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The Alphabet Soup Of Residency Visas And The Radiology Alternate Pathway: A Guide For The Foreign Radiology Residency Applicant

Due to increasing governmental bureaucracy, static to slightly increasing numbers of residency slots, and increasing numbers of American medical student positions applying for residencies, it has become harder than ever to get a residency slot as a foreign medical student in the United States (1). That is not to say it is impossible to get one, but rather it is just significantly more difficult. Even though this is the case, since a large proportion of my readers are from foreign countries (approximately 1/3) and are interested in the mechanics of obtaining a radiology residency in the United States, I have decided to create a post about the world of visas and the radiology alternate pathway for ABR certification. Hopefully, this will be of some assistance to those of you with competitive applications and a burning desire to come to the United States for training. Also, I think it is informative and interesting for the United States residency applicant and radiology resident to understand what the additional requirements are for those that are applying from foreign countries.

In order to organize this post, I am dividing it into two sections. The first section will talk about the different types of visas with an emphasis on J-1 visas since this is the usual pathway that most foreign residents take to get a residency in this country.  I will also briefly mention J-2 visas and go through some relevant information about H-1B visas and green cards/permanent resident status. The second part of this post will talk about the alternate pathway specific to radiology and what requirements are needed to satisfy the ABR if you have some foreign radiology experience and are considering not going through a standard four-year residency. Finally, I would also like to give a special thanks to Debbie Paciga, our graduate medical education secretary, who was nice enough to take the time to share her vast knowledge on the topic of visas after many years of experience with numerous entering and graduating residents. Without her help, I could not have written this article!

Visas

J-1 Visas

A J-1 Visa is the most common type of Visa used by non-immigrant status foreigners for completing a residency program in the United States. Essentially, the J-1 Visa is an exchange visitor program for trainees from foreign countries. So, it is not expected that the J-1 Visa holder will become a permanent resident or citizen of the United States, but rather that the holder will be here for the limited time period of training.

Once the foreign graduate student has met the requirements of the ECFMG (Educational Commission For Foreign Medical Graduates), he/she can apply through the online system called The Physician Applicant System Access (OASIS) to obtain a J-1 Visa. However, the J-1 Visa requires a hospital sponsor in order to complete the application. The liaison between the teaching hospital and the ECFMG is called the Training Program Liaison (TPL) and this person accomplishes much of the work needed to obtain the J-1 sponsor. Typically, this person is a secretary or administrator whose responsibility it is to make sure that all the appropriate paperwork is submitted. This assigned person uses a system called The Training Program Liaison System Access (EVNet) on the EFCMG website to manage the application for the foreign graduate. Therefore, as a foreign graduate, you need to make sure that you are in constant contact with this person in order to complete all the necessary requirements for the J-1 Visa so that all the appropriate paperwork is submitted to this EVNet system.

So, what are some of the items that need to be submitted to obtain the J-1 Visa? You need to have a passport, a passport biography page, a curriculum vitae, a signed contract by the hospital and graduate student/resident with all the necessary information, the appropriate online filled-out forms (including the DS-2019 form- a form submitted by the sponsor), and of course all of the fees. Also, just as important, if you have a family that needs to travel to the country of the residency, you need to make sure that they have submitted a J-2 Visa which also needs to be approved by the sponsoring institution.

But alas, obtaining the J-1 Visa is not so simple as this… (It could never be that easy when it comes to anything that has to do with the State Department!) Each country has its own requirements for the applicant to be able to apply for a United States graduate education program. In fact, some countries have significantly limited the availability of these J-1 Visas. Each foreign applicant needs to obtain a statement of need from their home country embassy in order to be able to apply for the J-1 Visa. Some countries have severely curtailed the numbers of statements of need in order to prevent applicants from leaving their home country. The purpose of limiting the numbers at these particular countries is usually due to a lack of expertise or increased numbers of physicians needed in the applicant’s home country. These countries do not want applicants to leave their home country and emigrate to the United States but rather want them to train and practice medicine in their home country overseas. Currently, some countries that limit the numbers of applicants the most to obtain a medical residency training J-1 Visa include South Korea, Sweden, and Canada. Then, there are countries such as India and Pakistan that tend to issue as many statements of need as warranted. Of course, this is a moving target and can change from year to year depending on a country’s needs.

Other Miscellaneous Requirements And Issues For The J-1 Visa Holder

Once the J-1 Visa is obtained, there are numerous other requirements that the J-1 Visa holder needs to be aware of. For instance, the J-1 Visa holder cannot arrive into the country more than 30 days prior to beginning their residency. Sometimes, this can be a difficult issue since there is such a rush to get everything the applicant needs ready prior to beginning residency (housing, etc.).

Other recurrent issues include updating the J-1 Visa on a yearly basis with a new signed contract, obtaining recurrent statements of need from the home country of origin (sometimes the statements of need are time limited for less than the time of the residency program), and making sure to bring all the necessary documents when entering and leaving the country (up-to-date passports, diplomas, and so on…)

Applicants also need to beware of the legal system within the United States. The state department tracks illegal activities for residents with J-1 Visas on a yearly basis. Any conflict with the law can be a potential reason for the applicant to be sent back to his/her home country.

Finally, it is important to recognize that a research J-1 Visa is not the same as a J-1 Visa for a clinical residency. So, if you are a foreign national applying for a residency program, you need to obtain an entirely new J-1 Visa in order to start the program. (Whew, that’s a lot of stuff to remember!!!)

H-1B Visas

So, what exactly is a H-1B Visa and how does it work for the residency applicant? An H1-B Visa implies that you are going to be working in a specialty field/occupation that has a need for a foreign worker that cannot be met by a United States resident. The H1-B visa holder is permitted to stay in the country indefinitely, different from the J-1 Visa holder.

Typically, the hospital needs to sponsor an H-1B Visa for an applicant in order to get the foreign graduate into one of its residency programs. In addition, the number of H-1B Visas is capped each year, making it more difficult to obtain one. It often costs the sponsoring hospital thousands of dollars to work on an H1-B Visa due to the necessary legal and processing fees. So, for these reasons, an H1-B Visa is an uncommon route for the foreign radiology resident applicant. At our institution, it has been only used for exceptional circumstances. One example would be an applicant that is already in a program in the institution but cannot get a J-1 Visa because this person has a D.O. degree and is from Canada. (Apparently a D.O degree does not qualify for the J-1 Visa pathway). Since it is a rarely used method for foreign applicants to obtain a radiology residency, I am going to limit discussion on this topic

Green Card/Permanent Resident Status

Finally, the goal of some foreign resident applicants is to declare permanent residency within the United States in order to remain within the country with a full time radiologist position and with the possibility of eventually becoming a citizen. The United States lists several mechanisms of obtaining a Green Card including via job offers, investing in enterprises, and self-petition (typically an individual of extraordinary ability). Many applicants will often get their green card once they have graduated from a residency program and have been accepted for a permanent radiologist position in the United States. At that point, the employer is required to file a petition for the employee so that he/she can undergo the application process and the applicant needs fill out the appropriate paperwork. Usually, this process occurs only after the J-1 Visa is no longer active.

One other pathway to obtaining green card status includes finding a position in an underserved area for a period of time, usually 5 years. This applies to not only primary care physicians, but also specialists as well. But again, it is usually completed after the radiology residency has ended.

The Radiology Alternate Pathway

In a past response to a question from a potential foreign applicant in the “Ask The Residency Director” section of this site about the alternate pathway, I briefly went over some of the requirements for the foreign radiology applicant to obtain ABR certification. The question asked about applying outside the typical route of a four-year qualified ACGME radiology residency based upon the applicant’s previous radiology experiences. This process is called the Radiology Alternate Pathway. According to the ABR policy, the applicant can satisfy the requirements only at institutions with an ACGME-accredited radiology residency-training program. The applicant needs to have 4 years of continuous work in the capacity of a “resident, ACGME accredited fellowship, non-ACGME accredited fellowship, or faculty member”.  In addition, the candidate must also have “4 months of clinical nuclear medicine training.” The nuclear medicine training needs to be dedicated although the applicant can get the training at an affiliated institution if that is available.

The challenge for the foreign radiology applicant is to find a program that is willing to recognize previous foreign training and accept him/her for a slot in one or more of these programs over a four-year period. Many programs are not willing to make an obligation of four years of employment in a mixture of residency, fellowship, or faculty positions and will require the applicant to go down the standard pathway of radiology residency. That is not to say it is impossible. But rather, it is not common and represents the exception rather than the rule.

Final Thoughts

Applying to radiology residency and performing well in a radiology residency program as a United States citizen without having to contend with the issues that arise from migrating to a new country can be challenging by itself. I can only imagine the additional difficulties that foreign applicants face applying to and attending radiology programs within the United States. There are certainly numerous hurdles and hoops for these applicants. But for those with the desire, ability, and grit/determination, it is still certainly possible to go through the process of getting a visa and obtaining a qualified residency spot or spot in an alternate pathway program. If this is your life’s desire, don’t let these hardships dissuade you!!!

Helpful Websites For The Foreign Medical Graduate

ABR Alternate Pathway Information- https://www.theabr.org/sites/all/themes/abr-media/pdf/PWIMG_DRandSubCert.pdf

ECFMG –   http://www.ecfmg.org/evsp/application-online.html

Governmental Green Card Website Information-  https://www.uscis.gov/greencard

Governmental J-1 Visa Website Information-  https://j1visa.state.gov/basics/common-questions/

Governmental J-2 Visa Website Information- https://j1visa.state.gov/basics/j2-visa/

Governmental H-1B Website Information-  https://www.uscis.gov/eir/visa-guide/h-1b-specialty-occupation/understanding-h-1b-requirements

 

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Malpractice Insurance: What Physicians Need To Know

If you are just starting practice as an employee with a physician group, you may think you don’t really need to know that much about malpractice insurance. Few physicians have the resources available to defend against a malpractice claim when legal services can cost tens of thousands of dollars and damages or settlements can be hundreds of thousands of dollars. When deciding on a malpractice insurance policy, there are two types to take into consideration: a claims-made policy or an occurrence-based policy.

An occurrence-based policy provides insurance against incidents that occurred during the term of the policy regardless of when the claim is made. A claims-made policy covers the insured for any incidents that occur during the policy period, as long as the claim for the incident is also filed during the policy term. Neither of the policies will provide coverage for incidents that occur before the inception date of the policy.

Tail insurance refers to a policy that the insured can purchase when he discontinues his claims-made policy. The tail allows the insured to report claims for incidents that occurred during the time the policy was active (from the retroactive date to the policy expiration date) even though the policy has been terminated. Tail insurance is generally a onetime payment.. If a physician decides to change employment, wants to continue practicing medicine, and requires a new malpractice policy, tail insurance will be required to continue coverage for all incidents that may have occurred under the old policy. Many claims-made policies offer “free” tail coverage for death, disability, or permanent retirement.

Based on this information alone, it would seem logical that an occurrence-based policy is the best option. However, the two types of policies vary greatly. Depending on how mature a policy is, and the specifics of the policy, the sum of all claims-made premiums along with the cost of tail insurance can approach the sum of all occurrence-based premiums over the same period. If it can be determined that a physician will be eligible for free tail coverage (i.e., he is covered by the same policy through retirement), claims-made insurance is usually the most cost effective. If a physician knows there is a high likelihood of changing employment and malpractice insurance, he may want to compare pricing of the two options including the cost of the tail coverage in his calculations. For example, a physician may want to consider an occurrence-based policy if he knows he is going to work at a location for a short amount of time and will not be able to take the coverage with him.

What To Look For In A Carrier:

While premium costs can’t be ignored, a company’s fiscal soundness, claims handling, and sensitivity to policy holders are also important considerations. Ask about the carrier’s A.M. Best rating. Given the current state of the medical malpractice climate, a rating of A minus is good. Your state insurance commissioner’s office can provide information about insurers licensed in your state and may also be permitted to give information about complaints that have been filed against the insurer.

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What Clinicians Don’t Want From A Radiologist- The 8 Deadly Sins

clinicians

A few months ago, one of my readers sent me the following message, “I would like you to write about what clinicians want from a radiologist.” That comment initiated some thoughts about the topic since our primary goal, as radiologists, is to answer the clinician’s questions. But let’s take this idea from a different angle. At some point in our careers, we all have made cardinal mistakes that turn off our referring clinicians. What is more interesting than the mistakes that most of us have made in our career to teach us lessons about how we can avoid angering our referring physicians and make things right for them? So, let’s talk about what clinicians don’t want from a radiologist! (The negative tends to be more interesting than the positive!) Let’s give this a whirl…

The Forced Hand

In training and board examinations, our instructors tell us to write recommendations for further management. So, how bad could it be to recommend a biopsy for a thyroid nodule when you see a new one? An angry head and neck surgeon stomps up to the department and looks for you. He yells loudly, “Why are you telling me what to do with my patient. He should not be getting a biopsy in this condition!!!” Bzzzzzzzz… (Buzzer sound)

Pretty darn bad! When you write a recommendation, you have to remember that you often don’t have the full picture of the patient’s situation. In other words, there is an asymmetry of information between the clinician, the radiologist, and the patient. Maybe, the patient can’t lie flat. Perhaps, the patient can’t handle needles. Possibly, the clinician knows about an outside study that you don’t. Or, the clinician is privy to some other issue that you cannot imagine. By recommending a biopsy of a thyroid nodule without a caveat, for instance, you are legally forcing the clinician into having to investigate it further. In contrast, it may not be the correct management protocol for the patient. I have learned to be very gentle with my management recommendations over the years!!! Always leave the clinician a way out…

Indecisiveness

We write a list of 10 items in our differential diagnosis without additional comment- like a laundry list to give a “complete differential.” Days later, you get a phone call from the clinician- “I don’t understand what you are saying- what do you think is going on here?”

How can we avoid this scenario? If you have an extensive differential diagnosis, always state what you think is most likely and why. Avoid delving too far into the 1 in a million diagnosis unless you have a real sneaking suspicion it might be the correct one. Clinicians appreciate when you make your best guess since it often will steer the doctor down the right path. Too much information without direction can be harmful!

The Saucy Radiology Report

You are angry that the referring physician did an inappropriate workup on a patient performing iodine scan as the first test in a workup for a palpable thyroid nodule. In contrast, you know that it should be a thyroid ultrasound instead, so you put in your report the following statement, Make sure to order the ultrasound instead of a thyroid scan in patients with a palpable lump. The doctor comes storming in, “How dare you to talk to me like this in your report. It is a legal document!”

If you have an issue with a clinician, make sure to air your dirty laundry outside of the report. The clinician is correct. You are putting the physician in a potential situation with legal liability. This sort of comment does not belong anywhere inside the report.

The Discrepant Report

You dictate a case from the night before when the overnight resident was on call. In the morning, you find a pulmonary embolus, but you do not look at the additional documentation from the resident or the nighthawk. You do not call the doctors to let them know. Later in the day, the ER doctor walks up to the emergency department and says, “What the hell is going on here?” It turns out the overnight doctors did not call the study positive and sent the patient home. You didn’t notify the doctor!

Discrepant reports between you and other physicians can cause negligent patient care. Be sure to check all the information to make sure that all parties are on the same page. Discrepancies will occur. But make sure to notify all parties!!!

Is It Better, Worse, Or Unchanged?

You are following a patient with breast cancer on a CT scan, and you proudly discover and then mention a subtle liver lesion in your report. Next, you refer to the prior study, but don’t look at it. You also do not document the size of the lesions, nor compare the size of the abnormalities to the previous study. Two days later, you get a phone call from the oncologist, “What is going with my patient? I need to know if I have to change chemotherapy. Are the hepatic masses changed?”

Clinicians always want to know if their patient is improving, unchanged, or progressively worsening. These imaging issues often change clinical management and are of the utmost importance to the clinician. Always make sure to put these findings under the impression of your report!!!

Incomprehensibility

You look at a pelvic MRI on a patient with fibroids. The fibroids seem to be growing over time. However, you don’t check the report and click the sign off button. Before you know it, the dictation goes out to the clinician. Three days later you get a phone call from the doctor, “It says here in the body of the report that there is interval enlargement and in the impression, there is no interval enlargement of the fibroids. Which one is correct?”

Make sure to check for grammatical and logical statements within a completed dictation before signing it off. Very few things piss off a clinician more than having them read an incomprehensible report. An unclear story leads the clinicians down this pathway. Always check your work!!!

The Wrong Diagnosis

You are looking at a hand x-ray with a type of arthritis that you have not seen before. Finally, you decide to dictate the case without confirming the diagnosis via Google or running it by another clinician. You call it osteoarthritis. The patient gets treated based on your report. One year later, the patient is still not getting better, and the doctor sends a new film to another one of your colleagues. He comes up to you later in the day and states, “you dictated a case and called it osteoarthritis. It was a definite case of gout!!!”

If you are not sure about a diagnosis, always make sure to either look it up or run it by someone else. We are in the business of healing others. You should never have too much pride to make guesses when you can get the correct answer!!!

Not Answering The Clinical Question

You dictate a plain film of the chest, and you happen to see a lytic lesion in the middle of the thoracic spine and a pulmonary nodule in the right lower lobe. So, you put in your impression- MRI of the thoracic spine recommended for further characterization. 8 mm right lower lobe pulmonary nodule. A few days later, you get a phone call from the physician- “We already know about the bony lesion, and it is a known hemangioma as seen in previous studies. The history said to compare the lung nodule with the prior study. Please take a look at that!”

It is imperative to scour the history for whatever clinical question the clinician wants you to answer. This way, you can provide a helpful answer to improve patient care. That is the main reason we are here as radiologists!

The Eight Deadly Sins- Lessons Learned

As clinicians, we always need to self-reflect to improve our practice of medicine. There is no room for too much pride. We should continuously look for ways to improve our clinical skills, reports, and communications with our colleagues. I have just given you eight different examples of issues that can arise if you want to cut corners. You can easily avoid further carnage with your reputation, your patients, and your colleagues by remembering these situations. Use these examples as a template to prevent the eight deadly sins of a radiologist!

 

 

 

 

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Teleradiology, A Risky Business?

It took years and years of hard work and dedication, long hours and sleepless nights, and the time has finally come.  You’ve got your home office set up, a couple of high resolution monitors, a few licenses and insurance in place.  You’re ready to take that leap of faith and get started in the world of teleradiology, right?

After all, entering the world of teleradiology seems like the dream choice for many radiologists.  Whether you’re working in a small practice by day, hospital at night, or trying to balance work and family, teleradiology can be the ideal choice for your primary income or to supplement your income.

Not so fast.  It’s 2017.  Just two decades ago, healthcare providers didn’t face significant penalties for improperly disclosing protected health information (PHI).  Since then, regulations surrounding the privacy and security of PHI have evolved to include strict requirements and corresponding steep financial penalties for non-compliance.

Where does this leave you? Is it far too risky to give it a try?

With security protocols and policies such as Information Security Risk Analysis, Information Security Risk Management Program, Information Security Audit Controls, System Activity Review Policy, Security Incident Response Policy, Data Backup and Storage Policy, Data Disposal Policy, Media Re-Use Policy, Workstation Policy, and Electronic PHI Movement Policy, is it best to stay out of the game?  You will also have to think about privacy policies such as PHI Uses and Disclosures, Patient Access, Accounting of Disclosures, Sanctions Policy, and Breach Policies and Procedures.  Don’t forget about the Regulations imposed by both federal and state authorities – there’s HIPAA, the Privacy Rule, Security Rule, HITRUST, The Omnibus Rule, Unique Identifiers Rule and the Enforcement Rule just to name a few.

Still ready?  Still have that home office, those high resolution monitors, various licenses and insurance in place?  Great!  Let’s do it!

But how?

My suggestion is, find a teleradiology company that has built a strong Data Security and Compliance Department.  A teleradiology company that has taken the necessary measures to secure Protected Health Information. One that is sought after by the larger urgent care centers, hospitals, and government entities because they have put these measures in place.  Urgent Care acquisitions are at an all time high.  These larger healthcare organizations are driving the teleradiology industry to be more security conscious.  If you want to be successful in this industry you will choose a teleradiology provider that is able to meet the expectations of these larger healthcare organizations.

This will be the teleradiology company that grows, and that contracts with the largest clients.

This will be the teleradiology company that safely and securely helps you realize the dream of becoming a teleradiologist.

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Which Radiology Meeting Should I Attend?

radiology meeting

Residents need to make a big decision. At some programs, each resident can attend one academic conference during the four years of residency without presenting a poster or paper, all expenses paid. It may be toward the end of your tenure as a resident, and time runs out to take advantage of the situation. You can “go big” and attend the largest radiology meeting out there- RSNA. On the other hand, you may want to “go small” and consider a subspecialty meeting to delve into your area of interest. Or, perhaps you want to check out the academic conference and hobnob with the faculty at the most critical educational meeting- the AUR. How do you make this difficult choice? Well, if you are in this enviable situation and need to make a decision, this article is for you!!!

“Going Big”- The RSNA

Plan Ahead

RSNA is the radiology meeting that most radiology residents decide to attend. It is a meeting that has “something for everyone,” literally. Traditionally, the RSNA is the largest of all radiology meetings and covers every subspecialty within radiology. But this also presents a problem: how do you decide what to attend when you are there? Because of the vast conference size, I would recommend following a road map before arriving. Know what meetings, poster presentations, or other areas of interest you will attend before arriving. Suppose you do not outline a plan before arriving. In that case, you will likely miss half of the more relevant, informative, and exciting presentations since the conference is so enormous. The different activities can be far, far away from one another.

Lots Of Activity

In addition, if you are in the process of studying for the core examination and the timing is right to attend a conference, this may be the conference for you. There are usually loads of activities for residents, including review courses that may be helpful for the resident scheduled to take his/her boards. It is possibly even more important than the review course itself. You will also network with other residents in a similar situation, allowing you to learn the best resources to study for examinations and learn about other programs throughout the country. In many practices, at least one attending from your group will be present at this conference. Mingling with the faculty also allows the resident to take advantage of the possibilities of dinners or other engagements scheduled with vendors.

The one significant disadvantage of a conference like this one: it tends to be a bit more impersonal than some of the available smaller meetings. Impersonal may not be an issue for a radiology resident, depending on your fellow attendees and how you schedule your days.

“going small”- The Subspecialty Conference

My preference is this sort of conference. I usually attend the Society of Nuclear Medicine Conference every other year, an example of a particular subspecialty conference. I find that this conference is the best for learning the intimate details of a specific subspecialty. The newest information in subspecialties tends to get presented for the first time in these sorts of conferences.

If a particular subspecialty interests you and you want to choose a fellowship in the conference subject matter, you can utilize these subspecialty meetings to network with the physicians in the subspecialty. These conferences offer this possibility because they are smaller and give more of a “feeling of camaraderie.” Why? Conference members tend to be more involved in specific subspecialty activities with fewer numbers.

AUR Meeting- The Academic Radiology Conference

Every year in our program, the program has funded and allowed the chief resident to participate in this conference. It is a wonderful conference to find out the state of academic radiology throughout the country from a resident perspective as they have specific programs available for the chief residents. As a program director, I also tend to go to this conference once per year to keep up with the changes in radiology academics every year. (although I have not made it the past few because of Covid!)

In addition to the potential relevancy, the conference is not that large. It is hard to get lost at this meeting like you can at the RSNA. You can quickly get to know the players in the academic world. I would highly recommend this conference if you are interested in academics or are the chief resident in your residency program. Residents attending this conference obtain an invaluable source of information about all residency programs throughout the United States that they can share with their resident colleagues when they return.

The “Pure” Board Review/CME Conference

Lastly, there is the board review or CME conference. Usually, these conferences are for board review or a specific topic/selection of topics. In our residency program, many residents attend local board review courses before taking the core exam. It is a good resource as a means to review the information learned from studying.

Other sorts of CME conferences are also widely available throughout the United States and abroad. Typically, the attendees of these conferences are more likely to be fully trained radiologists. And, they want to learn more about a particular area or may want to travel to a specific destination. (I recently went to a conference at Disney World like this to learn about digital breast tomography!) In general, radiology residency daily conferences usually cover similar material. So, the yield of this conference for a radiology resident may be slightly lower. From my experience, most trainees that attend these conferences are at the institution responsible for the meeting.

Best Radiology Meeting To Attend During Residency

Like almost everything else in this world, one size does not fit all when deciding to attend a conference. RSNA is an excellent introduction to the world of conferences as it is the largest and the most general. Subspecialty conferences are great for networking, especially if a particular subspecialty or fellowship interests you. The AUR meeting is an excellent option for academic sorts and chief residents. And finally, board reviews/CME conferences are a great tool to review studies for the boards/core examination. Many decisions to make and so little time… Hopefully, this article will give another perspective on making this big decision!

 

 

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Has Technology Ruined Your Chance Of Employment In Radiology?

Has Technology Ruined Your Chances of Employment in Radiology?

Among the many benefits of living in the Computer Age are the rapid technological advancements that continue to bring convenience and joy to our daily lives. From handheld devices with 24/7 internet access to cars that drive themselves, the future many hoped for (and dreamed of) is happening right now. But while the positive aspects of new technologies mostly outweigh the negatives, disruptive change naturally creates both winners and losers, particularly on the employment front. The medical field is not immune to this phenomenon.

In the recent past, victims of technological encroachment tended to be lower skilled workers whose roles could be easily automated. Today however, potential job automation targets include professionals in high-skill fields ranging from law to engineering to medicine. In short, automation is now “blind to the color of your collar”, according to Jerry Kaplan, author of “Humans Need Not Apply”, (https://www.amazon.com/Humans-Need-Not-Apply-Intelligence/dp/0300213557) a sobering book that sheds light on the uncertain future facing modern workforces.

All of this is a roundabout way of asking a very uncomfortable question: Are robots coming for your radiology job?

The short answer is no…but don’t let your guard down. Here’s why.

Today the poster child of artificial intelligence (AI), IBM’s “Watson”, can already find clots in pulmonary arteries. And unlike a busy radiologist who might read 20,000 or so studies per year, Watson is on target to review 30 billion medical images (http://www.medscape.com/viewarticle/863127) It goes without saying that Watson’s only going to get better.

What’s more, a number of Silicon Valley startups are currently applying new technologies to automate and improve the delivery of medicine. One firm in particular, Enlitic, is even developing a deep-learning system that uses AI to analyze X-ray and CT scans. According to an article in the Economist, (http://www.economist.com/news/special-report/21700758-will-smarter-machines-cause-mass-unemployment-automation-and-anxiety) Enlitic’s system has performed 50% better in tests than a group of three expert radiologists at classifying malignant tumors. When used to examine X-rays, their deep-learning system also significantly outperformed human experts. Of course, this emerging technology leaves much to be desired in the bedside manner department, but that’s what robot doctors (http://www.techtimes.com/articles/131870/20160209/will-robots-in-healthcare-make-doctors-obsolete.htm) are for.

Now before you go and trade your radiology degree for a barista outfit, consider the fact that according to most experts, including the CEO of Elitic himself (Igor Barani, MD, a radiation oncologist), artificial intelligence and radiologists aren’t diametrically opposed. In fact, they’re largely symbiotic. By design, AI will increasingly free radiologists from mundane tasks that can be automated, like reviewing CT scans for lung nodules. As Barani puts it, “tasks that can be automated should be given to the machine—not as surrender but secession.” This outlook portends a future in which radiologists are increasingly empowered to deliver better patient care, not supplanted by robotic overlords.

Regardless of what technology naysayers say, there will always be radiology careers for talented individuals (http://scpmgphysiciancareers.com/) to pursue. That being said, the role of radiologists will almost certainly narrow in the coming years and decades to one of inference, not detection — and that’s an important takeaway. With little doubt, the medical field will require fewer radiologists per capita because of deep learning technologies that simply do a better job of identifying anomalies. The successful radiologists of tomorrow will be the ones who can reduce AI-generated data into useful information that helps patients get better, faster. That’s not a future to be scared of; it’s one all current and prospective radiologists should eagerly anticipate.

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How To Prepare For Interdisciplinary Conferences As A Radiology Resident

prepare for interdisciplinary conferences

You get the email… There is a urology interdisciplinary conference on Tuesday at 7 AM, and you are responsible for showing 4 cases with multiple radiological studies. You’ve never done this before! How do you know which images to display to prepare for interdisciplinary conferences? Is there a logical order to the pictures? Will I be able to answer the questions posed by the clinicians in the room? Your heart beats a bit faster as you contemplate the issues.

This situation is common for the beginning radiology resident. Frequently, radiology programs thrust first-year radiology residents into their first interdisciplinary conference without much preparation. However, even though initially nerve-racking as an experience, these conferences are an excellent opportunity to get to know your non-radiological colleagues as well as a way for them to find out about how knowledgeable you are! Learning how to prepare for interdisciplinary conferences pays off big time!

Presenting for interdisciplinary conferences is slightly different from preparing for typical conferences. Your audience will be a bit more sensitive to mistakes that the presenter makes because decisions can often directly affect patient care. Therefore, today I will discuss some of the common questions that arise when you encounter your first interdisciplinary conference to make you feel more comfortable. These topics include how to sort through what is essential, what to discuss, and when to ask for additional help to prepare for your first solo interdisciplinary conference as a radiology resident. So let’s get started…

Selecting Cases To Prepare For Interdisciplinary Conferences

When going through a case, clinicians like to have the relevant initial diagnostic images and the subsequent follow-up images. So, it is imperative to get the correct history for the primary diagnosis. When you check the computerized records, make sure to find all studies that support the principal diagnosis. Then, you will need to look for the earliest studies of this sort. If the diagnosis is breast cancer, find the first mammogram and breast MRI present on the record. If the topic is metastatic colon cancer, look for the first CT scan showing the metastatic disease.

Next, you need to find the first post-treatment studies. So, find the next series of relevant images. If the topic is a retroperitoneal bleed, see the first series of post-intervention cases, such as the post embolization ct scan. These will usually be the second from the beginning.

And, then finally, look for the most recent relevant studies. If this was a case of metastatic colon cancer, find the most recent CT scan of the abdomen and pelvis to show the final consequences of treatment or lack of treatment.

Selecting Individual Images

There are two ways to show images during a presentation for interdisciplinary conferences. First of all, you can go to the source images in the PACs system and flip through the pictures directly. Or, you can select individual images and display them on a PowerPoint presentation. I would recommend doing the latter. Why? , You leave less interpretation by the audience, and you will get a lot fewer questions regarding things that you are not sure about during the presentation.

Additionally, the clinician will less likely ask about information and findings that are irrelevant. For instance, you are less likely to get a question about that borderline enlarged node on the corner of the film that was not mentioned but is present on the PACs display. By choosing the PowerPoint format, you have much more control over what is displayed, and it keeps the discussion centered on the essential topics.

Also, there is less chance for technical issues. PACs tend to go down when you most need it since it relies on an internet connection. A PowerPoint presentation is much more reliable since you do not have to rely upon the internet.

Also, when choosing individual images, make sure to look for the relevant information without the fluff. For instance, if it is a metastatic colon cancer patient, take those pictures only of the liver metastasis without the volume averaging artifact. If the case is a retroperitoneal bleed, show only those images containing the bleed without other distracting findings on the film. And so on…

Discussions

When it is your turn to discuss a case, keep the discussion targeted. You want only to start discussing those issues that are relevant to the clinician’s question. If they need to know if the metastatic colon cancer lesion is better, worse, or unchanged, provide the clinician the relevant information such as the measurements. If they want a differential diagnosis, offer it. But do not go off on a tangential vector! If you go off-topic, clinicians tend to get angry because of the limited time you will have during the morning to discuss patient care and other cases. So, please don’t do it!

Also, try to look up relevant information on the topic during your preparations before participating in the conference. If you want to look like a star, gain additional knowledge on the relevant issues so that you can answer those questions intelligently and with authority. Then, you will establish an excellent reputation for yourself during the conference. Imagine how you will sound describing the features of colon cancer metastasis if asked rather than muddling through and stuttering.

When To Ask For Help?

So, you’ve gathered your studies and selected your images. When is appropriate to ask your attending for some assistance? Here are some specific circumstances: You have never rotated through a particular modality, and you are presenting those images during that case. You are not sure that the report description is the same as the information on the images. You do not understand the disease entity issues they will discuss at the conference.

I always like to know about any questions the resident may have before completing preparations for a conference. Better to be safe than sorry!!!

How To Prepare For Interdisciplinary Conferences!

Preparing for your first interdisciplinary conference can be stressful, especially if you do not have much essential guidance. Hopefully, this summary will allow you to make more sense of the necessary preparations involved. Good luck with your next conference!

 

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Technological Essentials For The Radiology Resident

Technological Essentials For The Radiology Resident
By Daniel Choe

 

In an era of exponential technological growth, it is essential that trainees use the latest technology to improve their educational experience. Demands increase every year for the trainee to remain up to date. Moreover, the resident needs to access information seamlessly. So, let’s talk about a few technological essentials that enhance the graduate training experience for the radiology resident. Different from many articles out there, I have no direct financial disclosures about the products I mention in this article.

 

Smart Phone/Tablet

 

It seems like a no-brainer to have a smartphone/Ipad. However, believe it or not, I once had a colleague who started residency with a blackberry!

Regardless, the Ipad or tablet may serve as a surrogate or mobile substitute for a laptop/notebook. However, it has limited storage and computational power. While upgrading them is easy due to its backup/sync features, it often lacks in ease of use for programs that require hardcore graphics rendition or multi-program use. It is ideal for mobile use of editing online documents, viewing online lectures, storing a limited number of pdf files, and running apps for question banks. Several anatomy learning apps are available and extremely useful for a fee. There is a separate section on apps later on.

 

Cloud Services

 

Most users already have cloud services. In fact, that is often the problem – there seem to be too many online storage services. Google, Amazon, Dropbox, OneDrive to name a few. An elegant solution that helps consolidate all of the different clouds you may use is a service such as odrive. It is free, encrypted, and allows you to automatically sync when you copy files to the odrive folder on your computer. The caveat is that to use the sync feature, you must have enough space on your hard drive.

My suggestion is to invest in a cloud service that offers unlimited space and only the folders that you open most frequently. Obtaining a cloud service is essential for the resident who is continually doing research and keeping tabs on what lectures and videos he watches. Alternatively, if you use a pdf reader, it can keep track of which page you were on in one of the many textbooks you will inevitably read.

 

Computer

 

Regardless of whichever camp you fall into, Mac or PC, your home computer or laptop/notebook should be the workhorse for your education and work. I could write an entirely separate article on this topic. Nevertheless, for the sake of simplicity, a home desktop is not essential, but rather a plus. Because cloud services work seamlessly and storage space is a problem of the past, your desktop is a great way to consolidate your work and use programs that require slightly higher computing power and graphics rendition. For example, I use a remote desktop to do a majority of my preparation for tumor board research, presentations, research projects. Moreover, I have my computer permanently connected to my flat screen TV as a secondary monitor so I can multitask.

Also, I can watch lectures on my TV. Watching them on TV affords greater detail and helps when trying to take cases.

Finally, I recommend swapping out your primary hard drive for a solid state drive (SSD). As well, add a secondary storage drive. They are becoming more affordable these days. Keep in mind, much of the work can be accomplished with a laptop, MacBook, or even tablet/PC as well, at the cost of overall computational power and storage.

 

Universal Password Program

 

I use a password and personal information storage program. Using these tools cuts out approximately 50 hours a year in retyping and resetting passwords. For convenience, I have over 200 passwords stored. Moreover, I can routinely change and generate new complex passwords to maintain security. Password programs also allow you to store credit card information and secured notes for passwords and sensitive information. There are many services out there. I would select the one that suits your needs. It is definitely worth the money.

 

Remote Access

 

Most institutions provide remote access for its residents. If not, it behooves you to suggest that the residents have access to remote PACS and EMR. Remote access is critical not only for learning purposes but effective workflow in preparation for interdisciplinary rounds. Your time is better spent working or studying than having to schlep to the department or stay late (unless you are actively trying to avoid home for a particular reason).

 

Shared Network Storage

 

My institution did not initially provide shared in-network storage. However, since its inception, we have been able to provide essential resources for all residents and staff. More importantly, it serves as the institutional memory for a growing and developing residency program by eliminating the possibility of losing critical learning resources. It is also an excellent way to circumvent the elaborate HIPAA clauses in your IRB research protocol.

 

I also include in this topic the necessity of a secured (password protected) USB drive as a conduit for transferring secure data between machines. Your program or IT department may provide one for you. It will serve you well in the long run as it allows you to transfer sensitive documents from your personal computer to a secured hospital network.

 

Apps

 

There are so many great apps available, but I can only mention a few that are technological essentials for the resident. A document reader is critical. Specifically, it should be one that allows you to maintain a “bookmark” for each document you upload. Also, it should open and save highlights and notes you want to review later. This document reader is worth a few dollars because it allows you to carry your library wherever you go, saves highlights directly onto the document, and remembers your page position. I use Goodereader for my Ipad, because it was one of the best at the time, but there may be new readers out there that suit your preferences.

 

Several of my colleagues purchased a group subscription for e-anatomy. This app is a comprehensive anatomy atlas with corresponding radiology images.
Radiology Assistant has recently developed a new app, which is an adaptation to its website. The app allows you to review all the content on their website while offline if the data is pre-downloaded. If you like the website as a resource, it is an even better tool as an app.

 

The different learning apps available can turn your phone into an instant tutor with quiz programs such as Chegg or Anki to name a few. Also, most of the decks relevant to your training probably already exist. I found over 500 premade CORE exams cards. Use at your own risk since you cannot vet them all throughout your review. You can download and edit them as you go if you find the information is not up to date.

 

Conclusions About Technological Essentials

 

The bottom line is that your training experience relies heavily on how you learn. You may get by without some of the technologies mentioned above, so it’s entirely up to you to decide what you need. The items I have mentioned I recommend so that the resident, from day one, can optimize the use of time with relatively cheap resources (or otherwise covered/subsidized by your program). John Stuart Mill wrote, “there are many truths of which the full meaning cannot be realized until personal experience has brought it home.” Hopefully, my experience with these technological essentials serves its purpose to jump-start your journey through residency.

 

 

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Reading Room Background Music- A Hazard For Patient Care?

music

Walk into any radiology reading room, and you may see several radiologists with headphones plugged into iPhone music. Others are constantly shushing other residents, chatting amongst themselves in the reading room. These rads hate the moment that excess noise comes their way. This divergence of opinions on the matter is enormous. So, should we concentrate solely on the findings on the film and ban all music/noise from the reading room? Or, does music help radiologists to notice things they may have not as seen otherwise? Let’s look at several relevant articles and weigh the body of evidence to come up with a conclusion.

Music As Potential Benefactor In The Radiology Department

Mood

As I was combing through the internet, I came across several interesting positive articles on noise and productivity. However, overall, the scientific power of the studies was pretty weak. One particular study emphasized radiologists, and it was an interesting article in Science Daily. It summarized an American Roentgen Ray Society abstract. The study took eight radiologists and looked at how baroque, classical music affects mood, concentration, perceived diagnostic accuracy, and work satisfaction. It concluded that the most statistically significant positive effects were upon mood and work satisfaction. One physician even stated that there was a subjective improvement in concentration and interpretative abilities. However, it had a low number of included participants and didn’t look at the actual performance of the radiologists. So, I’m not sure if the results are that relevant.

Performance

One abstract in the literature with a slightly higher number of participants (26 radiologists) looked at acoustic noise within clinical departments and radiology performance. This study concluded that acoustic noise found in most radiology departments is not a distraction from work. However, this is not a direct study about music and reading films. Although a small study, the paper suggests no harm in listening to music and reading chest images.

Another article went through different types of music that are best for immersive tasks but are not specific to radiology. I think you can extrapolate these genres to radiology because radiology reading rooms are an immersive environment. Interestingly, it listed baroque, classical, electronic, video games, and low-volume ambient music as the most helpful. Nevertheless, the scientific literature did not back it up. 

The Journal of the Acoustical Society of America released a paper stating that natural sounds may “enhance cognitive functioning, ability to concentrate, and increase worker satisfaction.” I didn’t see the data behind the study, but it would be interesting to arrive at a reading room that sounds like a waterfall or a windy day. That could make me a bit more efficient and relaxed… But perhaps a bit sleepy as well!

A Case Report About Music And Performance

Nototallyrad.blogspot.com had an interesting expose on reading ICU chest films where he spoke specifically about his productivity based on different types of music in an unscientific format. He concluded that he was most efficient when listening to Bach instead of Metallica, White Noise, and Red Stick Ramblers! Call me crazy. But, if I listened to Metallica while reading anything, not only would I have a difficult time reading cases, I may come home with a headache!!!

Music As A Disruptor of Radiologist Concentration

Much of the literature regarding noise/music and adverse effects upon performance is not specific to the radiologist. These articles tend to be a bit more powerful but are certainly not complete. We can try to extrapolate from these articles the relevance to the radiologist. Specifically, if you look at the psychological literature, several negative articles reported on the radiologist regarding noise, music, and performance.

Performance Deterioration

The first one, The Impact of Listening to Music on Cognitive Performance, supported that performance scores were higher in silence than in all types of music conditions. That performance deteriorated as the intensity of the music increased. The kind of music did not affect performance, just the intensity of the music. Again, the sample size was not that large. And other biases were present that could alter the applicability of the results.

Another psychologically-based article called The Effect of Background Music and Background Noise on the Task Performance of Introverts and Extroverts looked at 10 participants and the effect of music with high arousal potential and negative affect, music with low arousal potential and positive affect, and everyday noise on cognitive task performance of introverts and extraverts. Similar to the previous study, performance was worse with background noise compared to silence. There was also differing performance among introverts and extraverts (I’m not sure how relevant that part would be toward radiologists!)

Outside of the psychological literature, a sociological study looked at the relationship between multitasking and academic performance. Although not specific to music, it had a significantly higher number of participants (1839 surveys). Moreover, it could potentially be relevant to the radiologist. The result was that multitasking with social media and academics could lead to a lower GPA. Although there is no direct link in this article between listening to music and radiologist performance, one can conclude that music is multitasking and can just as well interfere with radiology performance.

The Lone Radiology Resident Study- A Mixed Result

Finally, there was an article explicitly dedicated to the radiology resident! It specifically looked at resident detection of rib fractures. They divided eight radiology resident readers into two groups- one accustomed to reading in quiet environments and another group that reported to be unaffected by noise. It turned out that the resident’s attitude toward noise affected the detection of rib fractures. Those residents who usually read in silence had improved performance in silence, and those unaffected by noise had improved performance with noise. Again, not such a robust study, but interesting nonetheless.

So What Is The Preponderance Of Evidence?

Although the higher power studies currently lean toward music as an overall detractor of potential radiologist performance, there are no strict guidelines in either direction. You can still make an argument in some cases that music can help some radiologists get through the day in a better mood if nothing else. However, until there is some more substantial evidence that music has no effect or improved effect upon radiology reads, read films with music at your peril!

 

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Can Clinical Decision Support Systems Help To Improve Radiology Resident Education?

During my residency only a little bit more than 14 years ago, I can still remember grabbing a ream of sheets from the bin to check the day’s CT protocols. We would quickly read through each one to make sure that the appropriate test was indicated as was ordered by the referring physician. Somehow, I think this process is currently an anachronism at many radiology residency programs. The pressure to complete studies in rapid fashion have changed the way things are done. It seems almost all the cases come directly from either the emergency room or from the referring physician directly to the scanner. No longer is the resident an intermediary in the process (a potential delay in the system). Instead, there is a corresponding increase in tests with incorrect indications and/or wrong technique, only to increase radiation dosages and the cost to the system. The ordering physicians, not the imaging experts, have hijacked what should be the domain of the radiologist: to decide if imaging examinations are appropriate.

Why do I bring this topic to our attention? First and foremost, of course, patient care suffers. But also, as today’s topic implies, it also affects the education of the radiology resident. So how do we get control back over the reins of imaging from a standpoint of improving resident education? Initially, we have to understand the role of protocols in the education of the radiology resident. And then, I will briefly discuss what imaging clinical decision support systems are and how clinical decision support systems can potentially enhance the education of residents as well as the appropriate use of imaging.

Protocols And Educational Implications For The Radiology Resident

One of the most important roles of radiologist is to be a consultant for the appropriate use of imaging. As I described above, the process of checking protocols significantly enhanced my knowledge on this topic.  What may have seemed at the time as a questionable activity bordering on scut, I now see as invaluable. Related to my prior experience with protocoling CT scan studies, I now understand when contrast should be administered, how certain studies are typically performed, and most importantly, what are good indications for a study to be completed. At many programs, this educational opportunity is no longer available due to financial and political pressures upon radiology departments to get through the system. Any study ordered must get done in a timely fashion, no matter whether the study is indicated or not! It only matters that it was ordered. Correspondingly, resident involvement in this process has significantly decreased over time.

So, how does removing this educational opportunity for radiology residents change the knowledge base of the radiology resident?  First of all, you are taking away important practical knowledge that can reduce the value of new radiologists as a consultant for determining appropriateness of individual imaging studies. Second, new radiologists will be less likely to understand how to tailor individual studies to the indications of the ordering physician. And finally, the potential implications of issues like when to use intravenous contrast can be underestimated, both from a contrast complication and an appropriate indication point of view. So herein lies the potential savior to return the educational opportunities of protocoling back to the radiology resident- The Clinical Decision Support System!

The Clinical Decision Support System

Here is the definition of clinical decision support systems according to the government– “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”

In terms of imaging, the potential implications of a clinical decision support system from a cost and educational standpoint are myriad. No longer are all imaging studies going to be ordered without the approval a computerized system. When can this potentially occur? How would the radiology resident role going to be affected by the implementation of such systems? Let’s talk about both of these questions…

Institution of Clinical Decision Support Systems And The Potential Effect Upon The Radiology Resident

At first, institution of electronic clinical decision support systems were going to be mandatory as January 1, 2017. The date was subsequently changed to January 1, 2018. We will see if this date is going to be the finalized implementation deadline.

But let’s say that a good quality clinical decision support system became mandatory at all institutions for ordering imaging studies at the beginning of 2018. How would that affect the residents? First thing that would you notice, bogus indicated studies would all of a sudden significantly decrease dramatically. The system should theoretically block anything that has a questionable indication from getting through from the clinician order to actual practice. Second, there could potentially be a flood of phone calls. Since any study with a questionable indication or a complex protocol would not be able to get through the system, instead, clinicians would be forced to ask the radiologist what kind of protocol should be implemented for these cases. Not only would this be a boon for patient safety (decreased radiation dosages) and appropriateness of imaging, clinical decision support systems can actually bring the control of image ordering back to the radiologist. More specifically, a good quality clinical decision support system can theoretically allow the radiology resident to protocol examinations appropriately in concert with the ordering physician and tailor examinations to the indication that is needed. Resident protocol education can be restored!!!

Interestingly, a clinical decision support system for imaging was actually one of the few parts of the health care bill that actually had the potential to decrease costs and quality of care in addition to improving resident educational experiences. Ironically of course, it may never be implemented depending upon how the political situation in Washington affects health care.

Clinical Decision Support Systems For Imaging Can Be The Resident Radiologist’s Best Friend

In summary, clinical decision support systems have the potential to be one of the true benefits to the health care system, in terms of costs and quality of care. But, one of the most overlooked implications is actually the potential educational benefits to the radiology resident. No longer would ordering be in the hands of untrained ordering physicians. Instead, control will again lie in the hands of the radiology resident allowing him/her to protocol patients once again appropriately and giving the radiology resident the education he/she needs to become a true imaging expert.