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Radiology Golden Niches: Do What Others Don’t Want To!

golden niches

What do the following jobs have in common? Garbage Workers, Oil Cleanup Crews, Sewage Treatment Workers, and Doggy Pickup Services. No, it’s not just that they all clean the environment and serve essential functions in our society. These are jobs that very few people want to perform. And therefore, those that do can charge high rates to complete the services. And, you know what? It is harder to find employees for these professions. I call these sorts of jobs: golden niches.

How is this relevant to radiology? It’s simple. Find an area (or even better, more than one!) that no one else in practice wants to do, and make it your life’s work. Then, you have a job for life (assuming that the business is not bought out or downsized!)

So, this brings me to the topic for today, the golden niches. What radiology specialties are ripe for a new radiologist to practice that can lead to this extraordinary situation and why? Well, we will go through several radiology procedures and modalities that can potentially qualify for one of the golden niches. However, not all practices are the same. And therefore, I must put in this qualifier, golden niches in one hospital or imaging center may not be so in another. You may find that you may have many MRI MSK readers in your practice, and in another, you may have a few. Or, some centers have little need for some of these golden niches. I will point you toward some modalities and procedures that you should think about reading and performing when you interview for your next job!

MRI Cardiac/Cardiac CTA

In our practice, we have limited numbers of radiologists that read these modalities. It is also costly and time-consuming to learn if you did not complete a fellowship. So, if you come aboard and have lots of cardiac work, you can be the hero!

Cardiac Nuclear Medicine

During residency, many residents do not get a chance to dictate these cases since the cardiologists perform them. And, at some centers, they require their radiologists to be nuclear trained. Therefore, fewer radiologists tend to read these studies, allowing you to take over!

MSK Musculoskeletal MRI and Ultrasound

Still, many radiology residencies throughout the country provide limited MSK MRI experience and even fewer MSK ultrasound. So, you may be one of a few in the practice that feels comfortable with these modalities!

Facet Injection For Pain Management

In some centers, practices farm out these cases to the anesthesiologists or the pain medicine physicians. However, in some hospitals, radiologists do the work. And you know what? Only a few MSK radiologists feel comfortable with this procedure.

Informatics

How many of you know the latest about pdfs, HLA, and more? I thought so. And, some practices need these radiologists to run the show!

Virtual Colonoscopies

Most residents are not trained well in this modality during residency. And, even fewer take courses when they finish up. So, you want to run a virtual colonoscopy program in an institution that has the demand. Here’s your niche!

Nuclear Medicine Therapies

Drug companies have developed loads of new nuclear medicine therapies like Xofigo. Moreover, many radiologists do not feel comfortable treating even the old standby of I-131. So, here is an opportunity for you to take charge!

MR Spectroscopy/Perfusion Studies/Neck CTAs

MR spectroscopy/perfusion/neck CTA studies tend to be more esoteric modalities reserved for the neuroradiologists. So, if you have trained as a neuroradiologist, make sure not to skip out on instruction in these areas. You can become instrumental!

Complicated Neck/Temporal Bone Work

Have you ever noticed the remaining cases at most imaging centers and hospitals? It tends not to be the head and body CTs. Instead, no one wants to pick up the CT soft tissue neck and temporal bone studies. So, don’t forget to learn about these topics during residency and fellowship!

Neurointerventional

To feel comfortable performing neurointerventional procedures, you generally need one year of diagnostic neuroradiology and two years of interventional radiology training. That limits the playing field for this work. Need I say more?

Breast MRI

Almost universally, non-breast imagers want nothing to do with these procedures. You have liability issues and inexperience that prevent many from wanting to read these cases. Time to step in!

The Golden Niches

Well, there you have it. Here were some undesirable (and therefore most desirable!) jobs you should consider performing when you start. And, I’m sure there are a few more that I forgot. In any case, it’s not about love. Instead, it’s about job security, my friends. So, go forward and find your golden niches. You won’t regret it!

 

 

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Is Radiology Still A Career Or Just A Job? And What Does It Mean?

job

What exactly is a career? If you listen to the internet authority, Wikipedia, it is “an individual’s metaphorical “journey” through learning, work and other aspects of life.” And, what is the definition of a job? Again, if you listen to “all-knowing” Wikipedia, a job is an activity, often regular and often performed in exchange for payment (“for a living.”)

So, which definition does radiology meet today, a career or a mere job, a transaction made to make a simple living? Many long-standing radiologists and outsiders would say that radiology is a career. You spend countless years learning and practicing the art and science of radiology. Moreover, when you finish, you live and breathe the profession. You strive for professional excellence. More importantly, it becomes ingrained as part of your persona.

These everyday thoughts are an oversimplified answer to whether radiology is a career or a job. As such, the response has transformed itself over the past ten to 20 years.

Changes To The Equation of Job Versus Career For Radiologists

So, what has changed over the past decade or two that has morphed the answer to this question? First, the landscape of medicine has dramatically shifted. Students that formerly completed school with reasonable amounts of student loans are now graduating with hordes of debt. Additionally, external pressures from governmental bureaucracies have dramatically increased. The number of films radiologists need to read, and procedures they must perform have exponentially climbed. Some may say that the numbers have far surpassed what is safe for patients.

Finally, different demographics have joined the profession. Today, many radiologists want to practice part-time to raise a family or pursue other interests. Years ago, this type of radiologist was much less common.

Individually, each of these factors plays a role in the change. In the following few paragraphs, we will go into more detail about the reason for each.

Reasons Radiology Has Become A Job For Many

Student Debt

Let’s start by talking about the noose of enormous student debt hanging around the shoulder of new radiologists. In the past, radiology residency graduates could afford to pick and choose where and what to practice based on the merits of the post-residency job alone. No longer is that the case. Now, it becomes more important to make sure you can afford the debt service payments and the day-to-day living expenses of the region of practice. For many, finding work is about desperately needing to make ends meet. So, radiology merely becomes a means to this end.

Increased Bureaucracy

We all feel the weight of increased paperwork and regulations we must follow. To that end, maintenance of certification has become more stringent (although, more recently, it has been slightly letting up). Requirements for accreditation have been increasing exponentially. Also, the maze of insurance requirements to complete a study keeps rising. Moreover, these factors are the tip of the iceberg. For many radiologists, many bureaucratic factors lead them to resign themselves to practice radiology as a job.

The Work Treadmill

Nowadays, many radiologists are hostage to the ever-increasing number of studies they need to read. Public expectations for the delivery of results promptly and efficiently have climbed. Also, time to transcription has become the holy grail of the hospital administration. In these conditions, how can some radiologists perceive their work as more than just a cog in the wheel to make ends meet?

Changing Demographics

Finally, we need to also talk about why different radiologists pursue radiology. No longer do all radiologists fit the same mold. For some, their role in raising a family has become more crucial than the position that they may play in running a radiology practice. So, these radiologists merely want to fund their lifestyle and not get involved in the professional aspects of radiology.

What Does This All Mean?

Well, to start with, we know that the most consummate professionals invest heavily in their careers and see their profession as a calling. These are the incredible clinicians, the movers, and the “shakers.” Moreover, they perform groundbreaking research, make improbable diagnoses, teach their residents, and create radiology systems and businesses to promote the profession.

However, based on the new pressures on individual radiologists, we cannot expect all radiologists to see their original “calling” as a “career.” Instead, many other factors play into the equation. Student debt burdens some radiologists. Alternatively, the chains of bureaucracy and increasing workloads prevent the pursuit of their interests and infringe upon the professional lifestyle of a radiologist.

Regardless, we should not talk badly about radiologists who need to work in the profession merely as a job. Many radiologists have excellent reasons for that. Instead, we should work to fix those factors that have changed to make radiology into a job so that we can improve the quality of our profession and return it to a career for all.

 

 

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How Much Does It Take To Start A Radiology Imaging Center?

imaging center

Ever get a question that goes something like this, “Why don’t you start up an imaging center?” Well, in the land of pixie dust and chocolate-covered mountains, that may work. However, in an expensive world with loads of student debt, only the rare physician can gather enough cash to begin a new radiology practice. Additionally, who is to say that you will have enough patients in your location to survive? In any case, that got me wondering how much does it take to create an imaging center startup? So guess what? That is my insane plan for today. We will calculate the annual capital expenses to start/run your practice. So, at least, you will have a response that you can give to those naive friends and relatives of yours!

First, let’s sort out what kind of imaging center about which we are talking. Well, I am thinking about the average Joe diagnostic center with one of each piece of equipment. And let’s skip interventional and nuclear medicine for the sake of simplicity. Perhaps, this center will have an MRI, a CT scanner, an ultrasound unit, a mammogram tomography unit, and an x-ray apparatus. We will also assume that you locate your practice in an average part of the country with mediocre building costs. Let us say that we will amortize the sizeable capital-intensive equipment for over ten years. Finally, we will amortize the building for thirty years.

Most importantly, these calculations are made on “the back of the hand,” meaning that I would not rely on them to create your imaging center. Numbers can vary widely. Nevertheless, I am doing this so that you can get a sense of the costs involved.

What are the fixed capital costs for an imaging center?

Building

So, we will begin with fixed expenses. What are the most considerable fixed costs of an imaging center? Of course, these include the building that houses the equipment and staff and the imaging machines that make up the imaging center. Concerning the structure, we will assume that it is around 5000 square feet. So, how much is it annually to pay for an average space measuring 5000 square feet? It turns out I was able to find the average cost per square foot of retail and industrial space throughout the country. Based on the realtors website chart, the average industrial area would measure 6.92 per square foot, and the average retail space would be 17.12 per square foot. The building we would need could be in an industrial space but would need to be accessible to customers, so let’s make our cost 10 dollars per square foot or 50,000 dollars per year.

Not only do we need to pay for the building, but we also need to renovate the building before beginning our center. Designing the construction would involve spending on an architect to create the renovations—figure on another 20% of the building’s cost or 100,000 dollars. Let’s amortize over ten years and say that it will cost around an additional 12,000 dollars per year.

Then, of course, we need to pay property taxes. Let’s figure that the number is around 2% of the price per year or 10,000 dollars. Also, we need to insure the building and business. Let’s tack on another 10,000 for good measure.

Moreover, finally, the structure and practice need to be certified and inspected. So, let’s add another 10,000 dollars.

Total= 82,000 dollars per year

Machines/Service Contracts

How much is an MRI? Well, the answer to that is that it varies widely. However, we are talking about the average MRI, maybe even used. So, based upon this MRI price guide, let’s say that it costs around 200,000 dollars. That would amount to a monthly payment of about 2,000 dollars or 24,000 dollars per year. You will also need a service contract to maintain the system. That would run another 100,000 dollars.

Next, let’s take the price of an average CT scanner. Based on information on the lbnmedical website, it would cost around 100,000 euros or 116,000 dollars for a typical CT scanner. Again, amortized over ten years, we are talking approximately 1,200 dollars per month or 14,000 dollars per year. However, that is not the only significant expense for the MRI and CT scanner. You need a service contract. That service contract goes for around another 100,000 dollars per year per machine based on the blockimaging website.

Next, let’s look into the price of an average mammography unit. That would cost somewhere in the realm of 250,000 dollars (or 30,000 dollars per year) if we use the data from tractmanager with a service contract costing around 50,000 dollars per year.

Also, we need an x-ray unit. That would be around 100,000 for a digital machine, according to the blockimaging website(or 12,000 dollars per year). Finally, let’s say service would cost another 50,000 dollars per year.

Total= 380,000 dollars per year

PACs system/RIS

Naturally, our center will need an information system capable of handling all the studies that we are performing. That does not come for free! So, how much does that cost? For an average “smallish” imaging center like ours, the website purview.net states it costs around 1500 dollars a month or 18,000 dollars per year for a cloud-based solution, including IT. Not so bad, right? Well, you also need an information system management package to schedule, manage dictations, and more. That would run you another 450 dollars per month per user, according to this website. We will assume a couple of users. It would cost around 900 dollars per month for 12 months or 11,000 dollars per year.

Total= 29,000 dollars per year

Furniture/Room Items

Furnishings can be a hard one to estimate. Moreover, it can be more costly than you might think for desks and chairs, as well as patient tables, and more. Unfortunately, I cannot perform an exact calculation. However, I will estimate for the facility that it would cost around a few hundred thousand dollars. If we were to amortize that over ten years, we would say that it would cost about 24,000 dollars per year.

Total= 24,000 dollars per year

Sum Total For Capital Expenditures= 515,000 dollars per year

What are the annual recurrent costs for an imaging center?

Workforce

The annual recurrent costs include all the people and things you need to run a practice. Let’s start with the workforce. Most importantly, we will begin with the behemoth expense in the room, the radiologist. What is the average annual package for a radiologist? According to salary.com, that would be around 400,000 dollars, of course not including extras such as malpractice and more benefits. Let’s say for argument sake that would end up at approximately 500,000 dollars.

You also need technologists to run the show. So, we will assume that you have a moderately busy practice. Therefore, you will need an ultrasound tech, an MRI tech, a mammogram tech, and a CT/x-ray tech. According to salary.com, this would run around 60,000 dollars per year per technologist. For this imaging center, that would total about 240,000 dollars.

We would also need a medical physicist to make sure our practice is compliant with all regulations. The mean medical physicist salary is around 183,000 dollars per year. However, we don’t need a full-time physicist. Let’s say we were able to share a physicist among several other practices. So, let’s say that it would cost 183,000/4 or around 45,000 dollars per year.

Importantly, you need to hire secretaries to run the front desk. Let’s take a couple of secretaries for our practice at the cost of 40,000 each per year, according to salary.com. That would total to 80,000 dollars per year.

Also, you may need a business/marketing manager for the site to run the show. That does not come cheap as well. The cost would run around 100,000 dollars per year, according to salary.com.

And finally, you need someone to clean the facility. Perhaps, a janitor? Let’s say another 25,000 dollars per year.

Total= 990,000 dollars

Billing And Benefits Management

Nowadays, you also need an expert that helps with billing since it is complicated and takes much time to learn. Besides, it is critical for maximizing revenue for the practice as well as for avoiding Medicare fraud. Often, these same “experts” also help out with payroll, insurance, and more. Most work on a percentage of the gross revenue for the practice. We will say for the sake of argument around 5 percent. For an average facility, we will say total revenues are around 3,000,000 dollars. So, a billing/benefits management for this site would run approximately 150,000 dollars per year.

Total= 150,000 dollars

Other Costs

Of course, you also have to pay for heat, hot water, and electricity. These expenses do not come cheap, especially when you are running all this equipment. I will estimate a lump sum of around a couple of thousand per month or 24,000 dollars per year.

Moreover, it would help if you had miscellaneous recurrent expenses like toilet paper, contrast media, intravenous supplies, and more. Let’s figure on another 35,000.

Total=59,000 dollars

Sum Total For Recurrent Costs= 1,199,000 dollars/year

Let’s Add It All Up For The Imaging Center- Don’t Shoot The Messenger!

So, there we have it. I have created an approximation of most of the expenses that you might have if you were to start your imaging center. Of course, if you decide to plop the imaging center in the middle of Manhattan or San Francisco, my estimated costs would be a lot smaller than the real total costs. (You know what they say- location, location, location!) Alternatively, if you stationed the imaging center in the middle of nowhere or an undesirable area, the costs would likely be less. However, this may be somewhat closer to the actual expenses for an average place in the United States. So, drum roll, please… Here is the final summary total of our costs-

Building- 82,000 dollars per year

Machines/Service Contracts- 380,000 dollars per year

PACs System/RIS- 29,000 dollars per year

Furniture/Room Items- 24,000 dollars per year

Workforce- 990,000 dollars per year

Billing and Benefits Management- 150,000 dollars per year

Other Costs- 59,000 dollars per year

Final Total= 1,714,000 dollars/year

Think you can afford that, starting as a new radiologist? I bet for most of you out there, probably not. Of course, you may be able to obtain financing. However, for the majority of us without the experience, it is a tough nut to crack.

So, there you have it. You now have an answer for your naive family members when you get popped the question, “Why don’t you start an imaging center?” Until next time, signing off…

 

For those of you interested in how imaging centers market themselves online, especially during the time of Covid-19, take a look at some of these tips from tomatoes.digital below

7_marketing_tips-medical-imaging

Check out the following link if you are interested in more information: https://bit.ly/389WnlF

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A Dangerous Personality Trait: “Never in Doubt But Sometimes Wrong”

dangerous personality

This week I thought it was essential to discuss a dangerous personality trait that can lead to disaster when beginning a radiology residency. Coming from different programs, some residents start with bad habits formed from their preliminary year. I like to call this dangerous personality type “Never in Doubt But Sometimes Wrong.” More often than not, these residents trained for their prelim year in surgery (But not always!) and developed this personality trait during the internship. They would have formed skills like talking with strength and charisma. And, usually, this is a good thing. However, this is not the case when this resident does not have the knowledge and experience to back up their overconfidence.

This personality tends to persuade her audience, attendings, and residents, regardless of the evidence. Accessory staff follows these physicians to the ends of the earth based upon the sure command of her words. However, these residents (and other physicians) know the same or less than their colleagues. Moreover, they have not developed the experience to make the most critical decisions as a first-year radiology resident.

Why do I bring this up today? Well, I thought it was necessary to be aware of its consequences if you have developed these tendencies. Alternatively, for other residents, I want you to recognize this personality trait so that you do not go down with the proverbial “ship” as well. Also, what better time than at the beginning of residency?

Why is this so crucial? Well, I go through the three main reasons these beginning radiology residents need to alter their ways: Danger to the resident, increased liability, and potential for harm to the staff.

Danger To The Residents

Being sure of oneself is essential to becoming an excellent radiologist. However, not when the radiologist has not read up on the subject or understands the case. Especially for the first years, this is a danger to their career. Every once in a while, we hear these new residents telling the clinician the wrong diagnosis and management.

Moreover, since these residents have such charismatic personalities, they can often sway their opinion about the case. Unfortunately, the clinician listens and begins working up the patient incorrectly. In the end, the program directors hear about the mismanagement, and the resident can suffer from probation or even worse.

However, the danger is not only for the resident with the personality trait. Also, the followers can suffer just as much. You probably have seen attendings in other specialties that espouse facts with such enthusiasm, only to realize when you look them up that they are entirely incorrect. These attendings tend to be well respected by the hospital administration (but not so much by their colleagues) and wield much power due to their charisma. So, check everything twice before following one of these strong personalities.

Increased Liability

Not only is “Never in Doubt But Sometimes Wrong” a dangerous personality trait that can lead to bad medicine, but also it can significantly increase your medical liability. They can report whatever you communicate to the ER in the medical record. And guess what? You can be liable for the damages incurred to the patient if wrong.

For example, this sort of dangerous personality may confidently state that the patient does not have appendicitis on a CT scan as a first-year resident, even though having never seen a case. Subsequently, he convinces the ER doctor that the study is negative. Finally, unfortunately, the patient incurs harm. The medical license of this resident is potentially on the line.

Dangerous Personality Can Cause Potential Harm To Staff

In our profession, we must remember that the world is not always just about the physician. Instead, the rest of the team can play just as essential a role. Confidently knowing wrong information places our nurses, technologists, and aids in dangerous situations. Instructing a nurse to use the wrong needle can lead to injuries. Convincing a technologist that a patient with an ear implant can safely go in the MRI without knowing can cause a technologist to lose his job. These are potential situations that stem from a resident with misplaced confidence.

The “Never In Doubt But Sometimes Wrong” Dangerous Personality

In radiology, there is no space for overconfidence. According to the Hippocratic oath, our role, like other physicians, is to “do no harm.” And you can see the significant danger a resident can cause to themselves and others when they become overbearing without the accompanying knowledge and experience. So, I beg you. If you are not sure of something, maintain your humility. Let your colleagues, staff, and fellow faculty know. It is OK not to understand. However, it is not OK to let others think you do when you don’t.

 

 

 

 

 

 

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Top Ten Differences Between A Senior Resident And Radiology Attending

differences

You may be more than halfway through your residency program or about to graduate residency. And it may feel like you have been through the wringer. Not only have you made it through the call, but you have also studied all the minutia that you need to know to take the core exam. So, can life change that much more when you become an attending? I mean, it’s only a few years or less away. Well, for your education (and entertainment, of course!), we will go through the top ten differences between a senior resident and an attending. Let’s go from least to most noticeable!

Shallower Breadth And Increasing Depth Of Knowledge

Believe it or not, beginning a full-time job still changes what you know. Remember all that detailed information from the case review series and the survey books? And, of course, all that detail you learned from studying for the core examination? Where does it go? Let’s put it this way; your brain begins to trim out what you no longer use. So, that full breadth of knowledge you learned from studying for your core exam? Yes, gone! Instead, one of the biggest differences is that you remember the relevant information you need to know daily for your specific areas of expertise.

You’re Now The Expert

For the first time, you da’ man (or woman!). Regardless of your feelings, your colleagues see you as a guru in your specialty. A very different feel from your previous work as a resident or fellow in training!

Horses First, Then Zebras

As an attending, you know what you see because you have experienced it many times. The zebras only come out when you have exhausted all the horses first. Usually, not the case for residents!

Patients And Doctors Want To See You!

No longer are you an intermediary in the way of your attendings. Patients and doctors ultimately want to hear from the man or woman of final reckoning in the report. And that is you! Feels good to be desired. One of the biggest differences!

Need To Get A Move On!

No longer can you rest on your laurels as you did as a resident during the daytime. You have a job to do, and it must get done. If not you as an attending, then who? A hundred cases? If they do not get read by the end of the day, you hear and see a queue of angry clinicians and patients!

More Vacation But Perhaps Not At The Best Times!

You may notice that you took a vacation during residency, usually at the standard times- Christmas, spring break, or summer. And although the residency required some coverage from one or two of your fellow residents, most could still take off at those times. Well, alas, this is all about to change! And although you may receive more vacation in general, your practice will still need significant coverage during these favorite vacation slots. And who needs to work at these times? You!

Increased Liability

In the end, no longer can a senior cover for your mistakes. You are coming onto a shift in the morning and looking at the night resident’s dictations. Well, you own them. His and your mistakes are your problems! Miss cancer, your reputation, license, and nest egg are on the line!

Loans Come Due

You think all the money you earn as an attending is your own, right? Wrong! On day one, as you start your first job, the loan servicers ask for their due. Forbearance of your loans is no longer an option. Thousands of dollars per month only to service your student loan debt. Welcome to the real world.

Increased Pay

Imagine rolling along for years at a time, garnering biweekly or monthly paychecks, and coming home with a few thousand dollars a pop. And, then suddenly, Whoosh! You notice that the direct deposit fills your account with something more substantial. Feels good, doesn’t it?

Expenses Rise

Now for the bad news. The more significant paycheck comes with more considerable account drainage from those expenses. Those larger paychecks suddenly drain rapidly from your bank account with new costs from a new house, car, loan payments, and child care. Where did all that increased pay go?

 

Final Thoughts About Differences Between A Senior Resident And A Radiology Attending

So, there you go. Perhaps, not what you thought? Or, maybe it was? Regardless, now you know what to expect to change once you graduate!

 

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The Sharp Breast Ultrasound Technologist: The Key To A Well Run Practice!

technologist

In a thriving radiology practice, all technologists contribute to the functioning of the whole. However, one sort of technologist, in particular, can tip the balance between a smoothly run practice and disaster. Which one would that be? Well, if you read the title, you would know immediately!

Why does a breast ultrasound technologist wield so much power over a successful radiology practice? Unlike other technologists, I came up with three reasons why we rely on them so much. First, these technologists are the most “independent” of all other technologists. Second, they require a good eye, more so than other technologists. And finally, they must have excellent hand-eye coordination. We will examine all three characteristics and what happens when your practice uses a suboptimal technologist.

Independence

Sure, most technologists have some autonomy. I mean, CT techs must set the parameters for the scans independently. And mammography techs must ensure they perform all the QI before beginning a study. But breast ultrasound technologists are unique in this regard. When breast sonographers leave the room to create their images, you cannot check the quality of their work directly. What do I mean by that? Sure, there are required images. However, the ultrasonographer can choose to show you whatever they deem crucial. Alternatively, this same tech can leave out what they think is “unnecessary.”

I can’t think of any other technologists with such independence of action. You can almost always check the work of a CT, mammography, MRI, or fluoro technologist. The body part is complete, or it isn’t. The breast tissue is all on the film, or it’s not. On the other hand, with ultrasound techs, you can never know if they have completed what they were supposed to. You must rely on their word and their word alone.

What happens when the ultrasound technologist does not act independently? These technologists come reeling in and out of the reading room incessantly, asking questions and interrupting the day’s workflow. Furthermore, the radiologist’s stomach churns when unsure if the technologist knows the morphology and location of what they are searching for. That means they must check and recheck everything the breast ultrasound technologist completes. It wastes so much time that the radiologist cannot attend to his other duties.

The “Good Eye”

Radiologists rely on the ability of breast ultrasound technologists to pinpoint a specific lesion on mammography. Or, they need to find the proverbial needle in a haystack on screening ultrasound. In other words, they must keep constant awareness of their search. In addition, they need to identify the shapes and abnormalities they see on the mammogram. This task becomes challenging when you have a 350-pound patient with a large amount of breast tissue! A “good eye” varies widely among technologists, similar to radiologists. But, good technologists will reliably find what is needed and discard the impertinent findings in the breast.

I can’t tell you how often a technologist without a “good eye” will search and search for something, only to have you, the radiologist, come in and find the lesion first. Imagine the hours over a lifetime that a radiologist must waste to compensate for the ultrasound technologist without a “good eye”!

Hand-eye Coordination

Finally, an ultrasound technologist’s ability to scan patients relies upon a baseline level of coordination. This baseline becomes vital for two main reasons. First, the ultrasound technologist needs to find and rediscover a lesion. For instance, some lesions are tiny or roll off the transducer very easily. Good ultrasound technologists need a steady hand to create images of these abnormalities.

Furthermore, breast ultrasound technologists, in particular, play an essential role in performing procedures to assist radiologists with cyst aspirations and biopsies. They need to be able to keep the transducer on a specific plane at the time of a biopsy.

Frustrating is the singular word for performing procedures with a breast ultrasound technologist with two left hands! Imaging studies and techniques can take triple the amount of time with a technologist with poor coordination. That does not include contamination of the sterile field!

The Sharp Breast Ultrasound Technologist- The Key To A Well-Run Practice

As you can see, a breast ultrasound technologist is much more than just another member of the imaging center team. Without a quality breast ultrasound technologist, the center becomes much less efficient and can fall apart at the seams. If you find a great one, this team member becomes the glue holding the imaging center together. Keep the tech even if at a higher-than-average cost. Why? Because the costs to a practice pale compared to the damage if they leave!

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ESIR Programs: Let The Buyer Beware

Radiology programs, radiology program directors, Early Specialization In Interventional Radiology (ESIR) directors, and residents interested in interventional radiology are dealing with a mini-crisis. For years, programs have allowed residents to make a choice to start an interventional fellowship several years into residency. Instead today, new residents face the crunch of having to make this decision to join up with ESIR programs right away. And, they should not take this decision lightly. Why? Well, that is exactly what we are going to discuss today!

So, What’s The Urgency, Huh?

Like anything else in the world, when you have limited supply and excess demand, you create bottlenecks. And, unfortunately, in many programs across the country, the number of ESIR spots available does not equal the number of residents interested in the program. Therefore, this problem exists in some programs, right here right now.

So, if a program has two residents interested in this program, but it only has one spot available, the program director needs to make the final decision by either one of two methods. First, the program can decide on a first come first serve policy. But, let’s say that you have two residents that decide they want to join a program at the same time. Well then, that leads us to the other way to decide. And, that would be a long drawn out application process to determine the most “qualified” applicant.

Either way, this puts pressure on the applicant and the program to make a decision pronto. As you now understand, the resident and program need to make rushed decisions together.

Why Can This Decision To Join ESIR Have Permanent Implications?

OK. First, I will mention the positive. ESIR programs allow residents throughout the country to decrease the number of years of a fellowship from two to one. And, these residents will be able to hit the proverbial ground running at their interventional fellowships from the very beginning. But, at what cost?

Problem 1

Here comes the tough part. ESIR programs need to allow residents to complete approximately one year of interventional related activities during radiology residency. So, where does the time come from? It has to come from somewhere, right? Well, here is the rub. Programs need to draw the time allotted to ESIR from the normal diagnostic radiology activities. So, residents that complete an ESIR program have less overall experience in the standard rotations like MRI, ultrasound, etc. And therefore, the training of an ESIR resident is not truly equivalent to a standard diagnostic radiology resident.

So, what are the implications of this? In the workforce still, most practices need radiologists that can perform interventional radiology (IR) but can also help out with some of the general work. Well, residents that start a typical IR job will not have the same experience and comfort level with general radiology practice. As you can see, this creates a serious problem for the ESIR graduate.

Problem 2

Unfortunately, the problems do not end here. Let’s say that you start the ESIR program. And then, you then apply for fellowship toward the end of residency. Due to the changes in allocated slots for interventionalists with new DR/IR programs, ESIR programs, and “independent fellowships”, fewer residents can easily drop out of interventional radiology during residency. So, fewer spaces become available for interventional programs throughout the country. And therefore, you, as an ESIR applicant to fellowship, may have a lower likelihood of gaining admission to an interventional radiology fellowship than residents applying in prior years.

So, who is to say for sure that you can obtain an interventional fellowship after residency as an ESIR applicant? In this case, theoretically, ESIR programs have now doubly screwed this resident. First, they completed a program for which they have a real chance of not completing the required CAQ certification. And second, they have less diagnostic radiology experience.

Problem 3

Many folks that want to do interventional radiology really do not know what they want to do until they have completed several IR rotations. So, what happens if the ESIR program resident decides that they do not like interventional radiology toward the middle or end of their residency? Well, they potentially have prevented another interested applicant from getting a spot. In addition, they have again decreased their own training in diagnostic radiology- a lose-lose situation. They will potentially graduate as a “second-rate” diagnostic radiologist.

Bottom Line For The Applicant To ESIR Programs

For those of you applying to ESIR and know for sure that you want to do interventional radiology, well then, go for it. But, I have a sneaking suspicion that many ESIR applicants are not in this category. So, if the program offers you a choice to apply for an ESIR program, make sure to think twice. The implications of joining this program can be far-reaching for the rest of your career!

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Radiology As A Backup Specialty: Should Radiologists Be Offended?

backup

During the AUR meeting a few years ago, one of the speakers announced that more medical students than ever used radiology as a backup specialty. Well, how can that be? I mean, radiology is a fantastic specialty, right? Yet, our medical students have chewed us up and spit us out. At that point, you could just about hear the moans and groans in the background of the lecture hall. But then, I thought about it and felt a bit differently. Why? Well, that is what I would like to delve into today.

Most Applicants Don’t Know What They Want

Over the years, I have found that most radiology applicants, like other specialties, think they know what they want. However, when you dig a bit deeper, you find out they are not sure. Hell, I had no clue when I entered the specialty. When you ask applicants why they want to join specialty X, many have difficulty verbalizing their true motivations. Often you hear, “I like using my hands” or” I like coming up with differential diagnoses.”

Truthfully, however, these reasons are, at best nonspecific. And, if you dissect what these residents are saying, you would recognize that the reasons why an applicant claims to have applied to a specialty have no bearing upon what he wants. You can apply to surgery, interventional radiology, urology, and other specialties because you want to use your hands. Or, you can come up with differential diagnoses in almost any specialty in the medical field.

Often, applicants bury the real reason for applying to a specific specialty deep within their psyche. Perhaps, they want to say it’s the lifestyle, the culture, or the money. So, how can we become offended by medical students that don’t know what they want?

Our Specialty Is Getting Noticed!

For applicants to apply to our specialty, even as a backup, it means that they must have some foreknowledge about us, to begin with. That means we are doing something right. Maybe, we are training more medical students about imaging in medical school. Or, perhaps, they hear about an improving job market. In either case, residents have found reasons to apply to us, even though it may not be their first choice!

A Badge Of Honor

Only a few years ago, the radiology applications had dropped precipitously. In addition, the quality of applications had significantly decreased as well. Instead, today, we have become respectable enough to apply to! We are returning to the old norm. So, we should feel excited that qualified applicants are again considering our specialty.

So, We Are A Backup Specialty. Should We Be Offended?

Back to the original question again… Let’s look at radiology for what it is. It’s one of few specialties that allow physicians the flexibility to pursue so many avenues and satisfy the academic and clinical wants of most. And now, if we dissect why residents perceive us as a backup, I think we should not become offended. Instead, we should give the new applicants some credit. They are beginning once again to recognize the specialty of radiology for what it is: an excellent choice for a great career!

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Dealing With The Abusive Nighttime Physician: Rules Of The Road

abusive

Picture this scenario. A Napoleon-like 5 foot 2 verbally abusive surgeon enters the reading room. He begins to yell at you for not performing an intussusception reduction the way he likes. Moreover, a team of surgical residents stand behind him, each member turning red with embarrassment as he continues with his tirade. His verbal abusiveness becomes more and more aggressive. He uses terms such as “idiot” and “moron” to describe you as you attempt to get a word in edgewise. You feel like you want to strike your fist in his face. Does this situation sound vaguely familiar? How would you deal with this everyday but unfortunate situation when you are alone at nighttime?

#MeToo

First, no one should have to contend with harassment such as this. I don’t care if you are a resident, nurse, janitor, or attending. Unfortunately, although society has finally come to terms with refusing such abusive behavior and isolating these individuals, many hospitals still silently condone it. How and why? Perhaps, the hospital is understaffed and would rather have someone to fill the gaps even though he has an abusive personality. Or, the hospital may hire an inappropriate physician because she has a good reputation and brings many patients into the system. Regardless, the behavior is unacceptable and needs to be dealt with accordingly. So, let’s go through some of the processes you need to complete to prevent this harassment again.

Engage Softly With Team Response

The last thing you want to do as a resident is fight fire with fire. If you continue to raise your voice and tussle with this attending, you are making a containable situation into a nuclear bomb! Instead, what is the appropriate course of action?

You can say to this individual quietly, “I am just trying to help you care for your patients appropriately. We are in this together. I will talk to you again when you speak to me professionally so we can help your patient together.” Usually, the raving physician calms down if you maintain a quiet and calm demeanor. At this point, the situation usually de-escalates. Who knows? You may even receive an apology. But that may or may not be the case.

Document, Document, Document

So, what next, assuming the situation does not calm down? If the surgeon has been harassing you, it is most likely a long-standing observable pattern of inappropriate behavior. And this physician has likely affected many other employees within the hospital as well. Therefore, you should document the behavior in written form. State the time, place, and situation as objectively as you can. Then, place the document on the side for further use, if necessary.

Next, you may want to ask other observers, if present, to create a supporting document. This report lends credence to your inappropriate interaction. You are better off gathering multiple documents to establish a pattern of behavior.

And finally, for each time you encounter these behaviors with this individual, you create another document. You are making a paper trail that will help remedy this situation.

Speak To Your Supervisor

As for the next step, you must contact your residency director or associate residency director first thing in the morning. Speak to them and give them the documentation. If possible, leave the wheeling and dealing in the hands of the local administration. Why? Well, often, the lowly resident does not have the influence upon human resources or senior administration like a long-standing faculty member does. And, the administration can turn back the blame on you.

Last Resort- Human Resources

OK. So, your supervisor has not yet fixed the situation. Or, maybe she settled it for that one time, but the abuse is recurrent. Where do you go next? Sometimes you have to go right for the horse’s mouth. You may need to talk directly to human resources and hand in the documentation yourself. Usually, this will begin a full investigation into the matter. Of course, hopefully, you can avoid this situation. Unfortunately, on occasion, you need to act to protect yourself in this way.

Final Thoughts About The Abusive Physician

We all went to medical school and began training to become consummate professionals. Along the way, unfortunately, you will encounter abusive physicians that do not follow these rules of professionalism. Often they have issues of their own. But that does not excuse the actions of these individuals. We, as clinicians, should act according to the rules of civil behavior. And if these abusive physicians cannot play by the rules, either they need to change their ways, or they should not be able to practice medicine. So, we serve all by taking action and not remaining silent.

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Eight Ways To Find Inspiration During Residency

inspiration

You wake up to go to work. Maybe, you grind through what seems like a hundred films with your attending. And then, you arrive home exhausted, only to start reading books and case reviews. The work of a radiology resident never ends. So, how do residents find the inspiration to get through the day, study for the core exam, and get through the entire residency? And, what can residents do to have a fulfilling four years? Unfortunately, very few radiologists have the time to consider the resident’s plight. But I plan to tackle these issues today. Think of this post as chicken soup for the radiology resident, concepts one needs to tough things out for four brutal years.

 

Yes, You Will Save Some Lives

Never forget this fact. Imaging saves lives. And who interprets the images? You! So, get yourself right out of that funk. And, remember, we are not financiers, accountants, or lawyers. We directly prevent significant injuries and death!

Have A Hobby/Life Outside Of Residency

As much as you may love radiology, actively seeking other interests is just as important. I don’t care if it is swimming, stamps, reading, or traveling. Having a hobby enables you to return to work fresh and ready for the next day. Sometimes, studying and working improve when you have an unencumbered mind with the same old studying routine. Studies have shown that creativity and productivity also improve when you pursue activities outside your main interests. Why not let that be you? (1)

Sometimes It’s Not Just About The Work; It’s About You!

Inspiration does not only come from your patients and your films. Instead, feeling inspired stems from your moods and wants. To take care of others, you must also take care of yourself. So, remember… You have a responsibility to yourself to cater to yourself at times. Take a little time to yourself when things become tough studying. Or, if you lose focus during the day, sometimes you need to step away for a few moments. To regain your concentration, you need to refresh yourself!

Maintaining Health

It sounds strange that maintaining health can inspire you to become a great radiologist, right? Well, if you do not eat well, exercise, and sleep, it becomes much more likely for a resident to burn out before finishing residency! So, make sure to treat your body right!

Learning From Mistakes Can Be Inspiring

Mistakes are depressing and ugly, correct? If you continue to think that way, you should not become a radiologist. Expect mistakes. It’s part of the risk profile of our job (Although attorneys would think otherwise!). One study reported a significant error rate that ranges between 2 and 20% of all radiologist reports. (Br J Radiol. 2001 Oct;74(886):949-51.)

So, we need to become inspired to do better. How do we do that? Well, think of each mistake you or others make as an opportunity to prevent significant errors from happening again. If we want to get closer to perfection, we must inspire ourselves to learn from these mistakes, knowing we will not miss that finding or commit that knowledge error again!

Appreciate What You Have Accomplished

Think about the goals you have met to become a radiologist. You have completed college, medical school, and an internship. And remember all those tests that you have aced and passed to get to this point. This successful journey is a real accomplishment! Be proud of what you have achieved. You are not an average Joe. Instead, you have done what many folks can only dream about. And, if you have already gotten this far, imagine how far you can go… If that doesn’t inspire you, I don’t know what will!

Think About The End Goal

Inspiration often does not come from what you are doing right now. Many times, it comes from dreaming about what will be. So, it’s not about repeatedly reading that same paragraph to remember or understand a single concept. Instead, it is about how this pertains to the final goal of becoming a great radiologist. Therefore, don’t get stuck in the minutia. It’s about the big picture!

Education As Fun

Education is about the journey, not the destination. That is because we never really arrive. There is always more to learn and see. And what can be more exciting than discovering new ideas and concepts and applying them to the practical world? As radiologists, that is what we do! So, take each pillar and block of knowledge to form new and exciting structures. This process involves taking new ideas to create research projects or looking at studies in a different way that no one has thought about before. You are only limited by your imagination!

Final Thoughts About Finding Inspiration

Inspiration is what makes us tick. It gives us the passion for completing our dreams and going one step further. However, it does not come from the daily grind. Instead, it comes from our beliefs, hopes, dreams, and goals. So, appreciate what you have accomplished, think about what you do daily (and yes, that includes saving lives!), and remember your goals for the future. It’s all pretty amazing. That should be inspiration enough!

 

(1) http://www.cofcogroup.com/want-more-productivity-get-a-hobby/