your future private practice job prospects. You will be able to find a great job coming from almost any fellowship as long as you train and do reasonably well.
My two cents,
Barry Julius, MD

 

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2019 RSNA – All About Artificial Intelligence, Phase 2

RSNA

What is it that I love about the RSNA? Well, it’s the only conference out there that I have found that can give you a flavor of the direction that radiology is moving. It’s where you can see the newest trends from vendors, educators, and researchers alike. Everyone gathers in one place, from all over the world. And, therefore, it gives you the Zeitgeist (I love that word!) of the state of radiology. Naturally, the only downside is the size of the conference. There’s so much going on that you can get lost in the shuffle if you don’t make any plans to know what you are attending beforehand. (Which I certainly did before I came!) So, according to what I saw at the 2019 RSNA, let me synthesize what is happening out there!

To give a brief answer, may I repeat the following phrase: artificial intelligence, artificial intelligence, artificial intelligence. To prove that point, for the first time, the 2019 RSNA dedicated an entire tech floor to these businesses (although it was a little off the beaten path of the main floor!) And, in the interim, radiologists, researchers, engineers, and large companies hosted numerous conferences and speaking events.

The Real Zeitgeist of 2019 RSNA

So what has changed from last year to this one? Well, first and foremost, the speakers were no longer trying to convince us that radiology is going to replace our jobs. That approach was so last year! Instead, it seemed that everyone already knows that artificial intelligence will become more like assistance devices for the radiologist. Whether it be data integration, automated detection, triage, or report formation, the nuts and bolts of artificial intelligence now assume a much more benign path that will ingratiate the radiologist’s whims. No more terminator bots to destroy radiology!

Confirming this notion, interestingly enough, for all the hype and bluster, few applications are ready for prime time. And even more, most applications are not even close to FDA approval. But, I will talk about some of the apps that will eventually become day-to-day tools that have the potential to become ubiquitous and readily available to radiologists. Moreover, I will discuss some others that just got my attention (for better or for worse!) Here were some of my favorite discussions during the conference.

Artificial Intelligence Technologies

Watson- All About Integration

Now, if IBM could swing it, Watson has the potential to be the best of all technologies coming down the pike. From my perspective, they have one of the most useful approaches to artificial intelligence for the radiologist. So, what will Watson eventually do? Well, it’s attempting to satisfy the dream of all us. It will take all the patient history, labs, progress notes, priors, and other tidbits of information that become useful, even data about the patient’s primary disease entity itself. And then, Watson will integrate all the relevant data buried in the digital world on any imaging case and display it in a readable format for the radiologist.

If successful, this technology can be a game-changer. But, it depends on the ability to sift through immense amounts of information in RIS, PACS, and EHR systems, among other individual databases in any given hospital. I am most excited about this technology because it will render our interpretations so much more useful. I am sick of the irrelevant one-word histories that we often receive!

Mammo Dreams

Mammography also is a primary target on the radar in radiology. Loads of lecturers were coming up with ways to incorporate some of the technologies. Out of the ones that I heard, one of the applications would screen all the mammograms and officially read about a quarter or third of the mammograms that were stone cold (Steven Austin) normal. According to the radiology research, AI could achieve 100 percent specificity for a negative study in this percentage of cases without the input of the radiologist.

Now, I loved the idea of decreasing a radiologist’s mammography workload. But, they were looking at cases numbering in the thousands. Let’s say you have a million cases. Would you also have 100 percent specificity? That remains to be seen. And, I don’t know if any company will be able to take on that liability in our litigious environment. Scary, to say the least. These companies may want to think twice about that ramification!

Low Liability Products

Lower liability AI products will be in the cards for the more immediate future for radiology. Whether it be bone age, triage, improvement of image quality, reconstruction assistance, or improved CAD, these foci are the targeted products that we will see first. Although most products are under the radar or not in current use in radiology departments throughout the country, I think we will see them incorporated over the next five years. And I am looking forward to seeing their results!

What Artificial Intelligence Products Will Fail In The Short Term?

As I roamed through the AI floor, I realized that lots of products offered detection with probabilities of diagnosis. For instance, I saw a chest x-ray diagnosis booth. And, their artificial intelligence product showed the abnormality along with tons of percentages for the likelihood of diseases. At least, in the United States, I don’t see much of a role in this technology. In those places with a lack of a radiology workforce (third world countries), it may take on a different relevance. But, lots of these technologies have limited applicability to the current status of the field. And, I don’t think they are anywhere near prime time.

My Final Take On This All From The 2019 RSNA!

Slowly, under the radar, we are beginning to see some of the fruition of the promises that artificial intelligence has made. And some companies are beginning to incorporate these more focused technologies into the hardware and software that imaging centers are buying. But, we are a bit farther away from seeing the explosive changes that AI potentially can offer. Whether it be true integration, mammography reads, and more, unfortunately, we are not quite there yet. Let’s continue to keep a watch and revisit the changes. Until next year at the RSNA!