Month: December 2020

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Will Mini-Fellowships Replace Fellowships?

mini-fellowships

Question About Fellowships And Mini-Fellowships:

Hello,

Why is it that it is practically required to do a fellowship these days? Is there no value in being a general radiologist?

With many residency programs now moving towards offering “mini-fellowships” at the end of R4, could this trend change?

Sincerely,

Future Radiologist

Answer:

As you hinted, fellowships are not technically required, but they are very desirable. Why? Because most groups want someone that can help out with the studies that most others in groups cannot do. It could be interventional work, breast MRI biopsies, or high-end neuro cases. However, groups also want radiologists to be able to perform some general work. So, having the accompanying skill set of a general radiologist is very desirable. These are the most wanted radiologists, and you can call these sorts of radiologists generalists even though they have a specialty skill set. You will be sure to find an excellent job in this situation.

However, it is still possible to find work without a fellowship as a true general radiologist, especially in less popular places such as rural places in the USA. Herein lies the problem: If and when the job market changes, having no fellowship can put you in a bind if you decide you want to leave and find a job in more competitive parts of the country. So, my recommendation is always to do a fellowship just in case. It is for only one year.

Finally, mini-fellowships in a residency are excellent opportunities. But, they usually don’t provide the same in-depth dive into the subspecialty as a true fellowship. Usually, the mini-fellowship also lasts several months instead of a full year. So, I don’t see the trend of completing a full year fellowship changing so fast with the advent of these mini-fellowships. Furthermore, mini-fellowships have been around for five or more years. And, full fellowships remain much more desirable for practices than a few mini-fellowships during residency. Once again, if the job market changes and you only have mini-fellowships, you will be at a disadvantage. 

Great question,

Barry Julius, MD

 

 

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How To Succeed In Interventional Radiology

interventional radiology

No. I am not an interventionist by any stretch of the imagination. But I do have a clue about how best for you to succeed in this rotation. Let’s call it years of experience and intuition based on our interventional radiology rotations’ best residents. On this note, we will return to the How To Succeed series this week again, this time in Interventional Radiology.

When we compare interventional radiology to other subspecialties, it has less in common with other radiology areas. Why? Because it overlaps more with many of the features of other surgical subspecialties. So, it would help if you changed your mentality to succeed on this rotation. Let’s delve into what you need to succeed on this rotation and how you can adapt to the new expectations. First, we will discuss reading materials and the basic mechanics of what you must do. Then, we’ll talk about when you should learn the different aspects of interventional radiology.

Reading Materials 

Fortunately for some and unfortunately for others, reading plays a little bit less of a role in this subspecialty rotation in the traditional sense. Of course, you must read about cases and how to perform them. But, most of what you need to know for this rotation is experiential. For example, using the wires for a fistulogram is the best way to learn about them. The most salient way to understand the angle you need to use to approach a liver biopsy is to do it.

No amount of reading will allow you to translate everything you need to know to a successful procedure. You need to watch, perform with guidance, and finally complete a technique independently. There is almost no way around it. Therefore, your goal on this rotation should be to get into as many cases as possible.

Background Reading

Even though reading is not the central focus of this rotation, I will give you some background reading resources that some of my successful interventional residents have used. These include readings in the newly written book Vascular Interventional Radiology- A Core Review. Our residents also use Core Radiology and the Vascular and Interventional Case Review Series. Finally, one of my former residents (now an interventional resident) recommended looking at a book called Image-Guided Interventions. This book would be more for the gung-ho budding interventional radiologist, but it is another option. You can click on any of these Amazon links to purchase these books (I am an Amazon Affiliate and get a small percentage).

Other successful residents will google all the devices, wires, and other hardware every time they use one. All successful residents will look up information on significant cases the day before they perform them if they can!

Fundamental Doctrines Of Interventional Radiology

Here are some general guidelines for interventional radiology residents to maximize their interventional radiology experience.

Consent All Patients Early

Every single one of my successful interventional residents has said the same thing, “You need to make sure to consent patients as early as possible before a procedure!” If you cannot consent your patients before the procedure, you will not have the appropriate history that you will need. And your prep time will be taken by having to consent these patients. This consenting process will interfere with your getting into other procedures during the day. And a vicious cycle ensues. What does this mean? It would help if you got up early to start the process before the day’s procedures begin. There is no way around this!

Build Trust With Your Attendings

In interventional radiology, you will need to build trust with your faculty more than in almost any other specialty. And the reason is self-evident and straightforward. These radiologists are the key to allowing you to do more and get more “hands-on” experience. If a faculty member does not trust you, you cannot perform procedures. So, listen carefully to what your attendings have to say. And follow their instructions. Most importantly, do not forget to do something that they ask. I guarantee that being lackadaisical will ruin your entire experience!

Get Into As Many Interventional Radiology Cases As Possible

If you want to perform well in interventional radiology, your days will be non-stop. You will need to get involved in almost all the procedures you can. The experience counts, and there is no way around it. Why? Because to understand how to complete cases, you need to see and do them. You do not want to become an attending and perform a manual procedure you have never seen or performed!  

Therefore, you may not want to pause in the break room for too long for this rotation. There is time for that when and if you become an interventionist. Now is the time, however, to keep the department moving so that you can get into the next case! So, help get patients in and out of the department, take histories, and get consents. It’s the only way to maximize your case time!

Read The Night Before

Finally, any interventionist worth their salt will tell you that you must read about the procedure and the disease entities the night before. Look up the disease entity, the history you need from the patient, the technique, the wires required to complete the procedure, and how to finish it. You will enjoy what the interventionist is doing more the next day because you will understand the whole process. Furthermore, your attendings will be impressed with all that you learned. Even though you may be exhausted the night before, you should never skip this step!

Guidelines For Each Year Of Interventional Radiology

Year One

Just like surgical interns, you need to know the basics before getting heavily involved in the procedural aspects of interventional radiology. The first year is the best year to learn how to consent, take an appropriate interventional history, make orders, do tube rounds, and discharge patients. You need this background to get to the next step! 

Of course, many of you will get to start doing some procedures, but there is a lot more to interventional that you need to know. As a background for the rest of your time in interventional radiology, you should learn all these other tasks in your first year. Reading about procedures or learning about cases the night before is also vital, even though you may not get to help out as much with the manual techniques this year.

Years Two And Three

You should learn the “bread-and-butter” interventional radiology procedures during these two years. Get involved in biopsies, PICC lines, catheter placements, and nephrostomies. These are the procedures your attendings will allow you to do more, especially if you have established their trust. And you will build up your repertoire slowly. You should be able to perform these procedures as a general radiologist when you leave residency. Make sure to learn them well and execute them many times!

Year Four And Beyond

Year four is the time to get involved in the bizarre, complex, and engaging. Help with oncology cases, stent placements, uterine fibroid embolizations, and neurointerventional procedures. Get a sense of some of the more intricate techniques. These rotations may be the last time you will see the more esoteric aspects of interventional radiology. But the experience will be invaluable!

Completing Your Interventional Radiology Rotations Successfully

Anyone who says their interventional experience was easy will probably not maximize their opportunities to learn the subspecialty. To understand what you need to know and be successful, you should be busy in interventional radiology. You should actively take histories, consent patients for procedures, read up on patients/diseases, and get into as many cases as possible. There is no way around it. Experience is the crucial element of this subspecialty, and you desperately need it to succeed. You can not get ahead by sitting back on this rotation. So, take advantage of the opportunities that your residency affords you. Regardless of whether you go into interventional radiology as a career, this experience will go a long way in making you a well-rounded radiologist!

 

 

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What Makes The Ultimate Radiology Job?

Recently, I received a question from one of my readers about the ultimate radiology job. What kind of job would it be? I was about to spit out the dull answer: there is no perfect job for everyone, which is true. However, I thought about this question more deeply. I figured I could get a little more down and dirty because there might be a perfect job for a specific person. So, I will do just that. 

Let’s talk about the ideal job for three different particular kinds of radiology personalities. The first would be the perfect job for the lifestyle radiologist. The second would be for the academic radiologist. Finally, the third would be the money-loving radiologist who wants to pay off all their debts as quickly as possible. At the end of each description, I will give you what I think would be a reasonable but high-end salary for the job I describe. You can’t have all the lifestyle features with all the money. And, you can’t be hardcore academic and always have the best lifestyle. But you can find a radiology job with at least one of these features!

Lifestyle Radiologist’s Ultimate Radiology Job

Optimal Working Time

Picture this. You get up late at 10 am without a furrow in your brow after taking a stroll with your dog down the street. Afterward, you return home and start working at 11 am at your own pace. You encounter nary an interruption. After a few hours of work, you have had enough for today. So, you take a shower and plan your next vacation to Thailand. Of course, you have 16 weeks of vacation per year, so finding time for this next adventure is not too difficult. You spend a leisurely dinner with the family, and the day ends smoothly.

The next day, you get up a bit earlier because you had gotten more than enough sleep the day before. Today is your day to come to work. Out of every three days of work per week, you stay at home one day, the other one you come in for, and the third is a miscellaneous day to catch up on the practice’s studies in no particular place and without hurry.

Friendly Practice Situation

As you arrive, all the techs and nurses greet you excitedly and are happy to see you. You are well-liked in the imaging center. Because of the complexity, you start reading through interesting films in your subspecialty that no one else can read. Of course, there is a smattering of normal cases every once in a while in between. Lunchtime finally arrives around noon. You meet with your colleagues for about an hour and go to a fancy restaurant to chat and enjoy the lunch break like you do when you go to work. You return to work unrushed and unfettered, in no rush to complete the rest of the day because you could always finish the rest some other time. 

The following day, the last one of the week, you help the practice catch up on occasional studies. You log on from home and leisurely read your cases. You make a few phone calls and complete your day’s work in a few hours. Of course, you may not get paid like other radiologists who do more. But the time off is worth it!

Radiologist Pay:350,000 dollars

Academic Radiologist’s Ultimate Radiology Job

Out of every five days of work, you have three full days to work on your academic research. Of course, that does not include the eight weeks out of every year that you receive paid speaking engagements or have time for continuing medical education (CME). Moreover, you have the support staff that most others can only dream about. These include two statisticians, a research coordinator, and your secretary. And you have the software and backup to quickly garner the resources to create well-sourced papers at the drop of a hat. Additionally, you have the administration’s help to obtain grants from private and public sources. This help includes multiple connections that overcome many hurdles other academics may encounter. 

Then, you have several days every week to resume clinical work. But, you have the help of your resident, fellow, and junior attending. They do most of the dictation; you get to edit and sign off on their reports. Your residents, fellows, and observers also do much of the work to help you create your following research paper. 

Also, you have easy access and collaboration with multiple specialties throughout the institution. No one is at each other throats. Everyone is willing and able to help each other to come up with great ideas for projects. It’s an environment that fosters learning and research.

Finally, you have already accumulated tenure at your institution. There is almost no way that you can be “canned.” You have put in the time, and the work has paid you back. 

Radiologist Pay: 550,000 dollars

Money Loving Radiologist Ultimate Radiology Job

This radiologist is willing to work as hard as it takes to repay all their student loans as quickly as possible and accumulate enough income to retire as soon as possible. That is the prime goal of this radiologist. And they have found the job they need to meet this goal. 

First, they found a job where the practice pays them precisely what she is worth for each case, plus a stipend from the hospital because she is in a somewhat underserved location. Her days are busy, but they go by fast. They read 200 cases daily, and the caseload is light on findings but large in number. Fortunately, she also works in an area where the case complexity is relatively low and the payer mix is quite high. Of course, they don’t take much of a break during the day, but they work hard all day and reap the rewards.

They also have the backup they need to increase speed regarding radiologist support. These include radiology assistants, a fabulous computer IT department, and an excellent dictation system. They work five days a week, and she gets paid a lot of extra money when they work on the weekends. But most critically, they can do that when they want. Finally, they get lots of vacation, but only take a few weeks out of the year to go away because they don’t want to do this job for the rest of their lives. She would rather have the cash instead. 

Radiologist Pay: 800,000 dollars

The Ultimate Radiology Job- What Do You Think?

You may or may not think that any of these jobs sound great. And that is OK. However, these scenarios are perfectly reasonable for these individuals and can present an ideal situation for these individualized career paths. Let me know if you have an idea for the perfect job, and I can devise another scenario for you!

 

 

 

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How To Keep Up The Momentum For Residency?

momentum

 

Question About Maintaining Momentum For Residency

Hi Dr. Julius,

I’m a first-year DO, and I am just finishing up the final exams for the first term. I’ve done very well so far and am on track to be near the top of the class, if not first (Though it is just the first term, much can change). I’ve had a strong interest in radiology before medical school, much of it due to my physics background as an undergrad.

I wanted to ask, how can I keep the ball rolling to make for a successful radiology application? I’ve heard conflicting answers about research. Some say that research isn’t as important in the eyes of PDs, but most of that advice I hear is towards MD candidates and may not necessarily apply to me.

I have two publications from undergraduate in my specialty field of physics. Still, I am a little lost on finding opportunities in radiology research, given that my school does not have a radiology department. Is it unprofessional to reach out to nearby departments to see if residents have any ongoing projects?

The Momentum Chaser

Answer About Maintaining The Momentum:

Hi Momentum Chaser,

I’m glad to hear that you are starting your medical school on the right foot. However, remember that the first couple of years are very different from your school’s clinical portion. Many students who do well during the first two years do not repeat the same grades when they make it to the clinical years when the medical school evaluates you on some of your softer skills. (Although some do) So, try to play nice in the sandbox to keep the momentum when you get to your clinical years!

Importance Of Research For Residency

Regarding research, the importance of it to residency programs differs widely depending on where you apply. And, I don’t believe it changes anything if you are DO or an MD. Some highly academic programs rely on their residents performing research during the four-year residency program. So, a Mass General type of program is going to want to see lots of research. On the other hand, a community program will not care to the same extent about the research you have conducted already. They will worry a lot more about having a good quality clinical resident. Specifically, they want one that can handle the overnight call and the residency workload. So, the answer to your question about the importance of research is it depends.

What To Do If Your School Doesn’t Have Radiology Research Opportunities

To answer your last question, it is certainly appropriate to ask other departments within your school or other sites for ongoing research opportunities. You may also want to consider finding a project within your school that may overlap with radiology, although not radiology specific. For example, there may be an internal medicine project that requires some imaging. I mention this because it can be more challenging to find projects outside your institution (although possible). To also answer your question, it is also professional and appropriate to ask about projects in nearby departments. It may be helpful to continue the momentum for your application and career!

I hope that helps a bit,

Barry Julius, MD

 

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Is There A Link Between Jigsaw Puzzles And Being A Good Radiologist?

jigsaw puzzles

Putting together jigsaw puzzles is one of those hobbies that residents love to add to their ERAS resume, especially during Covid. What better way to spend your time when you have been quarantined in your apartment, right? To give you an idea of how popular jigsaw puzzles have become, out of every five or ten applications that I review, I see one that briefly mentions this pastime. Presumably, therefore, residents must think that jigsaw puzzles must have something to do with the practice of radiology.

To help me find the connections between radiology and jigsaw puzzles, I did a brief internet literature search to see what I could find on this topic. But I couldn’t find much. Let’s sort out for ourselves how strong the correlation is between the love for jigsaw puzzles and the ability to practice radiology. The connections, or lack thereof, might not be as apparent as you think!

Where Jigsaw Puzzles Overlap With Radiology

Understanding Geometry

You must have some knowledge of geometry when you have a three-thousand-piece puzzle. Why? It is almost only possible to complete the puzzle by recognizing the pieces’ asymmetry and how they fit together. It is a fundamental skill that radiologists also need. In what form? Well, our eyes always look for symmetry. Whether you look at a head CT or a chest film, many modalities require the reader to check for symmetry of density or contours. Therefore, there is some overlap with the jigsaw puzzle.

Methodicalness

To complete a jigsaw puzzle successfully, you need some strategy to get there. Most puzzle aficionados will begin with the corners and work their way to the edges. They could sort the pieces by colors or design to find the most likely candidates to fit together. Regardless, it is only possible with some organization to get to the end goal of completing a three thousand-piece puzzle or more. Likewise, all radiologists need some search pattern on any image to glean all the critical information from a film. If they forget to look at the spleen on a CT scan, you may miss a critical finding, such as an infarct, that could have helped you make the final diagnosis. This characteristic of jigsaw puzzles is also vital for the radiologist.

Doggedness

Finally, it would help if you had some tenaciousness and grit to get through that puzzle of thousands of pieces. It is just impossible to complete a jigsaw puzzle without that personality characteristic. It means sitting down for hours staring at the construction site, trying to mix and match multiple pieces. You can only achieve your final goal of a completed puzzle after putting the time in. Radiologists must also realize that they must read for hours and go through thousands of films to become a master or a radiology expert. Without putting in all this time, effectively practicing radiology is next to impossible.

What Being Good At Jigsaw Puzzles Doesn’t Mean

It Doesn’t Mean You Can Make The Findings.

Sure, you can put together that picture of a grassy knoll or a freeze-frame photograph of your favorite show with 4000 puzzle pieces. But, it doesn’t mean that you will necessarily make that finding of the mouse sitting in the corner of the grass or the misspelled t-shirt on your favorite character. All it means is that you can combine a picture from many fragments because the colors, patterns, and shapes fit together. Finding the little details within the image is a whole other skill!

Baseline Knowledge

Being good at jigsaw puzzles does not mean you necessarily understand the topic or theme of the puzzle you are putting together. You liked putting that jigsaw puzzle showing a nebula of stars because it looked so dazzling. But do you know anything about nebulae? Perhaps not; you don’t need to know that information to complete a puzzle. It helps to have a good baseline of knowledge to understand the images in radiology. Wisdom only comes with reading and an interest in learning.

Good Communication Skills

Does completing a jigsaw puzzle have anything to do with communicating the picturesque scene you just put together? Not! Jigsaw puzzles have little to do with sharing what you know with others!

Interpretation Skills

Finally, putting together a puzzle and identifying the picture doesn’t translate to understanding the more profound meanings of the jigsaw puzzle themes. You can complete a beautiful jigsaw puzzle without knowing why the water appears blue or why that character is smiling. Understanding what is happening when you assemble that final puzzle piece is another leap! We can indeed say the same about a radiologist who can identify the findings but can’t make a proper differential diagnosis!

Jigsaw Puzzles: What Do They Say About The Applicant?

Sure, there are some links between a radiology candidate’s quality and the ability to complete a jigsaw puzzle. However, there is undoubtedly a lot more that we need to assess before concluding whether an interviewee has all the qualifications to make a final decision. Geometric understanding and methodicalness/doggedness will take you further in our field. However, it is undoubtedly not enough without all the other components that go into becoming a great radiologist. The bottom line is to put your love for jigsaw puzzles on the application, but be aware that you must show us a lot more when you get to your interview!

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How Critical Are Connections To Getting Into Radiology Residency?

connections

Let’s face it. In any job, position, or institution, connections can make all the difference between getting an opportunity or falling short. Even in medicine and radiology, nepotism is alive and well. Sometimes, a lesser qualified applicant can get an interview because the father is a large donor to the institution. Maybe, a cousin of the applicant is a physician on staff and asks the coordinator to give her nephew an interview.

So if you ask the question, does influence sometimes trump qualifications on an application? The answer is still yes. Unless egregious, it is easy to disguise. Why? Because the evaluation of applicants for an interview is so subjective.

All this said, I believe most programs and program directors strive to take the best applicants possible to make sure that the most qualified applicants get the position. And I think that the radiology field is more equanimous than most!

So, How Critical Are Connections In Radiology Residency?

Well, all this discussion leads us to the theme. For the average applicant to radiology residency, how critical are these connections? And, my brief answer to that is not so much. Of course, this statement comes from someone who has vested interests not to expose the radiology program to undue scrutiny. However, in all sincerity, we strive to be as fair as is humanly possible. And, I believe for most program directors, the answer is the same.

It is exceedingly rare that a connection will have more influence than allowing a candidate to receive an interview that otherwise wouldn’t. But even if the candidate with a relationship gets an interview, most program directors and chairmen are unwilling to take candidates that cannot get through the rigorous requirements of a radiology residency no matter how “powerful” the connection. A resident who can’t make it through a four-year residency is far more damaging to the program’s reputation than the opportunity cost of an “upset connection.” The amount of time and effort wasted to support an unqualified candidate is enormous. And, the pain and suffering of having to terminate an incompetent resident is worse. Even more so, when the resident who we admitted is a relationship to a “connection.”

Should You Use A Connection If You Have One?

Given all this questionable power of the “connection” and how it affects the application process, you may ask, is it even worth it to use one. Well, as always, the answer is it depends. If you are a borderline candidate who may not score an interview, a kind word from a known connection can push your application into the interview pile. On the other hand, if you have excellent qualifications that speak for themselves, too much name dropping can irk the interviewers. Yet, a well-placed phone call from a trusted source can confirm the quality of the candidate.

So, you can see using a connection appropriately can be a bit tricky. You need to thread the needle, so to say. And make sure to do it diplomatically.

Using Connections To Get Into Radiology Residency- A Mixed Bag

So, there you have it. Connections can help, to some extent. But, more importantly, you need the appropriate qualifications to get the spot. No matter how good the link, make sure that the program is the right fit for you. And use the relationship discreetly so as not to overpower the admissions committee. A connection should confirm the candidate’s quality, particularly when the admissions committee may otherwise skip over the application before the interview ever happens. If used as a battering ram to push an unqualified candidate into an open residency slot, it doesn’t work. (At least at our program!)

 

 

 

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What Is The Difference Between Categorical And Advanced Radiology Positions?

categorical and advanced radiology positions

Question About Categorical And Advanced Radiology Positions:

Dear Dr. Julius,

I wasn’t sure of the difference between categorical and advanced radiology positions. What should I tell the applicants this year? Could you let me know the differences?

A Confused Program Coordinator

 

Answer:

For some reason, I have been receiving this question about categorical and advanced radiology positions a lot this year. Perhaps, it has something to do with how ERAS lists our residency program on its website. In any case, I had to look it up to make sure to give you the correct answer!

Definitions

First of all, some of you know that an Advanced residency, according to ERAS, is any residency that begins after the postgraduate one year. On the other hand, a categorical residency is any residency that begins at PGY-1 year. This categorical spot must continue for subsequent years until the end of the training. 

In this situation, how is it possible for some radiology programs to have a categorical spot when radiology training begins during the PGY-2 year? Well, some radiology programs have an affiliated prelim year at the same institution. And, usually, there is some form of agreement between the two programs. This combined prelim year could be any of the approved PGY-1 slots for radiology, including Prelim surgery, Prelim medicine, transitional year, etc. Therefore, if you are not applying to the prelim spot at the same institution, you should not apply for a categorical slot in radiology.

If Interested In A Prelim Spot At The Same Place As Radiology Residency, Ask!

Also, if you are interested in completing the PGY-1 year at the same institution as the radiology residency, make sure to ask the radiology program director if they have a categorical connection with the same institution’s prelim year. Some do, and others don’t. If they do, sometimes the radiology residency can make a phone call to the prelim program. In this case, this connection can give you a better shot of getting the prelim year slot at the same institution. Why? Because programs want to make sure that you will have an ACGME accredited prelim year before starting residency. Likewise, it’s harder to ensure that outside the institution.

However, if you apply to prelim and radiology spots at the same institution, you may or not be applying to a categorical position! It all depends on the residencies and agreement among the programs. Bottom line, make sure to check with the program director or the graduate medical education office.

Hopefully, you now know what you need to know about categorical and advanced positions!