Year: 2019

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What Is Your Work Limit? Find It Before You Get Your Next Job!

work limit

I’ve written before about RVUs and how much work is too much for a radiologist. But, let’s talk about how to figure your work limit before getting into RVU numbers. And that begins right where many of you are now, in radiology residency. Don’t just assume that you will start your first radiology job and you will comfortably work your tail off to make a gazillion dollars per year for the rest of your life. It’s not sustainable. Trust me. You will never be more miserable in your life.

So, how much can you do without going batty? Well, I am going to be a little bit formulaic and give you some ideas on how to figure that out now. Don’t make the wrong decision and work for that next burnout factory!

Do Some Thought Experiments To Determine Your Work Limit

Let’s Say You Could Do Your Favorite Specialty All The Time

Let’s begin by creating an ideal job for yourself where you could do just the right amount of work. For those of you who only want to practice within a specific subspecialty like mammography, this answer should be simple. How many of these studies can you realistically read in any given day without tiring yourself out? Is it twenty, forty, a hundred, or more? The number may not be entirely exact. But, it’s an excellent starting point when you begin to look.

Start thinking in this way because, for some lucky individuals, you can pick the number of studies you want to read in your desired subspecialty. Especially in this market, you can find many lifestyle jobs in the market. Who knows, maybe you can find one of them?

Let’s Say You Could Do Some of Your Favorite Specialty Some Of The Time

For many of you out there, you want to do some work within your area of expertise. But, you would also like to practice in other subspecialties as well. So, say you opt for 25% of the work in your area of fellowship training. And, maybe, the other 75 percent you will dedicate to outside your primary discipline. In this situation, think about which areas within radiology you would like to practice outside your subspecialty. And then, come up with a particular quantity of studies that you can comfortably read in a day.

Why is it more critical to figure out the number of studies you can read outside your primary area of expertise? Well, you want to figure out the most you can bear to do in specialties that you are the slowest. And, for most, that number relies on work they are willing to perform outside of their fellowship training.

In this thought experiment, I would recommend to base this number on your experience on call at nighttime or moonlighting. And then, take that number and apply it to your next job.

Imagine What It Would Be Like On A Day Of Your Worst Nightmares

And then finally, imagine what it would be like to have to practice on a day where your worst nightmares come true. Maybe, you hate reading triple-phase CT scans for pancreatic masses (probably one of my least favorite!) Well, pick a day where you have a ton of them. How much would it take to make you want to abandon ship? Well, you need to figure that number out. Why? Because Murphy’s Law says it will happen and likely more than once. Unless you make sure that you find a practice that will guarantee that you will not get a day like that, you will experience it.  So, figure out what this number would be.

Take A Test Drive Right Now- Apply The Ideal To Reality!

Now that you have some ideas about the numbers of studies that you would like to complete, you are now ready to confirm it all with real-world experience. How can you do that as a resident or fellow? Well, pick a day at your site. And then, go through the number of cases in your specialties of choice that you decided you can complete in any given day. Try it several times to confirm that this is a number that you can handle.

Of course, later on in your career, you will pick up speed and read more studies quicker. But, at least by giving it a trial run right now, it will provide you with a general idea of what your work limit might be. Well, how did it feel? Did it match with your thought experiments? If it doesn’t, and you feel like you should be reading more or less, rinse, wash, and repeat. Readjust the number depending on your experiences. There is no better time than the present to figure it all out!

Finding Your Work Limit The Right Way!

At this point, you have a realistic idea of the number of studies that you can handle. And you can apply it to your next job search. So, when you interview, ask questions about the numbers of cases that you are expected to read.  Does it match up with what you have calculated would work for you?  If it does, keep it in mind as a potential candidate for your next job.

Burnout is a hot topic these days with many job prospects expecting way too much from their applicants. If you want to prevent it from happening to you, be deliberate when you look for your next job. And, utilize these recommendations for helping you to vet the practices you seek. Being methodical and intentional about figuring how many cases you can comfortably and safely read now can be critical to your future career happiness and success!

 

 

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Techniques To Mitigate The Effects Of Sleep Deprivation

As physicians, and more specifically as radiologists, we all face the issue of sleep deprivation at one time or another. And, lack of sleep is unavoidable. Between late shifts, family issues, studying, and a late-night out with friends during the week, how does any of us get enough of it?

Moreover, we know that sleep has some potent effects on cognition and judgment. Just take a look at this link to an AJR article from 2008 about the liability of sleep deprivation. So, since we know lack of sleep is unavoidable and has potent effects, what techniques can you use to decrease its influence on you at nighttime? Let’s delve into some techniques I have used when I have been exhausted at work.

Know Your Stuff Cold

The more that you know search patterns reflexively, the more likely that you will not skip the findings, even when you are the most exhausted. Think of it as an insurance policy. When the eyes start to droop, the skills that you lose are those that are not second nature. So, take the time to learn radiology as you would understand the multiplication tables in elementary school. You should be able to spit out your search pattern as you look at the anatomy ad nauseum.

Also, make sure that you know all the most critical and common diseases that affect the population that your imaging cold. You are not going to have the wherewithal to look up everything when you are so tired that you barely keep your eyes open.

Concentrate Harder On The Key Elements

Pneumothorax, pneumothorax, pneumothorax. These words should be part of a mantra when you look at a chest film. And, that’s just one example. When you are sleepy, you want to concentrate very carefully on those entities that will make the most clinical difference for patient care. And, pneumothorax is one. But keep other critical diagnoses in mind when you are searching for findings on any new sort of study that you are reading.

Bounce Ideas Off Your Clinical Colleagues

If your mind is in a foggy rut from lack of sleep, sometimes it is helpful to talk to your clinical colleagues. That goes for both radiologists and non-radiologists alike to make sure you are keeping on the right track. Let me give you an example. Say you are staring at one site on a femur x-ray. And, you are not sure it might be either a fracture or a hallucinatory sleep-induced line. Well, give your ED doctors a call to find out if what you are looking at is even relevant to the case. Occasionally, another opinion can make the difference between a good and a bad call.

Take A Brisk Walk For A Few Minutes

When you are already sleepy, sometimes stagnation in a chair can lead to even more exhaustion. If so, think about getting up out of your seat and taking a brief walk for a few minutes. Sometimes, a brief interlude is all you need to rejuvenate your mind once again and get the adrenaline going.

Coffee (For Those That Can Handle It)

I am not saying that you should become a coffee fiend, relying on it until you get the jitters. Or, if you tend to go into cardiac arrhythmias, you should stay away. But, a dose or two at your most fatigued point, can help you to stay awake when you can’t seem to read the films. Plus, research has shown that coffee gives you some health benefits. Just take a gander at this article in Inc.!

Take A Five Minute Nap

Now, I am not suggesting that you should shirk your duties. That would be a disaster. Instead, if you get a moment, sometimes a five-minute nap can rejuvenate your mind to get back to a place where you can concentrate again on the work. Hell, it may save you time during the remainder of the night if it helps you to stay awake.

Sleep Deprivation Is Not Optimal, But We Need To Get Through It!

We live in an imperfect world. And, we participate in an error-prone specialty. Adding to the issues, we are forced to work when we are most exhausted. So, just don’t let the sleepiness take over. Fight back. Try some of these techniques to get you through the night. It may make the difference between a decent and hellish night!

 

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Don’t Skip Around! A Radiologist’s Mantra

skip around

Round, round, get around, don’t skip around. Reminds me a bit of the Beach Boys tune I Get Around. Regardless of the weak attention-grabbing first sentence, I think this advice is vital for the radiologist.  And it applies to us in many ways. First and foremost, it helps to ensure that you are covering all the findings. But, it is far more than this. Keeping reads in order without skipping around also will enable you to triage appropriately, allows you not to piss off your colleagues, and most critically, ensures that you don’t forget the reason for reading a study. So, let’s delve a little bit more behind each of the reasons behind the nitty-gritty of this philosophy.

Covering All The Findings

What is the best way to make your dictations less accurate? Well, have as many interruptions as possible! And what is it about these interruptions that cause missed findings? Typically, most radiologists will forget what they were doing before.

Since it is impossible to prevent all interruptions (although you can mitigate them), you can avoid loss of sensitivity by sticking to a routine without skipping around. So, the next time the surgeon barges into the room with a question while you are dictating, you will know exactly where to return your focus when the interruption ends. If you repeat a similar routine without skipping around, you will rarely lose your place for long!

Triage

What is it about skipping around through a list of patients that can cause triage issues? Well, it’s not fair to read a study first on a patient with similar urgency to others when he was the most recent one completed, right? How would you like it if someone cut in front of you in line at a supermarket? It’s the same philosophy.

But more critically, you should be reading the tech flagged positive findings first, the “STATS” second, the expedites third, and the routines last. Subverting this order can cause clinical disasters, potentially delaying reads on patients with positive results. Why would you want to read a routine oncology workup before a possible intracranial bleed after trauma? Finding a lung nodule is not equivalent to discovering an epidural hemorrhage. Triage in order and don’t skip around!

Order Among The Rank And File

When all members of a practice are working hard, they don’t want to worry about radiologists that are cherry-picking the most straightforward cases to spruce up their RVU numbers. How can a practice avoid such an issue? Well, have the readers read studies in order of when they were performed. Practices often perceive those members that skip around to be skirting the rules.  So, sticking to the list order can help morale!

Circling Back To The Impression

And then finally, to come up with an appropriate impression in any case you read, you should never jump to it without analyzing all the findings first. Skipping around and getting to the conclusion right away is a formula for disaster. Think of it like watching the end of a movie or novel without watching the beginning. How can you figure out the real answers to the clinician questions without going through an entire case? I know that just the mere description of the findings helps me to come up with an appropriate conclusion. Without that process, my impressions are more likely to be off-the-mark. Don’t’ skip this routine!

Following A Radiologist’s Mantra: Don’t Skip Around!

Order matters. Whether you are skipping around instead of using routine search patterns, reading cases in an illogical order, or creating an impression before looking at and analyzing all the findings, you can negatively affect both your partners and patients. We want to do the best for our patients and work partners. So, the next time you decide to accomplish a professional task out of order, think twice. It may not be the best for patient care!

 

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Read Like A Speed Demon: Goals To Read Cases Faster!

read cases faster

You are just beginning your residency, and your faculty expects you to dictate all the cases on the CT list, more than twenty. But, you are as slow as molasses, having just recently picked up a dictaphone. Unfortunately, this phenomenon is not uncommon. Faculty often forget what it is like to have recently started. Having the tools to read cases faster at the beginning is just not possible.

However, take heart. You have to begin somewhere. Most of us are not speed demons from day one. So, instead of worrying about this particular situation, it is much more critical to know how to set goals so that you can continually improve your speed. Each successive time you dictate, you need to feel more comfortable reading each case. And, eventually, you can run more adeptly through increasing numbers of cases in a shorter time.

In the past, I have written an article to help you out with increasing your knowledge to pick up speed called: How To Pick Up Speed In Radiology. Check it out to get some essential advice. But today, I am going to give you some guidelines for setting up specific goals to increase your speed. First, I will talk about what to avoid. Then, I will discuss what you should watch for from your experienced faculty. And, finally, I will go through the specifics of creating goals for increasing speed.

Do Not Deviate From The Search Pattern!

What is the worst way you can read cases faster in radiology? Cutting corners. But, I see it in residents all the time. They feel rushed, and what is the first rule that goes? Well, either they no longer search through all the fields of the film, or they skip looking at an organ system. Either way, these residents are destined to miss many critical findings as they begin to pick up speed, but in an unhealthy way. Training yourself to deviate from a search pattern is a recipe for disaster. If you cut corners as a resident, you will continue the same patterns even after you graduate. Learn the right way early on!

Learn The Tricks Of The Pros

Who should you learn from to read cases faster? Medical students rotating through radiology or attendings in other specialties? Of course not! The answer is simple, the radiology pros, of course! Learn from the best, your faculty.

So, you want to make sure to watch the people that already read cases quickly and accurately,  the seasoned radiology veterans. If you are reading CTs, for instance, sit down with the body imagers. You are bound to learn ways to cover organ systems with more accuracy in a shorter amount of time. One example would be to check out how they scroll through the cases. You may discover that running through the bowel is easier if you look at the contiguous intestine on each successive slice rather than randomly looking at the small and large bowel within the abdomen. By watching what the experienced professionals do, you can pick up additional tips such as this one to speed to your reads and search patterns.

Pick A Number And Increase Each Day

For those of you want to be weightlifters, you cannot start by bench pressing 350 lbs. That is a dangerous recipe for hurting yourself. Instead, most weightlifters set a long term goal to lift 350 pounds eventually, but increase little by little, setting daily and weekly goals. Just like that weightlifter, you need to set a long-term goal and then set shorter-term goals to slowly increase the number of cases in a day. Don’t overdo it at the beginning and strain yourself!

Let’s say that you are starting to read mammography. How many studies should you read? Well, try to pick a long term goal of reading the same number of cases that your attendings read in a day. So, say your breast faculty read around 100 mammograms each in a day. But, when you are starting, you can only read ten mammograms reasonably accurately and quickly. Then, each day, aim to complete a few more than the last.  You may not realize it ay first, but you are building mental connections and eye tracing patterns each time you look at a case. And, the more studies that you look at the stronger the connections. Eventually, it will seem effortless as you scroll through the images. However, it takes time to build this skill.

To Read Cases Faster, It’s Not A Sprint. It’s A Marathon!

Given the pressures of daily work in radiology, you need to run through lots of cases in a rapid amount of time. However, it’s not possible to begin to read accurately and quickly without starting slowly and deliberately. And, usually, it involves starting at a crawl, graduating to a walk, moving to a jog, and only then competing in a marathon.

Remember. As a resident, you have time to build up speed. So, don’t rush it. Habits that form today can last a career. Don’t let them be the wrong ones!

 

 

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

off cycle

Question About Off Cycle Fellowships And Funding:

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

Answers:

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

Off-Cycle Issues

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

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

Funding Issues

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

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

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

Thanks for the great questions,

Barry Julius, MD

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

low pass rate

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

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

This Group Of Test Takers Are Not As Smart

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

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

They Are Lazy

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

They Have Been Targeted To Fail The Boards

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

There is No Way To Predict Who Will Pass The Boards

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

Low Pass Rate And The Residents Taking The Exam

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

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

 

 

 

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Final Results From The Radiology Call Pain Points Poll!

pain points

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Radiology Pain Points Survey Results

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

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

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

Take-Home Message

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

 

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

technology background

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

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

Reasons For Learning “Buttonology” And Getting A Technology Background

Helps Us With Our Job

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

Can’t Function Without It!

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

May Use It After You Leave Residency!

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

Clinicians May Ask For It

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

Technological Features You Need To Know

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

Tools To Function Daily

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

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

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

Tools You May Need After Residency

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

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

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

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

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

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

All Cases That Can Significantly Change Patient Medical Management

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

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

Equivocal Findings

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

Discrepant Reports With The Nighthawk

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

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

Discrepant Reports With The Emergency Physician

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

Any Other Cases With Questions

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

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

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

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

lung nodules

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

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

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

Pros Of Missing The Tiny Lung Nodules

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

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

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

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

Cons About Skipping The Small Stuff

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

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

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

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

For And Against- Where Should You Lie?

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

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

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

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