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The New Core Exam- An Associate Program Director’s Lament

What are the essential ingredients of a successful radiologist? – the art of oral and written communication,  being able to distinguish one study from another, the ability to successfully analyze the findings, the masterful arrival at a reasonable differential diagnosis, and the creation of insightful management recommendations.

The oral boards enabled residents for years to learn these essential skills of a good radiologist. As much as we had heard horror stories of the trials and tribulations of the test takers in Louisville, Kentucky, it lit a fire under all of us. By the end of our fourth year and completion of our oral board at the last month of residency, all of us were artful in the realm of oral and written communications and powerhouses of essential radiological knowledge. We were immediately able to practice competently as radiologists on day one after completing our radiology residencies. This bygone era is no more…

Instead, what does the new core examination teach radiology residents? It forces residents to learn some radiological knowledge. But, more importantly it reinforces the strategies of multiple choice and matching format questions. As a radiologist, I never have options a,b,c,d, or e on a piece of paper or a computer screen. I need to have a baseline sum of knowledge to make my own assessments. On occasion, I will google a question. But, the only reason I know what question to ask is: I know the fundamentals of radiology. The fundamentals are no longer emphasized.

The style of a test can be just as important as the content because it reinforces the process of learning and communication. Now, instead of concentrating on practicing the most common methods of disseminating information to others, radiology residents are now concentrating on methods that are never used by radiologists in practice. Think about it…  A good oral test that actually forced residents to study the essence of radiology has been converted to an examination that reinforces the learning of the art of testing taking. Is that what we really want to be teaching residents?

In the latter half of every academic year, we encounter nervous third year residents fretting about the mechanics of a test that are not even utilized in daily practice at the expense of learning the fundamentals of radiology. I can understand their stresses because their role as studying residents is split twofold: to study for a test that does not directly correlate with what we do on a daily basis as well as study the fundamentals of becoming a good radiologist. There is conflict between the two. Residents waste time and energy devoting themselves to two divergent causes. It shouldn’t be like this.

So why has the ABR decided to resort to computerized multiple choice testing and changing the timing of the examinations?  I have a couple of theories.

Cost Cutting/Increased ABR Income

What are some of the biggest advantages of converting an oral examination to a written test? No longer do you have supply the manpower to meet the demand on the days of the boards. It can be extremely expensive and time consuming to host tens of seasoned radiologists at a hotel anywhere to provide the services needed for creating an oral board exam. The costs saved in the short term are enormous. In addition, you don’t need to rent out a space to accommodate these radiologists for many days. Instead, the ABR can create fixed computers in a fixed site that can be used year after year in a few sites with less manpower to run the annual examinations. The cost savings can be significant.

Annual income from the dues can still be increased without a concomitant increase in annual expenses, significantly increasing the income of the “nonprofit” organization of the ABR. Salaries within the organization can be buttressed and maintained, a possible incentive for changing the examination.

Creating More Subspecialized Radiologists Working in Academic Radiology

Notice the change in timing of the general examination from the end of fourth year to the end of third year of residency. Why would an organization want to do this? If you think about it, radiology residents study most intensely prior to taking an examination, oral or computerized/written. Before, residents would go out to their first job with a significant body of knowledge fresh in mind on day one. Now residents have a full year to forget about the information that they learned for the core examination. Sure, they take a specialty certification examination after they finish fellowship. But, the studying and content is not the same. It is instead mostly dedicated toward the individual specialty What does that mean for the first year employee? These new radiologists are less capable to practice general radiology because their general radiology knowledge is more remote and they are less comfortable with “bread and butter” radiology imaging studies. This idea matches in practice what we are experiencing with new hires. They are more likely to stick to subspecialty work and less likely to want to practice general radiology.

This outcome is even more harmful for private practices throughout the United States. According to the AUR meetings and multiple papers on the subject (1,2,3), most practices need new radiologists that are sub specialized but can also cover generalize radiology work. Because  of the new core examination timing and the content of the core exam, the needs of private practices continue to be unmet and do not match with the newly minted workforce.

So, where are more new radiologists, less competent in general radiology, forced to work? These new residents either need to work at academic facilities that can afford to harbor a highly subspecialized workforce or very large private practices and teleradiology companies that can divide the subspecialty work among its employees, providing benefits mostly to the chairmen of academic departments and the heads of very large private practices.

Who was most responsible for the decision of creating the test? It is the same representative body- chairmen of large academic departments and the largest of the private radiology practices that most likely will benefit from these changes. This represents a conflict of interest between the creators of the examination and the needs of radiology practices throughout the entire spectrum of radiology.

Final Thoughts

Examinations are important not just because it should establish a baseline of competency in a particular subject matter, but also just as importantly because it guides how the student learns. This process can change the landscape of a profession for years to come.   In addition, prior to the creation of any examination, the foreseen outcomes should be match the needs of the specialty. In my opinion, the core examination has failed on all of these accounts. It deemphasizes the fundamentals of radiology, guides the radiology resident to learn information in ways that are not relevant, and leads to the outcome of weakening private practices by causing a mismatch between the needs of radiology practices and the differing abilities of the newly minted radiologist.

Unfortunately, the core examination has already become embedded in the radiology residency process and culture. Since so much time, effort, and expense has been dedicated to changing the examination and timing, it is very difficult to navigate back to a different format that will better match the needs of the radiology specialty. But, it is something that we should consider to make a better prepared radiology resident for the job market and to sustain our specialty for years to come. We are better than that.

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How To Complete The ABR Alternate Pathway As A Foreign Physician

 

dear sir,
I have completed my radiology residency from India in 2015 and I wish to pursue radiology residency in usa.
I am unsure of how alternate pathway for radiology.ABR website says one must have a mix of radiology residency /fellowships/faculty post for four continuous years.If residency itself is for a duration of 5 years ,how would it be possible to have a combination of residency and fellowship for 4 years?
Is it possible to get 4 fellowships consecutively at the same institute?
kindly help me in this regard.

regards,
Fiona

Director1 response:
Radiology residency is for a total of 4 years in the United States. Prior to beginning a radiology residency, you need to have an additional year of clinical internship, usually medicine, surgery, or a transitional year (a year of multiple electives). The expectation from the ABR is that you will either repeat an entire 4 year radiology residency program at the same place (not the initial clinical year). The other possibility is that you have the experience to complete part of a radiology residency program and complete subsequent radiology related fellowships. So, you could theoretically have any combination or permutation of experiences, i.e. 2 residency years and 2 distinct fellowship years, 4 fellowship years, and so on/so forth. As you stated, all the years need to be performed at the same institution.

There are some large institutions that do have more than 4 different types of fellowships. But, if you did attend a United States residency program, more commonly, the foreign resident/fellow would complete a 2 or more year fellowship instead of a typical one year fellowship. (Nuclear medicine, neurointerventional, and neuroradiology fellowships can be 2 or more years) As long as you complete the prescribed 4 years in a radiology related area, you can satisfy the requirement.

Take a look at the following URL:

https://www.theabr.org/diagnostic-radiology/initial-certification/alternate-pathways/international-medical-graduates

 

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The Uncooperative Patient- The Radiology Resident’s View

uncooperative

As a radiology resident, the patient experience differs significantly from other specialty services. Typically, they see a patient for a single encounter or, even less commonly, a second or third chance episode. Rarely the radiology resident encounters the same patient more than that. Additionally, they have limited time to interact with the patients, even more so than other clinicians. Therefore, the trainee may not establish deep connections with patients like in other specialties. So, we have to view their experience through a very different lens.

In our “radiology world,” all of us will experience one of these dilemmas: The patient may refuse to drink barium, deny the imaging department the significant second portion of a test, physically combat the staff, refuse procedure consent, move during a study, or be noncompliant with our instructions. We often do not understand why the patient may not cooperate in these situations. So in this discussion, I will go through how you, as radiology residents, establish a rapport with these patients to motivate the patient to complete a test. Also, I will discuss some typical situations with “uncooperative” patients that you may encounter and how you can prevent them from escalating from bad to worse.

Patient Rapport and Motivation

As a human being, I can think of nothing less motivating than doing something for someone that I don’t know and for a reason that I don’t understand. Many times, this is precisely the situation that the patient experiences. Often, the floor will send a patient to our department without knowing what test they are having with people they don’t know. The staff may place the patient in confined quarters with minimal human interaction.

Think about it in your terms. Imagine coming down from one of the floors to have a procedure such as a barium enema. And, you see someone without any identification whatsoever. As a patient, I can picture the thoughts going through her head. Is this person qualified to do the procedure? Is someone going to butcher me that I don’t even know? Patients in this situation can often feel dehumanized and vulnerable. How can we minimize this poor patient experience? The first step is straightforward: introduce ourselves. Who are we, and why are we there? Making an introduction alone can motivate a patient to complete a study.

Second, explain the procedure. I have found that taking time to describe it will often go a long way to diffusing a potentially intense situation. Not only does explaining the procedure make the patient more comfortable and knowledgeable about their care, but it also establishes that you are a competent professional to perform a procedure.

And finally, let the patient know if you will perform the procedure. And, if not, at least you will be around to monitor them when it occurs. What a relief to know that someone in the department has your back!

A Couple of Special Situations

The Combative Uncooperative Patient/Family

The Situation

So, you are working in interventional radiology for the month. You are on your fourth consent for the evening before finishing your work. In the back of your mind, you think you are soon finally going home. You enter the room and introduce yourself to the patient and daughter. Subsequently, you start to discuss a PICC line consent that you have planned for tomorrow’s morning procedures, and you begin to rattle off the risks, alternatives, and benefits. As the discussion ensues, you notice on the room door a sign saying feeding precautions: Severe Risk of Aspiration- Do Not Feed the Patient!

You then look back to the patient/daughter and notice that the daughter is rapidly shoveling food from home into the patient’s mouth. You halt the discussion and tell the daughter, “You shouldn’t be feeding your Mom. She has aspiration precautions and can choke on the food you give her…” The daughter yells back, “How Dare You Tell Me How to Treat My Mom? She Has Not Eaten For Days, And I Will Give Her What She Wants!!!!” The patient then begins to cry, and the daughter gets right up into your face threateningly as if she will punch you.

What To Do

How would you deal with a possible real-world situation such as this? There are several options. But, as a radiology resident with limited knowledge of the uncooperative patient’s case, you need to treat it differently than a primary care doctor or specialist who sees the patient daily.

As a radiology resident, you first need to de-escalate the situation. You do not continue to argue with the patient’s daughter, as it could lead to physical confrontation or worse. Besides, there may be more to this situation than meets the eye. Perhaps, the daughter is responsible for the patient’s care and has an advance directive to feed the patient that the sign does not specify in the front of the room. You merely don’t know.

Second, you may want to reflect and say, “Sorry… I see you are upset. Why don’t I leave the room and get you someone who may know more about the situation and can help you.” You can then temporarily step out of the room and recruit the help of the caring physician or the nurse around the corner.

Your role as a radiology resident is not the patient’s total care. Instead, you become the physician ensuring the patient can undergo a procedure the following day. Therefore, letting the caring physicians and nurses know what is happening is appropriate. In this situation, if there is a potentially life-threatening emergency for the patient, it can be taken care of expeditiously. Do not argue with the uncooperative patient, as it can lead to a more active confrontation!

The Obtunded Uncooperative Patient

On interventional radiology rotations, this is a frequently encountered dilemma. You go upstairs to the floors and begin to consent a patient. And, As you are going through the motions, you realize that the patient doesn’t understand a word you are saying. What do you do???

First thing, check the charts. See if anything confirms that the patient is incompetent to make a decision. If not, what do you do? Make sure to think about whether the patient needs the procedure emergently. The consent can undoubtedly wait if it is not emergent.

On the other hand, if the procedure is essential, step out and ask the primary covering physician- what is the patient’s situation? Has the mental status changed? Is the patient on medications preventing them from understanding/responding to the consent? If you see a temporary change in mental status, you may reconsider consenting at a better time/place.

What is the next step if the procedure is emergent and you must complete it first thing in the morning? It is your responsibility to find the person responsible for the patient’s care when they are obtunded so that you can obtain patient consent. You may see an advanced directive in the chart explaining who is responsible for this patient’s care. Or perhaps, the nurse or physician may know who to contact in this event. In either case, contact the patient’s responsible decision-makers before getting consent. The consequences can be dire if you do a procedure and have “consented” a patient without the mental faculties. Legal action is a possibility! Never allow an obtunded patient to sign off on a procedure!!!

Lessons We Need To Learn About The Uncooperative Patient

The uncooperative patient is usually “uncooperative” for a good reason. As radiology residents, we are often not privy to all the information that may lead to the patient’s attitude or actions before or during a diagnostic or therapeutic radiology procedure. Also, remember that you are not alone in making decisions for the patient. Always get help from other clinicians when needed. And never make assumptions about the patient without getting the facts straight. Not following these guidelines can lead to patient care disasters!!!

 

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The Chief Radiology Resident- An Insider’s Perspective

chief radiology resident

Every year around the dead of winter in our program, the program directors sit around a table and discuss who will be the next year’s chief radiology resident. For many of you, this process may seem like a mystery box. Why do we even have a chief resident anyway? What exactly does she do? And, how do we make this decision? These are some of the questions you may be asking.

To enlighten you on the world of the chief radiology resident, I will answer these questions. To do so, I will talk about all the nitty-gritty details such as the myriad roles of a chief resident, the perks and downsides of the job, why some years it can be easy or challenging to decide who should be the chief, and how many programs make a choice.

What is the Role of a Chief Radiology Resident?

Roles and responsibilities may vary slightly from program to program across the country. But the essence of a chief radiology resident usually remains the same. The chief resident is the liaison between the resident program and the program directors/attendings. Residents will bring issues that arise among their classes first to the chief resident and then to the program director or responsible attending. Likewise, faculty will bring problems that occur to the chief resident’s attention first, then disseminating the information to the residents.

The duties of a radiology resident include administrative scheduling of residents, scheduling noon conferences, scheduling board reviews, running review courses for medical students and junior residents, voting as a member of the educational committee, attending chief resident conferences such as the AUR meeting, scheduling guest lecturers, planning budgetary arrangements for the residency, interviewing medical students, and more. The responsibilities are significant, and the chief resident needs to command both the attendings’ and residents’ respect alike.

Downsides and Benefits

Like any role with essential responsibilities, there are significant ups and downs to being the chief resident. Let’s start with the downside. The chief resident is often held responsible for conflicts among the residents and between the attendings and residents. They are front and center in many of these issues. Usually, there are no perfect outcomes. Also, the role of the chief resident can be time-consuming and challenging. The scheduling of residents alone is often fraught with lots of emotion and charged conflicts. Each resident wants the best possible schedule for himself/herself, and many times not everybody can be accommodated. The chief resident may be held accountable.

However, there are some significant perks to the role. First and foremost, it can’t hurt to have the words “chief resident” on your resume when applying for fellowships and later attending radiology positions. Sometimes the chief may get to participate in free conferences or get an additional stipend at some programs. Other times, they benefit from getting inside information about the residency program’s inner workings before any other residents. Occasionally, it may help to get a position within the hospital or private practice where the residency is situated.

What Do We Look For In A Chief?

The first most critical feature of an excellent chief resident is to command respect among fellow residents and attendings. We do not want to pick a resident that shows up late, gets involved in numerous conflicts with other attendings or residents, or who is not a “team player.” Second, we look for a resident who has generally performed well academically and can handle the additional load of chief resident administrative responsibilities. And finally, we look for a chief resident who possesses a calm demeanor and is likable by all.

All these personality traits and features will allow the residency to continue to run smoothly and reduce the potential for significant conflict that can make the program director’s job even more difficult. Also, it gives the program directors an additional “ear to the ground” and an advisor that can be extremely useful to prevent miscommunication.

What Makes The Decision To Find A Chief Resident Easy or Difficult?

Assessing who is to become chief is not a decision that we take lightly. An earnest discussion ensues every year among those that make the final decision. Some residency years, one or two residents have been responsible for organizing the class, settling issues within the program, and are performing well academically. And, you may have several interested parties in performing the role and responsibilities of chief resident. When these stars align, the choice to make chief resident is straightforward.

Other years, you have many interclass conflicts, or there is no clear leader that makes decisions for the class. On occasion, we have a year with no one interested in performing the chief resident’s role, knowing there are additional responsibilities. These factors can make it very difficult to come up with a final choice.

How Do Programs Choose The Chief Radiology Resident?

Different programs have distinct policies regarding the installation of a new chief resident. In our radiology residency, the faculty and program directors choose the chief resident during the third year with attendings’ and residents’ input. The chief resident will typically begin his/her duties when the final year starts in July. Some years we have had both educational and administrative chief radiology residents, and other years we have had a single chief resident that takes care of both responsibilities. 

Other programs have a democratic policy, with the residents forming a voting body that may vote upon individual or multiple chief residents. The bottom line: there is no right or wrong way. But instead, the individual culture and traditions of the residency often determine how they choose the chief resident.

“To Be or Not To Be” A Chief Radiology Resident

The chief resident has a significant role in the smooth running of a residency program. The responsibilities can be overwhelming for some and can be an excellent leadership opportunity for others. If the program chooses you to be a chief resident, it is undoubtedly an honor. But, it also involves a lot of extra work and hard choices. Make sure you are up to the task!!!

 

 

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How Far Should I Take That Procedure?

procedure

The Procedure Situation

Round 1

Your radiology attending tells you to interview a patient and then complete an ultrasound-guided breast biopsy, knowing that it was a large mass and a relatively simple case. You have done this procedure numerous times with this same faculty. So, you go ahead and do it again. No complications. No issues. After you complete the biopsy, you feel immense pride in your capabilities. You show the attending the pictures from the biopsy. The attending congratulates you on a job well done.

Round 2 later that same day…

A different radiology attending wants you to work up another patient and start the subsequent breast biopsy. So, you begin to interview the patient, set up the table and the sterile field, position the patient for the procedure, and place the ultrasound probe on the biopsy site. You begin to numb the overlying skin lidocaine and make a small incision for the biopsy gun. Since the attending still has not shown up, you decide to place the needle right near the lesion, hit the targeted breast nodule, and then subsequently collect multiple samples, placing each one into a little sterile cup on the side to send to pathology. You complete the rest of the procedure without complication. All seems to be well.

You clean up everything and let the patient know that everything went just fine. And, you tell her you are going to consult with the attending before you have her leave. So, you merrily step out of the room and walk down the hallway toward the radiologist’s office to let her know about the patient’s biopsy you completed. You enter the office and state, “I completed the biopsy successfully on patient “XYZ.” The attending stares at you with a stern, angry face and says, “How dare you complete the procedure without consulting with me!!!” You are the talk of the department for the next month!

How To Assess How Much You Can Do

Unfortunately, during radiology residency, you may encounter similar situations such as this one. Different attendings have entirely varying expectations for each radiology resident. Some may expect you to start and finish all procedures. Others may be less likely to allow the resident to have independence, even though he/she may be competent. So what to do? I will go through several guidelines in assessing whether you, as a radiology resident, should complete a given procedure on your own.

Are You Competent In The Procedure? 

Competency should be the first issue that you need to address as a radiology resident. Suppose you do not think you have done enough of a technique independently from start to finish. In that case, you certainly have no business doing any procedure or a portion of a procedure alone. The comfort level is also just as important. Even if you have the numbers of biopsies to back you up, if you do not feel comfortable with a procedure, you should also continue to make sure that you have your attending’s guidance at all times until you have that comfort level that you need.

Are We Doing the Procedure For The Right Reasons?

Before performing any procedure, you need to make sure that it has some clinical benefit. Nurses regularly come up to me and ask should we give intravenous contrast. The first thing I ask them is why are we doing the study/CT scan? It may not need contrast in the first place. Likewise, no matter how “minor” a procedure is, you always need to think about it if necessary first!!!

Level of Difficulty of Procedure/ Potential For Complications

Some procedures, such as an upper GI series, have a much lower complication rate than a complex liver embolization. So, it is essential to assess any given procedure’s difficulty and potential complications before deciding whether you should tackle it on your own. Most liver embolizations, stent placements, and angioplasties should probably be under the faculty’s direct supervision unless perhaps you are about to graduate from an IR fellowship in a few days. On the other hand, a paracentesis can undoubtedly be performed from start to finish by a resident.

Attending Expectations

Some attendings expect the resident to do almost everything and others feel the need to hold the resident’s hand at every step. Much of that decision may be related to the trust between the attending and resident. However, it is imperative to listen to the guidance of your attending before beginning or ending any procedure. Because you are not the physician who signs off on everything, you need to abide by the person’s rules in charge. Always make sure to get the OK from the supervising physician before performing any procedure!

Patient Expectations

Many patients expect an attending to complete a procedure. Always abide by the wishes of the patient. You never want to be caught in a situation where the patient does not want you to be performing a procedure, and you do so anyway. Not listening to the patient’s request is the realm of lawsuits and legal issues!!!

It’s All About Self-Awareness!

The difficulty of residency can be more about self-assessment/awareness and working with colleagues than about the actual day-to-day mechanics of performing cases. You, as a resident, need always to be aware of your strengths and weaknesses as well as your expectations. My advice: make sure to always know in advance that you are performing a procedure for the right reasons, have the abilities to conduct it, and your attending expects you to complete it. Only then should you consider performing a procedure independently!

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Taking Oral Radiology Cases- A Lost Art?

oral

The lights go down as the radiologist in front of the classroom prepares the computer for a case presentation. A switch is flicked on. Suddenly, a black and white PowerPoint case begins to shine brightly on the screen in front of you. The radiologist glances about the room looking to see who would be the best fit for this next case. You begin to sweat and fidget with your hands, praying your faculty will not call on you next. The attending’s glance remains fixed upon you. He says, “Tell me about this patient with a 2-year history of a cough!”. You become flustered and unsure what to say.

The scenario above occurs commonly in radiology residencies across the country. However, since the oral exam has disappeared, I have noticed an overall decrease in proficiency in how residents present each radiological case. The art has been lost. You can blame some of it on poor teaching. Decreased time allotted to education may cause some of it. Some of it can relate to the emphasis on the new board examination system. And, perhaps the new radiology residency culture may be responsible for some of the changes.

In whatever case, it is a shame. Taking oral cases is a crucial step to becoming a well-rounded radiologist. You need to relate to your colleagues’ images in a timely, logical manner, no matter what you are looking at. If you want to look like a star, you need to have this process down cold. To enable you to have the tools to get through a radiological case, I will go through the basics, including determining the kind of study, presenting descriptive findings, coming up with a differential diagnosis, and ultimately determining proper management.

What The Bleep Am I Looking At?

Whenever your attending introduces you to a new oral case, the first thing you need to do is determine what you are looking at. Take your time and think about what kind of images you see. You often lose the case discussion even before you have begun because you never identify the correct study. Is it an ultrasound, CT scan, MRI, x-ray, or nuclear medicine study? Is the examination performed with or without contrast? During what phase?

For nuclear medicine studies in particular, if you can identify the study before going through the case, you have already completed 80 percent of the heavy lifting. You have already isolated the differential diagnosis if you can identify the radiopharmaceutical. If you are not sure, you should start describing the physiological distribution of activity to determine the type of study. Often the act of defining the distribution helps the resident to understand the kind of study.

Also, scan the images for any identifying information. If it is an ultrasound, it will often tell you which organ you are looking at. I have found it can become difficult to tell the testes, ovaries, and kidneys apart on a single image. Usually, the ultrasound technologist labels these studies so you can differentiate among the options.

Finally, make sure to look at the top of the film to see if you can find the patient’s age and sex. This information can also further help you to hone in upon the correct differential diagnosis.

Describing The Findings

This part of the oral case is when the newer residents fall short compared to residents studying to take the oral boards. Residents tend to stop very quickly at the description part of the puzzle and then enter rapidly into a differential diagnosis. Often, a poor quick description leads to a poor differential diagnosis. Again, you need to take your time to describe all the salient points.

So, what should you include in this part of the case? Always describe the location, the size, the intensity (if nuclear medicine), the shape, the density, and borders. Describe its effect upon adjacent structures. Make sure to use buzzwords if available. If you see an angry-looking mass on a CT scan that looks like a star, you may want to use the words spiculated or stellate. If a lesion enhances with rim nodularity and fills in from the edge to the center, use peripheral nodular enhancement with centripetal filling. These buzzwords connote certain types of differentials in the minds of the radiologist listeners. They provide information on the kind of disease entity even before going through a differential diagnosis.

Finally, don’t get happy eye syndrome. Look for other findings that may support or refute your differential diagnosis. I can’t tell you how many times a resident will stare at one section of the film to forget to look at the rest of the images or film. He loses the forest for the trees.

Concise Relevant Differential Diagnoses

A novice and more seasoned resident starkly differ when they give a concise and relevant differential diagnosis. The beginner will have no idea what to say. Or, she will continue to drone on about multiple different possibilities for the final diagnosis. She does not even differentiate between the zebra and the most common diagnosis.

Again, take your time before speaking. Before even starting this process, you should go through broad categories of differential diagnosis in your mind. Is it neoplasm, infection, inflammation, iatrogenic, congenital, etc.? When you have come up mentally with some reasonable possibilities, make sure to talk about no more than three etiologies of the most likely diagnoses. And start with the most feasible and then go down to the least likely. This process will allow you to speak logically. Also, it will enable you to show that you have thought about the differential analytically.

What Next For The Patient?

Three options exist for the further management of the case after you have completed the basics of determining the findings and differential diagnosis. The first possibility: the patient needs no further workup, and you have made a final diagnosis. One example would be an adrenal nodule with a Hounsfield unit of 2. This finding is consistent with an adrenal adenoma—end of story. No further workup is needed.

Alternatively, it may be imperative that you need another step to work up the case. For instance, if you need to determine the matrix of an aggressive osseous lesion on a musculoskeletal MRI without a final diagnosis, make sure to recommend a plain film. Otherwise, you may never determine the final disposition of the patient.

And lastly, you may find a lesion with low clinical significance but needs to be followed over time. This category includes the small lung nodule or the nonaggressive indeterminate liver lesion.

You can almost always categorize your case into one of these three groups. And, it will show that you thought about the ramifications of the imaging upon the clinical picture of the patient.

Final Thoughts: Taking Oral Cases Should Be Fun!!

Taking oral imaging cases should not be a difficult or embarrassing process. It should become something that you should look forward to, building your confidence and becoming a better radiologist. It sums up the essential ingredients needed to make an excellent radiologist: the ability to make the findings, synthesize the data, develop an outcome, and communicate the clinician’s results.

Unfortunately, in many programs, the radiologist just expects you to know how to take an oral case despite not having been taught the process. If so, now you have a framework of the fundamentals of how to take a case outlined above. Like anything else, being adept at taking oral cases is simply a matter of practice and knowing the process. Once you have the process down and the base knowledge, you can more easily build upon your abilities and become better and better over time. You, too, can become a star at taking cases!!!

 

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Radiology Residency Night Float Vs. Standard Call- A Perpetual Controversy!!!

night float

Blurry vision setting in; eyelids drooping just wanting to shut; difficulty communicating; and impending malaise. Rarely would I have any chance whatsoever to lay my head down even once. The films would keep on streaming in. These feelings were typical on that first night of call on a 1 or 2 weeknight float rotation block or the occasional Saturday overnight calls that we would have to do every once in a while. I dreaded those days. But, it is still standard for many radiology residency programs. It is almost impossible not to have at least a few overnight shifts like the ones I just described.

At one point or another, many radiology programs and residents have come up with different schedules and options to minimize this extreme fatigue. Some have instituted night float schedules. Others maintain a standard rotating call schedule Q4,5, or 6. Some have long and short call schedules.

The choice to do one system or another is not so clear-cut. Programs have many considerations before deciding to have either of these systems before implementation. Although I tend to favor the night float system since I remember it mitigated fatigue after the initial day or two of calls when taking overnights, the decision to have a night float program is probably unsuitable for all programs.

So what factors would lead one program to have a night float system and another to have a standard call system? Some of the issues we need to address are the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies, and emergency department requests. I will also review each system’s disadvantages and advantages, allowing a program to decide which approach is best.

Factors For Instituting A Night Float Coverage System

 

Size of the Program

The smaller the program is, the less likely there will be adequate coverage for rotations during the daytime, let alone the nighttime. In fact, at many programs, a small residency cohort prevents the institution of a night float system. In a program with three or fewer residents per year, it may not be possible to have a resident out every night to be on call without severely compromising resident education. Also, many programs cannot cover daytime obligations without a night float system.

Attending Coverage

Institutions with attending nighthawk coverage at nighttime allow more flexibility for scheduling of night float. Some programs do not need full-time resident coverage during the nights and may share call obligations with the attending. Therefore, it is significantly easier to institute a night float system for the residency program.

Resident Preferences/Culture

In some residencies, the radiology residents have instituted a night coverage system because of the preferences of the individual residents. Many residents have fully invested in a given scenario. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or fewer calls than they would have in the old system. So, the night coverage system becomes engrained into the fabric of the residency program.

Also, the program director may set up this schedule to accommodate specific residency daytime programs. A nighttime schedule may allow the resident to maximize daytime educational opportunities. For some programs, that may mean either a standard cyclical call schedule, and for other programs, it may mean a night float schedule.

Program Director/Chairman Preferences/Department Culture

In many programs, the leaders may institute nighttime coverage based on their preferences. The program director or chairperson may believe a night float system or standard call schedule may be better for a residency program. Or, perhaps there are coverage requirements that the department desires. In either case, the decision is not up to the residents.

Number of Studies

Perhaps you are in a residency program that is a level 1 trauma center with significant numbers of ER studies at night time. Some programs are so busy that they may need more than one resident or attending on-call each evening. This factor may allow less flexibility in scheduling a night float system since a program may not be able to accommodate the call coverage at nighttime.

Emergency Department Factors

Emergency departments may have specific requirements for radiology coverage at nighttime. Some programs may only want to have senior residents take call. Others specifically want attendings to cover during the evening. Depending upon the demands of the emergency department, this may dictate the numbers, type, and presence of residents or attendings on call. A night float system or standard call system may reflect the whims of the emergency department.

 

Advantages/Disadvantages of Night Float And Standard Call

Night float

Most people think night float coverage for a week or two mitigates fatigue the most. The body tends to get used to the nighttime schedule over time, allowing the resident to function better on call. Sure, the first few days can be challenging because the body and mind have to adjust. But overall, the experience is much improved.

On the other hand, when you are on a night float system, the resident may lose touch with the “educational” aspects of the residency program. You miss daytime lectures, conferences, and attending readouts for long periods. While the time spent on night float is essential for training, receiving all the benefits of daytime resident education is impossible. You may lose out on understanding the context of the images you interpret. Education, in this sense, may also be compromised.

Standard Call

Sometimes a Q4, 5, or 6-day call schedule integrates better with a program than a night float system, allowing the resident a better overall experience. The resident does not miss all the noon conferences and educational experiences they would miss over a long block on a night float.

The two significant disadvantages to the cyclical call schedule are overnight fatigue and the “lost day.” As I mentioned, I always found it much more taxing to have an occasional overnight than a night float block because my body never adjusted to the system, just like most residents. In addition, the resident loses an extra day of residency experience every time they work because they are obligated to have a day off afterward, “the post-call day.” This loss can significantly decrease the educational opportunities for the resident.

 

Residency Call- Night Float or Overnight Calls?

Nighttime call is a crucial facet of every radiologist’s education. Whether or not you have a say in constructing your program’s night coverage system, you now realize that what works for one program may not work for yours. The decision to have one or another method can be complex, but it is important to weigh each of the factors to come up with an outcome. The key is to make the learning opportunity pleasant and mitigate fatigue. Hopefully, your residency has chosen your institution’s most appropriate night coverage system!

 

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I’m a sick radiologist- Should I come to work?

I am confident that most of you, whether a radiology resident or an attending, have felt sick at one time or another. And, most likely, you were unsure about coming to work. Moreover, this decision can become incredibly complex.

Here are some of the issues you probably thought about. Is there adequate coverage? How sick are you? Are you going to be seeing patients for that day? Are you going to be sitting down in isolation for most of the day? Are your reads or your procedures going to be compromised by your illness? What is the group’s culture about taking a sick day? How will it affect your colleagues if you do not show up? Will it prevent you from being promoted? Unfortunately, these difficult questions compound when you cannot think clearly due to illness.

Even more confusing, most of the articles that I have read regarding physicians and sickness are not written directly for the radiologist. Radiologists are a bit different than other hospital or outpatient physicians. Depending upon the day, the rotation, or job description we may or may not have direct patient contact. So, we have to have to think about the question of missing a day of work differently from other physicians.

What about the literature regarding sickness for the general physician? Many articles say not to come to work if you are a sick physician. (1,2) And others are more indeterminate. (3,4) However, the body of research is sparse about whether the ill physician, let alone a radiologist, should come to work. In this post,  I will try to address the most common issues that may sway your decision one way or the other.

Continue reading I’m a sick radiologist- Should I come to work?

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Best Radiology Electives for the Senior Resident

radiology electives

It’s getting toward the end of your 3rd year, and you are studying intensely for your core examination. All of a sudden, you get a phone call from your chief resident. He says, ” We are making the schedule for next year. What would you like to do for your senior year radiology electives?” You realize you haven’t thought this through, and you are not sure what to do. He just assigns you to a standard fourth-year schedule.

Believe it or not, this is a situation that often happens to most residents. Choosing your fourth-year electives is not a decision you should take lightly. You should not have the choice made for you, nor should you choose without thinking deeply about what you want. Your senior year elective decisions can have repercussions upon your comfort zones in private practice. This decision can also influence your practice patterns for years to come. Today, we will discuss what not to do when you decide upon your senior schedule, which standard rotations are the best for senior electives, and finally, some innovative ideas for creating rotations on your fourth-year schedule that will really enhance your residency education and your career.

Which Fourth Year Radiology Electives Should You Avoid?

Don’t Repeat Your Fellowship!

When you create a schedule for your fourth year, I recommend avoiding adding scheduled rotations that duplicate your fellowship. Several times, residents have requested six months in mammography when they have already signed up for a mammography fellowship. What’s the point in that? In most residency programs throughout the country, 90 percent of residents eventually do private practice. And, only 10 percent work in academia. So, chances are you will not be working only within your specialty. In fact, according to many articles (1,2,3), most radiology job descriptions want the new radiologist to not only practice in one subspecialty but also to cover other areas within radiology. So, if you decide to do a half year in your fellowship’s subspecialty, you are also decreasing the opportunity to learn subspecialties outside of your comfort zone. And, you are also reducing your desirability for being hired by a private practice.

For instance, if there are two candidates, one who wants only mammography work and another that feels comfortable reading MSK MRI and being sub-specialized in mammography, which candidate will be chosen by a private practice? It’s relatively simple. It’s almost always the one that can do both. You are missing out on a potential opportunity if you choose to duplicate your fellowship.

Avoid What You Already Know

I would also avoid choosing fellowships that are within your comfort zone. If you feel like you know MSK MRI well, it doesn’t make sense to do half the senior year in the same subspecialty. In private practice, you generally do not want to pigeonhole yourself into only a few areas of a subspecialty. A series of fourth-year electives or “mini-fellowships” in only subspecialties that you are well-versed in will limit your ability to learn other subjects and ultimately prevent you from being comfortable in these modalities after you complete a residency.

The Conventional Fourth Year Elective Approach

If you are going down the conventional route of fourth-year electives, there are two routes I would choose. First, it would be reasonable to select an emphasis in an area that you are interested but in which you are not doing your fellowship. Since you will be completing these electives reasonably close in time to looking for full-time radiologist work, you will have a second area of subspecialty confidence and diversify your competencies when looking for a job.

Second, I would choose electives in areas of weakness. Residency is the time to get to know the different subspecialties and get your hands dirty. The more competent you are in all aspects of radiology, the more desirable you will be for private practices. It behooves the budding radiologist to get to the point of basic competency in as many areas as possible.

The Unconventional Fourth Year Elective Choice

What is the difference between a good and a great radiologist? It’s pretty simple. A good radiologist can generally make the correct imaging calls. A great radiologist can make the right call, understand the call’s deep clinical significance, and predict the subsequent patient outcomes. If I had to redo my residency again, I would choose the unconventional radiology elective approach.  Why? Because correlating imaging with the practical deepens these great clinical radiology qualities.

So, how do you arrange an elective choice such as this? It definitely will take a bit more work on the part of the radiology resident, and you will have to go out of your way to communicate with other specialty directors. Still, it pays to arrange a few weeks or a month rotating on a medical or surgical rotation with correlative imaging.

Example Of The Unconventional Elective Choice

For example, if you are interested in musculoskeletal radiology, I would highly recommend calling the surgical director of orthopedics and ask him/her if you can watch and participate in the clinical workup of patients, orthopedic surgeries, and the subsequent follow-up of patients. Then, when you work up a patient with a medial meniscal tear, you will have seen the surgery and the after-care follow-up of these patients. You will understand how the imaging fits into the equation and the significance of your imaging calls. The learning that you achieve will stick with you for the rest of your radiology career.

I would also recommend washing, rinsing, and repeating. If you can arrange this elective in multiple subspecialties, in whatever specialty area interests you, it would be a highly effective way to have a tremendous diverse overall fourth-year experience that will last a lifetime. Also, you will have clinical knowledge of the imaged patient that most other radiologists do not have.

Final Thoughts About Fourth Year Radiology Electives

The fourth year of radiology residency is a time to explore in more depth the subspecialties that you have encountered during your first three years. Because you are so close to becoming a board-certified practicing radiologist, fourth-year radiology electives take on a vital significance where the learned subjects will make a difference in your clinical practice. So, please pay attention to creating a tremendous fourth-year elective experience. Don’t squander the opportunity!!!

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Hiring Radiology Physician Extenders- Helpful for Residents?

physician extenders

Many radiology practices throughout the country are understaffed and overworked. But, it is not just the attending radiologist that can suffer the consequences of decreased time and increasing workload; it is also the radiology resident. Due to the increased burdens of radiologists, radiology residents may have reduced time to attend conferences. They may also have increased service obligations and less availability to perform procedures. Overall, the psychological stresses of residents to complete the daily work increase every year. One potential solution for the hospital-based radiology practice to improve these conditions is to hire physician extenders. So, I will briefly discuss the types of physician extenders, how programs can utilize them in practice, and finally, how residencies can use physician extenders to improve the residency program.

Types of Physician Extenders

Multiple excellent articles describe the roles of physician extenders. Some of these articles include an Applied Radiology summary called Physician Extenders: Which one is right for you?. Another one is an ACR article called Registered Radiology Assistant/Radiologist Practitioner Assistant. And, then there is a sirweb report called: Position Statement: The Role of Physician Assistants in Interventional Radiology. I highly recommend reading these articles to get the nitty-gritty details of each type of radiology physician extender.

But to summarize, I am going to list the different types and describe each briefly. These include Physician Assistants, Nurse Practitioners, Radiology Practitioner Assistants, and Registered Radiology Assistants. According to the sirweb article, only Physician Assistants and Nurse Practitioners can “order tests, write prescriptions, make diagnoses, and get reimbursed for services performed.” On the other hand, all of these physician extenders, including the Radiology Practitioner Assistants and Registered Radiology Assistants, can perform procedures. So, for a practice that needs more than just procedural help, Radiology Practitioner Assistants and Registered Radiology Assistants may not fit the bill.

How Programs Utilize The Physician Extender?

As I have perused the literature and forums on this topic, I have found that the responsibilities of the Physician Extender to be pretty varied. (1) Most commonly, they tend to work with interventional radiology and help to perform procedures such as Paracentesis, Thoracentesis, and Catheter Placements. But, they can involve themselves in more complex procedures such as Nephrostomy tube placements.

In addition to procedures in many practices, they also take responsibility for preliminarily approving patients for cases, taking patient histories, and getting consents for procedures. And Nurse Practitioners and Physician Assistants can write orders before and after cases. Also, they can create preliminary dictations. In some academic practices, they can even help out with data collection in research studies. So, their practice responsibilities can be beneficial to many different types of educational environments.

Are Physician Extenders Helpful For Residencies?

Do not fear radiology residents. Physician extenders are not here to take over the world!!! For most radiology residencies, the ability of the physician extender to perform such varied work allows the radiology resident and staff to focus on other more critical needed learning issues. These physician extenders are independent but not independent enough to run a department for themselves, so they will never take over the radiologist’s job.

What Can They Do?

At the same time, imagine you are responsible for getting consent during the daytime for all the PICC lines, and for the first time, the practice has introduced a physician extender. Now you can share in the responsibility of obtaining consents. They can write notes on the floors and talk to family members. These activities will allow you and your attendings to concentrate on some of the more advanced work in the department.

In addition, some physician extenders have lots of procedure experience and are excellent teachers. You may have a physician extender who can teach you how to do a PICC line or Portacath when the attending is not directly available. Or, the physician extender can perform procedures such as paracenteses and allow the attending and the resident to take care of other more complicated cases simultaneously.

My Experiences

Although I am not an interventional radiologist, my experiences with physician extenders have also been highly positive. When I was a resident, the practice hired a nurse practitioner, and he helped organize what we called “tube rounds.” It was a time in the morning when we would decide if we needed to pull catheter tubes, keep them in, or recommend other interventions. I learned a lot from both the physician running the “tube rounds” and the nurse practitioner who became adept at taking great clinical histories and understood the patients he followed very well. He also became friendly with many of the clinicians, such as the surgeons and GI doctors. It was a net positive for the medical team and my learning experience. Also, I’m sure he brought in more business for the hospital as well.

Physician Extenders Can Be A Radiologist’s And Residency Program’s Best Friend

In today’s demanding environment, a physician extender can be the right fit for an academic department. The ability of the extender to do procedures, teach, and consult can be a significant benefit for the busy attendings on staff and the residents in the department. Not only can it increase department productivity, but it can significantly increase the morale of the attendings and residents alike. It is a decision that programs and hospitals need to weigh carefully. But for many departments and residency programs, the physician extender brings significant long-term benefits.

(1) J Allied Health. 2015 Winter;44(4):219-24. Radiology Physician Extenders: A Literature Review of the History and Current Roles of Physician Extenders in Medical Imaging.

Sanders VL1, Flanagan J.