Author: Barry Julius

My name is Barry Julius, MD and I am the founder and chief editor of the website. I have been practicing as the associate radiology residency director at Saint Barnabas Medical Center since 2009. Through many years of on-the-job training, I have gained significant insight regarding all things radiology resident related. Over this time, I have noticed a significant lack of organized online resources for many common radiology residency issues unrelated to the typical medical education and scientific side of radiology. Therefore, I have created a credible, reliable, and informative site that is dedicated to radiology residents, students, program directors, and physicians interested in other radiology residency topics. The emphasis is on day-to-day residency information that is not covered on most educational sites. Topics will include surviving a radiology residency, radiology residency learning materials/books, financial tips, jobs, among other subjects that residents and other visitors may be afraid to ask or unable to find out.
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The 2017 Annual AUR Meeting- A Radiology Residency Status Report

Each year in the heart of spring in the United States, academic/teaching radiologists get together at a different part of the country to discuss the newest teaching methods, radiology residency issues, and hot academic topics at a meeting called the annual Association of University Radiologists (AUR) meeting. For new applicants and radiology residents, this meeting is extremely important as it outlines significant changes to the training of radiologists throughout the country. This year is the first annual update from Hollywood, Florida. I am going to go over what I think are the most relevant and important topics at this conference for radiology trainees.

Increasing Competitiveness of Radiology Residency

Traditionally, it is somewhat difficult to measure competitiveness of radiology residency compared to other specialties. One of the more accurate methods is the United States senior U.S. fill rate. Since 2014, there has been a gradual uptick in the senior U.S. fill rate to 72% (last year 68%). In addition, the applicant pool is up 31 percent over the past 4 years. So, it appears that all this talk about artificial intelligence has not yet dampened the enthusiasm of radiology candidates!

There are always two sides to every story, however. Since U.S applicants usually get first priority, it is a bit more difficult for international medical graduates (IMGs) to get radiology residency slots. In fact, on a survey at the AUR meeting, it stated that only 64 percent of programs are willing to take international medical graduates. That number tends to go down as radiology becomes more competitive. Furthermore, programs are no longer able to accept foreign non-ACGME accredited preliminary year internships to satisfy the requirements of the clinical year.

Improving Radiology Job Market

According to the recent AUR survey, practices are increasing both new and current radiology job hires. In fact, projections show an increasing number of available jobs numbering about 2000 today (vs. 1300-1500 jobs a few years ago). The most popular specialties are body imaging, interventional radiology, and neuroradiology.  However, practices need breast imagers, interventional radiologists, and neuroradiologists the most. And, the majority of jobs are in private practice. That being said, large corporate practices do continue to increase hiring radiologists the most.

IR/DR and ESIR

Now that IR/DR is its own distinct specialty, it commanded a fairly competitive match this year. For this subspecialty, the fill rate with U.S. seniors was 85% versus 72% for diagnostic radiology. So by all accounts, the match was fairly successful. In addition, many new residency programs are applying to start up both IR/DR and ESIR programs. Both of these programs allow a resident to complete his/her entire training in 6 years. Unlike radiology residencies willing to add on these programs, residencies that do not start up IR/DR and ESIR programs will force their residents to have to complete a total of 7 years of residency/fellowship for interventional radiology trained subspecialists. Accordingly, those residencies not willing to add either ESIR or IR/DR programs are likely going to have difficulty recruiting new residents.

Rad Exam

The current in-service examinations do not correlate well with resident performance. In fact, many residencies (including my own) cannot utilize the test as a determiner of residency performance given the wide variability. In addition, there is no distinction in the testing questions between different residency levels. To remedy this issue, a new crowd sourced examination call Rad Exam is being created with institutional benchmarks and a large database. Time will tell if it becomes a useful examination to replace our current in-service examination, but it sounds very promising!

Simulation

Although not a discussed in conference at the AUR meeting, a vendor called Simulation was present and had an interesting solution for programs that want a structured precall examination. This company created an excellent standardized test that assesses finding and interpretive skills using a simulated PACS system to help define if a resident is ready to partake in independent call. Additionally, the test is benchmarked to other programs. It seems like it may be significant improvement over the current precall testing options.

ABR Core Examination Frustrations

Interestingly, according to faculty surveys, most faculty members reflect fondly upon the old oral board examination and give low marks to the new core examination as a means of  testing residents to meet basic radiology requirements at the end of their 3rd year. However, even more disappointing to me, the American Board of Radiology (ABR) now takes a new formalized position that they have no role in testing communication skills. In fact, they explicitly stated that their only role is the testing of medical knowledge. According to them, communication skills should be taught at the local residency level.

Call me crazy, but radiology is a specialty of communication, both written and oral, and not just a specialty of medical knowledge. If that is the case, does it make sense that the ABR as an accrediting body is not willing to standardize testing for communication skills as well as medical knowledge to establish a baseline level of competency? I think not. Academic radiologists need to push the board to change their stance regarding communication competency standardization with oral/written board testing!!!

Increasing Required Administration Time For Program Directors

And finally, on July 1, 2018, the ACGME will likely approve an increase in the minimum administration time requirements for program and associate program directors. Presently, program directors at small programs in the United States can have a few as 0.2 FTE time dedicated to radiology residency administration. That number is ridiculously small compared to other medical subspecialties. Now, that number is going to increase based on a sliding scale corresponding to size of programs in July, 2018 assuming approval by the ACGME. How is that going to affect incoming radiology residents? I believe it will significantly increase the productivity and efficiency of residency programs on issues as wide ranging as educational conferences, evaluations/assessments, milestones, and more… It has been long since overdue.

Summary

As I see it, these are some of the most pressing issues tackled at the AUR conference. There are certainly other issues faced by academic radiology programs. Some of them mentioned at the conference and others largely ignored. There is a bit of good and bad news from this conference for everyone involved in radiology residencies throughout the country. Until next year at the AUR meeting in Nashville, Tennessee!!!

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Curriculum/Teaching Issues In The United States And Abroad

curriculum

Question About Curriculum And Teaching In United States And Abroad:

Hello Barry,

Thank you for your outstanding posts and the constant stream of current topics promoting the dissemination of Radiology as both a profession and a collective guild. I’ve been hanging on every word you’ve written, and it’s almost as if you anticipate my questions in advance. So, I am very much encouraged by the relevancy of your blogs and posts.

I am a Canadian who is a first-year diagnostic radiology resident in Targu Mures, Romania. Here, we follow a five-year path outlined by the EU and the European Society of Radiology (ESR). The problem is that the actual ” teaching ” element is virtually non-existent, and the program expects us to follow or shadow senior residents all day and read on our own. I am lost and overwhelmed by all the modalities I see here daily. For example, a typical day involves spending a few hours in an ultrasonography clinic, seeing conventional or plain film radiography cases, and a CT or MRI following a patient scan.

Most often, the radiologists on staff consult with other physicians, and it’s not like they have the time to point out things. I’ve decided to follow a structured plan and would appreciate your curriculum. What should I cover in my first two years? I know I’m asking a lot of you. Perhaps you can abbreviate your own institution’s plan for me? The first thing I’ve begun to do is revisit skeletal anatomy, including the head and neck. I don’t have a lot of textbooks here (in English, that is), but I have a ton of PDF books on my PC. This lack of physical textbooks is another problem because I miss the tactile experience of actual texts, and looking at a laptop all day is tiring. I will digress and hope to hear from you. Take your time 🙂

Sincerely,

A Tired Romanian Resident

 

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Answer:

 

Thanks for the great compliments. It is much appreciated and makes writing these posts all worth it!

Teaching Differences

Interestingly, you mention that teaching is “non-existent” in Romania. It’s almost the opposite problem in the United States, where everything seems regulated by the government. We need to have x number of noon conferences, etc. I almost wish we had a model for teaching somewhere between the Romanian and the United States models. Residents seem to get bogged down by the regulations and spend less time learning by reading films. (It’s an essential ingredient for radiology!!!!) So, in a sense, you can consider yourself lucky, but you are also missing out on some types of the more didactic teachings.

Curriculum

Regarding the curriculum, the plain vanilla answer is that residents study all the material on the ABR website under the core study guide. It would help if you looked at that to understand everything you theoretically need to know. However, I find it a bit overwhelming, and you need to focus on studying for your time as a resident. So, in the real world, I recommend reading some of the basic overall books in each modality when you begin a rotation each month, such as Mettler for nuclear medicine and the requisite series for some other subjects. You can check out some of the curriculum and books on the web in U.S. Residency programs to get an idea of what you need to know and the books they use. You can also look at some of the books my residents like in the book links section of radsresident.

Most importantly, emphasize the pictures and captions and then secondarily look at the text to understand the images and captions. And keep in mind the ABR blueprints and core material when you are studying. Subsequently, go through the case review series to learn how to go through cases once you have the fundamental knowledge of each primary modality. This process will reinforce all that you studied.

You also make an essential point about missing the tactile experience of textbooks and looking at laptops. It happens to be the subject matter of my next article!!! PDF articles are great because you can download them easily. On the other hand, retention rates for PDFs are probably not as high as reading directly from a printed textbook.

I hope this helps a bit,

Barry Julius

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Barium Slinging And The Radiology Resident- Is It Really An Educational Activity?

barium

Barium slinging not too long ago was representative of the world of radiology. Now it seems, we relegate it to a tiny part. (1) When I started, I remember having many fluoroscopy days filled with double-contrast barium enemas, upper GI series, small bowel series, and esophagrams. Today’s barium work has changed radically, at least in our institution. It is exceedingly rare to catch a resident performing a barium enema. We complete a few daily upper GI series and esophagrams, but not nearly as many as when I was a resident. And, we seem to do bariatric post-intervention studies by the dozens (I remember only doing a few during my residency!). I am also sure the mix of studies has changed radically at many other institutions, not just mine.

Although the fluoroscopic exam mix has changed over the years, we think of a GI day as more service-oriented than educational. Some residents may go as far as to say it is a waste of time. Here is my goal for today: to show you why barium slinging is not just a scut activity but also an essential part of a radiology resident’s education.

Direct Contact With Technology And Patients

Much of radiology brings the radiology resident further away from patient contact than ever before. CT scans and plains films most times have become an almost independent activity. On the other hand, barium slinging is one of a few modalities (like mammography and interventional radiology) that keep the resident in the clinical realm, a critical skill for a future radiology practice. You need to tailor the examination to history and think on the fly. These are invaluable skills that serve the resident for years to come.

Also, you need to keep the patient reasonably happy and comfortable during the examination, both mentally and physically. Keeping patients engaged is a crucial characteristic to learn for getting informed consent and doing more complex procedures. Moreover, you can learn these skills under relatively benign conditions. (Complications from a barium study are infrequent!)

Closer Contact With The Referring Physicians

Before the days of PACS, clinicians would regularly return to our department to go over films. Now a clinician sighting is much rarer. In the realm of barium slinging, you are much more likely to interact with your referring physicians. The clinician often needs a particular question answered, and you need to respond to it rapidly. Perhaps, they need to know if there is a leak or small bowel obstruction. Regardless, you have to deal with the heated interactions that often come along with barium studies. Without barium slinging, it is possible to lose sight of who looks at our reports!

Additionally, these interactions prepare residents for calls. Having a surgical team come down to review a STAT study occurs fairly regularly at nighttime. When a first-year resident works in fluoroscopy during the daytime, they often come in direct contact with the ordering physician since they order these examinations STAT. For instance, esophagrams for foreign bodies, bariatric postoperative patients for GI leaks, and esophagrams for pneumomediastinum need immediate attention. Additionally, these studies require direct communication with the ordering physician’s team. How to relay this information to a rushed team or an angry surgeon quickly and transparently is a critical skill.

And finally, some clinicians ask for barium studies without realizing what they are ordering. They often ask for an upper GI series when what they want is a small bowel series. These subtleties allow the resident to learn when to call the physician to clarify the point of the study. Also, they discover how to tailor the procedure tailored to the history.

Developing Radiological Hand-Eye Coordination

When you start, “barium slinging” is a tremendous first rotation to learn how to position patients while holding on to a tower and snapping pictures. You are using your eyes, hands, and perhaps feet to get the correct images. Committing to fluoroscopy early in residency is a significant first step to learning more complicated interventional procedures later in residency. These principles are the same and build on what a resident knows during those first few fluoroscopy rotations.

Managing And Learning About Radiation

Today there is an enormous public outcry to decrease patient radiation dosage. Techniques such as intermittent fluoroscopy and last image hold are integral parts of managing patient radiation exposure. What better place than fluoroscopy to learn this? Just as importantly, fluoroscopy reinforces the physics studying for the core examination. There is nothing better for education than when the theoretical meets the practical.

Barium Work Is Not Sexy- But It Is Important!

Barium work is the stepchild of the radiology department. It commands little respect and is not as sexy as many newer “more exciting” modalities. Yet, it remains an integral part of the radiology resident’s education. For those who say there is no educational value in barium slinging, take a look at this article!!!

 

 

 

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Ten Surefire Ways To Destroy Your Radiology Experience (And Your Colleagues’ Too!!!)

radiology experience

I have seen it all. Some radiology residents make sure to glean every last drop of radiology experience from their residency so that by the time they graduate, they are ready to hit the ground running. But then other radiology residency graduates never quite live up to their full potential during their residency training. Many of these folks are great people, but when they are about to leave, I am not quite sure if they will handle the pressures of radiology practice.

In the end, I have learned some residents are late bloomers and do pull themselves up by the bootstraps once they leave residency, but a large percentage unfortunately constantly shift from job to job. Many of those folks are the same ones who seemed to do whatever they could to destroy their own residency experience during their four years of residency. And yes, we hear about them again when the paperwork comes back to us each time they change jobs when out in practice. Today I figured I would talk about those characteristics that are a surefire way to ruin your residency radiology experience. Don’t make those same awful mistakes!

Sweat The Small Stuff

In the heat of battle, it is effortless to forget the end goal of radiology residency, to be well trained and ready for practice when you leave. Remember… residency is only a 4-year experience. However, some residents get caught up in the moment and forget about the end game. They concern themselves with relatively minor things such as rising prices in the cafeteria, having to do a few extra shifts, or hearing some disheartening comments from one of their annoying colleagues. Sure, there is a place and time to worry about those things. But, it should not become an all-encompassing mission. Some never get over these issues and forget to learn what they need to know when they leave residency. In the process, they also upset their colleagues, distracting everyone from their training. Get over it!!!

Argue With Your Colleagues

Some residency classes always get along. Others have permanent hatred toward one another. The inability to get along spills over to other areas in a radiology residency. Studying suffers because some folks are left behind, and no one seems to care. Tempers flare and prevent classmates from covering each other when they need it. Everyone becomes exhausted and upset. Next thing you know, residency is over, and everyone is worse for the wear. Do whatever it takes to get along! It is not worth four years of frustration!

Sabotage Your Team

Every once in a while, one resident does not play fairly in the sandbox. Perhaps, he/she refuses to help out with a call. Or maybe, this person does not show up to work and constantly needs to have additional coverage. Not playing nicely with others affects the entire team. If you want to ruin the experience for everyone, it is elementary. But in the end, it will haunt you when you need your residency team the most!

Don’t Read

Radiology residency is a marathon, not a sprint. That means you constantly need to keep up with reading books and articles. I can guarantee that you will fall behind your classmates if you do not adequately read enough starting year one. You will not comprehend or perform well at conferences. Likewise, your call and board experiences will suffer. And, your colleagues will not want to have you’ve as a study partner since you are so far behind. You came to radiology residency to become a radiologist. Part of learning radiology is reading a lot. Why would you want to sabotage your training?

Always Compare Yourself To Others

Everybody learns and reads at different rates; and, some residents click with the material earlier than others. That is OK. As long as you are doing your due diligence during radiology residency, you will eventually get to the promised land of radiology competence and graduation. Don’t worry if some of your colleagues always seem to get things right and you don’t. The quickest path to misery is worrying about how everyone else is doing. Undue competition ruins the experience for everyone. Care first and foremost about your progress!

Don’t Show Up To Readouts

There are two main pillars to becoming a great radiologist, knowing the material and experience. If you were going through the hassle of completing a residency, why would you shortchange yourself and not try to get as much experience as possible? You will never understand the context of reading radiology without having the readout experience. Not being at the readout also affects your mentors’ day. Sit down with your residency mentor, and don’t miss the readout. You are only hurting your career and your relationship with your superiors. You never know when you will need their recommendations!

Do Not Improve Upon Your Weaknesses

You have been getting inadequate evaluations in the area of mammography. So, what do you do about it? Nothing. The complaints continue to come streaming in from attendings. But, you persist in not reading the material or studying your misses. Behaviors become habitual and will likely continue even after you graduate if you do not learn from your mistakes. These folks are the same folks that can never keep a job and never improve their lot. Ignoring practice-based improvement hurts you, your patients, and your colleagues. Residency is all about self-improvement to become the best you can so that you can help your patients. Why would you not pursue the same avenues during training?

Procedures Are Not For Me!

Some residents hate procedures and will do whatever they can to avoid them. I understand these folks may not become interventional radiologists. But, they still need to know the basics of specific procedures such as needle localization, arthrograms, and more. Sure, they can get away with this during residency. But, when they try to land their first job, they may have frustrations as they find the only jobs available require “light interventional” work. Not learning procedures may affect your future partners and colleagues. By not trying to feel comfortable with procedures during residency, you are only hurting yourself!

I Am Always Right

Some residents do not accept criticism. Residency is the time to learn and change harmful behaviors before they become ingrained in practice. We are in the game of treating people, not always thinking we are correct. Why would you not want to correct what you are doing wrong? It makes no sense. You are only hurting your patients and colleagues. There is no room for not accepting criticism both during and after residency!

Don’t Take On Extra Responsibilities

Each year of radiology residency, you accrue new responsibilities. Shirking your responsibilities is a surefire way to become a needy radiologist when you graduate. When the technologist comes along to ask a question, please don’t send them to someone else to answer it. Take charge of your situation and section. Those folks that never take on those additional responsibilities never learn to become an independent radiologist!!! Go forth and makes your path.

Avoid Destroying Your Residency Radiology Experience

It is far easier than one might think to destroy your own residency radiology experience. Sometimes you have to put a bit more effort in to get more out of residency. Please, please, don’t succumb to the pitfalls and traps that can prevent you from growing and improving as a person and a radiologist. Get over your issues… It is not worth it!

 

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eBooks vs. Printed Radiology Books- A Death Match Part II

books

The days of radiology residents lugging ten-pound textbooks around the department are over. I, too, prefer having a list of books to access at any time on my Ipad for convenience. I even reviewed and studied my Mettler textbook for nuclear medicine on my Ipad just before my recertification ABR examination a while back, and it worked out just fine. But based on recent literature, maybe we should not be giving up on carrying around that 10-pound book. Today I will review the arguments for and against buying and reading electronic radiology books versus carrying around and reading those unseemly heavy old-fashioned radiology textbooks.

Arguments For Reading Physical Radiology Books

Comprehension Retention Issues

When it comes explicitly to reading and retaining knowledge from radiology-specific books, I could not find much information on the web. However, significant studies discuss comparing the retention of general information from print materials vs. e-readers. Some of these studies are generally applicable to the radiology resident audience. In addition, some other issues can support the use of printed texts over e-readers.

Back in 2013, in the International Journal of Educational Research, lead author Anne Mangen in an article, studied 72 tenth graders and compared reading retention in PDF format on a computer screen and in print. She found that students reading the texts in print had significantly better retention of the material than those reading the material electronically. However, there are some differences in applicability to the radiologist. We tend to read images and look at the captions and text. So, perhaps there is some difference regarding the radiology resident.

Subjectively, there are also several surveys of readers touting the comprehension advantages of printed books. In an article in Scientific American, one survey reported a conclusion that “when it comes to reading a book, even they prefer good, old-fashioned print,” and another stated that readers “prefer to read text on paper as opposed to on a screen to ‘understand it with clarity.'” So, maybe there is something to the perception of increased retention with old-fashioned printed texts.

Miscellaneous Other Issues

In addition, you may have difficulty getting to sleep after reading with an electronic device. A study called “Sleep and use of electronic devices in adolescence: results from a large population-based study” concluded a negative relationship between the use of technology and sleep. Now, radiology residents are a bit past adolescence for the most part, but I still think you can generalize this information to the insomniac radiology resident, knowing how I feel after reading the news on my iPhone just prior to bedtime.

Also, there is the issue of eyestrain and reading eBooks. The information here is a bit more mixed as to the amount of eyestrain using eReaders vs. printed text. But, there was an interesting article presenting some of the issues regarding eye strain called “eReader Vs. Printed Book: Which Is Better For Your Eyesight?” They reported that Computer Vision Syndrome (CVS) is an actual entity that can affect readers using electronic readers. However, the claim that backlit devices and softer e-readers like the Nook and Kindle may help some readers counterbalance this argument.

And finally, there is the issue of diversion. When you read a printed textbook, you certainly do not have to worry about essential emails popping up, your spouse calling you, a silly text from your friend, or the thought that you need to click on the most recent exciting blog from radsresident.com! Instead, you can concentrate on the information with much less interruption.

Arguments For Reading Electronic Radiology Texts

Here I think the first and foremost issue supporting using the eReader is sheer convenience and instant availability. Carrying 1000 books in your pocket or your hand is a remarkable technological achievement. Furthermore, at any given moment, you can easily click on a link from your text and go directly to a source document you can confirm on your iPhone. You can’t do these sorts of things in a printed textbook.

Multiple new e-readers use different proprietary technologies to reduce eyestrain. In fact, one article reports eInk from the Kindle and the Nook is a significant improvement over other e-readers. Also, according to the same article, people with poor eyesight tended to read better with a backlit screen than on paper. In addition, for those with poor vision, one can easily adjust the text size with an e-reader, allowing the reader to enjoy an electronic text that they may not be able to read in the printed version.

Once you write on a printed text, you alter the text forever. On the other hand, you can highlight or write electronically in an ebook’s margins without worrying about destroying the book. Furthermore, you cannot write in someone else’s printed book without vandalizing someone else’s property. Another win for the electronic device!!!

This borrowing of books brings me to the next significant advantage of eReaders- sharing. Sharing a chapter, phrase, or critical point with a fellow reader is easy. All it takes is clicking a button with a message or email; many people have the same information. Printed text is just not the same when it comes to sharing.

And finally, there is the issue of bookmarks. Most eReaders automatically bookmark the last page that you look at. If you lose your page on a standard text, there is a good chance that if you return to it without a bookmark, you will not remember the last page you read. At least, this is a significant advantage for me!

So Who Wins This Death Match?

Unfortunately, convincing someone about how to read a radiology book is challenging. We all have our set ways and opinions about how to read and what is more effective for us as an individual. And there are real advantages and disadvantages to both. Although not conclusive, the body of evidence points to increased retention for paper, but for many, the convenience of e-texts outweighs the incremental retention. You can easily share an eBook, but you may have more eyestrain reading the same book. So what do you do in today’s world? I think it depends upon you as an individual and the available resources. The bottom line as a radiology resident is to read a lot regardless of the book type. It will serve as a permanent foundation for the rest of your career!

 

Other relevant articles

http://www.huffingtonpost.com/the-national-book-review/drop-that-kindle-10-reaso_b_8234890.html

 

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Is It Still Possible To Become An ABR Certified Radiologist Through The Alternate Pathway?

Dear Barry,

I am also interested as Fiona in the alternate Pathway. My biggest question here would be, if I have any chances after ABR certification in actually pursuing a career as an independent radiologist in the US. As far as I understand, in many if not all states, you are required to complete a minimum time of postgraduate education, within an ACGME accredited program, before being granted the corresponding state license to practice as a physician. Considering the rule that you are allowed to take a fellow position in an ACGME accredited fellowship program ONLY if you graduated from an ACGME accredited residency program (this because of recent changes); how could any radiologist trained abroad be able to fulfill the state licensing requirement after doing the 4 year alternate pathway. (To my disappointment explained here by the SPR – Society for pediatric radiology – ¨ http://www.pedrad.org/Education/Fellowship-Directors/Pediatric-Radiology-Fellowship-Directors-Library ¨ )

The ABR clarifies that the changes introduced by the ACGME are not affecting the alternate pathway, which I understand and see as no impediment for certification, however I still don’t see clearly the possibility of full licensing. Why would a foreign radiologist be interested in ABR certification if the chances of practicing radiology in the US are so scarce or null in the future.

One last question: wouldn’t a fully trained radiologist from abroad be a good candidate to match through the traditional residency system, under your perspective as a program director?.

(Dear Fiona: Maybe we can get in contact and share our views and findings. Please email me if you are interested).

Thank you for reading this, cheers, Esteban.

 

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Here are answers to your two separate questions here. To refer to the other information about the alternate pathway go to the ask the residency director question at the following link: How To Complete The ABR Alternate Pathway As A Foreign Physician

 

Answer to First Question:

In order to be licensed in a state, you do not get your certification from the ACGME. Rather, the ACGME certifies the program that you attend as a resident, fellow, or attending. So, it is still possible to be certified by the ABR and to get a state license via the alternate pathway. However, as you mentioned in the new addendum in 2015 to the alternate pathway, you will have a difficult time getting into an accredited fellowship via the alternate pathway because of the new requirement (having to get an ACGME fellowship only after completing an ACGME accredited residency).

Regardless, it is still possible to use the alternate pathway to become an ABR board certified radiologist. So, how would that happen?

Two Ways To Satisfy The Alternate Pathway Requirements.

1. An ACGME accredited institution would need to sponsor the foreign radiologist for a junior faculty position for four years. In other words, the institution would be responsible for getting the H1B visa for four years so that you could work in the ACGME accredited institution in the United States. The problem with this- the sponsoring institution will incur lots of legal and immigration fees in order for the applicant to get the H1B visa and the junior faculty position. So, it is unlikely that the institution will take a foreign applicant unless he/she offers something special or is trained in a subspecialty area that is useful to the institution and a United States applicant cannot fill that need. Therefore, it is true that the institution is much more likely to take a United States applicant than a foreign applicant for a faculty position.

2. It is possible to get an unaccredited fellowship in an institution that has an ACGME accredited residency program. This year of unaccredited fellowship would be enough to count toward the requirement of having 4 years of training. You would need four such years as this. Through this pathway, you would potentially only have to deal with the issues of getting a J-1 visa, which is a bit easier than an H1b visa.

Issues For The Alternate Pathway Applicant

For both of these alternate pathways, there is a possible complication of some individual states not recognizing the training of foreign residents who do not complete an ACGME accredited residency/fellowship. This means that the alternate pathway training may limit which states he/she chooses to work.

As you can see, it is possible but a bit complicated to go through the alternate pathway via both methods. The ABR alternate pathway has become a rarely trodden method of obtaining a radiologist position in the United States. (It is not impossible, but very difficult and probably involves lots of connections!!!) In addition, there is a risk that your opportunities as an alternate pathway candidate, could be more limited.

Answer To Second Question:

From an associate program director’s perspective, I would love to take a candidate who has been trained as a full-fledged radiologist in another country. Our job becomes a lot easier since these residents are usually very independent. In fact, one our best residents has been a candidate such as that who attended our program four or five years ago. He was absolutely fantastic!

Again, however, there are several impediments for the foreign radiologist who wants to repeat a United States residency. First of all, many programs do not want to have to deal with the stresses of getting a J-1 visa sponsorship for their foreign applicants, even though a J-1 visa is usually not that difficult to obtain. And, second, there is a prestige issue for many programs. Some high-end university programs take pride in the fact they do not take foreign applicants to their program. (Even though they will not say it on their website or brochures)

Bottom line… It is becoming more and more challenging for the foreign applicant to obtain a spot in a United States training position to eventually become a United States ABR trained radiologist. It’s not impossible but it’s very, very difficult. The applicant that is successful is going to have to be at the apex of the foreign applicant pool and is going to have to be on top of the visa situation.

 

Director1

 

 

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Radiology Textbooks Vs. Case Review Books- A Death Match

textbooks

One question that often arises is: what material should I study since there is so much information to learn? But I think a more appropriate question may be: how can I get the most bang for my buck when there are so many reading materials out there? In this post, I will address this issue by talking about when you should be reading textbooks and when you should emphasize case reviews since both play a role in getting up to speed during radiology residency or learning about a new area of interest as an attending. (This is our death match!!!)

Why Textbooks?

Sometimes you lack any understanding of a modality when you begin a residency program, are starting a new rotation, or are attempting to learn a new modality such as MRI, perhaps not covered in your residency. For instance, when they begin, most radiology residents have no clue about ultrasound: how it works, and the images the technologist takes. Therefore, starting to read a case series on ultrasound may not be helpful when beginning.

Instead, a general introductory textbook such as Ultrasound: The Requisites makes more sense at this point to understand the basic principles of ultrasound and the key images that need to be taken and interpreted during a renal ultrasound, Ob/Gynecology ultrasound, etc. Another example would be reading CT scans of the chest. Most residents, when they start, do not have a search pattern for reading chest CT scans. Nor do they know their CT chest anatomy well. An introductory textbook on chest CT scans, such as Computed Tomography and Magnetic Resonance of the Thorax by Webb, would be appropriate before reading a case series.

In addition, good textbooks usually better outline the fundamental knowledge needed to interpret images better than a case review series can. Textbooks are better organized by topics, whereas case review series tend to be more haphazard. For example, it may be more direct and efficient to learn the fundamentals of determining whether an intracranial mass is intra-axial or extra-axial once in a textbook than reading 10 case series on the topic and trying to figure the same approach out.

How To Read Textbooks

When you read a textbook, you should emphasize the images, read the captions, and then read the text to get the most out. Reading in this manner reinforces the information that you need to know better than starting from the text first. This process differs vastly from reading a medical school general medicine textbook, where the text is usually more important than the images. You are now a radiology resident, so you have to think differently!

Why Case Review Series?

In our field, we solely exist because we are image interpreters. So, it makes sense to learn those images and what they mean. What better means to reinforce and understand radiology than with a case series? But, this assumes that the reader has some background knowledge on the topic and can understand the basic principles/fundamentals/meanings behind the images in the case review series.

In addition, case review series tend to have more of a “real word bent.” The images we read daily tend not to follow in an orderly manner by topic. Usually, an almost random distribution of cases comes through our departments. Going through a case review series is usually more similar to going through many images in no particular order.

How To Approach Case Review Series

It would help to start the case review series as soon as you have the fundamental knowledge to understand the modality, anatomy, and primary disease processes on imaging. On each initial rotation, you should aim to start reading at least one case review type of book after you have learned the fundamentals from lectures and textbooks. Do not wait too long to get started, however. Going through the case review series will be more helpful and applicable than most textbooks when you read out cases with attendings and when taking cases at noon conferences. But remember- it often does not summarize the fundamentals of a given subject as well as a textbook.

The Moral Of The Death Match

Both textbooks and case review series are at the beginning resident’s learning armamentarium. Be wary of someone that tells you that you can get through residency by just reading textbooks or case reviews by themselves. Each has its place, and you should use the correct one depending on your level and knowledge base. Now become great radiologists: go forth and read!!!

 

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Top Traits Of Great Radiologists (They Might Not Be What You Expect!)

traits

Over the years, I have discovered that the best radiologists often do not comply with the stereotypical traits of one. For instance, you would think that the best radiologists all embrace technology. However, it is sometimes the opposite. Some of the best radiologists I know are the least technologically adept people you would ever meet, not able to conjure up an email password or conquer a new PACS system.

You would say that they would be masters of video games and spatial puzzles. Well, again, you would be squarely wrong. I know many-a-great-radiologist who find video games distasteful or who have no interest.

You would guess that the best radiologists have an “eye” for radiology from day one of radiology residency. Again, you would be incorrect. Some great radiology residents that I have trained had no clue how to read a film or make a finding on day one of residency.

So what is it that makes up the traits of the best of the best radiologists? Based on my experience, it is the following: enhanced clinical training, grit and determination, extreme organization, singular focus, and the passion for learning and maintaining scientific interest in our field. So, let’s go through each of these traits. Then, I’ll give you examples of how each allows some of the best radiologists to perform above and beyond the average radiologist. Finally, I will go through some recommendations on how you can train to be this great radiologist. Try to incorporate some this additional training or these personality quirks and traits into your daily practice.

Enhanced Clinical Training In Other Medical Fields

Some of the most incredible radiologists that I met had initially trained for a different medical subspecialty. The ones I know have either completed a second residency or participated in a residency in internal medicine or pediatrics for more than the required solitary clinical year. These radiologists have a complete understanding of the clinical issues involved in the patient’s films that they are reading. They take a step past the interpretation of the image and make it relevant for the clinician on the other end. They tend to know how to manage patients to a tee and use their skills to better the patient’s welfare. Excellent clinical management for a radiologist is a rare skill.

How can you add these traits to your practice in radiology? Participate in electives that involve interdisciplinary management. Question your fellow clinicians about the clinical significance of your interpretations. Shadow physicians in other specialties.

Grit and Determination

These excellent radiologists are folks that overcame incredible odds to get to where they are today. By sheer determination of will, they take an interpretation of a film to a new level, farther than the typical radiologist. They look into clinical issues more deeply than others. They don’t just stop at the conventional differential diagnosis. And, they can tell you the hows and the whys of what they find. When a clinician stops by, they are mesmerized by the litany of what these clinicians seem to know.

How can you add these incredible qualities to your arsenal? Don’t stop at the mere interpretation of the film. Look further into clinical history. Read up everything about the disease entity. Find out facts that would be clinically relevant to your patient’s care. Always look at priors that may have relevance to your case. Don’t be lazy with any of your imaging cases!

Incredible Organizational Skills

I have never met a great radiologist who has poor organizational skills. Conversely, the great radiologists I have met all have incredible organizational skills. These radiologists tend to keep track of all the patients they have ever seen. They use this information to interpret images and extrapolate the information to other patient’s circumstances. You can ask them about a case they may have seen a year ago, and they can go into their written or mental records and find it. They use all of this information for the betterment of patient care.

How can you become organized as a radiology resident? Always keep track of your unusual cases. Take pictures of the cases you see. Maintain a written or online notebook of what you learned. All these organizational skills will come in handy when you complete your residency and have questions about challenging cases.

Persistent Focus

Some of the most incredible radiologists have a single-minded focus that allows them to read cases, do research, or teach with such precision that they are best in their fields. They are not distracted by the daily minutia, the irrelevant red herrings, and the rumors of the day. They concentrate on their work and their work alone. These radiologists tend to miss very little. They are the type of radiologists that seem to have very few reports with errors and mistakes.

How can you maintain focus on your daily rotations? Maintain awareness of what you are doing at all times. Keep conversations and distractions to a minimum when you sit or stand to read multiple cases. The patient should be first and foremost on your day’s schedule. That is why we are here- to help people!

Passion For Learning/Maintaining Scientific Interest

Finally, the best radiologists I have encountered have a mission to either teach, research, or learn. They enjoy every minute of these processes and convey their passion to others in the specialty, whether they are fellow attendings, residents, nurses, techs, or patients. Moreover, their enthusiasm is infectious and inspires others to want to be the same. These are a rare breed and help overcome the problem of burnt-out physicians through teaching and personality. These radiologists go a step farther not because they have to, but because they enjoy radiology.

How can you become passionate about radiology? Don’t let the folks that complain all the time get you down. Find your path and what interests you. Don’t look to the negative, as those folks tend not to be the successful ones. People that love their specialty tend to become excellent at what they do. So, find your interests and passions and go with them all the way.

Final Inspiring Words

It is not typical traits such as being a techie, having “an innately good eye,” or being a puzzle master that makes a great radiologist. Instead, it is often those skills that we can work on that make us better than the average radiologist out there. So, go forth and learn about other specialties, keep determined, stay organized, maintain focus, and develop a passion for learning and radiology to become the best radiologist you can be!!!

 

 

 

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Five Reasons Why The First Year Of Radiology Residency Can Be The Most Difficult

first year

Second-year radiology residents become overwhelmed and burdened by call. Third-year radiology residents feel exhausted from studying for their core radiology examination. And, the fourth-year radiology residents fret about all the things they need to know before starting their career. But, what about the plight of the first-year resident? Many non-radiology physicians and some long-practicing radiologists think that these residents have it easy since he does not have many responsibilities. He can merely sit and watch the radiology attending to learn the practice of radiology, right? However, in this post, I am going to dispel that notion. I will go through five reasons why I think the 1st year of radiology residency is usually the most difficult.

Little Medical School Background In Radiology

Unlike internal medicine, surgical, ob/GYN, and psychiatric residents, most beginning first radiology residents have had almost no experience in the mechanics of all things radiology. Sure, they take a few courses during medical school. However, they are usually surveys. Also, they do not provide the vast experiences needed to function as a full-fledged radiology resident.

On the other hand, internal medicine residents have worked up patients with histories during their medical school training. Ob/GYN residents have usually delivered a few babies in medical school before beginning. Surgical residents have assisted in multiple surgeries and have worked the floors before their first day of residency. And psychiatry residents have interacted with numerous patients before starting. These initiated residents can almost entirely function from day one.

Instead, new 1st-year radiology residents cannot dictate, review films to be read, or finish the procedures that we perform daily. Since a first-year radiology resident cannot complete most of the functions to be “of use” to the senior radiologist, many first residents feel inadequate until they can begin call as a second-year. At that point, they can function much more independently. However, the lack of training certainly can make for a problematic initial year.

Incredible Amounts of Reading For The First Year

More so than other specialties, radiology requires a boatload of reading during the first year. You need to understand internal medicine, surgery, obstetrics/gynecology, orthopedics, neurology, and more to become a respectable radiologist. Unlike other specialties, you cannot get away with little reading and learn only from your experience with others. If you do not read for hours every day, you will fall behind and not pass the core examination. Many residents do not know the requirements before starting and take a long time to adjust to the nightly reading regimen, a painful process.

Dictations- A Difficult Road

Imagine your frustration as you first start with never having held a Dictaphone. You click the wrong buttons and feel unsure of yourself as you talk into a stick!!! This routine is typical for the first year that starts to dictate. Not only does the first-year resident have to get the physical mechanics of learning dictation, but they also have to create a report that makes sense. This process often occurs with little instruction or regimentation. It becomes hard to put ourselves in the shoes of the first-year resident. However, as an associate residency director, I regularly recognize how hard it is to start from scratch what we routinely do as radiologists daily.

Frustrated Attendings Who Don’t Want First Years Around

Unlike more independent senior residents, radiologists typically have to take extra time out of their day to teach a first-year radiology resident. Given the increasing workloads of radiologists, many attendings see this as a burden. They would instead get home to their family on time in the evening. Additionally, the attending does not know the first-year resident well. Therefore, he cannot figure out how much responsibility to give. Other radiologists feel forced and have no desire to teach. The frustrations of many attending radiologists reflect in the personal interactions with the first-year resident. Often, the resident gets the sense that he/she is not wanted around. Depressing, huh…

Noon Conferences- A Foreign Language

Have you ever listened to a conversation in a language that you do not understand? That is the feeling that the first-year radiology resident often gets when he/she goes to the first noon conference. Attendings give noon conferences on topics such as ultrasound or MRI. Yet, these radiology residents have never seen these images. On top of that, they use language that is not common vernacular.

Moreover, the findings are incomprehensible to the uninitiated resident. Many attending radiologists do not recall what it is was like to attend these conferences. However, these esoteric conferences are standard for first-year residents.

The Final Upshot For The First Year Resident

Senior radiologists can easily dismiss and forget the challenges that first-year radiology residents face. However, please don’t discount the first-year radiology resident’s frustrations, experiences, and anxieties, as they are genuine. It takes an extended period of adjustment to acclimate to the daily work experienced by radiology residents and attendings. Give the lowly first-year radiology resident a chance!!!

 

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The Precall Quiz: Mechanics of The Test And Preventing Failure

It’s getting to be that time of the year. Spring… Ahhh… Birds chirping, snow melting, and oh yeah… of course… first year resident preparation for the first night of call. Often times this process begins with a bang called the Precall Quiz.  Although it is not a specifically required measure for being able to start call, it is a way that many residencies assess the functioning of the soon-to-be second year in a “real-world” situation. Sometimes the residency program sets up the precall quiz. Other times, the residents create it. Regardless of who prepares the exam, the first year resident needs to prepare the same. Since the contents of the examination are generally limited to call cases, he/she should be able to expect what is going to be present on the quiz and be able to pass it without question. In today’s post, I am first going to go over the mechanics of a proper recall quiz, whether prepared by the chief resident or program director. And then most importantly, we will talk about how a resident should prepare to pass the test and make sure to feel “comfortable” taking his/her call for the first time. Here we go!

For The Residency Program: What Is A Fair Precall Quiz?

A precall quiz should consist of both the material/contents needed for the first night of call as well as be similar to the way that cases are taken on a night call. What does that mean? Emphasized cases should be situations that could “kill or severely injure patients” or are very common. In addition, it should also contain a few normal variants. These components will most simulate a real night on call.

Furthermore, the style of the examination should be given in the same way that call is taken. In other words, it should probably be administered on a PACS workstation in the way that cases are usually evaluated. Some residencies may still use the PowerPoint format. But, I think there is a danger to giving an exam with cases in this style. Giving individual pictures in a PowerPoint presentation format only assesses knowledge base and not the ability to find lesions on imaging modalities. Both of these qualities need to be evaluated prior tuo beginning call. Or else, a resident that passes this sort of examination is not truly assessed on all the fundamental knowledge bases needed to assess call competency. In fact, these residencies may be setting up certain residents for failure without the appropriate learned “finding strategies” when night call begins.

For The Examinee: How To Pass A Precall Quiz?

Studying should theoretically begin when the resident starts residency. However, many times residents will often cram knowledge into a short period of time prior to an exam. Either way, the examinee should really concentrate on ER case studies prior to taking the test. These should be the killer diseases such as aortic ruptures, pnemothoracies, neurological bleeds and infarcts, and so on. Also, you should be looking at lots of cases that are very common with some morbidity such as appendicitis, diverticulitis, cholecystitis, and more. I would recommend the Emergency Radiology Case Review Series as one resource that would be very help for taking the taking quiz. But, of course, it just a starting point. Make sure to look at hundreds of versions of the common disease entities so that there are no surprises on your first call night. It can be as simple as Googling appendicitis and looking at all the ways that this disease entity presents. But, it is just as important to attend your rotations real time so you have the experience of knowing how to use the PACS system to scroll and find these disease entities in a “real word” setting.

How To Feel “Comfortable” On That Dreaded First Night of Call

OK. I lied a bit at the beginning of this post. The truth is that no trainee radiology resident ever truly feels comfortable on their first night of call, unless you were born with the genius gene or you are missing the emotion of fear! So, do not expect to feel entirely in your element. That being said, if you know cold the entities that will kill or severely injure patients, have studied appropriate cased base material, and attend your daily rotations it is very unlikely that you injure anyone. The knowledge that you passed your precall quiz and know the basics should put you in good staid. Remember that most radiologists before you have been through the same situation as you and most have made it through the first night of call unscathed. And if you listen to me,  just like them, you will make it through the process too!