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Posted on December 2, 2018December 2, 2018 by Barry Julius

RSNA 2018 Meeting: What Residents Should Expect From Artificial Intelligence?

By far, the RSNA is the largest and most publicized radiology meeting of the year. But, I usually attend other meetings instead because so much goes on at once at the RSNA that it is next to impossible to concentrate on one area. Moreover, to get from one side of the Mccormick conference center to the other takes almost 10-15 minutes!

In any case, for the first time in eight years, I bit the bullet and decided to attend the RSNA meeting this year. Partly, I needed additional CME credits, but also I was not able to participate in the SNMMI meeting due to timing. But, I am delighted that I did. Why? It allowed me to grasp the most current themes in radiology that exist today. And, for residents, in particular, I thought it was critical to share with all of you what may be coming down the pike.

To start with, if I had to give one overarching theme from the conference, I would have to say that the central idea was artificial intelligence. Some of these revelations about artificial intelligence were not all that critical. But, others will play an enormous role in your careers down the road. So, I will try to emphasize those items from the conference that will undoubtedly influence your career. And, I will briefly talk about a few issues that the AI companies and academic sorts may overhype.

Strong AI Career Influences

Integration

When you pull up your PACS system to read cases ten or twenty years down the road, no longer will you have to pull up your history, labs, pathology, priors, EHR, and films separately. Instead, all hospitals and outpatient offices will have software and systems that will allow you to sort through all the information at once. Right now, some institutions are more integrated than others. For most of you, lack of integration this will become a relic of the past. Walking through the technical exhibits, you could see many solutions today that will allow the radiologists of the future to read films with all the clinical information at your fingertips.

Triage

Imagine having a helper sort through films to determine which ones you should look at first and others that can wait a bit. Well, now they have multiple software packages that use deep learning to create work lists that make sense. And other programs try to detect STAT findings such as brain bleeds to make sure that radiologists read these studies first. Finally, other software programs can make sure that the correct radiologists are reading the appropriate studies. Right now, most practices do not have the staff to scrutinize cases before dictation. So, all these AI solutions, will allow more efficient and appropriate reading of STAT and essential studies.

Reducing noise

Having stopped at numerous vendors, I noticed that most of the big ones were touting deep learning algorithms to increase the quality of images. What do I mean by that? Many had sophisticated programs that mitigated artifacts and increased conspicuity of lesions and vessels. Some allowed you to image patients with significantly lower contrast dosage to prevent acute renal failure. Motion artifact on a CT scan or PET-CT scan may become a rarity. The future in this arena is now!

Increasing Reading Efficiency And Quality

Right now, some companies have created Computer-Aided Detection (CAD) packages that assist the radiologist in reading images. At the meeting, these solutions seemed to emphasize lung nodules and mammography. I would expect some improvement over the coming years in these imaging modalities. And, I think we will begin to see other imaging modalities that utilize CAD. CAD will continue to reduce the time and effort that goes into reading studies.

One of the new types of CAD that I thought would be of help to the average radiologist was a bone age reader. It’s the perfect place for AI to begin because medical liability is a bit lower.

Additionally, new software packages can integrate CAD functions into the current dictation and PACS systems. We will see a lot more integration to improve radiologist reading efficiency.

Weaker AI Career Influences

Radiology 3.0

As much as the RSNA academics liked to state that we will no longer be image-centric and instead become patient-centric, I don’t see many powerful economic and political factors to drive the current radiology business in that direction. Currently, I am a bit skeptical about the rate of progress toward that goal. I have a feeling we will still have considerable time pressures to get tons of cases out rapidly. Until fee for service no longer becomes relevant, radiologists will not have the time to see each patient after reading their chest film. It’s just not realistic. However, we will have more information at our fingertips about our patients’ care to make better reports and decisions. But seeing a patient after reading each film is a pipe dream.

Driving Direct Patient Care

In one of the plenary sessions, a computer scientist gave a whole lecture on improving metrics such as hand washing and patient falls with artificial intelligence. She discussed placing sensors all around the hospital to create a virtual environment that can sense these events to improve patient morbidity and mortality. While I agree that we should try to improve these issues since they cause harm to patients, the lecturer did not convince me that hospitals and institutions are ready to spend the money and time to accomplish these goals. For the foreseeable future, I see too many financial and legal hurdles to extrapolate these ideas to a larger scale.

Artificial Intelligence And The RSNA- Final Take Home Messages

Artificial intelligence will have a profound effect upon all of our careers, for better or for worse. But, the younger generations of radiologists have more to gain and more to lose. Therefore, for residents, especially, it is critical to follow the developments within the field. And, the RSNA meeting is just the right place to get a sense of AI and your future. If you have an opportunity to attend a meeting like the RSNA, it is well worth it. Take advantage of the event and learn about how the main themes will affect your career!

Posted on November 25, 2018February 11, 2023 by Barry Julius

The Dean’s Letter Dilemma: A Rogue Evaluation

Within the application, few sources give as much information to the residency application committees as the Dean’s Letter. Yet, the Dean’s Letter also exposes a large crack in our system for deciding upon applicants. And today, I will talk about one of them- the rogue evaluation.

Here is an example of the sort of rotations comments that you may come across in a Deans Letter with a rogue evaluation:

Evaluations

Surgery- A, Excellent. Received glowing evaluations from all residents and attendings.

Psychiatry- A, Fantastic student, Able to empathize well with patients, acts as an intern (above his level of training!)

Family Medicine- A, Actively participated and gave excellent concise, and helpful histories

Radiology- A. Incredible eye, Great talk on Histiocytosis X/eosinophilic granuloma.

Medicine- A-, Worked hard, good scores on the shelf exam.

Ob/Gyn- B, Unable to do an appropriate pelvic exam, forgot to take a good history on several patients, and would not scrub in on many of the cases because he didn’t think it was necessary.

The Dilemma

Whoa. Look at that last rotation. Notice how it does not fit in with all the others. So, what are the possibilities behind the poor Ob/Gyn Deans Letter evaluation? What do admission committees do with this information? And, how does a Deans letter such as this one affect the applicant?

Why Did This Student Get Such A Horrible OB/GYN Evaluation?

Well, it could have been the medical student’s first rotation. Sometimes, in this situation, you have a medical student who initially had no clue how clinical rotations worked and just messed up. Or, maybe, one resident or attending had a vendetta against this medical student and wanted to stick it to him. And finally, perhaps, this medical student indeed did not function well in a rotation that did not interest him.

Regardless of the cause, this resident has been screwed (for lack of a better term!). What do you do when you have scores of applications without a significant blemish, and then you run into this one rogue Deans Letter? Well, you run it by your team, the admissions committee!

The Next Step: The Admissions Committee

So, how does the Admissions Committee deal with a Deans letter like this? And let’s assume that all the other factors, such as board scores, recommendations, personal statements, and extracurricular activities, were just fine.

Well, you can probably imagine the discussions at an admissions committee meeting. First, half the committee says we should give this candidate a shot at an interview because everything else on the applications sounded OK. And the other half wants to dump this application since it has a blemish. Moreover, this year has such stiff competition. In the real world, these are the discussions that take place.

As a program director, if the candidate makes it to the interview process, then the interview needs to proceed with this issue in mind. Typically, we need to press the medical student on this question. If he responds to the problem with a reasonable answer, we will then place the application in a separate pile where we need to confirm the candidate with another well-placed phone call to some of the faculty. On the other hand, if he evades the question or gives a vague answer, we put the application in the DNR (Do Not Rank) pile. The whole process can hinge on this one comment.

The Moral Of The Deans Letter

All this brings us back to the double point of this blog. First of all, as you can see, some schools do not filter the Dean’s Letter at all. And its comments can change the whole disposition of the applicant because often it is the only negative piece of information on the entire application. Is it fair? Sometimes, the alleged student misconduct is actual. But, often, a poorly edited/written Deans Letter is merely a function of the negligence of the institution delivering it. Vengeful comments do not belong in a Deans Letter. Truthful and objective statements do. But, most institutions will allow any old phrase to go into the Dean’s Letter. I see that as a significant issue with the system.

And lastly, all medical students must look at their Deans letter if they can. For one, they should try to edit it if they can. Or, at the very least, they need to know to address it if they make it to the interview stage. You are better off learning about the issues on the Dean’s Letter before starting your first interviews (if you are fortunate enough to get one).

Deans Letter Woes

My relationship with the Dean’s Letter is a love/hate one. Why? Primarily because it does help to ferret out differences among the candidates so that you can rank residents appropriately. At the same time, I am aware that it is an imperfect evaluation tool that can cause the demise of many applications of suitable candidates—bottom line. We need to find a better way to evaluate our medical students. Medical schools should take a second look to re-evaluate how they create the Dean’s Letter. It may lead to better selection criteria and improved treatment of their students!

Posted on November 18, 2018February 8, 2023 by Barry Julius

A Rarely Utilized But Effective Tool To Make Sure A Residency Program Is Reputable

Recommendations for “good” residency programs about where to apply are a “dime a dozen.” Residents and attendings often give you their opinions about programs based on previous reputations. Or, perhaps, they attended or have friends within the residency. Rarely a faculty member knows the current residency program well enough to tell you if the perceived residency quality matches its current status.

Additionally, any program’s directors, chairpersons, faculty, and residents continuously change. So, these folks may know much about the residency from many years ago but not much about the current status.

So, how do you confirm whether a radiology residency program is reputable once you arrive on the interview day? To do just that, it takes one straightforward but rarely performed step: Ask residents and attendings from other departments within the same hospital about the residency program at the interview site.

Why Does The Opinion Of Other Department Physicians About The Residency Program Matter So Much?

Remember. When you apply for a residency, the residency has a vested interest in selling you a spot. The residency director, residents, and faculty want all applicants, regardless of rank, to select their program to get “the best residents.” So, asking a radiology resident or residency director whether she likes his residency is like asking a car salesperson if he loves the car he is selling.

On the other hand, other department members may work directly with the radiology residency. However, they do not have the same filter. They can say whatever they want about the program without being directly affected by the repercussions. Therefore, asking these fellow physicians can give you a more truthful answer.

Moreover, physicians within most other departments often work directly with radiology residents and attendings. So, they have great insight into the quality of the radiology department as a whole.

Why Do Applicants Rarely Perform This Step?

First and foremost, most residents never consider the option. Interview days are so chock full of activities that asking other departments would never cross your consciousness. You may also think you do not have the time to bother.

For others, however, it may involve stepping outside your comfort zone. It would help if you asked other physicians you don’t know about another residency. You may worry if they will even respond. But, you will likely find that most physicians will be happy to talk.

What Kind Of Information Can You Find?

Well, the information you may discover can be invaluable. What about a question to an emergency department physician like: Do you trust the reads of the residents in this program? This question can give you a lot of information about the quality of a training program. You will get a much more truthful answer than asking the program director about the program’s quality.

Or, how about asking the oncologists, do you get along well with your radiology colleagues? This question can tell you more about a radiology program’s culture than any pointed question you may ask the radiology residents or faculty.

My advice is to consider some pointed questions to ask after the interviews. And, then, try to find a few residents and attendings in another department to ask about these questions.

Making Sure A Residency Program Is Reputable

If a particular residency seriously interests you and you want to confirm its reputation, then you want to consider taking the extra time to step out of your comfort zone. Ask a few random attendings from different departments about the program. It’s a great way to ensure that the residency matches your expectations. You may find that all is not as it seems!

Posted on November 15, 2018 by Barry Julius

Radiology Book Favorites – A Local Poll

I thought it would be interesting to informally poll my residents to find out their favorite radiology book by residency year and share the information with the readers of the website. Why? First of all, I figured many readers have a vague idea of what books to read, but sometimes they purchase radiology books without checking out what their colleagues liked the most. Second, I performed a brief survey by residency year to get a more specific idea about what you may want at your stage of residency. And finally, I was hoping to find a few patterns (which I did).

Well, these are the basics about what I found. Core Radiology was the only book that all years found to be useful. Brandt and Helms and Felson’s were popular in all years except the 4th year. Otherwise, there is a smattering of favorites throughout all 4 years of residency.

Check out the results from my informal radiology book poll (the first of its kind on this website!) at the bottom of this blog in order of popularity for each residency year.

Let’s Create A Radsresident Favorite Radiology Book Poll!

And lastly, I thought it would be a good idea to also have you, the reader, take a survey to determine which books were your favorites. If we gather enough data, we can create another list compiled from all my readers. I think that this information would also be helpful to decide upon which books to read. So, fill out the survey at the bottom of the page to give your opinion!

The Final Results!

So, now I present you a list of the results from my informal poll with links to the same books on Amazon (where I am an affiliate!)

Please fill out the survey below if you want to contribute your opinion to the “best of” radiology list of books for all readers of radsresident.com. If you cannot see the survey for whatever reason, you can click on the adjacent link that will take you directly to the survey site. Once again, thanks!!!

https://www.surveymonkey.com/r/RRLT759

Create your own user feedback survey

Posted on November 11, 2018 by Barry Julius

Radexam- A Bridge To Getting Rid Of The Core Exam?

For years and years, programs throughout the country have been utilizing the ACR in-service exam as a way to find out if residents have been keeping up with the material. And, from my experience, the correlation of the test with the Dow Jones Industrial Average on any given day is higher than that measure. And, many program directors believe the same. Now, for the past year or so, programs throughout the country have been utilizing the new Radexam to drill down on radiology topics to check the same measures. But, is this exam all that it cracked up to be and what do we know about it? What would be the optimal exam if I had my druthers? Should we be using any monthly or annual review to test residents at all? Or, perhaps, we should eventually overhaul the current core exam process in favor of Radexam-like alternative?

What We Know About Radexam Currently

Unlike the previous in-service examination, the ACR created Radexam as a crowdsourced evaluation tool. Academic radiologists are constantly vetting the questions. Also, dissimilar to the in-service, the exam evaluates the resident based on her specific rotation. You will be able to tailor particular question banks to your individualized monthly requirements at your institution, whether modality or topic based. If you have a cardiovascular MR rotation, theoretically, you can create an exam that tests on that rotation. And finally, you can evaluate residents with this tool on a monthly basis.

After I have seen an exam from the batch, the test looks hopeful as a tool for making sure that residents are keeping up with the material. But, the only way to know for sure is to correlate the test with resident evaluations and the core examination. That should be coming to a theater near you soon!

The Optimal Exam

OK. Deciding upon the optimal exam is a tough one. But, let’s give it a whirl. Well, first and foremost, we have to remember the purpose of an examination for residency. And, no the target of an exam is not to correlate with board passage rates. Instead, we should be thinking farther down the road. Is the test evaluating residents on the skills that they will need to become a good radiologist? Test authors often get hung up on creating an exam for the exam’s sake and forget about this end purpose. If I were a test creator, I would have none of that.

What else? Well, I would create an examination such that if you were able to pass it, you could demonstrate to your government, colleagues, and patients that you have the necessary skills to practice radiology. Forget about curves and complicated statistical mumbo-jumbo. I would not care if the pass rate was 87 percent, 100 percent, or 2 percent. All I care about is that our residents have the abilities and skills that they need to practice. In the end, that is all the public should care about too.

Additionally, it would not happen at one sitting. No more travel to Chicago, Tuscon, etc. Instead, you would take it continually throughout your residency at your program as a way to show you have gradually mastered the competencies that you need to practice.

Finally, the exam should be relatively reasonably priced on resident budgets so that they can afford the fees to create it. Theoretically, this is a tough one, I know. But, with large amounts of student debt racked up over medical school and residency, it cannot be more critical.

How Does Radexam Match Up To The ABR Core Exam?

Well, this is the million dollar question that residency directors throughout the country are trying to answer. The success or failure of this exam hinges on this answer. Unfortunately, we don’t know the answer to this right now. But, I suspect that the correlation will be higher than the previous in-service exam. It does not take much. So, in that respect, you would be able to call it a success.

Advantages Of A Monthly Exam Versus Annual Exam

The more often that we evaluate a resident during residency, the more likely that we can closely follow the learning process. On the downside, however, no one likes to be placed underneath a microscope at all times. Additionally, testing creates an artificial environment that differs from the day-to-day practice of radiology and medicine in general. But overall, the more often you test, the better you can check to see if the resident is completing the learning tasks necessary to become a radiologist. And, that brings me to my next and final thought.

Should We Consider Overhauling The Core Exam And Replacing It With Radexam?

If the core exam, as we know it, does not satisfy many of the criteria for an optimal examination, should we consider looking for alternatives? I believe that the curt answer is yes. And, Radexam may fit the bill if we drill down on it a bit.

First of all, it tests residents more often than a core exam, so that it allows a more accurate evaluation of the resident’s medical knowledge and skills throughout residency. Second, you can have residents take it on a home computer in a more realistic setting instead of some impersonal test center of some sort, leading to test-taking anxieties. Third, Radexam is crowdsourced and overhauled continuously throughout the year. Instead, the core exam questions are vetted, but only at a few intervals. And, finally, you can attune the Radexam to your program. Not all programs teach the same material throughout the country. Moreover, not all the content on the core exam will be relevant to your future practice of radiology. Radexam may resolve that issue.

Final Thoughts About The Radexam

We are still not quite there yet when it comes to knowing about exactly how Radexam will play out. In any case, I am hopeful that the outcomes will match up with the medical knowledge and skills that residents need to learn. And, as a bonus, I also would like to see a better correlation of Radexam with the core exam outcomes. (which I think we will) If these correlations are high, perhaps, we should consider Radexam as an alternative to entirely replace the in-service that we use right now and maybe sometime down the road, the core exam. Although no test is perfect, many of its features are significantly closer to my optimal examination than the current ones. Let’s start the debate to consider our best options.

Posted on November 8, 2018 by Barry Julius

Can I Get Into Radiology With Poor COMLEX Scores?

Question:

Hello Dr. Barry Julius,

I am a 4th-year osteopathic medical student that is struggling to figure out how I can pull off getting into a radiology residency with disappointing COMLEX scores and a completely sub-par application.

Background:

I finally realized what I wanted to do in medicine and now I fear it’s too late. I come from a surgical background having been a Certified Surgical Technologist and First Assistant for ten years before getting to medical school. I realized during my 3rd year that I didn’t want to be a surgeon.

I fell in love with radiology during my ER rotation this year. I loved feeling like I was finally helping patients by reading films. So many times, I felt like I never got to the root of a patient’s problems in internal medicine and family medicine but with radiology, I felt like I was solving a problem. As soon as the radiology bug bit me, I immediately started researching requirements for getting into a diagnostic radiology residency. This task broke my heart into a million pieces. All I found was how competitive the programs were and how essential board scores were.

Main Problem

Passing COMLEX level 1 was the hardest thing I’ve had to do in medical school. I failed twice and finally barely passed on my 3rd attempt. I’m both ashamed and proud of how many times took the exam. I’m proud because I never considered quitting. Medicine has always been my passion, and nothing would ever make me give up on the dream of becoming a physician. I never felt like COMLEX was ultimately going to defeat me.

I’m also proud because I learned a lot about how to study and how I learn best. I’m ashamed because it made me feel like I wouldn’t make a great physician. Many mentors and patients have told me that I would make a fantastic physician. In my heart I know I would.

My Current Situation

I made friends with the radiologist at the hospital where I did my ER rotation, and I’m doing an elective rotation with him starting next week. I’m really excited about this opportunity but lingering in the back of my mind is maybe I have no chance of getting into a radiology residency. Tons of people have told me there is no way to salvage my situation, but I can’t accept that. I’m a fighter and always have been.

Even if you never reply to this message I honestly appreciate the chance to vent. The bottom line is, I will never give up trying to achieve what I want especially now that I’m so passionate about it. After reading some of your posts, I just wanted to know what you would do in my situation. What is your advice for someone like me, with a worthless application, but a strong drive to do whatever is necessary to achieve a goal?

Regards,

Worried Radiology Applicant

Answer:

Sorry, I have been unable to get back to you sooner. It has been a crazy week. However, I have had some time to mull the issues that you present in the letter and I have come up with a potential solution. But, it will take some soul searching, grit, and determination.

Why are the medical school exam board exams so critical for radiology residencies? Simply because the radiology boards is also a multiple choice question computer exam that is difficult to pass. And, most residencies would not want to commit resources to a resident that will not be able to pass the boards.

Get To The Bottom Of The Situation

So, this is what do you need to do. First, you need to figure out why you have such a hard time with the exam. This may be the most difficult part for you, to admit there may be a psychological problem with test taking to begin with. Many times this is a simple issue that can be easily solved. They have testing psychologists that can get to the root cause. It would be well worth your time to splurge a few thousand dollars now to get the answer that may save you hardship down the road.

For some, the issue can be solved with something as simple as anxiety exercises before the test. For others, it could be a learning disability that you were not aware of. Regardless, make the time and effort to complete this step. It will be well worth it.

USMLE: The Solution

Second, you need to take the USMLE. The good news for you: Most radiology residencies do not like to use the COMLEX as a screening tool. So, if you were to do well on the USMLE, they would never even care about your score on the COMLEX.

So, finally, I would dedicate a year to studying for the USMLE exams and doing well on them. How would I approach it? I would take a year of research in radiology to stay involved in the field. And, I would study at the same time so that you can get the scores you need.

Bottom Line

It will take a lot of from you to really tackle the issue of passing the USMLE and getting into radiology residency. But, if you really want it that bad, there is a way.

Regards,

Barry Julius, MD

Posted on November 4, 2018February 19, 2023 by Barry Julius

What Does It Mean To Be One Of The Successful Radiology Residents?

So, your residency director begins to talk about his most successful radiology residents over the past ten years. But what does that mean exactly? And do you want to be part of that list? Well, maybe or maybe not.

Most of the time, the resident’s and program director’s expectations align precisely. But other times, the definition of a successful resident from a residency director’s perspective may vary widely from yours. In this light, we will talk about the expectations of a residency director and your expectations of the meaning of a “successful” radiology resident. Moreover, we will look into those conflicts of interest that may arise between the two expectations.

Residency Director Expectations

So, what makes a residency director happy with his residents? Well, for many directors, it comes down to reducing the heavy workloads. And, to keep their work to a minimum, most residency directors want their residents to comply with the basic expectations of a radiology residency program during the four years. In other words, these are some of the phrases that a residency director would want to apply to their best residents.

1. Passes the core exam on the first try

2. Completes all the necessary work on his own

3. Doesn’t create too much noise during residency.

4. Is expeditious with his work

5. Gets along well with others

6. Completes fellowship after residency

7. Enters academics and has a radiology career

8. Creates his research projects independently

9. Continues to produce research independently after graduation

Radiology Resident Expectations

On the other hand, what does a resident think would make the best sort of resident during his training? Here are some short descriptive sentences.

1. Reads enough during residency to have a good background for his career

2. Experiences and learns about all the procedures and modalities in the field.

3. Gets along well with colleagues and attendings

4. Makes connections for fellowship and beyond

5. Does not get sued

6. Can find a quality job in a desirable location with reasonable income after his residency

What Are The Potential Conflicts Of Interest Between The Resident’s and Program Director’s Expectations?

Research

The program gains more clout for a residency director when it produces large amounts of academics. For one, the Radiology Review Committee/ACGME will be much less likely to cite a residency if they have sent many abstracts to national conferences and have written numerous publications. On the other hand, many residents can care less about pursuing research and utilize it only as an avenue to graduate residency.

Making Noise

Often, residency directors like the status quo. To accomplish this, they would rather have their residents go through the motions of completing their work without changing the system. It becomes a less complex pathway with fewer chores to do. However, on some occasions, by not vocalizing educational issues, radiology residents may sacrifice their education and career. So, the resident may not find it appropriate to maintain silence.

Finding A “Good” Job

Sometimes, the program director’s definition of an acceptable career choice differs widely from his radiology residents. For instance, she may expect residents to go on to academic or prestigious private practice careers to maintain the “lineage” of the program. Nevertheless, the best career pathway may not always apply to each resident who comes through the system. Some residents may have business interests or may not have the desire to enter a typical career.

Taking And Passing The Boards

For most residents, completing the radiology boards become a critical step to obtaining a desirable job. And it also adds to the positive statistics of a program. But sometimes, passing the big exam is unnecessary to get the career the radiology resident wants. Perhaps, they want to enter the business world. Or, they have a job lined up in some other area. Taking and passing a board may become less critical to this resident than the radiology program.

Bottom Line About “Successful” Radiology Residents

The program director’s and the radiology resident’s expectations of the “successful” resident usually align. However, occasionally they don’t match up. It’s like parenting. Sometimes, we need to let our residents take an untraversed pathway. We, as program directors, cannot always force our residents down the same well-trodden trails. And radiology residents should not expect that they always need to perform the desired requirements. Instead, radiology residency directors, residents, and the external regulating bodies should redefine their expectations for success with the understanding that “successful” residents do not always fit an identical mold.

Posted on November 1, 2018 by Barry Julius

Halloween Special: Ten Scariest Radiology Resident Situations

In honor of today’s holiday, here is the second radsresident annual Halloween special: a top ten list of the scariest situations for radiology residents! See if you agree…

halloween

1. Taking your first night of call

2. Failing the core exam

3. Getting called into the program director’s office

4. Making your first significant miss on a film

5. Taking your first case at noon conference

6. Being unable to obtain a recommendation for fellowship.

7. Receiving a subpoena from an attorney

8. Getting chewed out by your faculty in front of your colleagues.

9. Falling asleep at nighttime while working and not getting up before morning readout.

10. Picking up the phone from the ER to find out you are not reading fast enough.

Posted on October 28, 2018February 26, 2023 by Barry Julius

Why A Strong Department Chair Is Critical To Residency

As an associate program director, I work with all the residents and faculty. But, one role, in particular, plays an even more significant role in the quality of the residency than the others. Which one would that be? (Hint: Well, if you have not guessed it by now, you may want to look at the title again! The Chair)

OK. So, the chair is critical to running a great residency. But what is it about a chairperson that makes the role so important? Well, the importance of the position is what we will run through over the following, oh, say, 8oo or so words!

Backbone When The Going Gets Tough

Everyone, once in a while, events conspire to mangle a residency program. Perhaps, a resident decides to leave for another career, and the hospital wants to take away the residency slot forever. Or, the emergency department determines they no longer want residents to give the final dictations at nighttime. In any of these cases, you need a firm chair to prevent these issues from negatively affecting the residency program. Sometimes you need a leader to fight for your department!

Allocation of Resources To The Residency Program

What would happen if you had a chair that decided to commit more resources to non-residency-associated imaging centers at the expense of a hospital-based residency program? Chaos, of course! You may not have enough physical bodies to teach the residents. Or, the chairperson decides to stop giving the program directors administration time to run the residency program. Either way, the chair controls many of these outcomes. And, if she decides to allocate the resources to the outside facilities instead, the residency loses out.

Carrot And The Stick

In any practice, some physicians have more or less interest in teaching. But, what happens if some of the attendings decide that they no longer want to give conferences? Well, the chair has the practice’s long arm to ensure that does not happen. The chairperson can either decide to provide money or non-monetary incentives to make sure that the faculty performs. Or, she can remove incentives from staff members who do not participate. Either way, the chair’s ability to utilize her power directly affects the program’s quality.

Sets The Tone Of The Department

Let’s say your chair runs the department as a dictator. Or, he is always just trying to appease friends instead of doing what is best. What happens to the residency in these cases? In the first case, the residency program runs on fear and misery. And in the second case, nothing ever gets accomplished. Bottom line: the chair sets the quality of interactions in the department and the residency.

Liaison Between The Hospital And The Program Director

Some departments have a chair who does not communicate the critical issues of the institution to the residency. What occurs in these situations? First, residents may lose out on remaining compliant with national requirements such as hospital ACLS training. Or the radiology program may not fulfill its obligations to stay accredited. Poor communication between the hospital, chair, and the program director can become a nidus for a residency to implode!

The Ceremonial Function

Sometimes, a chair may decide not to attend essential residency functions. The chairperson may not participate in the residency graduation or the annual hospital ball. What does this say about the department? Do you think the hospital will look fondly upon the residency program when its leader is remiss? Probably not. In this case, the chairperson and department will be much less likely to receive the resources they need from the hospital. It’s a “give and take” relationship. So, the chair must step up and set an excellent example for the residency and hospital.

Residency Advisor

We, as program directors, often need to get a feel for how the faculty will respond to a change before implementation. And residencies constantly need to institute new requirements. But will the faculty buy-in so we can implement the new development? A strong chairperson who knows his department well can ensure you can fulfill your change. Moreover, she can guide what works and what doesn’t. Without serving this role as a residency advisor, a program director will encounter many more pitfalls during his tenure!

The Chair As Leader

In any medical department, a chairperson plays a critical role in running the specialty service and ensuring the residency moves along smoothly. So, when you decide to look into a residency department, observe the chair. Does he participate in the interview process? Can you get a feel for how he behaves toward the department? All these factors will affect you long after the interview day. A chair reflects the face and culture of the department!

Posted on October 25, 2018March 1, 2023 by Barry Julius

The Gestalt Versus Segmental Approach For Radiology Residents (Doximity Article)

Ever watched an expert radiologist read a CT scan or an MRI? They gaze at a scan, digest the information in one fell swoop, and spit out impressive findings and differentials with the single Gestalt.

If the world’s greatest radiologists can do it this way, why can’t you?

Well, what if I was to tell you to avoid this expert radiologist’s approach? You might think I was crazy, even though it may be hazardous to your career! But this “Gestalt approach” is most likely the wrong one for you.

But why? Why does this Gestalt approach to films, used by expert radiologists, not work well for the neophyte radiologist? To answer this question, we will define Gestalt and explain why this approach can be dangerous for early radiologists. Then, instead, we will tackle why and how radiology residents should read films using the “segmental approach.”

Defining Gestalt

Let’s start by defining the principles of Gestalt. According to Wikipedia, these are “the idea that natural systems and their properties should be viewed as wholes, not as collections of parts.”

Radiologists use the Gestalt approach when they sense the findings and diagnosis without processing the individual steps. I like to think of the Gestalt approach like The Dog Whisperer, Cesar Milan. He can naturally sense the overall picture of a dog that others cannot. With this sixth sense, he can train dogs to do whatever he wants while mere mortals struggle to figure out exactly how to do what he does.

Why Avoid the Gestalt Approach When Starting?

Since you have not been practicing radiology for long, you will miss half the findings in the film. You don’t know what you don’t know. And, if you don’t look for a finding, you won’t mention it or find it. So, if you read a chest film and don’t know to look at the pulmonary arteries, you won’t find that case of pulmonary hypertension. The Gestalt approach does not allow for evaluating each of the individual sectors of the film to ensure you have looked at it.

How long have you been practicing radiology? At most, for residents, three or four years. Rarely is that enough time to build a network in your brain allowing you to look at a film rapidly once and then create a framework for arriving at a final impression of the study. You have not trained your eyes to search everything in the image in a short period. And, therefore, you will not catch everything.

Take it from me; the Gestalt approach is a fast way for a resident to look like a fool. When you review a case with another clinician, they will catch things you missed. What could be more embarrassing?

What Approach Should You Use?

Instead of the Gestalt approach, the beginner radiologist should utilize a segmental approach. What do I mean by that? The segmental system divides the film into individual parts. You then review the entire image until you have completed your search pattern. In essence, it is a glorified checklist.

In addition, the segmental approach can vary for each reader based on personal preference. For some, you may divide the chest film into quadrants. For others, on the chest film, you may look at the technique, the heart, the soft tissues, the bones, and the lungs. Whatever the pattern, it usually doesn’t matter except that you cover all bases. As a beginning radiologist, this approach will prevent you from missing critical findings. And you will look much more intelligent than the new radiologist that uses a Gestalt approach.

The Bottom Line About the Gestalt Versus Segmental Approach

The Gestalt approach does not work well for beginning radiologists unless they have a tremendous gift. Most learners cannot look at the whole to identify the abnormalities in each part. Instead, the new learner is more adept at looking at all the pieces to determine what went wrong with the whole. Therefore, until you have the experience to identify abnormalities with a glance rapidly, the Gestalt approach is a recipe for disaster.

So, create a great, all-inclusive search pattern to avoid missing individual findings. Who knows? Maybe someday you will become that great radiologist who uses that Gestalt approach!

Want to see the original Doximity version? Click on the following link!

Link to the Doximity Website Version