Since at least I was a resident, radiology faculty considered fluoroscopy to be one area in radiology that residents just learned “on their own.” Books never helped all that much with the mechanics of completing an upper GI series or barium enema successfully since it is more like a technical skill. Additionally, only a few attendings were willing to teach the mechanics a GI workup. Each one had their way of completing a study. And like a snowflake, no two attendings would ever have an identical method of conducting a fluoroscopy study. Many of us would resort to learning the specialty from other residents instead. So, to say learning fluoroscopy was difficult is an understatement!
Fast forward to today, and I believe it has become even more challenging for residents to learn. Why? Because fewer and fewer attendings take a keen interest in the art of fluoroscopy, even more so than before. Most faculty would rather be elsewhere interpreting and performing the newer modalities, whether MRI, nuclear medicine, or interventional radiology. Moreover, books about barium slinging have not changed much in the past 20 years or so. And after surveying my residents, they are still not so comprehensive or easy to understand. Nowadays, fluoroscopy has become more of a hodgepodge of studies than ever before. We have more bariatric studies, presurgical cases, and fewer and fewer bread-and-butter upper GI series and barium enemas. In the state of New Jersey, they don’t even sell the equipment for double-contrast barium enemas anymore!
I’ve ranted enough, incoherently! So, with all these obstacles in your way, how can you succeed on a fluoroscopy rotation? Let me give you a few pointers, including some so-so books that you will need, some general guidelines, and some more specifics using the usual year-by-year format about what else you need to do to succeed. I will emphasize year one because this is by far the most challenging year of them all.
Fluoroscopy Reading Materials
I will make this section relatively brief because after surveying multiple residents and knowing what I know about fluoroscopy, no one book is adequate for learning what you need to know. Nevertheless, here are a few suggestions from the peanut gallery. A few of my residents liked a book called Introduction To Fluoroscopy For Residents & Professionals Alike. (I am an affiliate of Amazon when you click any of these links to books on this page) It teaches some of the basic techniques of fluoroscopy, and they found it somewhat helpful. Again, it does not replace the experience of watching a colleague perform a study.
Additionally, some residents recommended Mayo Clinic Gastrointestinal Review for those who want to learn more about the pathology itself. This book is beneficial when you have a case with a specific pathology, and you want to learn more. Finally, you can always use other resources, such as Google and Radiopedia, to look up information. But, if you desire to read books, these are some of the best options.
Basic Guidelines For Performing Fluoroscopy
Listen, Watch, And Take Notes
The first and most critical item on the “to-do” list is to watch and listen carefully to your fellow residents or attendings who will show you the mechanics of what to do the first time. Take notes about exactly how they administer the barium, position the patients, snap the x-ray spot views, and turn them on the table. You want to have all this information in your working memory to emulate your teacher when you do your first study by yourself. So, you want to recite these steps for each procedure ad nauseam so that you can repeat them in your sleep. Furthermore, the books don’t cover all the technical information you need to know, as I said above. You can’t look up a fact or technical issue while the patient is drinking oral contrast!
Take Adequate Histories
Fluoroscopy studies are tailored examinations to identify something specific that both the ordering physician and patient want to be answered. I can’t tell you how many times I see first-residents going over a study only to realize that they skipped over the critical part. For instance, with a patient with dysphagia, you need to look at the upper esophagus and swallowing mechanism more closely. An esophagram that does not look at the upper esophagus is useless with this history. If you don’t know the problem, you will focus on the wrong information.
Complete As Many Procedures As You Can (Don’t let others do them for you)
Like in interventional radiology, the key to becoming an expert in fluoroscopy is to do lots of studies. Two or three barium enemas do not make you an expert. You need to understand the nuance of the techniques and how to tailor examinations to patients. The only way to do this is to practice. And, the more, the merrier!
Dictate All Cases And Remember Relevant Priors
Finally, whenever you complete a procedure, the person in the suite real-time needs to dictate it. Even though the attending may understand the case more than you do, she was not there at the examination. And, she will never be able to describe all the events that happened there. So, the performing resident must dictate the case.
Also, it is vital to remember to compare to relevant priors. Anytime a patient comes in for a GI examination, I always look for the prior chest, abdomen, and pelvic CT scans. I can’t tell you how many times I uncover why the patient is coming in for the procedure when no one else knows. Sometimes, even the patient does not know. It could be a questionable diverticulum or a leak that the radiologists saw on another exam. The only way to know for sure is to look at the priors!
Year By Year Outline Of How To Succeed in Fluoroscopy
Year One
By far, year one of fluoroscopy is the hardest. You have no clue what to do, and the surgeons and physicians that order these tests are unforgiving. Moreover, the patients themselves can be challenging. Some GI patients (more so than other patients) have other psychiatric ailments that can make cooperation difficult at best. So, how do you proceed? And what should you be focusing on this year?
For the first week or so, you should be watching and listening very carefully. And then, you should be performing as many cases as you can. Get to know the technology and fluoroscopy tower. Familiarity is key.
Especially during the first year, you also need to focus on taking histories and basic techniques. Also, practice improving your bedside manner. Patients will appreciate it!
By the end of this rotation, your goal is to become entirely independent to perform your studies before the second year. No studies in fluoroscopy are off-limits. Remember. Although not impossible, it is hard to hurt a patient with a bit of barium. (although I’ve seen it happen!) But, if you have any questions, be sure to ask your seniors and faculty.
Year Two
You should be focusing on more than just technique at this point. Instead, you should tailor the exams appropriately for the case at hand. If there is stomach pain, look for gastric and duodenal ulcers. And so on. Your goal should be to become a valued consultant to the ordering physicians. It is much more challenging to do this during your first year because of the focus on the technique. It easy to forget everything else!
Years Three And Four
During the last couple of years of fluoroscopy during residency, you should concentrate on continuing to refine your technique to get patients on and off the table quickly and efficiently. You should also spend time teaching your fellow junior residents. Teaching reinforces all of what you had learned the previous years. It will also make you much better at fluoroscopy as an attending when the time comes. At this point, you should feel comfortable with almost any study that comes into the department.
Summing Up Fluoroscopy
Although many folks consider fluoroscopy to be one of the ancient and dying arts in radiology, it continues to have critical patient care uses. Accordingly, you will still need to learn the techniques and skills to become a great fluoroscoper. You will need to sharpen your history taking skills, hand-eye coordination, and dictation abilities. It is still a great way to learn radiology. But, no one said it was going to be easy!
