Month: November 2020

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Live Second Look Interviews Post Covid: A Permanent Paradigm Shift?

live second look interviews

Nowadays, all radiology programs have migrated to a completely remote online interview model. And I get it. With Covid around, it needs to be that way. Regardless of the reasons, there are a few advantages to Zoom interviews. Especially now, applicants don’t have to waste time and money traveling from program to program. But it’s not all a bed of roses. The remote interview system leaves some significant issues. How do you get a good feel for the program when you are not present? And how do you know about the area around the residency? Here lies the new role for live second look interviews!

Rank Lists Will Be Different With Online Interviews!

I harken back to my interview experience back in the days of the dinosaur! If I couldn’t join the residents at my Brown University residency dinner the night before, I am not sure that I ever would have ranked them. By meeting the program’s capable and happy residents the night before (maybe it was something in the fruit punch!), I changed my opinion entirely. I don’t think I would have gotten that sense if I wasn’t there. My entire rank list would have looked wholly different, and not for the better. All these issues lead me to believe that we may have a significant problem. We have an application pool of residents this year who are applying to programs they might not want to go to but don’t quite know it yet.

So, how can we keep the low cost/time solution of Zoom interviews and allow residents to know the programs they are applying for? I am even thinking about the world post–Covid (yes, I believe that it is coming soon!). Well, the answer is straightforward. The second look will play a critical role as a new paradigm for interview seasons going forward.

The Rejuvenated Live Second Look Interviews

Second look interviews used to be the domain only of borderline or unsure candidates. Please take a look at my previous blog on this topic from 2017 about second looks. I mean, who else would want to return to a place they have already been for interviews? It’s expensive and time-consuming to do it again. Right? 

But, I have a feeling that this paradigm is about to shift in the long run. In the post-covid future, the second look interview will become the shortlist domain, those programs that residents are most interested in ranking highly. At the same time, I believe that residencies will also use this second look to reevaluate the candidate live to make sure that it is the right fit.

Think about it. Instead of going to ten to fifteen interviews or more, now you can go to your top two or three choices. And, you can get to know these programs well. Simultaneously, other programs that applicants are not interested in will not have the pleasure of meeting the resident. It makes a lot of sense because most applicants get one of their top three choices anyway. And now, applicants no longer have to waste as much time and money on interviews as they did before Covid.

Live Second Look Interviews Will No Longer Be Optional

So there you have it. The second look interview, I predict, will no longer be the domain of the few. It will become the tool for most residents to make sure they make the right choice for four years. Choosing a residency can be difficult. There is no reason you should make that decision without getting all the information you can. Think about taking a shot at a second look!

 

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How To Be Successful In MSK Imaging

successful in msk imaging

We’ve been through the first two parts of the how to be successful series, nuclear medicine, and breast imaging. Part three, today, is all about how to be successful in MSK imaging. Like the previous weeks, I will talk a bit about the reading materials for this rotation and discuss when you should learn what. All the text links to books in this summary will lead you to Amazon, where I am an affiliate. Afterward, I will give you some more final thoughts about MSK imaging in general and how you can succeed in this rotation.

MSK Reading

MSK reading is a bit more varied than some of the other rotations and more decentralized. Different books are better than others for various topics. Because you need several different books on this rotation, it can be a bit more expensive. If you can try to borrow some of the books, you can save a bit of money. But if you decide to purchase them, they are good references to have nonetheless. Either way, using multiple books on this rotation will be much more efficient for studying MSK than using just one because no one book is comprehensive and intelligible enough for both the core examination and real-world practice.

In the following sections, I will divide what you need to read by each year of MSK. We will cover the following topics: trauma MSK, arthritis, musculoskeletal MRI, bone tumors, and other miscellaneous topics like musculoskeletal ultrasound.

First Year

First, you need to learn bone and joint plain film anatomy. So, in the beginning, especially, you will want to know about normal anatomy to get a better sense of how the different sorts of fractures look. If you are a first-year resident, review your anatomy books again from medical school (i.e., Netter’s or a cross-sectional atlas like Cross Sectional anatomy CT & MRI). You will then want to start with a book of the basics about common types of fractures, especially in an emergency setting. One of the resident-recommended books for this stage as a first-year resident would be the Fundamentals Of Skeletal Radiology. I used something similar many years ago. This book gives you some of the essentials of what you will need to know.

First Or Second Year

After knowing the critical information about MSK injuries, you will want to continue staying on the plain film theme and learning the arthritides. This topic is more about outpatient MSK imaging, but it is also critical for learning to become a consummate MSK imager. One classic book that I found very helpful is the book called Arthritis in Black and White. It is a classic, but it briefly summarizes the findings and distributions of different types of arthritides with pictures to help you out as well. You can read this one also during the first year of MSK or early in your second year.

Second Or Third Year

As a second and or third year, you also need an intelligible MRI MSK book that will give you all you will need to understand and interpret MSK MRI, a common area of difficulty in residency because of lack of exposure. Be careful not to buy the wrong book because many books make this fairly intuitive topic into something more complicated than necessary. So for this subject, check out Musculoskeletal MRI. I found this book “way back when” to be an excellent source for elucidating MSK MRI’s mysteries. It was one of my all-time favorite books in radiology because the author’s style is easy to read and logical. My residents still like it to this day.

Final Year

Finally, toward your last rotations before the core exam, you need some resources to fill in the blanks like bone tumors and MSK ultrasound. For these topics, many residents will look at MSK Case Series Review. Cases are the key to knowing the different types of bone tumors. If you want a more generic overall summary of these miscellaneous topics, you can check out the Musculoskeletal Requisites book.

All Years

Be sure to use a reference tool to check out normal variants, especially for the bones. Have a copy of Keats Normal Variants Atlas available when you read cases. You can also google your images, but it is easier to have a normal variant book handy. I often use this book when I am unsure if what I am seeing is pathological or normal.

Other Thoughts About MSK Imaging

In MSK imaging, especially, you need to be a little more definitive than other areas in radiology. If you see a fracture, call it a fracture. Don’t beat around the bush. You will find that Orthopedists and Emergency Physicians alike will need your final diagnosis to make their final treatment plans or surgeries. So, saying that you are not sure won’t cut the mustard unless, of course, there is real uncertainty in what you see on imaging.

Also, try to get to know your Orthopedists and ER physicians to determine how your calls correspond to what they see clinically or in surgery. Or, even better, examine the patients yourself after making a call. It is a great way to get to know if your diagnoses are correct.

And finally, for those who don’t have as much exposure to MSK MR, I would try to look at the cases that your attendings read on your own time. Then, compare your conclusions based on the history and images to the dictations of your attending. It’s a great way to learn what you need to know.

How To Be Successful In MSK Imaging

To become successful in MSK imaging, you need several ingredients. First, you need the right books (unfortunately, a lot of them for MSK!). It would then be best if you had the right attitude (coming down a little bit harder on diagnoses than some other subspecialties!) And then finally, you need a good point of reference for your calls (correlate with your patients, ER physicians, and Orthopedists.) If you utilize these resources, you are bound to become an excellent MSK imager!

 

 

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Failed Course And Switched Schools: Is It Possible To Get Into Radiology Residency ?

course failure

Question About Failed Course And Acceptance To Radiology Residency:

 

Hello Dr. Julius,
I am an applicant for this year’s DR residency cycle. I’m in a unique position and would value your opinion. I began medical school at a DO program but am now graduating from a foreign MD program. In essence, I was not able to satisfactorily perform osteopathic manipulations. And, I couldn’t pass the final lab at the end of year 2. Instead of repeating the year, I transferred to an offshore school with US-based rotations on my original four-year timeline for graduating.

Nonetheless, I have otherwise satisfactory pre-clinical grades, clerkship scores, and decent board exams, without any other failures or professionalism concerns. My failure of the class and switching school is a large red flag in my profile. I’m very candid about all of this in my application but would like to know your initial impression as a program director if this scenario came across your desk.

Thanks for your time!

 

Answer:

Unfortunately, I have to say that you will have an uphill battle after your failed course, not to say that getting into residency is impossible. One of the red flags that most radiology residencies look for is why you have changed schools. And, if you couldn’t pass a particular class, most residencies will want to know why.

In radiology residency, you will need to perform procedures in interventional radiology and body imaging. You will need to develop a reasonable explanation of why you can perform these technical procedures competently even though you had a failed course of osteopathic manipulation. Maybe, you can demonstrate that you performed well in another technically based rotation and get recommendations in that area. That would certainly help your case. Nevertheless, your goal should be to explain to residencies why you can safely complete procedures, especially since that seems to be the reason why you were unable to complete your DO degree.

Hope that helps a bit,
Barry Julius, MD

 

 

 

 

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How To Be Successful In Breast Imaging

successful in breast imaging

In the second part of the “how to be successful” series, we will walk you through the ins and outs of the breast imaging rotation. Breast imaging, in general, is much different than almost any other area in radiology. (except for some interventional radiology) Why? Because the whole subspecialty hinges on management instead of differential diagnosis. Differentials are usually relatively limited and easy to remember. The challenging part of becoming successful in breast imaging is deciding what to do next. (As long as you don’t miss the finding!)

Also, there are multiple shades of gray in this area of radiology about how to manage patients appropriately. And, it takes a whole heck of a lot of experience to get good at it.

In any event, just like last week, let’s run through what you should read, what and when you should study the appropriate topics, and then finally how you should tackle learning for each year that you are on the breast imaging rotation.

Reading

First of all, I would highly recommend that you check out the free material from the ACR BIRADS atlas on the web. Here, you will get the most up-to-date resource to understand how we dictate breast imaging cases. Additionally, you will learn the appropriate semantics for all sorts of calcifications, masses, etc. I would also advise you to look for a copy of the paid atlas to see each of the different descriptors and associated findings. (see if you can find one lying around in your residency program because they cost 250 dollars!) These sources are the best way to understand the mechanics of reporting breast imaging modalities.

Furthermore, you should also have a supplemental reading to understand the rest of the gritty details about breast imaging. My residents have recommended Breast Imaging, the Requisites (I am an affiliate of Amazon for purchases when you click on the link) to do just that. Although reading during this rotation is required, it is a little less critical to function as well than some of the other radiology areas because it is so “experience-based.”

When To Study Topics In Breast Imaging

First-year

During the first year of breast imaging, I would recommend that you stick to reading out mostly screening and diagnostic breast imaging cases while reading the above resources. Why? It would help if you got acquainted with the basics of breast imaging. The basics include positioning/views, artifacts, searching for findings, and breast imaging’s basic mechanics. Try to hold off on doing too much interventional breast procedures until you are well acquainted with the imaging. You can check out a few to get your feet wet. However, the interventions may not make as much sense because most radiologists make the initial screening and diagnostic imaging findings to get to the intervention point. And, you need to understand these modalities first. You will benefit a lot more from understanding all the interventions better later on.

Second-year

Toward the end of your first rotation or beginning of your second rotation, try to be the initial reader on diagnostic mammography cases. Be in the position of deciding on the additional views and then run it by your attending. In mammography, the only way to learn is to handle parts of the cases yourself. If you don’t take charge, you will miss a good portion of the key to breast imaging- management. Also, be sure to enter the ultrasound room for all the breast ultrasound cases possible. Scanning patients will help you learn how to find lesions and what to look for when you find a mammography lesion.

Final residency years

For your subsequent months of mammography, you should make sure to learn how to perform stereotactic breast biopsies, needle localizations, and ultrasound guide breast biopsies. Also, this is the appropriate time to learn the basics of breast MRI. Breast MRI has become an integral part of imaging in the breast imagers arsenal. You need to understand its place and the basics of how to read them. Again, check out the ACR-BIRADS book for the reporting of MRI findings.

Finally, during your last year of mammography, learn all the new “fancy-schmancy delancy” add-ons. Learn about breast MRI biopsies, PEM imaging, or other modalities that may be unique to your institution. At this point, you want to fill in the blanks. Also, make sure that you have a mammography rotation during your fourth year of residency because the mammograms you read count toward MQSA requirements when you start reading mammograms after a one-year fellowship.

How You Should Learn Breast Imaging As A First Through Fourth Year Resident

More so than other specialties, breast imaging is not a “spectator sport” (a quote from my former chairman during my residency!). It involves being proactive in getting the experience that you need. Moreover, there have been a host of studies, specifically for mammography, that show you need to read tons of images to become an expert in breast imaging. So, you will have to be aggressive to get the numbers that you need to be successful in breast imaging. Not all residencies provide the same training in mammography, and some have significantly fewer cases than others. Therefore, this is a critical piece of the pie that you will need to become a consummate breast imager.

The Basics Of Being Successful In Breast Imaging 

To summarize, what are the critical factors in learning how to become an excellent breast imaging resident and future attending? Ensure that you read the BIRADS atlas and a supplemental book such as Breast imaging, the Requisites. Start with reading screenings, ultrasounds, and diagnostic mammography. Then, when you are ready, take charge of your cases independently. Perform and learn about interventional procedures a little later. Then finally, fill in the blanks during the final years. 

Also, I cannot repeat enough how important experience is for the breast imager. Writing down that you have seen “x” number of cases is not enough in the world of mammography. Make sure that you are looking carefully at each breast image. It is only with experience that you will feel competent enough to become a breast imager when you complete your residency. And, the best breast imagers have seen tens of thousands of cases!

 

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How To Be Successful In Nuclear Medicine

successful in nuclear medicine

For the next several weeks (and possibly months), we will start with a new theme: how to be successful in each of your subspecialty rotations. (and of course, today how to be successful in nuclear medicine!) Why should I even bother to tackle this theme? I mean, most residency programs have some guidelines about what residents need to do each month. Well, I can tell you that most of the time, these guidelines are only set up as a way to satisfy the needs of the ACGME and may not be all that relevant to what you need to know. Often, they are very boilerplate and merely copied from one institution to the next. Moreover, these summaries are “oh-so-boring” to read and likely outdated. Additionally, I aim to give this a bit more entertainment value (as I usually do!) and provide some more relevancy to what you actually should do on your rotations. 

To organize this series, I am going to mirror the subspecialty rotations at our institution. At Barnabas (my humble program), we have a mix of modality and organ-based rotations. Now, you may ask, how can this be relevant to your situation if your program arranges your month slightly differently? Well, regardless of how it’s sliced and diced, you can infer many of the same themes at your institution. The information is still here to help you out. These include the books you need to read, how you should learn the material during each year of residency, and the actions to succeed in your rotations.

So, why start with nuclear medicine? Well, for one, it is my area of expertise. And, of course, what better place to start than my home base?

What You Should Read

Hands down, there is one resource that I like the most. It used to be Nuclear Medicine, The Requisites (which is OK). But all that has changed since the newest version of Mettler. (I am an affiliate of Amazon if you decide to click on the links and buy them!) I found Mettler to be comprehensive and reasonable to tackle. It was straightforward to read when I had to study for my recertification examination in nuclear medicine/radiology. Also, it covers most of the nuclear medicine topics. And I believe that is an excellent way to go.

When To Study Topics In Nuclear Medicine

During that first year of nuclear medicine, you need to first start by concentrating on the studies that can kill patients or cause severe morbidity if you miss something. What are these sorts of cases? These include V/Q scans (you don’t want to miss pulmonary emboli). Then, check out myocardial perfusion scans (you don’t want to miss ischemia from a left main coronary artery widow-maker lesion). Go through GI bleeding scans (you don’t want your patients exsanguinating). And finally, read about renal transplant scans (missing dying kidneys).

Then, next, you need to study what is most common when you’ve covered these bases. Of course, what occurs frequently can vary somewhat from institution to institution. But, for the most part, we are talking about bone scans, hepatobiliary scans, infection detection studies (gallium, indium-WBC, and Ceretec-WBC), and iodine scans for thyroid disease. Or perhaps, your institution may specialize in procedures such as parathyroid adenomas (as we do at ours). The bottom line is that you should study what you see most often to communicate intelligently with your attending.

Finally, you should study everything else. And, in nuclear medicine, that can be a lot. But, the core exam will pretty much cover most of nuclear medicine. That includes anything from PET-CTs of all types to DAT SPECT studies to evaluate Parkinson’s disease (or even the rare salivagram!) This order should allow you to be successful in your successive nuclear medicine rotations.

How You Should Learn Nuclear Medicine As A First Through Fourth Year Resident

First Year

Try to sit with your attending as much as possible at the beginning. Get a feel for what your faculty dictates and why. Then, without much further ado, be aggressive and ask to dictate cases as soon as possible on your own. Why? Because you want to convert what your attendings are thinking into a viable and logical report. That is what we do as radiologists. Without this skill, all your learning with be for naught!

Also, try to spend a little bit of time with the technologists. See how they operate the machinery. Check out how the patients undergo stress tests. Watch how the cameras work. All this observation is essential for understanding how technology translates into clinical operations and patient care.

Second and Third Years

During these years, you need to become a bit more independent. Now that you know some of the basics, you should try to pre-dictate cases even before the nuclear medicine attending arrives on the scene. Grab that bone scan and give it a whirl. What’s the worst that can happen? You will miss a few findings and learn something!

Fourth Year

Instead of only concentrating on the less complicated material, try learning the nuts and bolts of some more esoteric studies. Also, be sure to understand how the software works. You might need it at your first job. For instance, ask how your attendings process the PET-FDG brains for quantification. Or, maybe you should try to interpret some of the more arcane PET scans like Amyvid, Axumin, and Dotatate. Bottom line: this is your last chance to learn nuclear medicine before starting your fellowship. Maximize what you know before it is too late. You don’t want to be struggling with nuclear medicine’s nuances when you take your first job if they assign you to tackle that specialty.

The Basics Of How To Be Successful In Nuclear Medicine

Let’s be honest. Nuclear medicine is not the most formidable rotation of all. (A little biased coming from a nuclear guy!) Or, what I mean is that you are usually not worked to the bone. However, it certainly has its challenges.

To summarize, I would concentrate on those studies that have the most clinical impact first, dictate soon after starting, spend some time with the technologists, and be somewhat aggressive and attempt to preview and dictate studies when you are ready. This targeted approach is how I would proceed if I were starting anew. These guidelines can give you a bit of a boost when starting out and give you the tools to be successful in nuclear medicine. Go for it!

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Pros And Cons Of Emergency Radiology!

emergency radiology

Question About Emergency Radiology:

 

Hi Dr. Julius. I have recently developed an interest in trauma radiology. I like it because I would get to work from anywhere. And, I don’t have to deal with patients and people in general, aka no tumor boards (I’m an introvert). Moreover, I read somewhere that there is a significant demand for fellowship-trained emergency radiologists. The salary is on par with other specialties, although I don’t understand how they can track RVUs for an emergency radiologist. I was wondering if you can discuss the CONS of the job. I know it is a one-week night float system with two weeks off (which I love). The night shifts are long, from 10 to 12-hour shifts. Maybe malpractice is higher? But I am not able to think of any other CONS. My ideal job would be a private practice in a suburban area (not in a big city). Would you recommend doing a dedicated emergency radiology fellowship or instead do an MSK/Neuro fellowship focused on emergency? The residency I am in gives an EXCELLENT exposure to body trauma causes.

Kind regards.

Answer:

So, what do I think about emergency/trauma radiology? Well, to start, let’s first say that the job can vary widely from one worksite to another. If you are doing teleradiology ER work, that is very different from an in-house radiologist. To say that it is an excellent job for an introvert also depends on what your job entails. I know some trauma radiology jobs that need extroverts to present cases to the emergency department, highlight their research, or examine patients!.

Night Work

Night shifts can be a bummer for some folks. (I found it a little quiet and depressing during my residency) For others, it can be the ultimate in convenience (imagine being able to go shopping at 11 AM when no one is there!). 

My Take On Emergency Radiology

Although what floats your boat can differ widely between you and me, I never really had a craving for trauma type cases. I found them a bit more repetitive than cancer or a rare disease. But, I came from a level one trauma center during my residency, so I had extensive exposure to the trauma experience (perhaps too much!)

Fellowships For Emergency Radiology

Regarding what to study to become an emergency radiologist, I would consider the MSK/Neuro route. Why? Because it gives you a bit more flexibility when you go out and find a job. You can become an emergency radiologist with those specialties under your belt. But, you can do other work in general radiology and some subspecialty work as well. From my experience, trauma radiology is more comfortable to practice, and almost anyone can do it. On the other hand, Neuro and MSK work is a bit more subspecialized, so I like that option as a fellowship a little bit better. (unless you want to do academic ER radiology as a career choice.)

 

Those are some of my random musings about emergency radiology!

 

Regards,

Barry Julius, MD

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What Are The Consequences Of Postponing The Core Exam?

postponing the core exam

It’s no surprise that the ABR decided to delay the core exam. For years, they were unwilling to go virtual, even before Covid, claiming they needed their computers at the RSNA to give an appropriate “image-rich” examination. And, then, of course, they were not prepared at all when the Covid disaster struck. How do you force over a thousand residents to go to Tuscon or Chicago to take an exam amid Covid? In any case, now, this is water under the bridge. So, what are the real consequences to the current fourth-year residents of postponing the core exam? Will the damage be permanent? Here are some of my thoughts on this issue.

Less Time For Mini-Fellowship Studies

Mini-fellowships have been all the rage since the conversion from the oral boards to the core exam. One reason for this change was more time for residents to dedicate toward more independent learning during the final year. No longer did they need to study for a board exam at the end of the fourth year. Well, now this has mostly changed. Since the examination will be in February, you lose most of your fourth year for studying for the core exam again. (almost like the good old days of the oral boards.) Likewise, the time residents can concentrate on subspecialization without worrying about an exam will suffer.

More Time Spent On Learning Facts Of Equivocal Utility

It’s taken eons to get to the point I am today. I have spent years trimming the useless radiology facts from my brain and concentrating on what is critical. Now, the residents will begin this process a bit later than before. They will regurgitate some of the less useful information at the expense of the critical information needed to become a practical radiologist for several additional months. It’s having completed the core exam that would have allowed this process to begin earlier.

Postponing The Core Exam Will Cause A More Anxiety Filled Year

Residents will continue to spend the majority of this year in the “what-if” phase. What do I mean? They will continuously think about what will happen if they don’t pass the examination. A clear, calm head is much more conducive to enjoying the experience of residency. Test-taking prevents the settling down process.

Less Time For Gearing Up For Fellowship

Some residents like to begin to get ready for their next phase of training. That may mean reading a bit extra on their favorite subspecialty. Or, they may spend time practicing the nuances of bone biopsies if they are going into MSK. Now, residents will be less apt to increase their experiences in their future areas of interest. It’s much harder to concentrate on other topics when a test looms ahead of you.

Missing Out On The Full Fourth Year Experience (It’s Now A Four-Month Experience)

Finally, residents no longer receive the authentic fourth-year experience (However, I never had that as I studied for the oral boards!). It was kind of like an unwritten promise that you will have a great last year if you complete and pass the core examination. Now, it is back to the grind for the majority of the year.

Postponing The Core Exam: Is It The End Of The World?

The short one-word answer to this question is NO! However, for every action, there is a consequence. And postponement of the exam is no exception. After a tough three years, it is a bit of a slap in the face for residents. Many of you have paid to have a great fourth year of residency with blood, tears, and sweat (literally!), working diligently during your training. “Fourth-year” will now only last a few months after the exam.  

Nevertheless, remember, in the end, all of you will still become radiologists. Life always throws a few curveballs. And, your residency will become no more than distant memory soon enough!