Month: February 2022

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Inheriting Other Program’s Problems – The Lateral Residency Transfer

lateral residency transfer

Every once in a while, a program will lose a resident for various reasons. It could be to move closer to family, poor performance, or a gazillion other reasons. When this unfortunate event occurs, a program is stuck trying to fill a spot. And, you would think at first glance that it would be pretty straightforward. I mean, radiology is pretty competitive nowadays. Instead, only a fixed small number of residents can transfer from one PGY3, PGY4, or PGY5 spot to another. And, programs need to be very careful when they recruit these positions. A lateral residency transfer from another residency program can become more problematic than having one less resident in the program.

So, what are the issues that residency programs face when recruiting residents from other programs? And, what kind of transfers are programs looking for? Here are some of my thoughts on these situations.

Lateral Residency Transfer: A Minefield Of Problems

Professionalism Issues

Many applicants from other institutions leave because their former residency program does not want to renew their contracts. Out of those reasons, one of the most common is the professionalism violation. It could be any one of thousands of professionalism infractions, including ethical, moral, and legal issues. Moreover, programs suffer from a lack of information about the resident’s former residency. Frequently, the former site of the applicant doesn’t release “all the information.” So, poor professionalism behaviors can quickly arise again when the resident enters your program.

Academic Issues

In addition to the professionalism issue, many lateral transfer residents cannot academically make it through their current program. Perhaps, it is related to test-taking skills, dictations, or inability to make the findings. If you hire them without knowing the real issues, these same issues will eventually surface when they transfer to your program.

Medical/Mental Health Issues That Can Interfere With Training

We also have to worry about medical and mental health problems interfering with resident training. Notably, this information can be complicated to retrieve because it is a HIPAA violation for a program to give this information out to another freely. And although programs make every attempt to overcome these issues, it can lead to all sorts of problems for both the incoming resident and their colleagues who need to cover them.

The Fickle Resident

Finally, some residents leave because they spontaneously want to abandon their former program for various unstable reasons. These include dating scenes, being in a warmer climate, or myriad other miscellaneous reasons. This sort of resident can decide to do the same when entering your program. Not a great situation!

What Programs Want From A Lateral Residency Transfer

Residents That Need To Leave To Be Closer To Family

Sometimes residents will have a sick relative, and they need to care for them. Or, they have a wife and children who live in a different country than their current residency program. These reasons are legitimate. And, they make for a happier resident that will be more likely to complete the radiology residency.

Particular Interests That The Former Residency Cannot Satisfy

Other times residents discover they have different interests that one residency cannot meet. Perhaps, they are interested in participating in bench research not available to them at their current site. Or, maybe the new site has a PET-MRI, which is the resident’s area of interest. Regardless, these reasons can be valid as to why the resident may want to come to your program.

Legitimate Medical Issues That Will Not Interfere With Training

Some residents need to be closer to certain cities/hospitals to get their treatment. And, perhaps, it is not available at the current institution/town. Or they need the care of family members to help them with health issues. These residents can potentially become a great asset to a new program if they meet its demands.

A Real Change Of Heart For The Lateral Residency Transfer

In medicine, it is effortless to make a mistake. We don’t necessarily know what we want to do when we get out of medical school. Medical schools do not give the best sampling of what life is like post-medical school in all specialties. And, many residents realize they made a mistake early on. Sometimes nuclear medicine residents or emergency medicine residents who have completed imaging rotations can qualify for these more advanced positions. Well, these sorts of residents can become the best trainees because of their dedication to doing something they want to do instead.

The Lateral Residency Transfer Can Be A Tough Situation!

Due to all the pitfalls and possibilities that a lateral transfer can offer, it can be challenging to cull residents that will fit the new program’s culture and meet the demands and rigorous tests of residency. Selecting residents with professional/academic violations, medical issues, or the fickle resident can throw a wrench in the new residency program when similar problems arise in the new program. And this situation can be worse than not recruiting any radiology resident. But, many residents have valid reasons for changing programs as well. So, residency programs, just like the residents, need to do their due diligence. The consequences of picking the wrong resident can be dire!

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Calcium Scoring CT Scans- Are They Worth The Risk?

calcium scoring

I am not a cardiovascular radiologist by any stretch of the imagination. However, I read lots of cardiac calcium scoring studies. And, a good chunk of the time, when I read these studies, I find all sorts of other issues. It may be a pulmonary nodule, a liver or renal lesion, or an adrenal nodule. Regardless, I see too many of these ancillary findings.

Why do all these incidental findings matter? Well, I have a sneaking suspicion that most of us don’t have a handle on the actual risks to this study. So, my question for today is, do these ancillary issues supersede the potential benefits of getting a cardiac calcium study. What are the complications of receiving this scan? And, what does the current literature say about how these “incidental” findings alter the actual risks of receiving this examination.

Calcium Scoring And Incidental Findings

If you want to read an excellent paper on the topic, look at the AJR article called Incidental Extracardiac Findings at Coronary CT: Clinical and Economic Impact. To summarize, around 43 percent of patients receiving this study had some form of incidental findings. And in 52 percent of these patients, the author deemed these findings significant. So, if we do the math, 22% (0.42 x 0.52= 0.22) of the time we read these studies, we will find a significant incidental finding.

Now, in my experience, this number sounds about right. I find pulmonary nodules and hepatic cysts all the time with an occasional smattering of all other sorts of problems. And, I hate recommending the Fleishner criteria and ultrasounds to follow up these studies. Why? Because I know that they will lead to undue additional radiation, procedures, and other complications that we have not even thought about most of the time. And these issues don’t even include the untold psychological tax for each patient with an incidental finding.

Moreover, other patients may even have higher numbers of incidental findings. Check out this paper on diabetics and incidental findings, and you’ll see what I mean. How do we deal with these subsets of the population getting these studies?

And, then, of course, the number of incidental findings depends on the field of view. Some scans use a wider field of view than others which logically should pick up more incidental findings. I always think that if I had to have this test, I would want to receive one with a smaller field of view to decrease the possibility of the incidental finding!

What Is The Real Complication Rate Of Incidental Findings?

At this point, my research on this topic gets a little bit dicey. Unfortunately, I have not found quality information that reports on the actual complications of incidental findings of a relatively healthy person that receives a Cardiac Calcium Scoring CT scan.

Instead, I find myself having to turn to personal stories of relatively healthy patients that had issues with some of these incidental findings. I know one relatively young patient with a remote history of non-metastatic superficial melanoma who had multiple pulmonary nodules. The interpreting radiologist read them as significant enough to be suspicious for malignancy. The patient felt fine, but the surgeon wanted a VATS. Fortunately, the patient’s doctor canceled the surgery and allowed the patient to follow up with serial short-term chest CT scans. The nodules turned out benign!

Or, I think about a breast nodule that a radiologist found that turned out to be a small benign fibroadenoma. The patient had a significant workup with a slightly complicated course of bleeding. It may have gone unnoticed if not for the calcium scoring CT scan.

I am sure these individual cases are just the tip of the proverbial iceberg. Now, you may point out that we do find all sorts of lung cancers, metastatic disease, cirrhosis, and other diseases that may have some benefit of making findings early on a calcium-scoring CT scan. And, I can give you a few of those stories as well. However, these tend to be in a sicker population. Moreover, from my experience, these are a significant minority of cases compared to the world of the benign incidental findings on a Calcium scoring CT scan.

What Do You Say To Colleagues And Patients That Want To Get A Calcium Scoring Study?

Because the hardcore truth about complications and Calcium scoring is not out there yet, here is what I tend to tell relatively healthy patients. First, make sure that you have the risk factors to support receiving this test. As I described above, the complications are not benign. Second, if you think it is worthwhile and will change medical management, make sure to find an institution that uses a small field of view that encompasses less adjacent anatomy. There are many different protocols so that they can make a difference. And, then finally, if the radiologist discovers an incidental finding unless it is glaringly problematic, make sure to take a conservative approach if reasonably possible.

If you receive the test, we can’t undo the incidental finding. But, at least, you are aware of some of its risks and can mitigate some of the problems you may encounter!

 

 

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DO Or Foreign MD- Which One Is Better For Radiology?

foreign md

Each specialty looks for different skill sets and activities when selecting candidates for residency. As part of an admissions committee, institutions scour dean’s letters, recommendations, board scores, volunteer activities, and more to ensure that the candidate makes it through rigorous residencies. However, one of the most “in-your-face” factors that most residencies cannot overlook is the degree applicants have completed. Yes, it is a soft criterion because a suitable candidate can graduate from most foreign MD programs or DO institutions in the United States. Nevertheless, it can become an issue, especially when the committee is not sure of the quality of the medical school.

So, for radiology residency specifically, which degree stands out as the best for applicants? And, which one gives them the best chance of getting into a radiology residency program? I will break down the different degrees into Caribbean MD, Other Foreign MD, and DO schools to accomplish this feat. For each, I will give you the insider advantages and disadvantages. Then, I will provide you with my opinion of the rank order based on the objective facts of each degree.

Top Tier Caribbean MD Schools

Within the Caribbean MD schools, there are undoubtedly several tiers. First of all, we know the quality of St George’s institution since we have had a relationship with them in the past. And, we know that a top student from this school performs at the level of most United States medical schools as we see in our program. Moreover, many other program directors feel the same way from what I have heard. Unfortunately, many medical schools nowadays are biased against Caribbean graduates, even St. George. Many large prestigious academic institutions won’t even touch one of these applications unless the applicant is an exception to the rule.

Furthermore, with the AOA (American Osteopathic Association) combination with the ACGME (Accreditation College For Graduate Medical Education), having a DO degree is no longer a disadvantage for getting a residency. DO residents no longer have to complete separate osteopathic internships and osteopathic accredited residencies. So, Caribbean residents have more competition than ever before to get into ACGME accredited residencies. But, at least, the Caribbean schools with a known reputation can help these applicants secure a spot.

And then finally, the new Step I board pass/fail non-scoring criteria will prevent radiology residency programs from assessing incoming students’ test-taking acumen, which correlates with passing the radiology boards. Therefore, residencies will be more wary of accepting a Caribbean student, even from a top-tier program, especially without knowing if they are a good test taker.

Other Foreign MD Schools

For other foreign MD programs, residencies have the same problems. It’s a problem of familiarity. What does a degree from a Taiwanese, Indian, or Iranian institution mean? This problem is even more complicated than the top-tier Caribbean schools (where we are more familiar). How do we know how students compare to United States schools that graduate? Perhaps, a few institutions do break this mold. But for the most part, we cannot figure out where a candidate stands. Nor do we have the time and energy to tease that out. Primarily, we don’t need to when programs have so many excellent United States candidates to choose from nowadays.

Additionally, the ACGME combining the AOA and the new Step I board pass-fail criteria will make it much more difficult for these students to secure a radiology residency slot due to the increased competition.

DO Schools

Today, many MD radiology residency programs still have a bias against DO candidates, especially at larger academic institutions. Nevertheless, all DO schools must meet the same criteria as MD schools since the AOA and the ACGME have combined into one organization. Therefore, even at the most questionable United States DO institution, theoretically, we should know the baseline training of the medical student applicant. We cannot receive this same assurance from a foreign graduate school.

Moreover, getting rid of the Step I board scores will have a negligible effect on these applicants. Why? Because we have an idea of the baseline quality of these US accredited schools.

So, What’s The Final Ranking Of DO AND Foreign MD Degrees For 2022?

From best to worst chance of securing a radiology residency spot:

  1. DO Schools
  2. Top Tier Caribbean MD Schools
  3. Other Foreign MD Schools

 Just a few words of advice, because you may have graduated from a lesser-known foreign medical school does not mean you have no shot of acquiring a radiology residency. And, if you are coming from a top-tier United States medical school, it does not mean you are guaranteed a spot. But, the type of program you are coming from influences the chances of getting in. You were wondering about probabilities, right?

 

 

 

 

 

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Should Radiology Residents Have Workstations At Home?

workstations

One of the most significant changes in radiology in the post-Covid age is the ability for radiologists to “telecommute” to work. The pandemic has hastened the adoption of these technologies, not just for teleradiologists but for almost every practicing radiologist. Nevertheless, most radiology residents still cannot read from home workstations (although I have heard of a few).

So, is it a good idea for residents to have workstations at home? Well, I will go through some of the pros and cons of home workstations for residents. And, then I will give you my conclusion for which if any residents should have workstations from home.

Reasons For Residents To Not Have Workstations

Need Real-Time Consultations To Learn

My best teaching situations are routine phone calls and visits from our physician colleagues at the workstation. And when a resident takes these consults, they are most likely to learn how to practice and communicate in radiology. Working from home decreases these potential connections to the daily consultations that radiology residents will receive.

“No Real Time Teaching”

Especially for first-year residents, there is no substitute for sitting with an attending at a workstation for a bit to learn radiology. Yes, it is possible to make phone calls to your faculty to go over the images. But, usually, only after you have seen the case and without a faculty member by your side. So, you lose out on many teachable moments to learn about normal findings or ask miscellaneous questions on all the cases you see. These questions can be the most thought-provoking.

Reading In A Bubble

Yes. You need to make independent decisions and read by yourself eventually. But, when you are at the institution reading, you can more easily recruit the help of nurses, technologists, faculty, and more. It is much easier to talk to the ultrasound technologists about patients’ histories in person who just completed a case than to catch staff on the phone somewhere. Ancillary staff and fellow physicians add critical information to your findings and interpretations.

Expense

It is a significant additional expense for institutions to allow residents to read from home. Workstations can run in price from thousands to tens of thousands of dollars. And Medicare only indirectly reimburses for resident dictations, so it has low perceived value for the institutions. Therefore, resident workstations can theoretically increase the cost of healthcare.

Reasons To Have Workstations

Sick Residents

Residents get sick just like everyone else. And, sometimes, it’s a mild bug (or even Covid!). Most residents don’t want to infect everyone else. Yet, they still may have the ability and desire to work. Well, with a home workstation, that is still possible. Having a workstation from home opens the possibility of continuing to learn and read without having to take a day off!

Looking Up And Reading Cases Off-Hours

Sometimes, you just want to look at actual cases at any hour. Maybe, it was an interesting case from the day. Or, you just want to learn more about a particular subspecialty, say MR MSK. For that matter, residents (and faculty) are much more likely to learn about these cases and subjects on off hours if they can look them up quickly at home. That power can undoubtedly add to resident education.

More Accessible To Prepare Interdisciplinary Presentations

We often see residents scrambling to get all the cases they need for the next tumor board during the day. This process can often interfere with daily work. If you have a workstation at home, there is no excuse for doing these activities off-hours when you are home. It’s much easier to complete when you don’t have to go to the hospital.

Is It Worth It For Radiology Residents To Get Workstations?

I am certainly one of the biggest proponents for onsite learning as a faculty member. Based on the many reasons above, such as real-time teaching, I tend to learn more when sitting at the hospital surrounded by colleagues instead of reading cases from home. Something about being present with others enhances the learning process. And that is one of the main reasons residents do a radiology residency, to learn.

Nevertheless, there is no denying that the flexibility of home workstations can also help when a “traditional” learning environment is unavailable, whether due to sickness or after-hours work. So, I am not against residents having home workstations if the institution can afford to pay for it. But, home workstations should not replace the residency experience. Instead, workstations can supplement the learning environment for the resident. As an add-on tool, it’s not a bad idea!