January 2020 - RadsResident

Posted on January 26, 2020January 26, 2020 by Barry Julius

Radiology Should No Longer Be Just An Elective: Get With The Times, Medical Schools!

As the 2020 interview season begins to wane, I have noticed a continued pattern among many medical schools. They still consider radiology to be just an “elective.” So, why do medical schools not take the specialty of radiology seriously enough to make it a requirement? Well, I have a few theories. Maybe, they want to limit exposure to medical students to shunt them toward the primary care track. (Yes, they do get government and private funds for doing so!) Perhaps, it’s a bit of inertia that schools don’t like to change. Or, it may take the place of education in other specialties since there is only so much time.

Regardless, they are making a big mistake for several reasons. First, of course, radiology insinuates itself into almost every medical specialty. And then, let’s face it, all students should learn a bit of radiology to be a well-rounded clinician. But, most importantly for society, however, radiology is one of the most expensive cost centers in health care for patients. So, let me give you a few good reasons for why medical schools should make radiology into a requirement instead of an elective and how it increases the cost of patient care.

Incorrect Orders

As a radiologist, if you haven’t noticed all the incorrect orders that flow through the system, you are probably living under a rock! Daily in breast imaging alone, I see at least a few ordering mistakes come through the department. For instance, the doctor orders a bilateral breast ultrasound when the patient only needs a unilateral breast ultrasound. Or, a clinician requests an ultrasound of the breast when a mammogram is in order. Sometimes, I can catch these mistakes before the imaging ensues. But other times, the study is completed before I even had time to decide on appropriateness. And, yes, doctors sometimes order these studies incorrectly because they have not had experienced a radiology rotation! Imagine the decreased costs of getting these orders correct?

Repeat Tests

Along with the theme of incorrect orders, clinicians wind up reduplicating their efforts because some don’t know what they are ordering. Let me go back to the example of breast imaging. Typically, we do a mammogram first in older patients when they say they feel a lump. If you do the ultrasound first before a mammogram, you are more likely to have to do two ultrasound exams instead of one. Why? Because you are more likely to find other findings on the mammogram that you will need to image with ultrasound. If the ordering clinician knew this, he would have been much more likely to save the extra test. And, this is just one example among many!

Wrong Disease Pathways

Then, of course, ordering the incorrect test leads to working up incidental findings. You gotta love those incidental findings! Noninvasive imaging is not benign. Why? Because it can lead to invasive procedures. How about that thyroid nodule that you incidentally detect on an unindicated MRI of the cervical spine? Or, you find a benign lung nodule on a CT chest that the doctor should have ordered as a regular chest film. You now need to work it up! All these incidental findings add undue costs to the system!

Lack Of Understanding of Reports

And finally, without adequate training in radiology, you can blow the significance of findings out of proportion or shove them under the rug. For instance, I have reported on a Schmorl’s node in the lumbar spine (intravertebral disc herniation) with little clinical significance. And I have received phone calls asking what to do for the patient with this diagnosis, biopsy, or not! (Absolutely nothing, of course!) Likewise, I have seen patients with new cortically active bone lesions that a clinician may ignore due to a lack of understanding of its significance. Nevertheless, in both situations, the costs of acting or being inactive incorrectly can rapidly add up for the patient and the system!

For The Sake Of Society- Make Radiology A Requirement, Not An Elective!

Unfortunately, these examples are just the tip of the iceberg. Inadequate radiology education as only an elective allows physicians to skip out on radiology in medical school. And, since radiologists do not control the flow of imaging exams, incorrect orders from poorly trained physicians will continually slip under the radar. So, the solution is simple yet bold. Make sure that all medical students receive a basic education about radiology and ordering radiological tests. We will markedly decrease the cost to the health care system and improve patient care. You got that, medical school administrators!

Posted on January 19, 2020January 19, 2020 by Barry Julius

Radiology Resident Myths Versus Reality

One of my mission statements is to be an excellent forum to dispel the myths and false expectations about radiology and radiology residency. So, I’ve done a post on the top myths about personal statements (Radiology Personal Statement Mythbusters: Five Common Misconceptions About Radiologists). And, I’ve written about the unexpected traits of great radiologists (Top Traits Of Great Radiologists (They Might Not Be What You Expect) ). But, I have not yet written about what is real versus myth for radiologist residents. And, yes, there are lots of false information out there!

So, one by one, I will take each bit of rumor and conjecture you might have heard bandied about the internet below. Then, I will dismiss the fake truth about radiology residency that you may listen to from your classmates and colleagues. Beware the false information that you may see posted on forums, social media, and other websites. Here are some of the more common statements you may hear from your fellow students, and medical colleagues about radiology residency that are not the truth!

You Don’t Need Good Communication Skills To Become A Radiology Resident!

Have you ever heard of a successful radiology resident that cannot communicate with her colleagues? Among all the reports, conferences, and all physician interactions, the only successful residents are those that can speak and write in a manner that others can understand. Moreover, I have never seen a halfway decent radiology resident that can’t give an interdisciplinary conference or handle a team of ornery surgeons at nighttime. You cannot just pump out ill-conceived reports in the dark sitting at a computer. It just doesn’t work that way!

It’s A Cush Residency Compared To Others

Talk to most any resident at nighttime. And, she will tell you the hardest working resident in the hospital is the radiology resident. Regularly, they are bombarded with orders, phone calls, demands for reports, and diagnoses at any moment without a refrain. Do they get a wink of sleep? You have a much better shot at some rest as a surgeon or internal medicine resident between cases!

You Can Get Away With Reading Like You Did In Your Subinternship And Internship

Total BS! I don’t care what they might say about on that radiology forum that you have read. Never, and I mean NEVER, have I seen a resident that can perform well without putting in the time to read. It’s just not possible. We are covering almost every single specialty of radiology. And, yes, that even includes psychiatry and dermatology (on occasion)!

All The Residents Will Be Nerd Techies

Radiology attracts all types. I’ve seen men and women come through who have been “fashionistas.” I have also seen the more techie/nerdish sorts. And I have seen all kinds in between. A stereotype like this does not do justice to the wide variety of personalities that enter our fold. Just stop by most any residency program and see for yourself!

We Hedge More Than Everyone Else

Medicine is not physics. There are so many variables in medicine that no one in any particular specialty can be one hundred percent sure of the future. Radiologists, like any other specialist, operate in this same environment. And, if you talk to almost any excellent physician in any specialty, they are aware of this fact. And, they hedge just as much. Check it out for yourself. Go into the medical records and charts, and look at all the notes from all sorts of specialists. You will see the same!

It’s The Best Way To Get Away From People

Well, it depends on which people!. Indeed, you will have less patient contact if you are working on some outpatient imaging rotations. But, you will not get away without speaking to other nurses, technologists, and other physicians. That is part of our job description! We talk to these folks every day.

It’s Impossible To Get In If You Are A Foreign Resident

Yes, it is a bit more challenging to get into radiology if you are coming from outside the United States. But, certainly not impossible. About a little less than a third of radiology residents graduate from outside the country. (From the NRMP) That’s a decent number of residents!

Radiology Resident Myths Versus Reality

We exist in an environment where it is effortless to propagate untruths and fake data. In a world of inaccurate information, I aim to provide you a bit of the truth in the world of radiology residency from a reliable inside source. So, don’t just take the information about radiology residents at face value. At radsresident.com, you can discover facts about radiology residency like these, which is the reality rather than myths!

Posted on January 12, 2020January 12, 2020 by Barry Julius

Is The Adult Abdominal Series Like Reading Tea Leaves?

At some point, most of you have probably come across the adult abdominal series, most often used for abdominal pain. You will see these exams performed in most Emergency Departments throughout the country. Typically, it includes a supine and upright or decubitus view of the abdomen. At some institutions (like ours), it also consists of an upright chest x-ray. So, why do I want to bother discussing this imaging examination? It must have some issues, right? Well, of course!

So, what’s my beef with this exam? Well, I will go through all my issues with the study one by one. First of all, we will mull over the purpose of the imaging examination and its redundancies within the system. Then, we will discuss precisely who may be ordering the study and why that has repercussions for the expense and overutilization of patient care. And finally, I will go into detail on how the ordering clinician uses the information (if they do at all!). All these points will show why I have negative feelings about the abdominal x-ray series. And, by the time you are done reading this, I believe you will too (assuming you don’t already!)

The Lowly Abdominal Series: Is It Being Used As It Should?

It may seem that every time a patient walks through the door with the complaint of abdominal pain, he gets an abdominal/pelvic CT scan and an abdominal series. But, what is the point of getting an abdominal series if you already know that the patient is going to receive an abdominal CT scan for the same complaint? Can’t you get more information from a CT scan than an abdominal series? Well, the answer to that is clearly yes. That abdominal series becomes nothing more than redundant when you have already have a CT scan on the same patient.

Moreover, some clinicians say that they need it for triage. Well, in my experience, that is debatable as well. I can’t tell you how many times clinicians report that they will utilize the test to help them to determine if the patient needs a CT scan. But, if you think about that usage, it does not make sense as well. Why? Because the abdominal series is a notoriously insensitive and nonspecific test. I can think of gazillion times that I have seen a negative abdominal series in the setting of a rip-roaring positive abdominal/pelvic CT scan. Likewise, I see lots of positive tests that turned out to be nothing on the CT scan.

And, I have the data to back me up. Check this out. Here is a paper from the Radiology journal that gives the sensitivity of an abdominal series compared to a CT scan of 30%. Now, that statistic alone is pretty horrible. Translating that number into everyday English, it means that you will miss a positive abdominal diagnosis of about 70% of the time. Moreover, the specificity of a plain is around 56.5 percent. Or, that means that only just over about half the amount of time will the study give you the correct diagnosis. Not much of an improvement, huh? All this information begs the question, should we use this examination at all for triage for the complaint of general abdominal pain? Probably not!

Who Is Ordering This Study And Why It May Be A Problem

I don’t know about your ED, but at ours, ordering this study has almost become reflexive. As soon as the patient walks through the door, a “midlevel” orders the study. Very rarely is the abdominal series used as initially intended, as a triage tool. And, using the abdominal films for triage is also likely not of much value, with such low sensitivity and specificity. It will misguide as often as it will send you in the correct direction.

So, why do clinicians utilize the study? I have a theory that it is no more than a crutch of tradition. It’s something that some clinicians hang onto because it was the test of choice in the past. And, the less you know, the more you cling onto things. Unfortunately, that leaves the less informed and educated staff to continue ordering the study.

And it is not a “benign test.” There is a significant radiation dose that accompanies it. Check out the list of radiation doses on this RSNA sponsored informational site. Each clinician needs to think about every test they order before they do so. I have a feeling that is not happening!

Does It Help Managing Patient Care?

And, then finally, what happens when the clinicians receive the report from the lowly abdominal series? Is that information used? Well, I hope not! If you buy the previous studies, you will miss most diagnoses if you use it without a CT scan. Given the sensitivity and specificity, I believe the exam more likely increases the expense of healthcare because of false negatives and positives. The abdominal series is a prime example of a test that may cause the caring physician to order more tests than otherwise needed.

Abdominal Series For Abdominal Pain: Is It Like Reading Tea Leaves?

Based on the preponderance of evidence here, I believe it is probably not the best usage of our health care dollars. Sure, it is a quick and easy test. But, quick and easy does not imply cost-effective and useful for patient care. We need to reconsider the use of this unhelpful exam, especially for the general complaint of abdominal pain. It does no more than lead our clinicians astray and increase the costs of health care for you and me.

Posted on January 5, 2020 by Barry Julius

There’s No Substitute For Learning Diagnostic Breast Imaging!

Diagnostic breast imaging is the nexus between screening mammography and procedures. It is that step where a breast imager has already made the screening finding but needs to figure out what to do next before an invasive procedure. So, why do I bring up this point?

At our residency program, we are currently restructuring rotations in the expectation of a newly merged program. And, more specifically, we recently started discussing the breast imaging rotation. So, we are communicating with our residents about the best ways to do so. (Their input is critical!) Recently, I took the chief resident aside to discuss the best way to accomplish this task. In the midst of it all, he stated, “we can just have our residents do screening mammograms and procedures, right?”

I paused for a moment and reflected. Then, I exclaimed, “Uh, no!” Why? Well, herein, let me show you why reading diagnostic breast imaging is, perhaps, the most critical element of breast imaging training. Screenings and procedures alone are not enough!

Mammo’s All About The Management

Unlike other specialties in the field of radiology, the main decisions that we make in mammography are not diagnostic dilemmas. And, the diagnostic mammogram is where the rubber meets the road. Here, our big choice is what to do next. For instance, in a case with a complex cyst, you need to decide between biopsy, six-month follow-up, or MRI. The answer can depend on the context of the breast imaging findings and the patient’s personality. How do you know how to make those decisions? You need to have the experience of what to do next. That’s how!

Off The Cuff Decision Making

With diagnostic mammography, mammographers need to make decisions in a short time frame. You have a patient waiting for your answer as they lie on a table waiting for you to hand down your final decision. With screening mammography, you have lots of time to mull everything over. But diagnostic mammography is very different. It’s real-time. And real-time decision making can be hard. Especially when you have had little practice. Patients can get angry fast if you don’t make responsible and reasonable decisions. It shows!

Management For Mammo Is Very Flexible- Can’t Learn In It A Book

In many specialties, the protocols do not vary at all. Diagnostic mammography is very different. For the claustrophobic patient, you may need to avoid the use of MRI. On the other hand, you may have a nervous patient that would benefit the most from an aspiration because she can’t handle the wait. The only way to discover the appropriate individualized management for each patient is to make those decisions. And, I have never found any book that can adequately describe the techniques to make these decisions. It’s one of those specialties that you have to live to practice!

Need To Learn Appropriate Interactions With Patients

Finally, diagnostic breast imaging is one of those skills that hinges upon appropriate interactions. A patient encounter can go sour very fast if you do not appear competent. How do you address recommending a biopsy with a crying patient? Or, how do you scan a patient with a mass when you don’t know what it is? You learn these patient interactions only when you are practicing the art of diagnostic breast imaging. Skipping this step will surely make life difficult if you practice breast imaging when you begin a new job.

Diagnostic Breast Imaging Training: More Than Just Optional!

To become a breast imager in practice, you can’t get away with reading only screening studies. That will only get you a part of the way to understanding the role of breast imaging for patient care. Additionally, learning technical procedures, although crucial for full-time breast imagers, may or may not need to be part of your repertoire. However, every breast imager must be able to make competent decisions on how to manage patients. And, the only way to learn management is to have practiced diagnostic breast imaging. If you have the choice, don’t skip this step!

Posted on January 2, 2020 by Barry Julius

2019: Best Of Radsresident.com

It’s now the new year, so it’s time to look back at what happened in 2019. And, last year there was no shortage of events that affect radiology training and residents. Therefore, I figured what better time than now to look at the most popular articles from 2019. Moreover, there’s lots of great information to help radiology applicants, residents, fellows, and early attendings alike. And, I don’t want you missing out. So, here is a list of links for the most popular articles written in 2019 and another list with links to the most popular articles of all time in the year 2019! Read through what you didn’t have time to read the last time! Enjoy!!!