Month: May 2021

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Don’t Forget To Learn How To Make The Findings!

make the findings

In a few more weeks, most first-year residents will begin to take call and metamorphose from a student into a valuable member of the radiology team. Nightime independent call is what separates the radiology child from the adult. But, as always, most residents have a few hurdles to overcome before they begin. They need to be able to make the findings.

One of the hurdles is the precall quiz—a test before the start of the new year. And, not all first-year residents are ready for the task. Why is that? And what can residents and programs do to equip radiology residents for their newfound role?

Knowledge Versus Search: Two Separate Skills.

Most radiology residents concentrate on the information side of the equation. It’s a much more familiar task. From time and memoriam, including medical school and internship, residents have been studying from books. So, reading books is what they know how to do best. They can remember the names of the disease entities and perhaps some descriptions associated with them. But, radiology is a lot more than recall and picking out a few disease entities from your memory. Instead, it is also the process of making the finding while scrolling through many images on a PACs system. This skill is entirely different. If you don’t believe me, have your average fairly knowledgeable internal medicine physician attempt to read a CT scan and make the findings. It doesn’t tend to work out too well! (There are exceptions to every rule, however!)

How Not To Be Just A Bastion Of Knowledge And Also Make The Findings

Practice

Just like another task in life, you need to put the time in to become proficient—the same works in radiology. You need to spend hours at the workstations scrolling through images in addition to reading the books (as you have been doing for years). If you don’t spend the time with the mouse and the computer on the PACs, your brain will not be ready to pick out the findings when the time comes.

Study Checklists

Whether they admit it or not, every radiologist uses some form of checklist to make sure they have looked at all the parts of the study. And every resident needs to create the same. If you don’t create a checklist, you will never know what is missing. Why? Because residents and non-radiology physicians tend to make positive findings. But, the negative findings can be just as important to figure out history and disposition. Splenectomies, adrenalectomies, and appendectomies are some of the discoveries you will miss on a CT scan if you do not have a checklist for every organ system. And if you miss these, some of your impressions will sound silly or meaningless.,

Look At Pictures

Finally, residents also need to read. And reading differs from the standard physician resident. Internal medicine residents, surgical residents, and ob/GYN residents can get away with reading only the text or reading the text first. But, we radiologists have to do things a bit backward. We need to look at the pictures first, then the captions, and then the text. Why? Because we are an imaging-based specialty, and if we don’t see the findings on an image, we will never know what to find!

Make The Findings!

Remember. Radiologists read a ton because we cross over so many different specialties. But, in the end, we are primarily an imaging specialty. So, we have to learn how to make the findings, not just be an information bank for consultation with our colleagues. Don’t forget to practice a lot by reading lots of films on PACs, utilizing checklists to avoid missing critical findings, and reading the pictures first when reading textbooks. Practicing these skills will enable you to become an excellent radiology resident and a great radiologist. It’s not all about just reading books!

 

 

 

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External Moonlighting In Private Practice: Tread Carefully!

external moonlighting

It’s exciting to collect that first paycheck which can be an order of magnitude higher than your residency salary when you first start as a fully trained radiologist. But, many of you may want to make even more at the beginning. It’s not uncommon to have debt loads that would make regular folks cringe. Nevertheless, some private practices discourage external moonlighting to make that extra money when starting. Why do some businesses work this way? And, what do you do if you want to continue working at your first practice but are not happy about this policy? Let us muddle through some of the issues that you may face when you want to make some extra dough when starting.

Why Do Some Practices Discourage External Moonlighting?

External Allegiances

Moonlighting outside the realm of your main job could create loyalties external to the practice. Let’s say you sign a contract to work during a vacation at an external site, but the primary imaging business also could use your help. This dichotomy of purpose can create a conflict of interest since you will support another practice instead of your primary allegiance. Furthermore, perhaps that other job can be more enticing than the one that does not allow moonlighting. Radiology practices fear having employees change jobs. It is very costly and causes the other practice members to have to take up the slack.

Practices Want To Encourage Their Own Internal Moonlighting

Sometimes the work can get busy. Maybe, it’s a new MRI that opened up. Or, perhaps a senior partner recently retired. In either case, there are many times that practices need all hands on deck to cover the rotations with the extra work. Why would a business allow external moonlighting when it may have many opportunities of its own? The practice needs to cover this extra work!

Exhaustion/Burnout/Vacation

Some practices are more lifestyle-oriented and encourage their radiologists to take their vacations. Burnout is an actual entity. And, we all need a break once in a while. Working all the time on your vacation time can be a recipe for burnout. The exhaustion of the partners and employees is a very costly situation. Why not go to the extra lengths to discourage burnout by forbidding doing external work outside the practice?

I Like The Practice But How Can I Deal With Strong Policies Discouraging External Moonlighting?

Ask For Internal Moonlighting Gigs

Some practices don’t advertise moonlighting opportunities that they have available. So, instead of assuming that your primary radiology practice has nothing available, just ask around. Sometimes senior partners would rather have time off rather than the extra money. Other times, work needs to get done that is making the days longer and more stressful. Both situations often occur. And although not advertised many times, they are potential extra ways to earn some extra dough. Sometimes all you need to do is ask!

Have Them Make An Exception

Sometimes rules are made to be broken. Practice by-laws are in place for the average situation for the average employee or partner. But, who is to say that you are average? If you provide a compelling reason for the business to make an exception to the external moonlighting policy, sometimes they will. Some practices may be more liberal for non-partners or partners. If need be, check with the chair and find out if it is possible.

Work Only During Vacations Or Out Of State

Suppose the practice is concerned that you won’t be dedicating your full attention to your primary job as an external moonlighter. Or, your main radiology job is worried that you will be competing locally with your primary radiology practice. Then let the radiology practice know that your external work will not interfere with either. Guaranteeing that you will only work out-of-state or on vacations may convince the partnership to allow a bit of extra work to make some more cash.

External Moonlighting: The Unwritten Rules

When you look at external moonlighting policies from a birds-eye view, it can make a lot of sense for a practice. It can protect the business from losing their employees and partners, ensuring that work does not go uncovered, and preventing burnout and exhaustion. But there are ways to deal with these issues and get the extra work that you want. So, instead of folding your hand, ask around and make sure to let your practice know that you are interested in moonlighting from the get-go. You may get the extra work you want without destroying your primary job!

 

 

 

 

 

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What Are The Best Extracurriculars For Radiology?

extracurriculars

Question About The Best Extracurriculars:

 Hello Dr. Julius. I am an incoming MS1 interested in radiology, and I wondered if you had any recommendations for medical school extracurriculars that radiology residency directors highly value. Having talked to several medical students about their extracurriculars, there seems to be a wide variety of options. I know that I will be swamped in medical school and only have time for a few activities. I would love to know if any extracurriculars would be particularly helpful in preparing me for radiology. Thank you!

 

Answer:

Radiology Relevant Extracurriculars

There are two types of extracurricular activities that radiology program directors like to see. The first are those that are relevant to radiology. These would include research, participating in national radiology specialty conferences, etc. These show a depth of interest in radiology and not just taking a two or 4-week rotation.

Non-Radiology Relevant Extracurriculars 

The second of those extracurriculars that you do that may have nothing whatsoever to do radiology but are something that you have explored profoundly and have been successful performing. It could be music but not just strumming a guitar. Maybe you have played in Carnegie Hall or were doing vocals for a cover band. Or, if it is astronomy, you don’t just look at stars at nighttime. But maybe you are actively involved in searching for new planets and found one that has your name!

I am trying to point out that we like to see that you have other interests outside of radiology that make you not just another number but also an interesting person. And that you want to do things, not just superficially, but will work at it to get better and better. These second sorts of interests are so important because we can sit with you for hours at a time. And, we want to make sure that we will like the person that is by our side and have a person there that will work hard for the residency program. 

The Crux Of The Matter 

So, get involved in some radiology-specific research or organizations if you can. But, also explore things that interest you like to do on the side. Doing too much and mastering nothing does not mean much. But, someone that pursues their interests to the nth degree, now that is special.

Even after all this discussion, more important than all the extracurriculars in the world, is doing well in your medical school and getting good grades for the Dean’s letter and good board scores (correlated with passing the core radiology examination). So, don’t forget about the basics!

 

Good luck,

Barry Julius, MD

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Which Radiology Reporting System Should I Use?

reporting systems

Nowadays, there are so many different reporting systems: TI-RADS, PI-RADS, BI-RADS, ELCAP, Fleishner criteria, LI-RADS, and more (If you like acronyms, you are in heaven!) Sometimes, like the Fleishner criteria, LI-RADS, and ELCAP, there are multiple reporting systems for the same specialty reads. And, in our practice, we tend to use two of them for lung screenings, both the ELCAP and the Fleishner criteria. But, when you have so many systems to choose from, which ones do you choose and why? Can or should you use two different types? Here are some suggestions to make your decisions to use one reporting system over another a bit easier.

Recognize That There Is No One Right Reporting System

First of all, you need to recognize that there is no one correct answer. Each reporting system is just that, a reporting system. So, your conclusions and management can slightly differ. Even within the reporting system itself, there is a bit of wiggle room because patients don’t always follow the rule books. In my experience, I can find exceptions to almost every “rule.” For example, sometimes, you might think that they need a follow at a slightly smaller or larger interval than one year for a lung cancer screening because the patient cannot come in at a particular time. Regardless, many different systems have the potential to work for your practice. Check out all the ones that may be useful for your practice.

Decide On And Ask Your Audience

Who is referring the patients to you? Is it the pulmonologists, primary care docs, or cardiothoracic surgeons? Once you find out which is the source, then you should find out what they want. Or, at least use the type of system for which the authors have written. Why? Because they are the ones that are going to be reading your reports and deciding on patient management. Making your referrers happy is one of your top goals. If some want one type of reporting system and others wish to have another. Consider using both if your technology has the capability. It may be worth it to keep your referrers from using the practice down the street.

What Is The Simplest For You

Next, what is the most straightforward reporting system to manage? Do you have preset templates in your system that make it easier to use one reporting system over another? Or, can you do your reports freehand? What do the radiologists in your group prefer? Sometimes, these factors can be the overwhelming cause to choose one reporting system over another. Especially in the case that many of the systems could potentially work for your referrers.

Revisit The Data

Finally, once you’ve been using one or two reporting systems for a while, check how they have fared. Canvas the referrers to find out if they think the reporting and management suggestions have been reasonable. Make sure to keep up the changes within the reporting system to make sure that you are up to date. I have found that the reporting instructions for any given system have new recommendations every few years.

Also, a head-to-head comparison from time to time between the different reporting systems in terms of patient outcomes may help to decide which one to keep and which ones to chuck. This comparison can be your mini-research project or a review of the literature.

Selecting A Reporting System- The Final Decision

Arriving at a reporting system does take a bit of forethought and action. Recognize that more than one reporting system can work for you. Ask your audience and find out what works best. Utilize what makes the most sense with your system’s capabilities. And constantly check the data to make sure that your reporting systems are working as they should. Completing each of these steps will ensure that you make that you are making the right decision. Remember, reporting systems are a critical part of creating an actionable final report!

 

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Virtual Radiology Conferences: Are They Worth It?

virtual conferences

Nowadays, when you look online for your favorite conferences, most of them have still not returned to the live format. For me, it is RSNA, AUR, and SNMMI. (of which I believe RSNA will be going live later this year). And this goes for most radiology and radiology subspecialty conferences. So, what have we lost by going to the virtual meeting format? And, why have I not signed up for virtual radiology conferences this year (I also have a sneaking suspicion that many of you are in the same boat!) We will embark on all these issues and more as we delve into the frailties of the virtual conference.

Hard To Concentrate At Home On a Computer – Kids, Dogs, etc.

I don’t know about you, but home is a different environment compared to a conference. Many of us have constant interruptions from all sorts of creatures, kids, relatives, love ones, and more. It is challenging to listen to a conference when the dog is barking and the kids need dinner. Virtual radiology conferences provide an escape from the daily trials and tribulations of home and allow you to learn without interruptions!

No Meetings With Colleagues Over Lunch/Dinner

At conferences, I often learn more from my colleagues than I do from the speakers themselves. Going to events, dinners, and scheduled meetings allows you to learn about other radiologists’ practices and issues throughout the country. These meetings are where I often find out about what is going on in other residencies or the radiology business world. And, many times, I will try to apply it to our own. Going to virtual conferences does not allow you to have these experiences without a significant challenge!

Loss Of Esprit De Corps

Then, of course, something about attending a meeting and being in the same boat as the other hundreds or thousands of attendees rejuvenates my excitement for all the new possibilities in the world of radiology. Knowing that you are there and not alone makes you feel like part of a large team. Listening to miscellaneous lectures anonymously on the computer does not have the same effect, even though many others are also attending!

Can’t Check Out The New Wares

It’s hard to get a feel for the latest and greatest equipment when you cannot see the demos, play with the software, and check out the sizes and shapes of the new PET-CTs, MRI, etc. Going to conferences allows you to talk to the vendors and get an idea of what to push your hospital to purchase. It’s kind of hard to do all this from home.

Opportunity For Side Vacations Gone

Ever thought about bringing your whole family to check out the scenery while you are at a conference? Or have a desire to take a few hours or a day off to check out the local sightseeing and food? It’s kind of challenging to do that from home. One of the reasons to go to a conference is to experience something new. Traveling allows you to do all that.

Virtual Radiology Conferences: It’s Just Not The Same!

For me, virtual radiology conferences are a no-go. All the interruptions, lack of interpersonal connections, loss of the ability to check out all the new gadgets, and the lack of ability to explore the area do not make these semblances of conferences worth my while. Until we return to a fully open live conference format again, I’d instead just get my CMEs the old-fashioned way: at home!

 

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ABNM-ABR Pathway Completed: Do I Need A Breast Fellowship?

abnm-abr

Question About ABNM-ABR Pathway And Breast Fellowship

Hi,

I am a 4th-year radiology resident graduating from the ABR-ABNM 16-month dual certification pathway in June. I matched fellowship in breast imaging starting July. However, I am liking nucs and am considering bagging the breast fellowship and working in nucs.

Can you help me think through if this would be advisable?

Thanks,

Nucs Versus Breast

 

Answer

Dear Nucs Versus Breast,

 

If you are graduating from an excellent ABNM-ABR dual certification program, you have completed a “fellowship.” So, if you can find a job in nuclear medicine or nuclear radiology that you like, I don’t think it would be unreasonable to forgo the breast fellowship. Especially nowadays, the market for all sub-specialist radiologists is excellent (nucs included).

 

However, some breast fellowships rely on their fellows a lot. So, bailing out just before the start of the fellowship year may not be the best way to make strong connections in radiology. Of course, this is especially the case if you have already committed and signed on the dotted line. So, make sure to discuss the issue with the breast fellowship director if that is what you want to do. See if they can find another fellow easily and if it will be a hardship on the program if you decide to leave before starting. But before you do anything, make sure you have a job (with a contract in hand) before you talk to anyone about canceling the breast fellowship!

 

Also, just because you are not doing a breast fellowship doesn’t mean that you can’t practice breast imaging when you leave. I have been reading screening mammos and diagnostic mammos for some time now without a fellowship. And, you will likely have the opportunity to do interventional mammo as well if you want to go in that direction, with or without a fellowship. Completing a fellowship only implies having some additional expertise. It does not mean that other radiologists cannot be excellent breast imagers!

 

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What Do Private Radiology Practices Need To Survive? (From A Real Private Practice Radiologist!)

private radiology practices

Like many of you trying to keep abreast in the radiology world, you will notice many articles by academic radiologists about the status and survival of private radiology practice. (JACR article, i.e., State of Private Practice) Answering these questions as an academic radiologist is like asking your average physician how to fly a plane. Most of them will not have a clue! Without having ever worked in the trenches of a private radiology practice, an academic radiologist will give a very partial response about what they think about the status of private radiology practices. So, let me give you some real insights about what private radiology practices need to survive! Here are five critical pillars to ensure you will weather the most storms!

Readers That Can Plough Through Cases

First and foremost, a private practice needs work to be completed. (Academic radiologists tend not to consider this issue as much!) These include general and subspecialty work alike. (Not all cases need a sub-specialist!) Therefore, there needs to be a certain percentage of employees or partners that can manage high-volume workloads to meet the demands. It does not have to be the entire practice. However, you need a minimum base of these types of radiologists to ensure that your patients, referrers, and administrators are satisfied with the numbers. Work grinders are still a necessity in today’s day and age. We have still not arrived at Radiology 3.0 for most patients!

Physicians That Can Appease Administration

Next, you need a certain number of radiologists in any organization who can schmooze with the best. These sorts need to attend all hospital events, parties, and golf outings. They need to be available to manage, negotiate, and make nice to the hospitals, imaging centers, and other referring physicians in high positions. These folks are vital to keeping friendly relations between the practice and the systems that ensure success. We need our administrators unless the group is independently wealthy and can afford to donate the next latest and most fantastic gazillion detector CT scanner!

Good Systemic Organization To Maintain The Peace 

It’s not just about appeasing the administrators; you need to take care of your own. Scheduling and a chairman or president who cares about practice stewardship are some of the critical roles that your group will need to fill. You need to schedule your workers fairly so that there is an “even” distribution of work. It would also help if you had folks who care for the workers to make it to family functions, graduations, funerals, etc. 

Also, it would help if you had leaders willing to help the group in times of need and crisis. Leadership must step up and protect the worker bees, whether you have angry clinicians from a recent miss or other systemic issues. It goes a long way toward maintaining peace.

An Excellent Management Team To Ensure The Bills Roll In

Management can be external or internal. Either way, you need a quality organization that can negotiate contracts, send out the bills, take care of benefits, and all the other fun stuff that goes into keeping a practice alive. A practice with thieves at the top won’t last too long. A disorganized management team will not allow you to capture all the income that you should. In either case, your practice will lose out on maintaining the income that private practice radiologists should make.

Appropriate Technology To Meet The Demands

For some groups that own their equipment, this involves the hardware itself or a PACs system. For others that rely on professional fees alone, it may be home workstations or scheduling software. In any case, you must have the appropriate technology to tackle all the problems. If not, other practices will rapidly leave you behind!

Meeting Private Radiology Practices Need To Survive

So, now you know some of the basics that most private practices need to continue with operations. It is not to call every patient with their result. And, it is not kowtowing to every referrer. But, it is the daily plowing through work, maintaining relations with administration and staff, keeping the bills flowing, and having the appropriate technologies to do so. These roles and skills will ensure your practice will be around for many more years to come!