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Are You Ready?

ready

The middle of June begins the annual season of change for radiology residencies. The first graduates start to move out as they have held their last few weeks of residency vacation to dedicate this time to move. And new residents prepare to find housing in the area and prepare for the new academic year. Even the first-year residents have an enormous transition from readers and observers to active participants in night shifts and calls. Since so much happens now, let’s discuss a checklist of some items you may not think about or forget before starting the new year. Don’t worry. I have you covered!

Bone Up A Bit On The Basics To Get Ready Before Starting

Whether you are about to start residency, call, or fellowship, why not take the time to read a bit before starting. Many fellow interns and residents say not to do anything before starting your new phase. But, many of them are not radiology trainees. We have more reading than most other specialties out there. So, get cracking. 

Suppose you are an intern. Read some anatomy atlases (if you haven’t done so already!). If you are about to take overnight call, consider some case review series, especially for ER radiology. And, if you are a fellow, start reading about some of the critical areas within your newfound subspecialty. Any bit of reading can give you a headstart.

Find Housing Close To Your Residency Program

You have limited time to get out there and find housing with all the pressures upon you. But, if I have to give one sagely piece of advice, you are usually best off living fairly close (optimally within a ten-minute radius)—the less time in the car or some form of transport, the better. You will have more time for studying and, perhaps just as importantly, more time for yourself. This advice comes from someone who has lived near and far from their line of work. It’s not worth the pain to live farther away!

Remember To Start Up Your Savings And Investments

Some of you will have the option of starting up 401ks with matches or making automatic contributions to Roth IRA. Regardless, before starting, don’t forget to automatize all these investments. As residents, you will not have as much time for a hands-on approach. So, start up those automated investments into those stock index funds before beginning. Trust me. Your future self will thank you many years from now!

Start-Up Car And Renters Insurance

Many of you are moving. So, don’t forget to change up all your insurances. Sure it can be a pain in the neck, especially if you are moving to a new state. But, it is a necessary evil. The last event you need is to start residency after a theft that you can’t recover or have issues with your car once you have already started. Make sure all these insurances are in place before you start.

Make Sure You Have Your Medical Licenses And Credentialing Ready To Go

Some of you will need your state medical license before beginning residency. Others will be able to use the hospital license. Either way, you will still have much to do to ensure that you get it processed and ready to go. Credentialing in all forms can be more arduous than you might think. And, it pays not to worry much about it after you start. So, get everything in as soon as possible, so you will not worry about the details during your residency!

J1 Visas, Etc…

Finally, for foreign graduates, don’t forget to ensure that all the paperwork you need to stick around is complete and ready to go. We have seen a few folks that had a problem getting back into the United States because they did not finish their paperwork. It happens!

Are You Ready? Get Psyched For The Change!

So many errands to do before starting and so little time to do them. Here is a bit of a nudge to get you going so you can start the year with a bang. Before starting, take a gander at this list and ask yourself, what did I forget? This list can help you recall what you need. But, most importantly look forward to the next academic year. Change is exciting and will be here before you know it!

 

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Why Radiologists Need To Protocol Cases

protocol

Like many institutions, we perform cardiac CTA studies at the behest of our emergency medicine, internal medicine, and cardiology colleagues. They say do the study, with or without a protocol, and the technologists jump without a reflexive thought. For example, one patient had a chest CT scan a few days earlier for shortness of breath. It turned out that the patient had enough calcium in their coronary arteries to make their vessels look like lead pipes. For those who know anything about cardiac imaging and CTAs, tons of calcium within the coronary arteries make it nearly impossible to interpret them for stenosis because of significant beam hardening artifact, limiting evaluation of the lumen.

Nevertheless, without batting an eyelash, the technologists completed the coronary CTA, which was uninterpretable for detecting coronary stenosis. It had a calcium score of over 4400! Now, if only someone had looked at the CT chest, we could have avoided the CTA chest at the cost of unnecessary contrast, additional radiation, and of course, the financial cost to the patient.

This case is a microcosm of what is happening to radiology. Scans come through fast and furious, making it difficult to vet the protocol and the priors on everyone. But, by letting cases get through the system without forethought and protocols, we expose our patients to subpar medicine. In light of these facts, here are some of the critical reasons why radiologists need to protocol cases.

Avoid Unnecessary Studies

How often do we get the wrong orders for the indication? Very frequently! Daily we get orders for CT scans that ask for contrast when none is needed and vice-versa. Of course, a patient with flank pain should not generally get contrast on the first scan if they are looking for stones. But, wrong orders for studies with contrast happen all the time, causing unnecessary exposure to radiation and contrast that is not needed. Protocoling can prevent most of that.!

A Protocol Can Make Sure Studies Are Done For The Right Reason

When technologists and nurses come up to me and ask if they are performing the correct study, the first question I always ask is, “why are we doing the study?” There is a reason for that. We get orders that are not necessarily for the indication that clinicians want. It could be a white blood cell scan for when a simple gallium scan is warranted. Nevertheless, we can correct most of these potential errors before they get to the table!

Protocols Can Add Information To The Case

Protocoling can add critical information to the case. It may help find a relevant prior like the cardiac CTA above. Or you might find a valid reason for a study that might not be evident initially. Perhaps, the doctor is looking for a fistula and needs rectal contrast. Sometimes, you can only figure that out by digging deeper. You know what they say… Garbage in. Garbage out!

Prevent Patient Discomfort

Many radiology studies are uncomfortable and difficult. A CT scan on a patient with severe back pain can be a nightmare. Imagine going through a CT scan in this situation when you could have avoided the test if the radiologist had protocoled it beforehand. Well, this issue happens all the time. We owe it to the patients to prevent additional harm!

Prevent Angry Clinicians

When we do not protocol cases before imaging, we do not get the answers that the doctors are looking for. This cycle leads to unhappy referrers that do not receive the intended study. And, we get these irate phone calls afterward. Do you want your clinician to send patients back to your department again? Well, if you consistently deliver the wrong studies for the patients, that will not happen!

A Protocol Can Decreases Costs

The costs to image patients are immense. And simply one incorrect study can cost the patient and the institution thousands of dollars. Protocoling is a tremendous backstop to ensure that health care costs are more reasonable. Sure, we may not have much time in our busy schedules. But, protocoling can certainly decrease costs to the system!

Protocol: An Easy Way To Prevent Bad Medicine

If your attending asks you to take a stack of patients and ensure the protocols are correct, it is not a waste of time. With all the benefits of eliminating waste and practicing good medicine, it is something that we should all do regularly. So, look at those orders before the hospital performs the studies. Protocoling can make a huge difference in patient care!

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Know Your Marketplace Value!

value

As you meander through your training, it is rare to hear from your hospital or training program about your actual value. Sure, you can look on the internet and figure out what the average radiologist in a particular place and situation makes. Of course, you will find salary surveys like Doximity and Medscape. But, they are often off base for your specific situation. These surveys are an odd mixture/overall average of all sorts of practitioners- part-timers, owners, full-time employees, and other employment situations.

So, why is the most accurate information so difficult to find? First of all, hospitals, corporate practices, partnerships, and teleradiology firms (and even your residency program!) are vested in either obfuscating or undercutting the value of radiologists and their practices. It is in their vested interest to hire you at the lowest possible rate to save the most money. Furthermore, you are less likely to change jobs if you don’t know your worth. And, you know what that means. Whether you are a new graduate from residency or an owner/partner of a practice, every radiology trainee and radiologist needs to know their value in the workplace. So, today I will talk about how you can figure out a closer approximation of your value in the marketplace. Knowing your worth is essential for negotiating your next offer to get your best and most comparable value in the market.

Look On Job Sites- Can Give You A Ballpark Value!

Nowadays, many job sites (comp health, radworking, etc.) can give you a vague idea about what radiologists are getting in your market. Sometimes these numbers are inflated for bad situations such as too many RVUs or inappropriate working environments. Nevertheless, it can give a general gestalt of the numbers in that particular radiologist market.

Read ACR Magazine And JACR

The ACR tends to have some good information about the state of the marketplace. It tends to tell you which trends are taking place right now. These trends can give you an idea about the hiring environment. For instance, every once in a while, they will have surveys on working environments or market demand. I find it an interesting ancillary source to figure out the general trends about how radiologists are valued.

Check Out The Big Surveys, But With A Grain Of Salt!

I mentioned some more prominent surveys before, like Medscape, Doximity, and the Aunt Minnie Salary Survey. However, you can’t entirely rely on these for your specifics. Some even include the average with residents who mistakenly add their numbers to the mix. But, if you are looking into the practice of radiology in general, they are not horrible. Then, there is the paid-for evaluation of physician salaries, which has biases. Some have a hospital bent. Others lean toward a private practice or even partnership. You need to be very careful when interpreting this information. It may not apply to your particular situation!

What Are The Needs At Your Hospital And Network?

Sometimes a microcosm of the radiologists at your local residency can be applied to other practices in radiology. For example, is your practice having a tough time findings mammographers. Most of you will hear murmurs of these issues during your residency. This gossip can help determine the value of particular specialties and know how valuable you may become to your future radiology practice when the time comes.

What Is The Mood Of The Forums?

Here is another criterion that is not entirely objective. But, it does give you a flavor of the needs of radiologists in the general community. I like the Aunt Minnie Forum because it has a general radiology bent. And, you see here all sorts of opinions on there. Of course, you will find a few trolls. But, it does give the overall mood of the specialty at a given time when it comes to radiologists and radiology practice valuation. It works as a starting point.

Knowing Your Marketplace Value Is Essential!

When the time comes to look for a job, knowing your worth is essential. Some offers will not be close to the actual value of the work that you will do. And others will be more realistic. To negotiate appropriately, knowing this number is essential. So, consider surveys, but remember they are not entirely correct. Also, consider using other ancillary methods such as the ACR magazine, online job sites, your own hospital needs, and even the overall gestalt when you scroll through the forums. All these are tools that can help to give you a better idea of your magic number. If you don’t learn this information, there is a good chance you will not receive what you are worth!

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Hospitals Need to Invest More In Radiology IT Support!

radiology IT support

In an environment where hospitals’ profit margins are becoming tighter, what is the most likely area where they can cut costs? Well, it’s undoubtedly not surgery or nursing. That would look not very good for the hospital and drive competitors elsewhere. Could it be hospital beds? No, because that would lead to direct patient complaints and less capacity. Is it the high-tech equipment and hardware? Not usually, because that is a great marketing tool to get doctors to refer patients your way. Instead, unfortunately, the places where a hospital can cut costs are usually the behind-the-scenes. And one of these areas on the chopping block is radiology IT support.

Who cares if the radiologists if a radiologist’s job is more demanding? It doesn’t affect the hospital’s bottom line, right? Does it matter if the radiologists must stay an hour later to deal with PACS crashes, firewall issues, and incompatibility with outside studies? The radiologists need to get their job done anyway for patient care. Well, that philosophy has become commonplace in the world of hospital savings.

In reality, the costs of not supporting a hospital’s information technology are enormous. It decreases efficiency for doctors, patient outcomes, and staff morale. And hospitals certainly do get complaints, albeit on the back end. So, what are the tangible results of having poor IT support, and why should hospitals treat this issue as mission-critical for the system. Let’s delve into the reasons why.

Radiology IT Support Allows For Quicker Turn Around Time

Turnaround time is one of those statistics that hospitals hang their hats on to show that they are efficient. And what is one of the most significant factors in a delayed turnaround time? Well, it’s the radiology study. The time it takes for the patient to have dictated images is widely dependent on having a constantly functioning PACS and dictation system. Patients will have to stick around longer without a functioning IT support system, a money-losing proposition.

Better Patient Treatment

Not having IT support may mean malfunctioning networks and servers for many reasons (decreased bandwidth, storage capacity, etc.). Often, this process results in loss of access to priors. And guess what? As I said in my previous rant on priors, this leads to poorer patient care because of decreased specificity and sensitivity. Or, it can even lead to disastrous outcomes if you can’t process studies like CTAs of the brain. And these are just some horrible outcomes of many!

Increases Morale (Waiting on The Phone)

Want to keep your doctors within the hospital system in a competitive market. Then be sure to support IT. Radiologists, physicians, and nurses are more apt to leave when they notice a constant breakdown of the electronic health records and PACS systems. These nagging factors are a continuous source of reported physician burnout (among others). We should be trying to maintain our physicians, not creating a revolving door!

Increasing Patient Satisfaction Scores

One of those other factors that hospitals love to tout is their patient satisfaction surveys. Hospitals regularly feature positive survey outcomes on billboards and commercials to show that they are competent institutions. Well, guess what? Those scores will not cut the mustard if patients have to stay in-house because no one can access the electronic records!

Saves Hospital Costs

The costs of malfunctioning electronic support systems are substantial. Imagine having to keep your patient for extra days in the department because a lack of support prevents patient discharge. Based on this issue alone, costs skyrocket to thousands of dollars per day for a hospital stay. And this doesn’t account for all the other expenses that a poorly served electronic health records and PACs system entail!

Radiology IT Support Is Not An Option That Hospitals Can Skip!

Although many hospitals would like to skip this “expensive” service to save money, you need the full-time support of a dedicated IT team for better patient care, decreasing hospital costs, and increasing the system’s efficiency. Although not evident on the front end, the downstream effects can be enormous. By not supporting IT, hospitals are merely shooting themselves in the foot. It’s not an option that hospitals can skip!

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Three Days May Be The Optimum Workweek For A Radiologist

optimum workweek

With the onset of Covid, between late March and April 2020, imaging volumes suddenly dried up for many radiologists. This change brought radiologists a taste of what life would be like if we had only to work three days a week. And, it was not so bad. Sure, radiologists did not bring home as much income. But, it was certainly nice to have multiple three and four-day weekends. It was sort of a sampling of the life of three days a week for radiologists. For many radiologists, this became a dream to continue to work with such a shortened optimum workweek. And these are the reasons why.

More Refreshed At Work By The Optimum Workweek

If you only have three days at work as an optimum workweek, you are more likely to have increased time to rest and relax on the days you are off. Therefore, radiologists felt less hurried and calmer on their workdays. We had more time for lunch and could even check the internet every once in a while. Not only that, we could savor every case. We could read about diseases and take the time to learn more with each Google search. This more lackadaisical attitude was refreshing for its time.

More Outdoor Exercise

As opposed to the pandemic, many radiologists became healthier because they had more time to walk and run outdoors. We spent more time out of our seats and less time staying in one position. My walks with my dog became longer. And, it was not just because spring had sprung.

Time For New Hobbies

During this time, many of us started to participate in new endeavors. Whether just to keep your hands busy, such as knitting, or to increase your daily output of exercise by running, many radiologists began exploring all sorts of activities they didn’t have time for. Some even lasted past the time of the pandemic.

Time To Go Back To Old Hobbies

Others began pursuing activities they could not before because of lack of time. I spent more time learning a couple of languages and learning guitar. With three days’ work, pursuing these hobbies could become more permanent.

Home Repairs

I am not a home repair guru. But, for many folks, all of a sudden, home projects that we delayed for lack of time no longer sat fallow. We repaired sinks, rooves, shelves, and more. When you have the time, it is much easier to complete do-it-yourself home projects.

Traveling On The Weekends With The Optimum Workweek

A three-day workweek, flanked by extra days on either weekend, leaves some time for weekly travel if you choose. Sure, it wasn’t easy to go abroad at that time. However, many of us opted for local jaunts to the country or local getaways. This experience was not so bad!

More Time With Family

With kids at home from school and radiologists spending more time at home, many families became closer and more tight-knit. We spent more time with our spouses, dogs, and kids. That’s what a three-day workweek could do!

A Three-Day Radiologist Optimum Workweek, Not So Bad!

Sure, working five days a week in the United States is standard. But, if you can afford the living standards, there are many advantages to working three days a week as a radiologist. Whether spending more time doing what you like or just feeling refreshed and excited about your next case, the three-day radiologist gig can work for you!

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The Magic Of Priors

magic

As I was scrolling through the worklist, I came across a case with priors that significantly changed the disposition of a patient, emphasizing the magic of priors. A chest CTA showed numerous pulmonary emboli sitting in multiple branches of the pulmonary arteries. At first glance, any radiologist would be ready to pick up the phone and call the ER to let them know about the pulmonary emboli. Of course, this patient would most likely need anti-coagulation and possibly thrombolysis. But then, at the very end of the list of prior studies, I noticed a previous chest CTA from 2017. To my surprise, the images looked the same. Those bilateral pulmonary emboli were most likely chronic! No new treatment would likely be necessary. If you want to talk about why priors are so important, this is an excellent example of why. It entirely changed the management of this patient. And it is the proverbial tip of the iceberg. So, if you ever get that feeling of laziness, here are some reasons it pays to take the time to press on and look at the patient’s prior studies.

Increases Sensitivity

No, it is not cheating to look at the prior report. Instead, it is excellent patient care. Some lesions, for instance, pancreatic lesions, can be very subtle. And, if you don’t look back at the prior report and the prior study, you are much more likely to miss it. You may neglect to recommend follow-up on this sort of lesion. And, in this case, you never know what can happen next. It can grow and need further treatment or not. Regardless, why not increase your chances of picking up significant findings?

Increases Specificity

Let’s give the example of that lowly nonspecific liver lesion that we always seem to find. The second time around, the diagnosis can become a lot more specific. If the lesion has been stable for the past ten years, it is highly likely to not be malignant. And, you have made of critical management decision of leaving the lesion alone. Otherwise, a whole workup can ensue, wasting health care dollars and causing potential psychological discomfort to the patient. These issues happen all the time, so don’t forget to compare to the priors.

The Magic Of Priors Changes Patient Treatment

I can’t tell you how often I get calls from oncologists that fail to give us the most recent priors, subsequently add them to our system, and then request an addendum. Why is that, you might ask? Well, most oncologists know the value of comparing to priors. How would you know whether to continue on a chemotherapeutic regimen or not? In an imaging study, learning if there is improvement, stability, or progression takes the guesswork of how to treat the patient next. And this is not to mention the potential life-saving acute issues I mentioned with the chronic PE case at the beginning!

Increases Referring Physician Confidence

Knowing that you have an eye on the previous study on all your reports allows your referrers to feel comfortable that you are safely and methodically correctly interpreting images. Of course, this step can lead to a virtuous circle. You get more patients referred because you increase clinician confidence and patient well-being. And, you earn a better living. It’s all good!

The Magic Of Priors

One of the big life lessons of practicing radiology for so many years is to avoid neglecting prior studies. I have seen one too many cases slip through the cracks, and I certainly don’t want the same to happen on my watch. And, I am sure that you probably don’t want that on yours. So remember why the magic of priors is so essential- increasing sensitivity and specificity, changing patient management, and increasing clinician confidence. And, you should make it part of your standard protocol never to forget to look at them too!

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Should You Pull The Trigger In This Housing Market?

housing market

Lately, I have been speaking to some younger radiologists about what to do in this housing market. Interest rates are climbing. With that, housing prices continue to rise, making homeownership even more expensive. Moreover, many folks want to start a family in a “big-enough” house to meet their needs. But, monthly payments are climbing higher and higher to pay off a 15 or 30-year mortgage. Is it worthwhile to wait, or should you jump right into the housing market? Let’s discuss some of the benefits and disadvantages of delaying vs. waiting so you can make the right decision for yourself.

Reasons Why Buying A Home May Not Make Sense In This Housing Market

You Are Not A Partner Or Tenured Attending Yet

This rule works. You never know for sure what will happen before you can claim the status of a shareholder or partner. I know countless stories of folks buying their houses only to discover that they did not receive their vaunted position. Some, then, feel the need to leave. And, with that, you will probably have to sell your house. Rarely, when this happens, do you make money on the transaction because of all the fees and taxes that you will pay with little or no equity. Even worse, if the market turns bad for sellers, you may not be able to sell your house. So, regardless of the interest or economy, it is usually not in your best interest before you know you will stay in the area.

Higher Payments And Not Enough Down Payment For This Housing Market

Getting a mortgage below three percent in the current mortgage market will no longer happen. So, you can expect your payments to be a lot higher than they would have been just a few months ago. This situation is especially true when you have not built up enough downpayment. So, if you don’t have the cash to make the new payments based on higher mortgage interest, don’t purchase the property. You will become “house poor.” And you will not be able to build wealth so quickly outside of your house.

You May Need To Move Again

Maybe you are thinking about changing jobs. Or, you are thinking about buying a house for your current family, but you are about to give birth to a set of twins. If you have a good chance that you will have to move soon after purchasing your house, it is better to delay the purchase until you know what you will need. Transaction costs and taxes for buying and selling real estate are prohibitively expensive. Moreover, these costs don’t even include the hassle of moving and purchasing a place twice. So, if you need to move soon, you are better off waiting until you know what you want!

Renting Can Be Cheaper Than Owning In This Housing Market

In some situations, renting can be a better and less expensive option than owning a place. In high cost of living areas, especially, buying a home can be unaffordable. Mortgage payments can dwarf what you would pay for a monthly rental. But, you need to do the math to see if it works out this way.

Reasons Why Buying A House Now May Not Be So Bad In This Housing Market

Just Because Interest Rates Are Rising Doesn’t Mean Housing Prices Will Fall

Sure, rising interest rates can affect the demand for housing. However, historically speaking, many periods of rising interest rates have not included a time of declining prices. And that is because housing prices are subject to many other factors such as availability, demand, employment in the neighborhood, and more. So, if you buy a house now, it does not necessarily mean you will lose your shirt even though you are paying more for the house and the mortgage interest.

Yes, Interest Rates May Go Down After Going Up- You Can Refinance!

Just because interest rates are high now does not mean that they will remain the same forever. Remember, buying a house is a long-term purchase, and you will likely own it through higher and lower interest rate environments. So, you may have the opportunity to decrease the interest you pay later. The longer you hold on to your house, the more likely that this situation will happen to you.

You Need A Place To Live- So Why Not Build Equity?

Perhaps, you have a family and need a decent-sized place to live now. Sure, you could find a rental now. However, if you have a stable situation, it may pay to build equity in a house. Of course, that assumes that you have saved up for an emergency fund, home down payment, and paid off a significant chunk of your loans. But why not build roots and own something if it makes sense?

You Are In A Stable Situation

Maybe you have become a partner or have loads of family around, and you know that you will be around for a very long time. The longer you stay in one place, the more likely you will ride out any downturns in the housing market. And the more likely that you will come out ahead when you finally decide to move.

Should You Pull The Trigger In This Housing Market?

Waiting to buy a house or purchasing a home is a personal decision based on many factors, some of which I have listed above. So, consider the amount you have saved, your job situation, your family, and the deal you will get when making this decision. Currently, buying a house is not a simple decision as interest rates and prices are relatively higher, but it can make sense!

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Let’s Go Back To The Fundamentals Of Radiology

fundamentals

Yes. I lived in a different world from residents today. We didn’t have all the electronic resources such as virtual flashcards, digital ebooks for almost everything, Radexams, Case stacks, Radprimer, question banks, and other online electronic resources. In addition, there were fewer texts for every topic than what we see today. And, we had only one general review text for the boards (Dahnert). But, as I remember, almost all radiology residents back in my day would read these topic-based physical textbooks to understand the fundamentals of radiology. We needed to read this material to grasp the essence of what we needed to know. Many of today’s residents no longer ascribe to this philosophy and jump right into other ancillary electronic material. 

Moreover, without reading the textbooks that I did when I started, I would never have had the fundamentals I have today to synthesize findings and differentials quickly. By skipping out on reading the fundamental texts, residents build knowledge layered upon a flimsy thin base. They can’t answer the why and how of what we do. And they are much less likely to pass the written board examination. This result is precisely what we ultimately find. So, let’s talk about why returning to reading primary physical textbooks is critical before jumping into all the electronic resources.

Active Learning With A Physical Textbook Is Better For The Fundamentals

Reading with a physical textbook rather than electronic reading material is more efficient. If you are not convinced, take a look at my former article, eBooks vs. Printed Radiology Books- A Death Match Part II. In this article, you will find evidence that using physical texts is better than electronic material for learning material. Holding a book in your hand, highlighting, and taking active notes on flashcards, is more efficient for remembering the material. So, although more portable, electronic resources may not give you the same bang for your buck.

Putting Your Money Where Your Mouth Is!

I know. Many of you have tons of debt from medical school. However, when you pay for something, you establish an unwritten commitment to it. So, when you buy your textbook, you are much more likely to feel like you have to use it, read it, and mark it up. Sharing ebooks with your colleagues is just not the same. Therefore, you should consider going back to the old-fashioned concept of owning your textbooks to increase your retention and maximize the possibility of passing the written boards.

Much Better To Have Conceptual Learning Than Learning Lists!

To this day, I can still remember where and when I learned certain concepts, such as features of extra-axial vs. intra-axial brain tumors (check out Osborn!) or patterns of arthritis (Arthritis In Black And White). When you go directly to the electronic references without reading these source textbooks, you are much more likely to see random lists without knowing the why behind the finding. And, you are much less likely to remember the key concepts that will help you make diagnoses later on. You know what they say – give a man a fish, and he will eat for a day. Teach a man to fish, and they will be able to eat for a lifetime! It’s true! So, make sure to learn the concepts from the text first!

More Difficulties With Complexities And Artifacts

It is much easier to figure out complex problems that don’t follow the rules if you know the basics. And, in radiology, very few cases are precisely what the literature describes. When you know the concepts behind the images, you can adjust your ideas to suit the case and allow you to make the appropriate differential diagnosis because you understand why it can fit what you are seeing. When you are reading electronic material distilled down to the bare bones, you lose out on this ability to make the diagnosis when it doesn’t necessarily follow the rules!

Getting Back To Fundamentals!

I am a purveyor of electronics. It is fun to play around with cell phones, computers, and gadgets. But, based on real-world experience with resident success, I implore residents from the first through third years to opt into reading primary textbooks to establish foundations in their knowledge base. Electronic media does play a role in learning. But, residents should consider delegating that role to the reinforcement of knowledge and not as a place to start. In the end, it is your choice. But, residents that read the introductory texts do better on the boards and make themselves better radiologists!

 

 

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Most Commonly Mistaken Orders From Clinicians

mistaken orders

Teaching radiology to students is not the priority at many medical and physician assistant schools. Eventually, these students become staff, faculty, and attendings. And, knowing how to avoid mistaken orders in radiology takes a little bit of savvy and education. Therefore, many folks do not know what to request, even though they are responsible for ordering the correct studies. And I’m sure many of you have noticed this issue, whether beginning on your path through radiology or as a more seasoned veteran.

To make this point, recently, a group of referrers wanted to me give them some tips about how they should order studies. In particular, they wanted to know when to request contrast and how to make sure their patients are getting the proper test. So, as I mulled over how to present this information to them, I realized this would create an excellent blog! So, let’s go through some of the most commonly mistaken orders that clinicians make when they order studies.

Most Commonly Mistaken Orders!

Chest CT

Hilar and Mediastinal Masses

How often do you see patients receiving non-contrast chest CT studies where the primary diagnosis is a hilar or mediastinal mass? I don’t know about you, but we come across these mistaken orders frequently, especially in cases where the patient has no contraindication to intravenous contrast. Why is this a mistake? Well, you need to be able to separate the mediastinal vessels from an adjacent mass of the same density to evaluate it!

Pulmonary Nodules

Likewise, for pulmonary nodules, typically, we don’t need contrast because the contrast between a soft tissue density nodule and the adjacent pulmonary parenchyma is spectacular, to begin with! With all its complications, intravenous contrast does not play a role in the situation of following a pulmonary nodule.

Ordering Chest CTAs vs. VQ Scans

Commonly, we see the mistaken orders for this situation all the time. First of all, a chest CTA is usually the best test when you are not sure about the diagnosis. For example, one of many possible diagnoses is pulmonary embolus. A chest CTA will allow you to figure out if pulmonary emboli are causing the symptoms and if one of a million other diagnoses are causing the same (pneumonia, pneumothorax, masses, etc.)

On the other hand, a VQ scan is best when the patient is significantly less likely to have an alternative diagnosis. Of course, VQ scans should also be the first-line test when patients have c0ntraindications to contrast for any one of many reasons.

Moreover, if the patient has a history of pulmonary embolus, diagnosed on any test, and you want to check for interval change, you should order the same test next time. It adds specificity to the diagnosis, whether the prior was a chest CTA or a VQ scan.

Abdominal Imaging

Mistaken Orders For Abscesses And CT Scans

We see patients who receive mistaken abdominal and pelvic CT scans orders that do not recommend intravenous or oral contrast for a suspected abscess. Why are these specifications critical for performing a workup for abscess? Well, bowel loops and abscesses can have the same density. So, you can quickly lose the forest for the trees and miss an abdominal abscess.

Additionally, we often see a workup with an order that only includes an abdomen or pelvis for an intra-abdominal abscess. It is an incomplete study if you only order an abdomen without the pelvis and a pelvis without the abdomen. Patients refer visceral pain to many places different from the site of symptoms! So, don’t limit yourself to only one if you are unsure.

When To Order Abdominal MRI

One of the biggest confusions I see is when to order an abdominal MRI vs. CT scan. In the case of any time when non-ionizing radiation can take the place of a CT scan with similar or better specificity, MRI is the preferred exam. Therefore, ordering an MRI for a possible hepatic hemangioma would make a lot of sense. Imaging pancreatic cysts is also usually the preferred method for the same reasons!

Don’t Order Ultrasound For Pancreatic Mass/Pancreatitis Screening!

Ultrasound is an inferior test for the evaluation of the pancreas. You can miss as much pathology as you can find because it sits in a location that bowel and body habitus can easily obscure. So, consider another test instead!

Extremities CT vs. MRI

Ligamentous/Cartilaginous Pathology

MRI of the extremities is a better option for almost all soft tissue pathology. CT does not resolve the nuanced difference in soft tissue because it relies upon different densities to pick out pathology. And, pathologies of the ligaments, cartilage, and muscles usually have the same density as the adjacent normal tissue. MRI allows you to differentiate the differences between these tissues based on water and fat content!

Bone Pathology

CT works much better for evaluating primary bone abnormalities such as fractures, bone tumors, and degenerative changes to help make an initial diagnosis. CT scan allows for a better evaluation of the calcific matrix. On the other hand, MR or CT may make sense in a follow-up study of a bone issue, depending on the situation. For instance, a follow-up of the extent of a known bone tumor or metastases can be more sensitive on an MRI. I would recommend calling the reading radiologist if there is any question!

Breast Imaging

Ordering Mammograms Vs. Breast Ultrasound

In general, for patients with a breast lump, clinicians should order a breast ultrasound when the patient is under 30 and a mammogram over 30. Why do we recommend this? Under the age of thirty, breast tissue is more sensitive to radiation. Additionally, the pathologies, such as cysts and fibroadenomas, tend to be more specific. Do an ultrasound before the mammogram in the older population. You can miss the entire picture and need to bring the patient back for a wasteful second ultrasound to figure out if there is pathology!

Ultrasound Breast Screening Versus Diagnostic Breast Ultrasound

I find this issue one of the most frustrating of them all. But, it is also confusing for the ordering clinician. We will often get a prescription for a patient with breast pain for a mammogram and ultrasound. A mammogram is often all you need for this symptom because breast pain is not a risk factor for detecting breast cancer. But, sometimes, the ordering doctor may want a screening ultrasound test or a focused diagnostic ultrasound, not both. A screening ultrasound involves all of both breasts. And a focused diagnostic ultrasound is only for the area of symptoms. Based on the order, we often cannot tell which one it is. So, the ordering doctor must tell us what they want. Otherwise, the patient may not get the correct exam!

Lumbar Spine MRI

Contrast Vs. No Contrast

Get this one right because it can waste time for the radiologist and the patient! For generalized back pain, MRI without contrast is sufficient. It can detect all sorts of disc and bone pathology. Intravenous contrast is not harmless and usually does not add any particular benefit in this situation. And, if there is something that needs further workup, we will rarely recommend an additional test with intravenous contrast. On the other hand, prior surgery is a common indication for intravenous contrast because it can be difficult to distinguish between post-surgical scarring and disc pathology.

Fluoroscopy Mistaken Orders

Upper GI series vs. esophageal vs. small bowel series

Clinicians should be as specific as they can with what they want to order. If they’re going to evaluate dysphagia, request an esophagram. Or if you a patient has reflux with abdominal pain and possible ulcer, order an upper GI series. Likewise, if the patient has anemia, order a small bowel series. Fluoroscopy exams are focused, and these examinations are not precisely the same, so they need to let us know what they want!

Mistaken Orders- A Radiology Conundrum!

As radiologists, we want to ensure that the patients receive the best exam possible for their condition. Doing the proper examination can improve patient health, prevent undue complications, and decrease the length of the disease course. And, many ordering clinicians do not have the training we have had. So, make sure that the tests that clinicians order are correct and make sense. We need to continue educating the folks who order these studies to improve the health care system for all!

 

 

 

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Am I Efficient Enough?

efficient

The ACGME requires all radiology residents to fill out a log of studies that they have reviewed in all radiology residencies throughout the country. Unfortunately, though, the onus is on the resident to assess for themselves if the numbers mean that they have learned enough to build their skills to the appropriate level. And, as most residency directors are aware, that number can significantly deviate among residents. Some residents fill out numbers that may reflect a glance at a study. Others give in the number of studies that they have dictated. These numbers can be high or low. Regardless, the gross number maybe not be so critical if you still cannot get through as many cases when you start in practice. In that case, how can you tell how efficient you are right now? And, where should you be at any stage of your training? Let me start by talking about rotation goals and objectives (because you might think that would help), and then I will give you a few guideposts that you may be able to use.

Can Goals And Objectives Tell You Where You Are?

Every program has written goals and objectives for each rotation that you should aim to complete before you finish it. As you scan through this list, you will probably notice a list of bullet points that you are supposed to do and know during any year. You can use it to figure out what information you have learned and where you need to focus. Nevertheless, I am the first to admit that it may not be all that helpful to determine efficiency. Additionally, the goals and objectives are often outdated. Or even worse, the residency program has copied it from other residency programs! So, the utility is equivocal for determining your efficiency.

Fundamental Ways To Tell You How Efficient You Are At Any Level During Residency

Clocking Speed To Become More Efficient

Clocking your reading speed can be an effective tool to determine how fast you are. But I bet many of you have never tried it. Take ten cases in any modality and read them like you usually would. And measure how fast you read them all. Then, compare with your peers. This technique can be a starting point to determine your actual speed. You may be surprised to learn that you are faster or slower than you initially thought!

Do You Have A Search Pattern That Is Second Nature?

If you are a long-time reader of my blogs, you have probably seen a pattern where I mention search patterns a lot. But, there is a reason for it. A search pattern is a primary tool that radiologists do to make the findings. So, think about your search patterns. Do you know them cold? Or, are always forgetting one or two parts of a film or CT scan each time you read. By the second year of your residency, the search pattern should become ingrained in your psyche. If not, think about reviewing them repeatedly until they become second nature.

Comfort Level Is Critical

If you dread reading certain studies or doing particular procedures, there is probably a good reason. Either you haven’t done the background reading for them. Or you have not participated in reading or doing them. So, assessing your comfort level in any rotation is an excellent way to determine if you are efficient at this point.

Can You Dictate Rapidly?

At this point in my career, when I have a dictaphone in hand, I will often go into a “holy chant.” It is a snappy banter that gets my point across in a relatively short amount of time. Most of you are probably not at this level because you have not read as many images. But, if you struggle to dictate a case at the end of your second year, there is a pretty good chance you are not all that efficient yet!

Am I Efficient Enough?

Anyone who poo-poos or ignores efficiency will have a problem when they get into practice. You will not be able to meet the hospital or imaging centers benchmarks. So, there is no better time than the present to measure how efficient you are.

Remember, you typically will want to avoid using goals and objectives as a primary resource. On the other hand, consider clocking speed, determining if your search patterns are second nature, and assessing your comfort levels and dictation speeds. Think about using these recommendations because efficiency is essential. Efficiency becomes more and more critical as you continue through residency and eventually on to your first job!