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Should I Join A Practice With A High Buy-in?

buy-in

As of the end of 2020, the job market is beginning to improve post-covid. And, for those of you considering your first job nowadays, you may receive offers from multiple practices. And, some of those offers may seem enticing. Perhaps, you hear that the partners make 600,00o, 700,000, or 800,000 dollars or more. And when you interview, the President of the private practice tells you that you will have to pay a large sum of money into the business. This sum of cash called a buy-in can range from zero to as high as into the millions. So, here are the questions you need to answer. Is a high buy-in ever worth your while? In fact, should you even entertain the possibility of starting at one of these practices that come with an enormous buy-in? Well, I am here to help you to answer these questions today!

 

 

The Hope

OK, all things considered, paying into a practice a large sum of money doesn’t sound so bad if the practice guarantees that you will bring in gobs of money each year, right? If you are paying a million to own a radiology practice’s technical shares, you can potentially receive outsized benefits in return. For one, your salary can become much higher. That initial sum of money that you add to the practice equity can significantly increase in value if the practice does well. You can also diversify your income a bit by collecting the professional fees and the technical component. These hopes can all come true.

But Then…

OK. There is always more to the story. Practices can dash hopes in an instant. Let’s say you don’t receive a share of the partnership during your partnership track. Where does that leave you? A lot poorer!

Or, perhaps, the practice equity declines as you finally earn the golden ring of partnership. Can a practice’s equity decline that much? Sure, can! Assets can not only decline to zero but can become a debt burden as well. Think about it. Equipment depreciates. And physical properties can decrease in value. The money you put in can no longer exist after you put all that equity into the business. And some!

Besides, you may overpay for the practice more than it’s worth. Who is to say that you have paid a fair price to become a partner? The practice partners? How do you know if they know how to value the practice. Or, maybe, they are trying to defraud you. You never know.

Weighing The Risks Versus Benefits Of A Large Buy-in

So, let’s see. The potential for large rewards versus the possibility of paying into something that is not worth it. What should you do? As always, this comes back to a trust and numbers game. Only by vetting the practice’s balance sheet and getting detailed information about the practice owners can you make the decision. So, how do you go about making this weighty decision?

Of course, you need to assess the people that run the practice. But how? Track record becomes very important. Have they strung along with multiple employees on partnership track to never make them a partner in the business? Are these physicians respected members of the radiology community? Do your residency and fellowship directors know something about the practice?

To get at the matter of trust, you must research the practice well. Check for lawsuits and hiring indiscretions. These can all become red flags that the imaging business may not be what you think.

And then get to the bottom of the balance sheet. Be wary of any practice that does not let you know what the partners have made in the past. Think twice if the practice does not allow you to talk to the business manager about the finances and the assets the practice owns. I know of several radiologists who had been through an extended partnership track to find out that they became partners in only the professional component, not the technical component/equipment and real estate. They were sorely disappointed when the time came to make “partner.” So, make sure to find out what you are really “buying-into”!

Finally, you need to consider the current environment of the practice. Are private equity firms or large hospitals in the area taking control of practices? Is the area economically growing or contracting? These factors may influence the risk of entering a partnership track that you may not be able to complete.

A High Buy-in And Your Final Decision

Depending on the situation and the practice, a high buy-in may or may not be worth the risk. Take into account not just the great potential of the business. Instead, you also need to consider the risks you need to take to earn that potential outcome. It might turn out well, but it might not. So, maximize your probabilities of success. Do your due diligence!

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Can You Pass The 2018 Saint Barnabas Precall Quiz?

Due to the popularity of last year’s precall quiz post, I am back at it again. Today, I am posting 10 cases from the real 2018 quiz that we used to ensure our residents are ready prior to beginning call. Of course, we used our PACS system to see if they could not only understand the disease entities but also make the findings as well. Unfortunately, you will not have the same option. However, these cases will help to benchmark where you may stand.

When you go through the test, come up with the findings, diagnosis, and if asked/relevant, management. In order to see how you did, answers are at the bottom of this page. (Don’t peek until you are finished!) One more thing… in order to pass the test without conditioning, you need to get at least 70 percent right. Enjoy!

Precall Quiz

Case 1

 

Case 2

 

 

Case 3

 

 

How would you manage this case?

Case 4

 

 

 

 

 

 

 

 

 

 

 

Case 5

 

What questions do you need to ask?

How do you manage this case?

 

Case 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 7

part A

 

 

 

 

 

 

 

 

 

1st film- 2 years ago

2nd film- today

What is the differential diagnosis?

What do you want to do next?

 

part B

 

 

 

Case 8

 

 

 

 

Case 9

 

 

 

Case 10

 

 

 

 

 

 

Answers:

Case 1:

Right thalamic/basal ganglia intraparenchymal bleed with intraventricular extension.

Accompanying early transtentorial herniation. (needs to be mentioned for full credit!)

Case 2:

Right-sided pyelonephritis/early abscess formation. Renal mass/neoplasm can be within differential diagnosis.

Case 3:

Aortic dissection extending from the inferior thoracic cavity to iliac arteries.

Accompanying perivascular fluid and effusion- possibly blood products, consider ruptured dissection

For full credit-need to mention that you would call the vascular surgeons

Case 4:

Ultrasound appendicitis with appendicoliths

Case 5:

You need to ask history. (?B-HCG positive)

Ruptured ectopic pregnancy.

Case 6:

Homolateral Lisfranc fracture dislocation

Case 7:

Part A

New prominent bilateral hila- Interval development of adenopathy or pulmonary arterial hypertension

CT of the chest recommended for further characterization.

Part B

Bilateral chronic pulmonary emboli with pulmonary hypertension

Case 8:

Acute biliary leak with extraluminal radiopharmaceutical.

Focus within the hepatic hila- most likely biloma/origin of the biliary leak

Case 9:

Distal left ureteral stone with left renal hydronephrosis and hydroureter. Accompanying inflammatory change at the left kidney and ureter.

Case 10:

No acute disease. Possible recently ruptured left ovarian cyst.

 

 

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Radiology Residency Day One – How To Start On The Right Foot

residency day one

Last week, I wrote about what to do on the first day on the job as a radiology attending. For those of you about to begin radiology residency, I thought it would be unfair to leave you in the dust. So, today, we will talk about what to do on day one of the radiology residency. For this discussion, we will disregard all the formal introduction courses from the hospital. Mostly, that is a passive activity. Instead, I need you to know what you must do on your first day in the department. So, let’s start!

Get To Work Early

On that first day, I recommend arriving early. Get to know the parking, the bathrooms, and the building. You never know how long things will take until you arrive. And as a resident, impressions become exceedingly important. The last thing you want to do is to arrive late on that first fateful radiology residency day one!

Introductions And Thank You

OK. This one does not differ much from your attending’s first day. Your new colleagues and faculty want to make sure they made the right choice when they selected you. So, do this right. Make sure to thank all the folks who helped to get you into the program. This gratitude goes a long way to building solid relationships for the next four years!

Don’t Stand Out Too Much

When you begin your first rotation, be careful about what you say. You certainly don’t want your attendings tagging you as the class troublemaker. That can lead to undue negative attention later on. So, if you think you may say something that may upset your new employers, I would hold back until they get to know you later!

Ask About Special Programs (If Interested)

Some radiology programs have Early Specialization In Interventional Radiology (ESIR) slots. If you do not inform your program directors early on that you maintain interest in the program, the program may fill up, and the ESIR program may exclude you. So, ask to sign up, if interested, on that residency day one.

Ask About Expectations For The Rotation

Different from starting as an attending, most of you have no clue what you should begin to do on residency day one. On day one of our nuclear medicine program, the technologist showed the residents how myocardial perfusion scans work. But, in the following days, you would sit with an attending to learn the basics. You certainly would not want to miss either of those opportunities. On the other hand, if you start on fluoroscopy, perhaps you need to watch a few esophagrams on the first day. And then, a few days later, the attending may expect you to attempt one on your own. Without these clear expectations, perhaps not in the manual, you will start your rotation at a disadvantage. It is hard to meet expectations you don’t have!

Learn The PACS

Like a new attending, you must learn how to look at cases at your institution. Therefore, it behooves you to play around with the PACS system a bit. Also, make sure to ask for tips from your colleagues and attendings. Many times, if you don’t ask at the beginning, you will only learn much later after you have wasted many hours. Remember: these tips can save significant amounts of time and headaches!

Start Learning How To Dictate

Again and again, you will hear that learning to dictate has a steep learning curve. Therefore, there is no time like the present to learn. Begin with a few simple cases. But start now if you can. As a resident, this activity is one of the most active ways to learn radiology. It reinforces the buttonology of the PACS and the learning of the basics of radiology. In addition, it can help the attending out during the daytime. So, why not start on day one?

Let Your Attending Know The Plans

On that first day, you will often need to attend several activities that are integral to starting but maybe off-rotation. As a courtesy, let your attending for the day know when and what you need to do. This act of doing this establishes a rapport between you and your faculty!

Listen Carefully To The Program Director (Or Associate Program Director) Welcome

Most programs have an early morning or noon conference from the program director or associate program director. This conference is crucial! Most of the time, the program directors will give you their expectations and requirements. Usually, they will not repeat the tips and advice you will get from this session. So, take notes, and don’t miss a beat!

Borrow, Rent, Or Buy Books

By the end of the first day, you should know what you will need to complete your first rotation successfully. Most of the time, you will discover what to purchase, rent, or borrow books from your colleagues in digital or print form. So, make sure to get these necessary resources on day one!

Radiology Residency Day One- Final Thoughts

As with any first day of a new job, the first day of residency can become a nerve-racking experience. But don’t let it be. Instead, try to absorb all the unique experiences that you encounter. So, make sure to take in the new situation, the people, and your place of work. And most importantly, don’t be too hard on yourself. The staff and your colleagues have low expectations for the residents on your first fateful day. Later on, you will have many more days ahead of you to stress about giving that next tumor board or taking the core exam. For today, you can relax and enjoy!

 

 

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Radiology Attending Day One: How To Get Started On The Right Foot

day one

Imagine: Your whole adult life consisted of schooling, including four years of college, four years of medical school, one year of internship, four years of residency, and perhaps one or two years of fellowship. And you will finish it all in a few days. This situation will be yours at some point. (If not at this moment!) Now, it’s day one, and you embark upon your new life as an attending.

For most, this transition is like moving from the confines of jail to the free world. No longer do you have someone to monitor you all the time. Now you become the arbiter of last resort. The buck stops with you. (All those hackneyed phrases are true!)

The transition to becoming an attending is enormous. And you want to make sure that you do it right. So, what are the most important tasks to accomplish on day one of your new job? What do you want to avoid? Assuming you have completed your administrative tasks before starting, we will go through some boxes you should check off on your first fateful work day.

Introduce Yourself To All The Staff

After the hospital orientations, ALS courses, and all that jazz has died down; you need to make a good impression on day one. The people you meet on that first may work with you for the next 30 years! So, make your introductions to all staff. That includes fellow attendings, technologists, nurses, secretaries, and janitors. By introducing yourself to everyone, you make yourself seem like a team player that is not “standoffish.” Who wants to work with someone who can’t talk to anyone in the department?

Dress The Part Of An Attending

You don’t want to stand out too much on that fateful day. So, make sure that your attire is appropriate to the department. I remember a few attendings at my prior residency that arrived at the department without a tie for the first time. The department chairman made these attendings return home and get a tie from their closet! You don’t want to start on the wrong foot in a department where you expect to work for many years.

Make Sure To Listen Carefully To Your New Colleagues

You will hear much on the first day of your new life. Sometimes, however, you will receive invaluable advice from your colleagues that you may never get again. So, pay attention. And, take notes if you don’t have a photographic memory. You are better off having the information you will need now than having to find someone to get the same information later on when you become really busy!

Stake Out The Joint

The first days are the time to explore your surroundings (Don’t break into the chairman’s office, though!) Discover the locations of the best bathrooms, cafeteria locations, local restaurants (if at an imaging center), physician and secretarial offices, reading rooms, interventional suites, and more. Become as familiar with the surroundings as you can. This is your new home!

Ask Lots Of Questions

OK. You don’t want to ask too many indiscriminate questions (It may seem like you don’t know anything!) But you do want to ask lots of important and relevant questions. Get to the practice’s expectations, pitfalls, and more. After the first day, your colleagues may become less attuned to answering these questions, as you will no longer be the new kid on the block. Get those questions in before it is too late!

Discover Your Boundaries

Especially on that first day, you do not want to step on anyone’s toes. Ask first if you want to help with a study that may not be in your daily expected routine. The last thing you want to do: is dictating a case only to find out that the clinical attending wanted a read from someone else. It does not look good for you or the practice. So, get to know and ask what you can and cannot do.

Get Dictation Standards

Different practices have specific requirements for all radiologists’ dictations. Some want structured reports, and others need the impression at the beginning. Make sure to ask your colleagues what exactly they expect before beginning your work. You certainly don’t want to rock the boat too much!

Learn The PACS and EHR

The PACS and Electronic Health Records systems have become crucial for relevant and quality reports. In addition, knowing these systems will significantly help your efficiency (You want to get out of work on time, don’t you?) Therefore, you need to spend your first day working to make sure that you get to know the PACS and EHR well. A little time now will save tons of time in the future. Think of it as an investment.

Work Slowly And Deliberately

As a fresh radiologist right out of fellowship, you don’t want to be known as the gal who does careless dictations. So, especially on that first day, slow down. Make sure everything you dictate is correct. You have years and years to pick up speed with your work. Now is not the time to rush, and newbies make more mistakes. Don’t add to the reputation!

Radiology Attending Day One- Final Thoughts

The first day as an attending is tough. You are transitioning to a new world, just like the many worlds you had transitioned to before. So, go forward and welcome the changes with open arms. Believe it or not, you will find your comfort zone one day. It just takes a bit of time!

 

 

 

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Is The Specialty of Radiology Better Off With Increased Competition?

increased competition

With the increasingly hot job market for new radiologists, medical student applications to residency programs have steadily increased over the past several years. But that got me thinking. Is the specialty of radiology better off with more hardcore medical students wanting to enter the profession? Or does radiology benefit more from residents who genuinely want to be here when times are tough? So, let’s go through the advantages and disadvantages of having both a competitive and a non-competitive application process. And then, we will come up with a conclusion to the final question: Is the specialty of radiology better off with increased competition?

 

What Happens With A Competitive Application Process

Advantages

From a program director’s perspective, let’s begin by saying that a program director’s job becomes much easier with increased competition. To find applicants, you do not have to interview as many candidates. And the applications tend to have fewer “blemishes.” That said, as much as it helps me, this factor impacts the specialty very little.

So, what other advantages does a competitive process offer? First, the candidates will often have more experience in research. But does this create better radiologists? Depending on whether the resident wants an academic career, that is up for debate. However, I can say that it again makes the program director’s job a little bit easier because the faculty do not need to teach some of the primary research mechanics to get them started. Additionally, this resident will also likely produce more research during residency.

With increased competition, residents tend to be slightly more attentive to keeping up with reading. Moreover, these residents tend to be more motivated by passing tests. In other words, they may be a bit more “obsessive-compulsive.” Now, this would theoretically work in favor of passing the boards. However, according to the infinite wisdom of the test makers (the ABR), this doesn’t change the pass rates since they opt to create tests based on curves, not content.

Disadvantages:

Over the years, I have noticed that competition also motivates applicants who want radiology because of the competition, not necessarily for the love of radiology. In the long run, this can lead to increased burnout. Furthermore, it can change the culture of radiology residency and radiologists into a less forgiving and highly pressured environment. Again, this is more of a tendency rather than a truism.

Increased competition also brings out fewer nontraditional applicants to radiology. These include folks who have completed other residencies and different careers. In the setting of increased competition, they have a much harder time receiving interviews because programs often screen them out of the system due to their increased time in or before residency. However, nontraditional applicants bring a different perspective to residencies. Moreover, they have been through more, are more mature, and often make better leaders.

What Happens With A Non-competitive Application Process

Advantages

Residents who apply during a less competitive time are a different group of candidates. I like to call them type B personalities. These folks create a less pressured environment and a calmer culture for the residency program. This decreased stress can make the four-year residency process more tolerable for everyone.

Likewise, during tough times, the limited selection of candidates forces residency programs to accept nontraditional candidates. As stated, these candidates lend a mature perspective to a residency program. In addition, these residents want to be involved in radiology for the love of the specialty rather than the competition and the “great” job market.

And then, programs will often downgrade their expectations of these non-competitive residents. Decreased expectations lower the pressures on the residents during their program and can create a less harried culture with reduced burnout.

Disadvantages

I don’t have the statistics to back this up. But, from my experience, tough times lead to residents with a higher dropout rate. Sometimes, these residents cannot meet the rigorous academic challenges of residency. When this occurs, residencies can lose their precious spots to other specialties like primary care.

Also, these residents have overall less experience with research. So, most residencies with non-competitive applicants will create less output during these challenging times. (This is a disadvantage for the more academic residency!)

And then, finally, residencies have more work cut out for them. They must put more time into teaching and spoon-feeding the residents to ensure they complete the program.

Weighing The Balance- Is Increased Competition Better For The Specialty?

So, where do I stand in this controversy? Well, residency directors and their programs must put more work into the residents during the “tough” years to get them “up to snuff.” But, you know, I’ve seen great residents during the lean times and times of abundance. So, I think we put more emphasis on competition to get better residents than we should. In the end, good residencies mold their residents into great radiologists regardless of the zeitgeist of the times. And that’s the way it should be!

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Transparency And The ABR: Are The Leaders As Transparent As They Like To Think?

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At the recent Association of University Radiologists (AUR) meeting, the American Board of Radiology (ABR) adopted the theme of transparency in its lectures. However, as I sat and listened to the seminar on the ABR updates, the words did not jibe well with the theme.

How The ABR Supported Its New Found Transparency

Brent Wagner, MD, the President-Elect of the organization, attempted to show as a nonprofit entity, the books are wide open. And that, the money that they raise from testing fees and MOC mostly goes to the upkeep of the organization. In fact, they showed the public income tax form they filed with the IRS. In it, he stated that anyone could pretty much look up the finances of the organization and its members. So, I pulled up a copy of the nonprofit 990 IRS form for the 2016 tax year at the following link:  http://990s.foundationcenter.org/990_pdf_archive/410/410773787/410773787_201703_990O.pdf

Yes, much of the money does go to the running maintenance of certification, testing, and other appropriate uses. But, that is not all. If you look at the form, you will see listed the compensation for the executive board listed on page 7. According to the document, compensation for the president was 720,000 dollars for 50 hours of weekly work. In addition, the ABR paid the associate executive directors on the list who worked 20 hours over 260,00o dollars including all compensation. Of course, this compensation does not include any other outside remuneration that these individuals may receive from outside practices and institutions. So, if you take all the income into consideration, it is significantly more than the typical radiologist’s. But yes, it was available for all to see.

My Issues With ABR Executive Compensation

So, what is that did not sit well with me about the executive compensation? For one, you have an army of volunteers that the ABR does not pay for all their time and effort. Meanwhile, you have a small group at the top who collect significant rewards. Yes, this is a nonprofit organization and the folks that run it should get paid for its work. However, at the top, these folks earn a lot more than a typical radiologist. When I pay my annual dues, I don’t believe there is much value in paying a president of this organization over 700,000 dollars not including additional outside compensation that she may receive.

I mean, what exactly is the point of the organization? Simply, the ABR should dedicate itself to the high standards of the end product of residency, the radiologist. Additionally, the organization should make sure that it’s diplomates meet the minimum requirements to practice radiology safely while maintaining a relationship with the public and government. Should the leader at the top earn almost twice the average radiologist for this mission (not including other side income)? It’s certainly hard for me to justify.

And just because the organization exists as a nonprofit entity and must distribute all profits by the end of the year does not mean that the nonprofit model is fair. A nonprofit is only as good as its ability to distribute its funds appropriately for the betterment of a cause. Rewarding the executives with salaries above and beyond the typical radiologist does not qualify as a cause I want to support.

Moreover, finally, in order to justify the salaries it paid to its executives, the speaker compared itself to other nonprofit organizations. However, just because other nonprofit entities overpay its executives does not mean that the ABR should do so as well.

My Final Thoughts About ABR Transparency

Alright, I will give the ABR some points for coming clean with the whereabouts of its funding. And, I will give them some credit for talking about the remuneration of its members. As well, they gave us the means to access the information. On the other hand, the ABR is not forthcoming with providing the reasons for the exorbitant compensation of its leaders. We should advocate for more transparency and demand more from the ABR. Creating more equitable compensation to its employees and leaders should take a higher priority.

 

 

 

 

 

 

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Clinician Interruptions In The Reading Room: A Necessary Evil Or An Avoidable Interaction?

clinician interruptions

For those of you that practice radiology, how often do clinicians interrupt you on a busy rotation? And, what percentage of the time does the clinician provide helpful information without interrupting your train of thought? I know I can only speak for myself, but many clinical interactions prevent me from completing my work, increase my inattention, and should probably occur at another time. How often does a clinician stop by to ask you when you will finish his patient’s report only to lengthen the time to complete the dictation? Assuming my experience is similar to others, I believe those clinician interruptions can overwhelm many positive daily interactions.

 Plus, based on the evidence (check out Should Radiologists Ignore The Phone?), we know that interruptions cause an increase in error rate with our reads. So, therefore, clinician interruptions become much more than an issue of mere convenience. Instead, we need to take clinician interruptions very seriously. To cover this longstanding theme, we will discuss whether clinicians and providers should be allowed to enter the radiology reading room. Then, we will talk about potential solutions to these problems. So, let’s begin!

Reasons To Allow Clinicians To Enter The Reading Room

Knowing that interruptions prevent us from reading cases to the best of our ability, one could make a case that we should nail our reading room doors shut. But fortunately (or unfortunately!), this cannot happen in reality. Moreover, it probably is not such a good idea.

So, what are some legitimate situations when a clinician in the room may enhance the reading of our cases? Well, first of all, we must welcome all good histories that help us to make a diagnosis. A clinician coming into the room with this message can become a lifesaver, literally. The clinician can change the diagnosis and management.

Second, a clinician in the room can help when we need to relay an urgent message. For instance, perhaps you find an impending aortic rupture and need to get in touch with the vascular surgeon. Wouldn’t it be nice if the physician just happened to be standing next to you instead of calling all over the hospital to find him?

And then, sometimes, a clinician can enhance our reads when we are unsure of the best way to manage the patient. For instance, maybe, you recommend an MRI, but unknowingly the patient already has a pacemaker. Yet, if a knowledgeable clinician stood next to you, you would ensure that the patient had received some other test, such as a gallium scan.

Clinician Interactions That You Should Prevent

As I discussed above, clinicians should not ask the radiologist when he will complete the study. An assistant or secretary should handle these requests. Furthermore, the technologist or clinician should mark a study as STAT, priority, or routine. And the radiologists should dictate these cases in an appropriate order from most emergent to least. For this reason, a clinician stopping by the reading room interrupts the workflow and is redundant.

In addition, as much as I like medicine rounds from an educational point of view, having a team of medical physicians interrupting the radiology workflow on initial patient reads does not contribute to good patient care. Educational rounds during live readouts can disrupt search patterns and often warrant inefficient rereads of the same films. Furthermore, these types of interactions can cause other errors. On the other hand, educational rounds at a specified time after the radiologist made the reading would not detract from patient care.

Finally, as much as I like a suitable, quality, friendly conversation, clinicians should not use the reading room as a place for small talk. These sorts of conversations can also act as a nidus for errors!

What Are Some Potential Solutions To Allow Useful Clinical Interactions While Mitigating Interruptions?

Unfortunately, the task is not easy. But here are some logical recommendations:

First of all, having a “1st line triage” can help the process of selecting who can enter the reading room. Like other professionals with secretaries and assistants, radiologists should also have clinical assistants who can manage interactions with our colleagues. Radiology assistants can serve this function. (a more expensive option) Alternatively, junior residents may also help to prevent unwarranted interaction. Rather than interrupting the clinician workflow, the junior resident can field the questions and may interact appropriately with the physician. The junior resident can also learn about clinical medicine from the interaction.

Second, make sure to make it understood that the reading room should exist as a place for reading films and not unwarranted conversations. The placement of signs and a general culture of using the reading room as a workplace can prevent some of these disruptions.

Finally, we should proactively inform and train our clinical colleagues regarding the appropriate questions and times to enter a reading room. Continuing education via interdisciplinary conferences and general interactions can undoubtedly help.

Final Thoughts About Clinician Interruptions In The Reading Room

Clinical interruptions are more than just a nuisance. Instead, they directly impact workflow and increase the error rates of the interpreting radiologist. Therefore, hospitals and imaging centers should create appropriate reading environments for beneficial clinical interactions with radiologists. At the same time, they should create an environment that avoids significant clinician interruptions. Hiring more staff, using residents appropriately to triage, and creating quiet reading rooms can allow uninterrupted workflow. So, next time you are interrupted, be proactive and do not allow these interactions to continue. Politely ask the offending clinician to wait until you complete the reading. And then consider discussing the issue with your residency or hospital. Working to improve the efficiency and quality of clinical interactions can save lives!

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What Really Goes On At A Radiology Practice Partners’ Meeting?

partners' meeting

I can remember back during my radiology residency many years ago. Every so often, the radiologists at my hospital would meet secretly outside the hospital for their partners’ meetings. As the radiology attendings rapidly left to abandon their shifts to get to this meeting, I thought perhaps the partnership was just like the secret societies such as the Freemasons or the Illuminati. Maybe, they had a secret handshake? Or could they be plotting the overthrow of the hospital or government? What was going on at the partners’ meeting?

Most likely, you also wonder what happens during the partners’ meeting since you have never experienced anything like it. Moreover, you are an outsider, not privy to private practice business. Yet, one day many of you will also become a partner in a radiology practice. So, today I will reveal the secrets behind what partners discuss at their business meetings. Therefore, pull up a chair, read this post, sit back, drink, relax, and enjoy. Now, you will learn the truth behind what the partners discuss at a partners’ meeting!

Finances

As you might expect, at most meetings, a business manager often discusses the current state of a practice’s finances. Are reimbursements declining? Do new potential sources of revenue exist? What imaging modalities are trending higher? Should the business renegotiate insurance contracts? For some of you, your eyes may glaze over when you hear about a practice’s finances. However, these discussions are essential for continuing business as usual. And, yes, radiology is not just about health care. It also needs to run positive income to pay the employees, the fixed costs, the partners’ salaries, that end-of-the-year Christmas party, and more. Most meetings involve financial discussions.

Long-Term Strategies- Mergers, Acquisitions, And Partnerships

Nowadays, practice size has trended upward. Many practices must evolve to create larger entities so that they can use economies of scale to reduce costs and maximize profits. What do I mean by that? Essentially, practices can distribute fixed costs among a larger group of employees, thus saving money for the business. Therefore, you probably hear a lot about practices merging or private equity firms buying out imaging companies to save on costs. Well, partner meetings are common private forums for discussing these issues. In addition, you can expect practices to talk about ways to maintain good relationships with the hospitals and clinical colleagues as a long-term strategy. This long-term strategizing all happens at some partners’ meetings.

Manpower Issues/ Human Resources

Almost every practice has its fair share of issues with employees. Perhaps, some physicians do not meet the requirements of the hospital. Or maybe, clinicians have been complaining about certain practice members. Partners meetings are the appropriate forums to discuss these practice problems. In addition, partners discuss hiring new employees to meet the demands of the practice. Partners will discuss these problems and attempt to devise solutions to match the workforce to the practice’s needs.

Scheduling

One thing that is constant in any practice is change! Whether it be new imaging modalities, increasing requirements of films to be read, or losing business to other clinicians, the scheduling demands must meet the appropriate workloads. Partnerships will broach better ways to schedule partners and employees to maintain maximal efficiency. In this same vein, practices will also debate vacation policy schedules and the appropriate workloads for daily and weekly rotations whose needs may differ over time. These items commonly enter into the typical partners’ meeting.

Beauracracy and Compliance Issues

Every year, governments develop new rules and regulations for practices to follow. A few years ago, it was ICD-10 codes. Now we have new quality improvement mandates set by Medicare. Whether for certification maintenance or hospital credentialing bylaws, these items constantly change and can be crucial for maintaining the practice and complying with the law. All partners need to keep aware of the newest compliance issues to run an imaging business successfully. What better forum than a partner’s meeting to discuss this?

Insurance And Benefits

In this category, I will include malpractice, health, life, and disability insurance, pension plans, and yearly bonuses. Partners must approve the renewal and disbandment of these annual benefits. These changes depend on the costs and overall contribution to the practice and partners. You wonder how they come up with these policies. Well, usually, this occurs at the partnership meeting!

Residency Issues

Lastly, although residency issues crop up, that can affect the practice. If you have an imaging company with a residency, the partners may or may not discuss it in a partnership meeting. But, they occasionally make it to the partners’ meeting agenda. The discussion could be about new residency requirements, a site visit from the ACGME that all partners need to plan for, a specific resident issue, a problem resident, and more.

The Secret Partners’ Meeting- Final Thoughts

A partners’ meeting is a necessary evil to maintain a practice. And, as you can see, a partners’ meeting agenda can fill up quickly. Depending on the time of year and the number of issues, meetings can take hours and hours. Yet, the partners’ meeting is an essential aspect of a quality partnership and business. So, the next time you see the partners disappearing to attend the partners’ meeting, you now have some faint idea of what happens. Although you may never learn the secret handshake (or the nitty-gritty financial details), you now know what to expect from that occult partners’ meeting. And no, it’s most likely not just about discussing you!

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Top 10 Resident Issues That Radiology Faculty Wants You To Know But Can’t Say

Top 10 Resident Issues

Most radiology attendings want their residents to succeed. However, etiquette rules cause many to withhold their feedback about some of the resident issues that they encounter on a daily, weekly, or monthly basis. Unfortunately, for that reason, they keep many of you in the dark. However, please learn from their mistakes and enlighten you all. So, to prevent you from continuing with these resident issues, I thought I would create a top 10 list that the faculty wants you to know but may not say… Here we go!!!

You’re Too Aggressive

Are you overcalling everything or coming down hard on a final diagnosis without any other differential? Are you accustomed to the surgical mentality? No longer can you just nod in agreement, but you push, push, push? Everything is an argument. And, your attending does not have the time to talk back. Gosh darn it, perhaps you are more aggressive than you should be at this stage of the game!

He Misses Everything

When your attending sees that you are missing all the findings during the night, he may not feel so great telling you about all these errors. How will that help anything? And I mean, he doesn’t want you to feel bad about it when he tells you, does he? Unfortunately, you may miss out on some of these learning experiences. But, your attending may not let you know!

She Has Poor Hygiene

Poor hygiene can be just plain embarrassing. But, sometimes, your faculty may become very uncomfortable dealing with malodors or unkempt appearance. It often needs to be said to the resident but doesn’t. And, all the other faculty and residents suffer from this resident’s poor hygiene!

You Just Don’t Listen

The attending keeps on telling the same resident the same old thing. But, time after time, nothing changes. No longer can the attending tell you what to do anymore because it does not seem to work? So, your attending does not bother you anymore. What’s the point of hurting your feelings?

He’s Way Too Enthusiastic

Don’t get me wrong, but it is great to be enthusiastic. And, your attending certainly does want you to become excited about radiology. But, too much of anything is no good. And sometimes too much enthusiasm can be a bit too much. It can wear on your techs, nurses, and attendings. So, temper that enthusiasm just a bit!

You’re Just Plain Dumb

Often, your attending will ask you questions to see if you have been reading enough. And it is OK to get some things wrong. However, on occasion, a resident does not know anything that he should. Is your attending going to tell you that, maybe or maybe not? Who wants to say to the resident that she is just plain dumb?

She’s Getting A Bit Too Chummy For My Liking

On occasion, our residents can become a little too familiar with us if you catch my drift. It can all be a little too “touchy-feely.” So, think about how you communicate with your attending. Is it appropriate? Or are you trying too hard to become his best friend?

He Wants Always To Be Spoon Fed

Most residents want to learn from their attendings. Some residents expect all the learning to come from their attendings with no work on their part. If you desire to breed ill-will, you can do just that. Don’t help out your attending. Instead, just expect them to teach. It can be very irritating!

You’re Always Abandoning Ship When The Work Is Not Done

Excuses, excuses, excuses… You have to get to a wedding. Or, maybe you need to go on a date with that new beau. Well, your attending does not want to be the one to break it to you. He does not want to be the unfeeling guy that ruins the resident’s time. But, is it right that you are always missing all that work?

He’s Preventing Me From Getting Anything Done

Some residents like to talk a lot. And, most attendings like a good conversation as well. But, sometimes, it can interfere with the daily work that needs to get completed. How can your attending break it to you when she likes you a lot. Well, it can be challenging at times!

Final Thoughts About Resident Issues That Faculty Want You To Know But Can’t Say

Rightfully or wrongfully so, many taboos exist that prevent faculty from telling you, the radiology resident, what is going on. And even though attendings are supposed to evaluate and give direct constructive criticism and feedback, that is not the reality of the situation. So, if you think that you may have one of these ten resident issues listed above, try to change it on your own because you may never get the real story!

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AUR Meeting 2018- Themes And Undercurrents

Welcome to the second annual review of the Association Of University Radiologists meeting in 2018! So, why do I think we should review this meeting on an annual basis? Well, for one, many of the changes in residency you will experience stem from the academic realm.

Moreover, if you were to read the headlines and the summary of the lecture topics of the conference alone you would not get a good sense of what they will be changing. For example, this year, the heading of the meeting states “Health And Well-Being Of Profession And The Professional”. However, this theme is a small part of what actually happened at the meeting.

Yes, the lecturers did cover the topics of burnout and depression, relevant to the heading. But, if you dig a little bit deeper, compared to these themes, you would recognize that many other themes will impact future residents much more. So, what are the undercurrents that were most relevant? Basically, I am going to divide these topics as follows: continued improvement of the job market, increasing radiology residency match competition, the online longitudinal assessment, Radexam, and increasing time requirements for program directors.

The Hot Improving Radiology Job Market

Out of all the news, I think this is probably the most important. Based upon the hot topics lecture series at the AUR meeting, radiology has climbed out of its doldrums and now returns to a more normal job market. In the most recent year, over 1800 positions were available for new graduates. Very recently, the number of new hires amounted to the low 1100-1300. Furthermore, according to the conference, next year they predict that practices will need 2133 new hires. So, workforce demands are significantly increasing. My reasoning for the sudden increase in available jobs: a wave of retirements and willingness of practices to hire due to stable/good economic conditions. So, congratulations to all residents who chose radiology over the past 4-5 years! You can look forward to a great job market.

Continued Increasing Competitiveness Of Diagnostic Radiology Residency

Similar to the previous year, the competitiveness of radiology residency in the match continues to increase. As in the previous year, the unfilled spots continues to decrease and the percentage of US grads entering radiology residency continues to increase. All of these signs point to a much more difficult time for the US and foreign grads to match in radiology.

Online Longitudinal Assessment Replacing 10 Year Exam

Yes, I know that many of you have not yet thought about the maintenance of certification requirements once you have completed your residency. However, this new program will impact all residents today once you graduate and become board certified. No longer will ABR diplomates need to take an exam every 10 years to maintain certification (unless you do not satisfy the requirements of the new program). Rather, everyone who takes the online assessment will be able to skip the test and simply answer weekly questions that you receive via email.

Each year you will receive 104 question opportunities and you can choose to answer as few as 52 per year. You need to pass the scoring performance criteria based on 200 questions every 4 years. Fortunately, this system will replace the time sink of having to attend a test in Chicago every 10 years with all its expenses. I am certainly looking forward to bagging my unnecessary trip to Chicago for the recertification examination!

Radexam Now Operational

For residency programs throughout the country, many have implemented the new Radexam, replacing the old in-service examination. From my experience, the old in-service examination served a futile role in evaluating residents over the 4 years of residency. I believe no correlation existed between the passage of the core examination and the in-service exam. Now, this fact may change. The new Radexam crowdsources questions from numerous question writers throughout the country. And, the questions are vetted and evaluated for validity. In addition, the exam tests residents according to individual residency level. They can be used at the end of a rotation. Eventually, the exams can be tailored toward the types of rotations the radiology residency has (modality or organ based). I look forward to evaluating the quality of this new exam. More importantly, I believe it has the potential to revolutionize evaluation of residents, especially at smaller programs.

Increased Mandated Program Director Time Requirements Officially Implemented Starting July 1, 2018

Especially at the smaller programs like ours, the new ACGME rules about program director minimum time requirements will create an enormous impact on the management of residency programs throughout the country. Check out this webpage from the ACGME and the associated chart below:

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/420_DiagnosticRadiology_2018-07-01.pdf?ver=2017-08-10-081454-583

0.3 full-time equivalent (FTE) for programs approved for eight to 15 residents; (Core)
0.4 FTE for programs approved for 16 to 23 residents; (Core)
0.5 FTE for programs approved for 24 to 31 residents; (Core)
0.6 FTE for programs approved for 32 to 39 residents; (Core)
0.7 FTE for programs approved for 40 to 47 residents; (Core)
0.8 FTE for programs approved for 48 to 55 residents; (Core)
0.9 FTE for programs approved for 56 to 63 residents; (Core)
1.0 FTE for programs approved for 64 to 71 residents; (Core)
1.1 FTE for programs approved for 72 or more residents. (Core)

 

Basically, the minimum required time for program directors to administrate programs has in many cases doubled. At our program, we are going from a 0.2 Full-Time Equivalent (FTE) (one day of administration time per week) to a 0.4 FTE (two days of administration time per week). As many programs have suffered from lack of administration time for programs directors, this change should enhance the quality of many radiology residencies. Some manpower/administrative issues that remained unresolved in radiology residencies can now be tackled due to decreased time pressures.

Final Thoughts About The AUR Meeting

Unlike previous meetings over the past four or five years, most of the doom and gloom has passed. Ironically, although the headline lectures were about depression and burnout, the mood was much more upbeat for new and graduating residents. Between the rising job market and the stable economy, the new MOC, increased program director time requirements, and the new Radexam, things are looking up. Even the wave of concerns about artificial intelligence replacing radiologist has seemed to pass us by! (No one believes that it will replace radiologists any time soon).  So, for all radiology residents, you are entering the field at a great time. And, this meeting certainly confirmed my suspicions!