Month: November 2021

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Radiology Residency Makeover: What Can Make A Truly Excellent Program!

radiology residency makeover

Everyone has a different vision of what residency should be when they start. And some discover that residency is nothing as expected. Perhaps, you thought that you would get more lectures, but you are not receiving enough. Or, maybe you thought you would receive more thorough assessments by the faculty every week, but no one is checking up on you. Every residency has its sore points. But let’s say you could construct a radiology residency from scratch; what are some of the most critical elements you would like to fix? From an associate program director’s perspective, here are some essential items for a radiology residency makeover from the beginning!

Filling Out Evaluations- Seriously

In many residencies, evaluations get placed on the back-burner because attendings are busy and barely have time to do their work. But, what if faculty took these assessments seriously and took the time to give you real constructive criticism? I mean the type of analysis that would help fix your dictations or make you better at performing procedures. That takes a bit of time. But, receiving constructive criticism such as this would be well worth the price.

Formalized Guideposts For Applicants

Yes, most residencies claim to use milestones to ensure that residents are well on their way toward becoming independent radiologists. However, it’s more of a checkbox that most residencies place in residents’ portfolios to document progress. However, wouldn’t it be nice to have a radiology residency makeover so that you have specific achievable requirements to meet the goals and expectations of the program. I am talking about the type of thing such as the ability to read x numbers of chest films in a day by year two or having a formal standardized assessment for performing paracenteses that everyone needs to complete before allowing residents to do them independently. These guideposts are helpful and will enable you to know where you are at any given moment!

Lectures- Quality And Quantity

Some residencies promise lectures to all residents but do not deliver. Lecturers regularly cancel noon conferences due to other work obligations that they need to meet. Other residences give talks, but they are not of sufficient quality for residents to learn the material. Wouldn’t it be nice to have a residency that consistently provides the material you need to know with excellent lectures? And, lecturers that cancel permanently have a backup on deck—furthermore, all lessons are of homogeneously excellent quality.

A Radiology Residency Makeover So That All Faculty Care About Resident Welfare

Every program has some knowledgeable faculty. Nevertheless, it is another thing to care about resident well-being. Wouldn’t it be nice to have all faculty on board looking out for residents’ self-interest? It only takes a few caring attendings to help their residents along so that they can achieve great things. Whether it is helping pass the boards or having an interested soul to talk to, caring faculty can make all the difference in the residency experience.

Residents Running The Show

In the end, we need to be able to train residents to work competently and independently. On the other hand, some residencies don’t give the residents enough independence on all the rotations to truly get the experience they need to take charge of their service. Maybe they have needy patients that want attendings performing all the procedures. Or the faculty does all the work. Perhaps, an attending on-call overreads all your dictations. Wouldn’t it be nice if you could show that you could run the rotation at some point during your four years?

Residency Makeover: What Can Make A Truly Excellent Program!

As an associate program director, taking evaluations seriously, formalized guideposts, quality lectures, caring faculty, and allowing residents to take charge are some features that can transform a mediocre program into an excellent one. If you are lucky, your program follows these descriptions to a tee. But, life is not perfect, and neither are residency programs nor their faculty. Nevertheless, now you know, in an ideal world, this is probably your residency director’s dream!

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Evaluating The Pancreas On A Triple-Phase CT Scan Is A Minefield

triple-phase

I don’t know about you. But, for me, my least favorite CT scan has been the triple-phase CT scan to evaluate pancreatic masses. And, by most accounts in my group, many of our radiologists feel the same. For this reason, I would like to call the evaluation of the pancreas on a triple-phase CT scan a minefield. Many pitfalls in making the findings and interpretations abound. And no one, including the physicians and patients, is ever satisfied. But I thought this might be a good time to go through some of the issues you might encounter!

Subtle Lesions On A Triple-Phase

Pancreatic lesions tend to be some of the most subtle ones to detect. They can be hypovascular or hypervascular, infiltrative or circumscribed, versus cystic or solid. Sometimes, we see them in only one phase out of many in a triple-phase protocol. Even worse, you may only catch one of these lesions on a coronal or sagittal plane, which is not well confirmed by any other. You can miss one of these lesions in about a billion ways.

Severe Consequences For Missing A Lesion

Patient Tragedies

The lesions that you miss in the pancreas can be killers, literally. Both complex cystic and solid lesions can rapidly grow and kill the patient. I’ve seen significant changes over a few months or even less. Even worse, you can make the case that the patient would have significantly fewer complications if you had caught it earlier. These complications can include more extensive surgery, more potent chemotherapy with its consequences, or broader radiation treatment plans for palliative care. And the list goes on and on.

Legal Tragedies

Also, with the potential patient tragedies for missing lesions comes the potential for malpractice lawsuits in the “retrospectoscope.” Judges and juries can easily mistake “not-so-subtle” pancreatic lesions for prospectively discovered subtle ones. Along with the possibility of doing significant harm to patients for missing findings, this discrepancy can cause high-cost malpractice lawsuits/claims. If you read enough of these studies, it is only a matter of time before you receive one!

Numerous Additional Findings

In addition to the problem of finding the primary lesion, many different additional findings can change a patient’s management dramatically. These findings can also be very subtle. I’ve seen numerous permutations and combinations of various venous and arterial thromboses that folks always miss. Then, there is a debate about whether a lesion surrounds a vessel and to what extent. This issue necessarily affects whether or not one gets surgery. And I can’t tell you how often that outcome can differ depending on who is reading the study. Of course, you also have subtle lymph nodes with the porta adjacent to the head of the pancreas and within the celiac axis. All these different additional findings that you have to think about can make your head spin. And the consequences of missing them are dire!

Angry Surgeons

Finally, you must contend with the people who ultimately ordered the study. These tend to be the busiest of surgeons. And for that reason, the word “ornery” almost does not do justice. These folks are often on the edge of burnout from overworking and complex patients. They have their requirements for the reader they want and how they want their studies. You will notice at your institution that they might call a study for this surgeon a Dr. “John Doe” protocol because every surgeon wants the triple-phase protocol done slightly differently.

The Triple-Phase Protocol For The Pancreas Is A Minefield!

As you can see, when you find one of these studies coming through your department, batten down the hatches and do not let your attention stray. Making the findings can be challenging, and there are potentially “oh” so many of them. Remember to look at all the images and phases. And make sure to relay all the information neatly and logically. The triple-phase protocol for the pancreas is not for the faint of heart. It’s a veritable minefield of potential misses and problems!

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Is Radiology Training Like Learning A New Language?

language

Over the past few years, I have become more serious about learning Spanish and Hebrew. And after many years of stagnation, both have significantly improved. But what does this have to do with learning radiology as a resident? At first glance, it does not seem much. But as I took a deeper dive into the subject, it had everything to do with learning radiology. Radiology is a new language, different from almost every other aspect of medicine. You will learn a culture and terms you will hear almost nowhere else in medicine. To illustrate this point, when I went to my first noon conference as a medical student, the sound of residents describing and interpreting cases almost sounded like gobbledegook. Does that seem familiar to those who have attempted to learn a new language? It probably does!

So what are the features of successful linguists who can speak fluent second and third languages, which also appear when we learn radiology successfully? It includes everything from attitude to the amount of time you must put in. Let’s go through some of the most considerable similarities that I have found.

Steep Learning Curve

When you learn a new language, it is essential to remember those words that repeat time after time, like want, need, person, etc. So, in the beginning, you can say some simple sentences and string together simple ideas. During the first year of radiology residency, it’s the same. You learn all the basics quickly, including dictation and physics. But stringing together a more complex answer to a case is complicated. For that, it takes a very long time until you achieve mastery.

Don’t Be So Hard On Yourself

Language learning involves a lot of repetition. And, you may not be able to recall a word after seeing it ten, twenty times, or more. If you see learning after much repetition as a failure, you will no longer want to pursue language learning. It is part of the human learning process to forget and remember. Recognizing this natural part of language learning makes you realize you shouldn’t be so hard on yourself. 

Well, the same ideas work for radiology. You may not remember the findings of a particular disease entity or the energies of a radiopharmaceutical. It may be many times that you need to hear it before it sticks in your brain. That process is how human beings learn. We have to forgive our imperfections!

Continued Language Immersion Works

After a while in language learning, you will feel like you have hit a wall and nothing else sticks. But nothing can be farther from the truth. The more exposure you have, the better you get at speaking a language. Similarly, the more you spend time with other radiologists, the better you will become. Many things that we learn are almost subconscious. And, of course, the same applies to radiology learning. We need to constantly read, sit at the workstation, and perform procedures to get more and more exposure. Yes, you are learning, even when you don’t think you are actively doing so!

The More You Put Into A Language, The More You Get Out

The more time you put into a language every day, the quicker it will take you to achieve a significant level of fluency. If you take a thousand hours to learn a language, you will be much better off than studying it for 500 hours. The same applies to radiology residency. Whether you read 1 hour, 2 hours, or 3 hours per night affects how long it will take to become a superstar radiologist later in life. All the work you put in eventually pays off in spades.

Some Words/Accents Will Be Hard To Imitate

Sounding like a native speaker after learning a new language can almost seem impossible. The subtleties of language learning can take forever to achieve. Many language learners never even shed their old accents, but they sound slightly more and more native year after year. The same applies to the radiologist. We constantly strive to become like our favorite mentors and learn the radiology vocabulary. But, to do it right, we must work for years until we get to Shangri-La. Honing our dictation skills and coming up with the appropriate differentials and management on every case is what we all strive for, but never to perfection. We get asymptotically closer and closer to perfect fluency.

Read And Listen A Lot Before Speaking And Writing!

Before you hope to converse in a new language or become a proficient writer, you need to have an active vocabulary at your fingertips and know the sounds of the language. One cannot reasonably start to speak before one gets to this point. The same applies to radiology. Before taking cases and giving your opinions, you must read a ton and listen to your mentors dictating. It takes hours and hours before you have the power to do the same well. It’s a long process before you can dictate cases independently!

Radiology Is A New Language 

There are so many similarities between language learning and learning radiology because they are pretty much the same. We have to walk the walk to talk the talk. So, if you have ever had to learn a new language and have done it successfully, treat learning radiology almost identically. This experience is directly transferable to the process of learning the specialty. And if you have only had experience learning English, that’s okay too. Take some of these similarities between radiology and languages and heed some of the recommendations above. You will find the process of learning radiology a whole lot easier and more fun!

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Best Add-on Subspecialties As A Radiology Attending

add-on subspecialites

Have you ever thought about what would happen if you decided to specialize in an area different from your fellowship? Well, believe it or not, many radiologists commonly accomplish this feat after starting in practice. Maybe they want to try their hands on something new. Or, perhaps the group needs a sub-specialist that they don’t cover well. In any case, it happens all the time. So, what add-on subspecialties are the most conducive to on-the-job training and why? Here is a list of what I think attendings are most successful at tackling after fellowship.

MSK MRI

For many new attendings who already know other forms of MRI, taking up the requirements for MSK MRI is just a little more. There are great sources available. You can find loads of excellent MRI MSK outside courses. It’s relatively easy to find cases to overread at most institutions. Additionally, although present, the legal issues for MSK MRI are lower than for other areas, such as having misses in neuroradiology or a complication from an intervention. All these factors make MSK MRI an excellent modality to start to pick up after you finish your training.

Mammography

You may ask why it is reasonable to start practicing mammography after fellowship when it has the highest frequency of lawsuits from any other specialty. Although true, it also has some of the other lowest barriers to entry:

  1. Most radiologists have had some training in this specialty before working as an attending.
  2. The differential diagnosis is limited (though case management can be relatively complex but learnable on the job). And, it is relatively easy to overread your colleagues’ films. Many courses are available that can give you a refresher on the basics of tomography, MRI, and more.
  3. Most practices require additional coverage in this area.

Cardiac/Thoracic Imaging

Although some rads have completed fellowships, most folks who read cardiac studies such as Cardiac CTAs, calcium scorings, lung screenings, and Cardiac MRIs are not fellowship-trained. So, it is a doable add-on to your current skills. Courses are readily available, and the baseline knowledge needed for calcium scoring, lung screenings, and Cardiac CTAs is moderate. To become a cardiac MRI reader is a bit more time-consuming, but this area is wide open for folks that want to learn. Plus, most practices would love to have an additional reader or two.

Nuclear Medicine

I am not too proud as a nuclear radiologist to admit that nuclear medicine is one of those options conducive to an encore in your career. PET-CT is relatively easy to learn, aside from some artifacts and subtleties. After reviewing and over-reading some nuclear medicine studies, most general nuclear medicine is very doable. Cardiac perfusion imaging can be a challenge for some. But, I know of many radiologists who went to take a course and then came back to read additional cases with a radiologist. And they were excellent with their reads. If you are considering practicing nuclear medicine at any point, pay attention during residency!

Informatics

For this topic, all it takes is significant interest to become the go-to computer person in your group. Typically, by default, you, too, can become the guru. These folks like to play around with computers and are keenly interested in becoming part of the hospital information committees. Also, they are hobbyist programmers and closet geeks who love technology. All you need to do is read a lot and love all the nitty-gritty details of your PACs and information systems. With all this interest, you will have a leg up on the world of informatics and can become an expert in your practice. You don’t necessarily need a fellowship!

The Best Add-on Subspecialties To Practice

I firmly believe that no subspecialty in radiology is out of the realm of possibility once you become a full-fledged radiologist. However, some add-on subspecialties are more challenging when you are out in practice. Nevertheless, MSK MRI, mammography, cardiac/thoracic imaging, nuclear medicine, and informatics have lower entry barriers and are doable if you take an interest and there is a need. Something to consider if you want to try something new and you are out in practice!