Year: 2021

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How To Succeed On Pediatric Radiology Rotation

pediatric radiology

One of the statements that you will often hear when performing pediatric radiology is the following, “Children are not just little adults.” And, nothing could be further from the truth. Many of the rules and diseases you have learned for the adult population do not apply to kids. You will find a whole new vocabulary and subset of conditions that are unique to this population. So, what does this mean for residents trying to learn pediatric radiology? Well, there is a lot to learn! So, as in the other “how to be successful” series, let’s go through some of the reading materials you will need to know, and then we will delve into what you should be doing and learn on a year-by-year rotation basis.

Reading Materials For Pediatric Radiology

Reading, like in other modalities, is critical to performing well. Therefore, I wanted to give you what I think are some of the best resources. Overwhelmingly, our residents recommended the Cleveland Clinic Pediatric Modules. And, having checked out the site myself, I have to agree. It is an excellent resource with useful summaries and pictures. Moreover, at the moment, it is free! So, I would recommend you to take a look at the site. 

If you are interested in a more traditional book, you can try the Pediatric Requisites. However, having seen the website and the online information’s high quality, I am more biased toward the modules. Plus, the modules give you excellent pre-and post-test questions. What more can you ask?

Year-By-Year Summary: What You Need To Do

Year One

Pediatrics has more procedures than you may have thought. Of course, you will need to know how to do the basics such as VCUGs, barium work, intussception reductions, and g-tube placements. Plus, you need to complete all these procedures on babies and children, some of which are very scared. And you must also deal with their parents. All this is part of your first year’s introduction to pediatric radiology. So, get familiar with these procedures and learn how to handle the interpersonal situations you will encounter. The attendings will want to have a “go-t0* resident that can help them out during the day. Learning these skills is what it takes to become part of the team. It is all key to having a successful first month.

Also, you will need to learn the basics of pediatric chest and abdominal x-rays. The litany of diseases and findings markedly differs from the adult population. Moreover, there are tons of these films you will need to interpret. So, get cracking! Also, be sure to read lots of pediatric trauma films. Fracture patterns in pediatrics do differ from adults. So, make sure to learn these. Most residents will spend the majority of their time on these plain films.

However, also get to know the disease entities in other modalities that you will encounter on-call that you will need to interpret. These include ultrasound and CT scan for pediatric appendicitis, ultrasound for intussceptions, and ultrasound for pyloric stenosis. Indeed, you don’t want to miss these pathologies at night time. So, you will need to know these entities and findings cold.

Years Two And Three

Now that you know some of the basics, concentrate on other pediatric radiology areas, you will need to know. Start getting to know the other critical disease entities that you may encounter on CT scan and MRI. I’m talking about hepatic tumors, pediatric cancers such as neuroblastoma, Wilm’s tumors, lymphomas, and more. You will need to know these disease entities for the boards.

Become more adept at pediatric ultrasound. For kids, pediatric ultrasound is a critical tool for making all sorts of diagnoses. Why? Because kids are much smaller than adults, it’s a lot easier to see delicate structures that you cannot penetrate in an adult. Pediatric radiologists, therefore, tend to play a more hands-on role than ultrasound in adults. So, be sure to watch how some of the more senior radiologists do their exams and make their more complex diagnoses.

Year Four

Esoterica should be the theme for this last year. Make sure to try to see and participate in cases that you may never see again. Maybe it is brain ultrasounds or pediatric neurointerventional workups. By the way, if there is a pediatric interventionalist, stop by the interventional radiology department and follow some of the compelling cases you started to work up in pediatric radiology. Hang out with the pediatric surgeons for a bit, especially when they workup unusual congenital abnormality cases. You may also learn a lot about new and fascinating disease entities from these folks.

Make sure to also learn about some of the other areas you may have skipped over the years. Check out the unusual congenital abnormality cases. Pediatric radiologists love them. And, most pediatric departments have collections of these either on film or on PACS. Bottom line. You should fill this year with all the gaps that you would have missed out on otherwise.

Learning Pediatric Radiology: Like Starting From Scratch!

Learning about pediatric radiology differs from the rest of radiology because the disease entities are so different. But, all with the online resources, procedures, and hands-on experiences, you will be sure to learn most of them. Additionally, clinical acumen and bedside manner will go hand in hand on this rotation. It is more critical than ever. So, don’t expect only to sit by the PACS workstations. Instead, roll up your sleeves and be prepared to get up and work. Only this way will you succeed in this excellent rotation experience!

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Postponed COMLEX Due To Covid: What Do I Do?

postponed COMLEX

Question About Postponed COMLEX:

Hello, I am DO third year medical student interested in radiology. However, I worry about the current situation that I put myself in. During this COVID summer, exam dates got thoroughly messed up to the point where my COMLEX was pushed back two times, leaving me with the decision to delay the beginning of my third year to take Step I or to leave it and focus on COMLEX 1. I chose the latter decision because I was thoroughly exhausted from studying due to my postponed COMLEX. Unfortunately, I received a low score and have dug a relatively large hole for myself.

I know that trying to take Steps I, II, and COMLEX 2 is not an option in my third year. But I wanted to ask you if I had to take a year off, would it be worth taking Step 1 since by then it would be a pass/fail exam? And if I did not take Step I and significantly improved on Step 2 and COMLEX 2, what would my chances be for matching into DR after 4th year? What are other things that I can do to optimize my chances of matching right away or, if not, matching after taking a year off?
Best

Answer:

For most programs, the COMLEX exam holds much less weight than the USMLE. If you score well on the USMLE and don’t score so well on the COMLEX, it does not matter as much. That said, if you decide to take the new pass/fail USMLE Step I, the scores for the USMLE Step II become much more important, especially coming from a DO school. So, it will become a much more critical exam to do well on. I would go as far as to say that a good USMLE Step II score will become a requirement for you to get in since programs will most likely use this score as a screening criterion for interviews. (in the past, you only needed Step I.)

Taking a year off to take an exam is a red flag from a program director’s perspective. Why? Because it shows that you may not be able to multitask well. And, radiology residencies involve lots of multitasking. So, if you are taking off an entire year to take exams, it raises lots of questions from a program director’s view. If you decide to take that route, you need to do something else that will add to your CV for getting into a radiology program, such as a relevant radiology research year/fellowship. Taking off a year just to retake the exams would be a disaster for your application.

My two cents,
Barry Julius, MD

 

 

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How To Succeed On Hospital Plain Film Rotation

plain film rotation

Even with all the more sophisticated modalities, most radiology residencies still have a plain film rotation. Sometimes this rotation goes by the moniker chest. Other times, it is more generally called plain films and includes both chest and musculoskeletal x-rays. Regardless, since we are generally modality-based and not organ-based at my institution, today, we will go through how to succeed in this rotation’s more generalized version. To do this, we will start with some of the recommended readings for this rotation. Then we will delve into some more of the specific year-by-year recommendations for achieving success.

Recommended reading for the Plain Film Rotation

Overwhelming, upon surveying my residents, one book was the clear winner for learning the basics of reading chest films. It was easy to understand and logically arranged, using the programmed learning style. Check out Felson’s Principles Of Chest Roentgenology. (I am an Amazon affiliate and receive a small commission on any purchases through the links!) When you complete this book, you are ready to start reading films. On the other hand, for those of you who prefer an online tutorial, some of my residents like the University of Virginia chest tutorial to help with the learning process.

As I had mentioned previously in a discussion of how to succeed in MSK imaging, I would also recommend Fundamentals of Skeletal Radiology to learn the basics of reading films on this rotation. Specifically, it has a reputation for helping out with trauma and fractures. But, it will get you started reading with what you will need to know on this rotation. Finally, I would also advise you to have a copy of the Keats Atlas of Normal Roentgen Variants That May Simulate Disease: Expert Consult by your side to help you distinguish normal variants. Knowing normal vs. abnormal is probably the most challenging part of being an excellent plain film reader. And, most departments have a copy of this book lying around somewhere in the dark!

Finally, I want also to emphasize that reading is supplemental to looking at films on rotation. It will never replace sitting down and reading studies at a PACS station. So, don’t disappear to go reading books during the daily rotations. You will only be hurting your residency education!

Year By Year Learning Recommendations For Hospital Plain Film Rotation

First Year

Learning By Doing!

In the world of x-rays, reading books is not enough. Every first-year resident should be immersing themselves in reading cases live on a PACS. Even better, during the first few days to a week on this plain film rotation, they should sit with an attending and watch how they make the findings, interpret the images, and dictate cases. In the times of Covid, this exercise may be a bit more complicated. However, it is critical to read x-rays in this way and return to a semblance of normalcy, especially after the pandemic ends. (It will eventually!) You need to go through this exercise to understand the mechanics of how your faculty reads the films.

Soon afterward, all residents should dictate the cases themselves after going through the images with an attending. Remember also to try to take notes on the relevant cases before dictating. You don’t want to forget the findings that the radiology faculty told you to add to the dictation. Residents should try to get through as many cases as they can.

How Much To Read

Back in the day, we would measure the number of cases read based on boards. (I’m dating myself!) Each electric panel would have around 20-30 cases. First years would go through up to one full board of films each day on rotation. That number is a reasonable goal for most first-year residents when they finish their first rotation in plain films.

Second And Third Years

Now, it is time to take the proverbial bull by the horns. Since you have learned the basic mechanics of looking at and dictating films, it is time to mix up the equation a bit. Try to read some cases independently and then go over the results with an attending afterward as she is signing off the reports. Reading cases first by yourself allows you the independence of making decisions and gives you insight as to what you missed and what you can do better. It is the ultimate way to get feedback on every one of the cases that you read. I would also recommend occasionally sitting with an attending, especially ones that you may not have worked with as much, to get to know each faculty member’s style. You can still learn a lot about watching how each reader operates the plain film station.

At this time, you should be able to get through at least the equivalent of two boards or up to 60 films at the end of this rotation. That would be an entirely reasonable goal.

Fourth Year

During your final year, you should be reading cases entirely independently. Of course, your attending will need to sign off on the cases at the end of the day. So, at this point, you should pretend that you are the attending, except that you should check the results of your dictation with the final read. Of course, if you find a complicated case or you have a question during the day, you should ask your attending what you should dictate/do. But for the most part, you should be able to the cases entirely by yourself. As a fourth year, you are very close to reading cases independently as an attending, and you should act like one!

Plain Films- Still Part Of The World Of Radiology

As much as we love to read all the more complex and sophisticated radiology modalities, most practices have their radiologists read plain films. Chest films and basic trauma radiology serve a critical need. And, we have not found any reasonable way to replace them. So, don’t poo-poo the plain film rotation. As an attending, most practices will expect you to read lots and lots of films, even in the 2020s. So, get cracking. Start learning to read plain films well during residency so you can hit the ground running when you begin your first job!

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How To Succeed In Fluoroscopy

fluoroscopy

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!