Year: 2019

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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!

 

 

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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!

 

 

 

 

 

 

 

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When Should I Change My Search Pattern?

search pattern

Heraclitus, a Greek philosopher, has been quoted as saying, “change is the only constant in life.” And that concept also extends to how radiologists should commit to a search pattern. Yes, I have stated that you should affix your search patterns so that you make sure to remember to go through all parts of a study. Of course, we don’t want to forget about the images and organs that we need to report. However, every once in awhile the tide changes and we do need to modify our search strategies to incorporate new information.

Sometimes, protocols change. And other times, how you report disease can vary. Now, that does not mean that you should entirely forego your old search pattern. Instead, you can consider adding the new concept to your old one. Based on this thought process, let’s give you some examples of how and when I have accommodated a new change in my search patterns over my career lifetime. Hopefully, these modifications will provide a better idea of when you should make the change as well.

Coronal/Sagittal imaging

Believe it or not, CT scans at one time were only imaged and reconstructed in the axial plane. In fact, there was a big uproar when we decided to add these images to our studies. The techs, administration, and radiologists said there would be too many images to look at and store. But, it turned out that these reconstructions are critical for the interpretation of CT studies. Often, the appendix only shows up well on the coronal images. And, you can have a challenging time catching many sorts of vertebral body fractures on the axial view. Additionally, I’ve seen a few renal and colon masses that you could only pick up on the coronal view. Scary stuff if you decide to neglect these reconstructions.

So, like most radiologists, I had to add these recons to my search pattern to improve my sensitivity for picking up disease. And, this also goes for other sorts of studies. Remember, different planes can be helpful on MRI to catch glenoid labral tears. So, I no longer neglect the reconstructed images and have added them to my search pattern!

TI-RADS

I figured I would also add an example of a required reporting change that had changed my search patterns for a thyroid ultrasound. Previously, I would only make a brief description of a thyroid nodule’s size and cystic/solid consistency. Now, knowing more characteristics that make thyroid nodules more suspicious for thyroid cancer, I incorporate these findings into my reports. In my mind, I run through all the attributes of each nodule using TI-RADS criterion so that I don’t miss critical descriptors.  Unfortunately, in the interest of time, I can’t always put a TI-RADS rating for each nodule. But, all the nodules have the description needed for the clinician to make that assessment. New reporting systems will often change how you look at and report the images.

“New” Techniques- Diffusion-Weighted Sequences

And, finally, as an example, new techniques and sequences can also alter your search patterns. They force you to look at new images that you had not seen before. In that regard, the diffusion-weighted technique was a game-changer for acute infarct imaging. Naturally, I always look at them first before any other to make sure patients have no acute infarct. Before the advent of this sequence, our sensitivity for detection of acute ischemia was much lower. Anytime a new technique helps with improving patient care; you need to incorporate it into your search pattern.

“Change Is The Only Constant In Life”: An Application To The Search Pattern

Like this great quote implies, we, as radiologists, cannot rest on our laurels. We need to go with the flow to improve patient care. So, when you have new ways of looking at imaging studies that help with diagnosing or treating patients, make sure to add it to your search pattern. Whether it be, different reconstructions, changing reporting systems, or entirely new techniques, our patients will be better for it!

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Radsresident 3rd Year Birthday Celebration!

birthday celebration

Hard to believe it. It’s already been three years since the invention of this grand ole’ experiment, and it keeps on chugging! Lot’s of new content to help out the radiology resident and still, lot’s more to come. As an annual tradition of the birthday celebration, I have talked about what’s been happening with the blog.  And, this year’s no different. So, let’s review the stats for the past three years, talk about what’s happening right now, and delve a bit more into our future. All three are very exciting (at least for me!)

How Much We’ve Grown!

For a relatively “small total potential audience” of radiology residents and associated staff and faculty, I am proud to say that this blog has done very well. Based on google analytics in the initial year from September 24, 2016, to September 23, 2017, we initially had around 35,000 total visitors. And, as of this year from September 24, 2018- September 23, 2019, we now have approximately 121,000 total visitors. That’s almost 300% growth over the past three years. And, if you look back and compare the previous year to this year, we have still grown by approximately 45%. Pretty impressive.

Even more exciting, from the humble beginnings of just a few posts, you now can peruse through 289 posts (including this one) and another 25 pages. And, you can download a helpful free ebook called The New Attending Physician Guidebook: How To Search For The Right Job And What To Do Once You Start if you sign up to the website. You can also purchase our signature book on Amazon called Radsresident: A Guidebook For Radiology Applicant And Radiology Resident. And, that does not include the precall quizzes that you can take to see if you are yet ready to take overnight call. Also, take a look at some of our more popular articles in the list below!

Most Popular Posts

Past Year (Top Ten In Order)

How Much Work Is Too Much For A Radiologist? (Think RVUs!)

How Much Does It Take To Start A Radiology Imaging Center?

How To Create A Killer Radiology Personal Statement

How to Choose a Radiology Fellowship

Top Traits Of Great Radiologists (They Might Not Be What You Expect!)

The Post Interview Second Look – Is It Worth My Time?

Up To Date Book Reviews For The Radiology Core Examination

The Mega Five: The Ultimate Resources For The First-Year Radiology Resident

What Is The Best Specialty For A Lazy Radiologist?

Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?

 

All Time Most Popular (Top Ten In Order)

How Much Work Is Too Much For A Radiologist? (Think RVUs!)

How to Choose a Radiology Fellowship

How To Create A Killer Radiology Personal Statement

Top Traits Of Great Radiologists (They Might Not Be What You Expect!)

Up To Date Book Reviews For The Radiology Core Examination

How Much Does It Take To Start A Radiology Imaging Center?

A Common Radiology Applicant USMLE Step I Misconception

Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?

The Post Interview Second Look – Is It Worth My Time?

Five Reasons Why The First Year Of Radiology Residency Can Be The Most Difficult

 

What’s Changed Recently!

Some of you may have noticed that I have started to write articles with a little bit more of an educational bent. It seems that there is a significant demand for these sorts of posts. So, I have happily obliged and written more on these topics. Additionally this year, I had upgraded the website’s speed because it was running too slow for my liking. No more!

Then, of course, you have probably seen a few surveys. I kind of like them. Moreover, it turns out you like being interactive too. So, I expect to continue with a few more of those throughout the year. And, you may have noticed more ask the residency director posts. That’s simply because my audience asks such great questions. I couldn’t help but post these letters with my accompanying answers. Thank you for your incredible insights!

Lastly, some of you may have noticed an easy to use registration page and popups that allow you to sign up for the weekly newsletter. No more errors! Registration for the newsletter/website has almost doubled since I instituted the improvement.

New Directions!

In addition to continuing to write articles that I hope you find useful, I am still working on my first real video project. It’s going to be a series called Reading More Quickly, Accurately, And Getting More Sleep. I am creating exclusive videos to go through each of the imaging modalities with specific anatomic regions. In the first video, you will get a lecture on head CT and possibly CT facial bones (remains to be determined). Eventually, I would like to create many more.

When you have completed each video, you will have the search patterns of a seasoned attending in that particular area. We will make sure that you don’t miss critical findings and can get through a night of call with less time spent on each case. (And get more sleep!). I will certainly let you know when the first part of the series is available. It’s taking a lot of work and time, but I want to make sure it is of high quality!

Would Love To Hear From You!

Finally, once again, I always welcome comments, criticism, and emails from anyone in my insightful audience. I appreciate guest posts and ask the residency director questions. Also, I would be happy to guest lecture at your institution. If any of these situations apply to you, shoot me an email through the Ask The Residency Director part of the site. Once again, thank you for another great year at Radsresident.com!