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The Art Of Benign Neglect In Radiology

benign neglect

One of the most formidable skills in radiology is the art of benign neglect. Knowing when not to complete a request can be as important as finishing a test rapidly. It is a critical skill to learn in radiology when on call, running a department, or covering a rotation. With benign neglect, what you don’t do right away often resolves itself. It is a powerful tool. Although we usually like to be direct, sometimes, it can improve patient care by decreasing hospital stays and ensuring the patient gets the correct diagnosis and treatment. So, when does it make sense to practice this technique? And, how can you make sure that these requests are changed, tabled, or canceled?

Orders/Requests That Benefit From Benign Neglect

Redundant Orders

Technologists will often come up to you and ask you if an order makes sense at nighttime. For instance, a patient will get an order for a VQ scan with a normal CTA for pulmonary embolus. And, you have to decide whether to call the technologist to perform the study. Yes, there is a remote possibility that the new VQ scan would be positive, but highly unlikely. And the patient will receive more radiation when another test has made the diagnosis. 

Orders With Marginal Utility

Frequently, in fluoroscopy, you will receive an excessive order. For instance, a physician orders an upper GI series for a patient with a history of upper esophageal dysphagia. Usually, performing the upper GI series, which includes the stomach and duodenum, does not make sense when you only need to analyze the swallowing mechanism based on the history. Looking at the duodenum will not add much to the patient’s workup!

Orders That Clinicians Don’t Want But Ask For

In this category, let me give you the example of a patient with a right-sided breast lump but an order for a bilateral mammogram/ultrasound. Reflexively, many clinicians will send a patient in for a workup of a lump with a script for a bilateral mammogram and ultrasound when they only need a workup on one site based on having additional recent studies. Most clinicians don’t necessarily want the workup of the other side, especially when the patient recently had another negative test.

Requests To Look At Ancient Films Without Current Benefit

Especially on call, every once in a while, you will get a request to look at films from 2 weeks earlier because a resident has a research project or presentation. It is very appropriate to ignore these requests when you have a gazillion other tasks to complete that have a meaningful impact on patient care. In fact, by attending to these requests, you would be delaying urgently needed care!

Orders That Will Open A Can Of Worms For The Clinician

Referrers will sometimes order studies that can open up a whole new set of problems for their patient without solving the initial reasons for the order. Let me direct your attention to ordering an MRCP in the case of a patient that has an indeterminate test for cholecystitis on an ultrasound. Instead, the patient needs a hepatobiliary scan to make the diagnosis. First of all, by complying with the order, you may find additional irrelevant findings such as hepatic or adrenal lesions. And, of course, it will not be as specific for diagnosing cholecystitis as a hepatobiliary scan.

Techniques To Be Successful At Benign Neglect

What are some basic techniques to ensure that you are performing benign neglect for good patient care? First, you can table those orders with less significant clinical impact to the end of the shift. This technique works particularly well on a busy night when you have loads of orders and not much time to get them all done. Additionally, delaying a return phone call in the situation of an unreasonable attending can help ensure that the doctor does not place the order in the system. And finally, make sure to limit a study for the right reasons to limit additional exposure to yourself and the patient. 

“Benign Neglect” As A Tool To Achieving Good Radiology Patient Care

With all the redundant orders, requests that don’t make sense, unruly referrers, and time sinks for completing critical patient care; benign neglect is sometimes the best option to ensure a patient gets the best care possible. Sure, it is not optimal. But, it can work to make sure patients receive the proper test at the right time. It’s a tool to consider when others do not work!

 

 

 

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Residency Is Not The Time To Live Far Away!

live far away

It’s about that time of the year. You have recently matched into your internship or are about to move on to your radiology residency. And, it’s time to choose a place to live. You are probably not sure about the areas; many choices await you or your loved ones. Do you move close to your residency where not much happens? Or, do you live in a more cultural part of town? How about living closer to where you and your spouse want to be? How much should you spend? Is the area safe around the hospital where you are going to work? Many of you will face these questions over the next several months as you start your search for a place.

Out of all those questions, what is the most critical decision? Of course, you can stare at the title and probably come up with the conclusion! But, it is true. Make sure to prioritize living reasonably close to your residency site. Let me give you some good reasons for making this a significant priority during residency.

Every Minute On The Road Reduces Your Time To Study And Family Time

Time is one of your most valuable commodities as a radiology resident. You need it to study, spend time with family, and accomplish all the goals you set out to do. However, the farther you decide to live, the less time you will have for fitting all these critical activities into your schedule. Especially when you have very little, to begin with. Does it matter if there are tons of theaters nearby if you can rarely get to them because you need to study for your boards? Probably not!

Paying Up Now To Be Closer May Make The Difference Between Owing More Later!

If living close to the hospital costs more, it may pay for itself eventually. Let me explain. Living far away has many additional costs. Remember you have to factor in other expenses as well. There is the gas price (now at a record high!). And, of course, there is also the price of not passing the boards because you do not have the time to study. So, consider keeping close to the residency program site if you can!

If You Live Far Away, The More Exhausted You Will Be

Trust me. This factor is critical. I used to drive an hour or hour and a half to get back and forth to work. And, you don’t realize the tax that your will body will encounter with all that driving time. Traffic can become very frustrating. And, there is always a risk of getting into an accident late at night when on call.

Moreover, sitting for so long is not so great for you either. It’s a recipe for bad health and exhaustion. You can avoid all this by renting nearby!

More Things To Do, More Distractions!

Perhaps, you will have lots to do when you live in the city’s heart, possibly far from your residency program. But, that may come at the expense of the time you will need to study and participate in the residency program. Distractions can take a toll on the constant need that you will have to learn radiology. So, consider this when you make your final decision about where to live.

Emergencies Happen 

And, finally, of course, invariably, you will have emergencies at work that will happen. Maybe you forget your bag at work. Or, you need to help to cover a colleague. Whatever the case may be, it can be very challenging to take care of these events when you live far from the hospital!

Don’t Live Far Away During Residency!

Residency is a time to hunker down and complete all the requirements you need to succeed in your prospective field. Why jeopardize your future by making it more difficult for yourself now? Living far away can reduce the time for work and life, increase expenses, augment exhaustion and distractions, and make it much more difficult in an emergency. So, if you have to pick the most critical issue about selecting a place to live, it is to live closer to your new job. It will make a world of difference!

 

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Why Was Radiology Significantly More Competitive in 2022?

More Competitive in 2022

So, my midstream 2022 radiology NRMP predictions have come true. I had noticed a significant uptick in the quality of the applications and the interview candidates. And, it looks like it matched what we have found in the national radiology match results. I base this assessment upon seeing all the slots in Radiology filled and the significant increase in American MD seniors filling spots. Radiology has become more competitive in 2022.

But, we have to ask what the real reasons behind this boost in radiology interest are? And, are these results sustainable over the long haul? Let me give you my take on the situation. And, you can decide if you agree. 

The Real First Post Covid Application

Out of all the reasons for the specialty becoming more competitive in 2022, I believe this reason is the most significant. It takes time to apply to ERAS for radiology. The interview process that terminated at the beginning of 2022 began in June of 2021 in ERAS. And the activities that decided the application process began up to a year before that (2020-2021). So, the issues with Covid and medicine had begun to sink in. And, I believe that some residents that would have initially thought about more “front-line” specialties such as Emergency Medicine may have seen the chaos and burnout of its physicians during the time of most intense crisis. This display likely led some applicants to choose a more sustainable and flexible lifestyle without the hassles and hazards of a pandemic. Hence, you can see the significant drop-off in specialties like Emergency Medicine. Where did these applicants go? Well, some of them probably entered the radiology fold!

Increasing Flexibility

Every year, our specialty becomes more flexible. The software and hardware for working at home continue to improve. And, we have more options to work from home and work. If you wish to stay home all the time, you can work in teleradiology. On the other hand, you can enter a partnership for those who want private practice. And then, of course, if you want a lifestyle of flexible hours, corporate radiology may be for you. Whatever the case may be, there is some working environment that can be right for almost anyone that enters the field.

Artificial Intelligence Hype Continues To Decline

I have noticed a steep decline in the optimism by the silicon valley folks that artificial intelligence will take over the radiologist’s job. On my end, very little has changed in the radiology field compared to the hype present 5-10 years ago. The tentacles of artificial intelligence have only slowly infiltrated our specialty. And, I don’t expect so much radical change on this front. This information is most likely trickling down to the applicants as well.

Job Market – A Necessary Ingredient To Be More Competitive In 2022

Of course, a hot job market for radiologists does not hurt. We have been going strong since after the initial phase of the pandemic. And, no one expects any change over the coming years. Nevertheless, the job market in radiology is somewhat cyclical. But, there is no hint that the cycle will end soon. Great job offers abound, and this is what the applicants hear!

The Zoom Effect

Interviewing via a screen is much less time-consuming and expensive than the old-fashioned interview. This process allows applicants to interview in other specialties than what they have considered if they did not have the zoom option. I am sure some of the applicants to radiology decided to interview with us because it is easier than ever before to do so in multiple specialties. Don’t dismiss the influence of zoom!

Radiology Residency- More Competitive In 2022!

So, what does this all mean for the next several years? Given the post-Covid effect, the excellent job market, and the increasing desirability of radiology due to the expanding flexibility, I believe this increase in applications to radiology is justifiable and sustainable for a while. I’m more bullish on radiology, which will most likely turn into the continued increasing numbers and quality of the applications. Of course, I am not a seer, so it is possible for a cyclical change, as we have seen during the Clinton presidency and the Great Recession. But, the boom in residency applications, I believe, will continue!

 

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Losing A Radiology Partnership Track Midstream

radiology partnership track

Imagine this. You have been working hard coming in day after day at the crack of dawn before anyone else starts dictating for years while on the radiology partnership track. And, you leave last. The techs and nurses love you. You answer all their questions with enthusiasm. You are nice to all your colleagues, partners, and non-partners alike. And, you have a family that relies on you to bring home a salary to pay for the house and the kid’s school. Then, one day, suddenly, one of the senior partners enters the workroom and says they need to speak to you. OK. No problem

The senior partner tells you that you are off the radiology partnership track. Unbeknownst to you, a quirky primary referrer is angry about some of the reads you have made over the past year. He threatens to send patients elsewhere if you stay on as a partner. And, the senior partner says as much as the rest of the practice likes your work, your employer has no choice but to discontinue your partnership track. You protest that your work ethic and your dictations are second to none. It doesn’t even move the needle.

This situation or something like it plays out every year at some practice in the country. The reasons for the termination of a partnership can vary widely. Anything from insubordination to malpractice, personality conflicts, or financial reasons can all cause the end. Once you lose partnership tract, you lose several years of your life to a place you have dedicated your time to a job that does not love you back. No matter how you slice it, it is a heart-wrenching situation for the employee. So, if this situation happens to you, what are your options? Which ones can work, and which ones can you avoid? Here are some of my thoughts.

Continue Working At The Practice As A Non-Partner

Usually, this is a short-term solution if at all possible. But, sometimes, you have to continue to work at the site for a bit. You may have a family where you cannot just take up and leave. And, many practices have non-compete clauses that can make it very difficult to pick up and move to another local employer. So, as painful as it may be, it can still be reasonable to work at the site for a while until you are ready to move on and start another job.

Quitting And Moving To Another Place

You will most likely still have loads of opportunities available in this market (as it stands today!). But, you will have to explain what happened at the previous practice to throw you off the partnership track. Many places will continue to allow you to work if you have a reasonable explanation. Most employers know that getting thrown off a partnership track can happen for many reasons, some nonsensical. In many cases, they may be willing to give you another chance.

However, starting another partnership track may not be feasible in certain situations. For instance, if you have one of many red flags, such as losing a partnership track for the fourth time. Or if you have a horrible reputation with poor recommendations from another site. You may need to opt for a nonpartnership job, work in teleradiology, or some corporate gigs in these situations.

Suing The Practice For Damages For Loss Of Radiology Partnership Track

Sometimes, your anger can get the best of you. And, you may not understand why the employer had to let you off the partnership track. Furthermore, all the time and money you put into the partnership track can seem wasted. However, unless egregious, this path does not usually work very well. For one, the contract laws favor the practice. A business can typically hire and fire an employee for multiple reasons. And, it will be tough to prove that not making you a partner has been illegal. Also, the practice will have deeper pockets to protect itself than you will have as a solitary employee. And finally, this pathway can establish you as a non-hirable radiologist because all this can go on the public record. Most practices will think twice about hiring someone who will sue them if they don’t get what they want.

It’s Tough To Lose A Radiology Partnership Track Midstream

Hands down, it is one of the most challenging experiences for radiologists when a practice throws them off of a partnership track. Losing out on time and the energy you put into a job can drain you professionally, emotionally, and physically. 

A partnership is subject to the whim and fancy of multiple factors. So, make sure not to establish roots before you make a partner. And, choose the best option for you and your family when and if the time arises that you don’t make the final cut. A partnership is rarely guaranteed. But, making the right choices afterward can help you move on in the best way possible.

 

 

 

 

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How To Maintain Focus In Radiology While Armageddon Begins

armageddon

We are witnessing a sea change in the world order as hostilities brew between Russia and Ukraine. Additionally, for the first time in over 30 years, we are experiencing a new cold war with the possibility of triggering a nuclear catastrophe. One small wrong move from the NATO allies or Russia can cause Armageddon. It can be as simple as cyber hackers shutting the lights off in Ukraine that accidentally do the same in Poland. Or, perhaps, a rogue pilot can cross into the wrong territory. We have more to worry about in the world than ever before. To top that off, the news and social media constantly bombard us with images and updates. These pictures of desperation can make what we do seem insignificant, especially with news tweets and updates all the time.

Yet, regardless of the catastrophes brewing abroad and the frustrations we experience, what we do as a profession still has meaning to the patients we diagnose and treat and the referrers that order the studies. So how can we keep our cool and concentrate on what we do as a profession without losing focus from the nightmares happening abroad? Here is some essential advice to remember to maintain our focus while the world changes.

We Cannot Control Armageddon In Ukraine But We Can Control What We Do At Home

In Ukraine, Russia, and abroad, what’s going on are events in an ongoing Armageddon that we can’t stop. Elected and unelected politicians on both sides control the reigns. We can make our feelings known about these disasters. But, we can’t do much to stop the flow of these events.

On the other hand, we can control what we do at work to help patients using the tools we have learned in radiology. Regardless of what is happening in the world can continue to provide excellent patient care. And, we make all the findings and diagnoses so that patients are treated well and get better. So, we should continue to do so.

Remember What We Do Helps People

We still provide a valuable service that helps physicians and their patients regardless of the suffering abroad. It can be easy to forget that since some of us provide indirect patient care sitting at a computer and reading films. But, ask almost any one of our clinical friends, and they will tell you that what we do is not insignificant. We diagnose appendicitis and aortic ruptures, potentially saving lives and complications. We should never forget that.

Appreciate Your Situation

We, outside of Ukraine, are fortunate not to be refugees. We are not running away from bombardment and have a job always to return. Sure, the information age connects us to everything in the world. But, it is not on our doorstep right now. And fortunately, we can continue to perform our daily rituals and lives. We need to appreciate how lucky we are.

Donate/Charity

It is still possible to do something about the situation for all the badness happening in Ukraine. If we cannot be there, you can at least support your favorite charities to ensure that you are helping out the victims. Donating can help alleviate some of those feelings of helplessness for the folks in Ukraine.

Maintaining Our Focus While There Is Armageddon In Ukraine

Listening to the horrible stories of millions of people leaving their country under the threat of Armageddon can be difficult. But, if we recognize that we can’t control external factors, realize what we do is essential, and at least donate to the cause, these are some ways to allow us to continue to focus on the critical roles that we serve for the community. Although the situation abroad does not look promising in the short term, let’s hope that our democratic ideals will win out in the end. Time will tell.

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Coping With The Disruptive Study

disruptive study

Ever notice how one or two studies can become the focal point of any night?. Hordes of surgeons, medical specialists, and more come down every fifteen minutes to look at or discuss the case with the radiologist. And, you become the “most popular physician in town.” Sure, it can feel good to be so popular. But, you will find many costs to the disruptive study. On a busy night, you cannot get to the next case. And, the tick-tock of the clock becomes more ominous as the weight of an ungodly list of additional studies piles up. Most critically, you become unable to read everything else. So, how do you prevent a disastrous outcome with unread studies, unhappy doctors, and a nightmarishly long shift? Here are some tips for decreasing the suffering that a disruptive study can cause.

Make Preemptive Phonecalls!

If you know that a case will be “interestingly” positive, make sure to call all the relevant parties beforehand. Although not a guarantee, this polite maneuver will often prevent a group of surgeons or ob/gynecologists from asking you about the case while you are in the middle of dictating something entirely different and complex. Plus, it will make it seem like you are on top of everything.

Don’t Be Ambiguous

Sometimes cases are like magnets to the clinicians because your dictation or what you tell them is not clear. It could be a nodule that you measured as 2 cm in the body of the report, but you stated it was 2 mm in the impression. Or, perhaps, you were not straightforward with your differential diagnosis. Ambiguous reports lead clinicians to find out what is going on by searching for you, especially while dictating something else!

Dictate The Disruptive Study As Quickly As Possible

Cases have a shelf life. If you don’t dictate them on time, the shelf life will end, and you will have a clinician coming down to review the case before you know it, interrupting the workflow for your day. So, as a rule, I try to dictate the “interesting: report as soon as possible. You significantly decrease your colleagues’ chances of stopping you in your tracks.

Tell Your Junior Resident About The Case

Sometimes you are on buddy call or have another radiologist help you out. This opportunity is perfect for teaching your junior resident and then having them go over the case with everyone else! Firstly, this will prepare the resident to learn about a radiological finding or a disease entity. But, it will also teach your junior resident how to go over cases. And the fringe benefit is that you can get the rest of your work done!

Worst Case Scenario- Batten Down The Hatches!

Sometimes the night can get extremely busy. And, you have no time to beat around the bush. As a last resort, sometimes you have to tell the doctors that you are in the middle of doing something else. And that you don’t have the time to go over the study. If you don’t have the time, it’s not cruel to delay a third interpretation of the same case. You do have other cases to read!

The Disruptive Study- Not The End Of The World!

The disruptive study is simply part of our job. Bizarre and challenging cases spark the interest of our colleagues, and they will want to address the issues with you. Nevertheless, we can mitigate the interruptions that it will cause by calling clinicians, increasing clarity, reading cases efficiently, or telling other junior radiologists about them. And worst-case scenario, you can ask them to come back when you are ready. The disruptive study can be painful. But, at least, you have some ways to decrease the potential for it to ruin your whole day!

 

 

 

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Inheriting Other Program’s Problems – The Lateral Residency Transfer

lateral residency transfer

Every once in a while, a program will lose a resident for various reasons. It could be to move closer to family, poor performance, or a gazillion other reasons. When this unfortunate event occurs, a program is stuck trying to fill a spot. And, you would think at first glance that it would be pretty straightforward. I mean, radiology is pretty competitive nowadays. Instead, only a fixed small number of residents can transfer from one PGY3, PGY4, or PGY5 spot to another. And, programs need to be very careful when they recruit these positions. A lateral residency transfer from another residency program can become more problematic than having one less resident in the program.

So, what are the issues that residency programs face when recruiting residents from other programs? And, what kind of transfers are programs looking for? Here are some of my thoughts on these situations.

Lateral Residency Transfer: A Minefield Of Problems

Professionalism Issues

Many applicants from other institutions leave because their former residency program does not want to renew their contracts. Out of those reasons, one of the most common is the professionalism violation. It could be any one of thousands of professionalism infractions, including ethical, moral, and legal issues. Moreover, programs suffer from a lack of information about the resident’s former residency. Frequently, the former site of the applicant doesn’t release “all the information.” So, poor professionalism behaviors can quickly arise again when the resident enters your program.

Academic Issues

In addition to the professionalism issue, many lateral transfer residents cannot academically make it through their current program. Perhaps, it is related to test-taking skills, dictations, or inability to make the findings. If you hire them without knowing the real issues, these same issues will eventually surface when they transfer to your program.

Medical/Mental Health Issues That Can Interfere With Training

We also have to worry about medical and mental health problems interfering with resident training. Notably, this information can be complicated to retrieve because it is a HIPAA violation for a program to give this information out to another freely. And although programs make every attempt to overcome these issues, it can lead to all sorts of problems for both the incoming resident and their colleagues who need to cover them.

The Fickle Resident

Finally, some residents leave because they spontaneously want to abandon their former program for various unstable reasons. These include dating scenes, being in a warmer climate, or myriad other miscellaneous reasons. This sort of resident can decide to do the same when entering your program. Not a great situation!

What Programs Want From A Lateral Residency Transfer

Residents That Need To Leave To Be Closer To Family

Sometimes residents will have a sick relative, and they need to care for them. Or, they have a wife and children who live in a different country than their current residency program. These reasons are legitimate. And, they make for a happier resident that will be more likely to complete the radiology residency.

Particular Interests That The Former Residency Cannot Satisfy

Other times residents discover they have different interests that one residency cannot meet. Perhaps, they are interested in participating in bench research not available to them at their current site. Or, maybe the new site has a PET-MRI, which is the resident’s area of interest. Regardless, these reasons can be valid as to why the resident may want to come to your program.

Legitimate Medical Issues That Will Not Interfere With Training

Some residents need to be closer to certain cities/hospitals to get their treatment. And, perhaps, it is not available at the current institution/town. Or they need the care of family members to help them with health issues. These residents can potentially become a great asset to a new program if they meet its demands.

A Real Change Of Heart For The Lateral Residency Transfer

In medicine, it is effortless to make a mistake. We don’t necessarily know what we want to do when we get out of medical school. Medical schools do not give the best sampling of what life is like post-medical school in all specialties. And, many residents realize they made a mistake early on. Sometimes nuclear medicine residents or emergency medicine residents who have completed imaging rotations can qualify for these more advanced positions. Well, these sorts of residents can become the best trainees because of their dedication to doing something they want to do instead.

The Lateral Residency Transfer Can Be A Tough Situation!

Due to all the pitfalls and possibilities that a lateral transfer can offer, it can be challenging to cull residents that will fit the new program’s culture and meet the demands and rigorous tests of residency. Selecting residents with professional/academic violations, medical issues, or the fickle resident can throw a wrench in the new residency program when similar problems arise in the new program. And this situation can be worse than not recruiting any radiology resident. But, many residents have valid reasons for changing programs as well. So, residency programs, just like the residents, need to do their due diligence. The consequences of picking the wrong resident can be dire!

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Calcium Scoring CT Scans- Are They Worth The Risk?

calcium scoring

I am not a cardiovascular radiologist by any stretch of the imagination. However, I read lots of cardiac calcium scoring studies. And, a good chunk of the time, when I read these studies, I find all sorts of other issues. It may be a pulmonary nodule, a liver or renal lesion, or an adrenal nodule. Regardless, I see too many of these ancillary findings.

Why do all these incidental findings matter? Well, I have a sneaking suspicion that most of us don’t have a handle on the actual risks to this study. So, my question for today is, do these ancillary issues supersede the potential benefits of getting a cardiac calcium study. What are the complications of receiving this scan? And, what does the current literature say about how these “incidental” findings alter the actual risks of receiving this examination.

Calcium Scoring And Incidental Findings

If you want to read an excellent paper on the topic, look at the AJR article called Incidental Extracardiac Findings at Coronary CT: Clinical and Economic Impact. To summarize, around 43 percent of patients receiving this study had some form of incidental findings. And in 52 percent of these patients, the author deemed these findings significant. So, if we do the math, 22% (0.42 x 0.52= 0.22) of the time we read these studies, we will find a significant incidental finding.

Now, in my experience, this number sounds about right. I find pulmonary nodules and hepatic cysts all the time with an occasional smattering of all other sorts of problems. And, I hate recommending the Fleishner criteria and ultrasounds to follow up these studies. Why? Because I know that they will lead to undue additional radiation, procedures, and other complications that we have not even thought about most of the time. And these issues don’t even include the untold psychological tax for each patient with an incidental finding.

Moreover, other patients may even have higher numbers of incidental findings. Check out this paper on diabetics and incidental findings, and you’ll see what I mean. How do we deal with these subsets of the population getting these studies?

And, then, of course, the number of incidental findings depends on the field of view. Some scans use a wider field of view than others which logically should pick up more incidental findings. I always think that if I had to have this test, I would want to receive one with a smaller field of view to decrease the possibility of the incidental finding!

What Is The Real Complication Rate Of Incidental Findings?

At this point, my research on this topic gets a little bit dicey. Unfortunately, I have not found quality information that reports on the actual complications of incidental findings of a relatively healthy person that receives a Cardiac Calcium Scoring CT scan.

Instead, I find myself having to turn to personal stories of relatively healthy patients that had issues with some of these incidental findings. I know one relatively young patient with a remote history of non-metastatic superficial melanoma who had multiple pulmonary nodules. The interpreting radiologist read them as significant enough to be suspicious for malignancy. The patient felt fine, but the surgeon wanted a VATS. Fortunately, the patient’s doctor canceled the surgery and allowed the patient to follow up with serial short-term chest CT scans. The nodules turned out benign!

Or, I think about a breast nodule that a radiologist found that turned out to be a small benign fibroadenoma. The patient had a significant workup with a slightly complicated course of bleeding. It may have gone unnoticed if not for the calcium scoring CT scan.

I am sure these individual cases are just the tip of the proverbial iceberg. Now, you may point out that we do find all sorts of lung cancers, metastatic disease, cirrhosis, and other diseases that may have some benefit of making findings early on a calcium-scoring CT scan. And, I can give you a few of those stories as well. However, these tend to be in a sicker population. Moreover, from my experience, these are a significant minority of cases compared to the world of the benign incidental findings on a Calcium scoring CT scan.

What Do You Say To Colleagues And Patients That Want To Get A Calcium Scoring Study?

Because the hardcore truth about complications and Calcium scoring is not out there yet, here is what I tend to tell relatively healthy patients. First, make sure that you have the risk factors to support receiving this test. As I described above, the complications are not benign. Second, if you think it is worthwhile and will change medical management, make sure to find an institution that uses a small field of view that encompasses less adjacent anatomy. There are many different protocols so that they can make a difference. And, then finally, if the radiologist discovers an incidental finding unless it is glaringly problematic, make sure to take a conservative approach if reasonably possible.

If you receive the test, we can’t undo the incidental finding. But, at least, you are aware of some of its risks and can mitigate some of the problems you may encounter!

 

 

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DO Or Foreign MD- Which One Is Better For Radiology?

foreign md

Each specialty looks for different skill sets and activities when selecting candidates for residency. As part of an admissions committee, institutions scour dean’s letters, recommendations, board scores, volunteer activities, and more to ensure that the candidate makes it through rigorous residencies. However, one of the most “in-your-face” factors that most residencies cannot overlook is the degree applicants have completed. Yes, it is a soft criterion because a suitable candidate can graduate from most foreign MD programs or DO institutions in the United States. Nevertheless, it can become an issue, especially when the committee is not sure of the quality of the medical school.

So, for radiology residency specifically, which degree stands out as the best for applicants? And, which one gives them the best chance of getting into a radiology residency program? I will break down the different degrees into Caribbean MD, Other Foreign MD, and DO schools to accomplish this feat. For each, I will give you the insider advantages and disadvantages. Then, I will provide you with my opinion of the rank order based on the objective facts of each degree.

Top Tier Caribbean MD Schools

Within the Caribbean MD schools, there are undoubtedly several tiers. First of all, we know the quality of St George’s institution since we have had a relationship with them in the past. And, we know that a top student from this school performs at the level of most United States medical schools as we see in our program. Moreover, many other program directors feel the same way from what I have heard. Unfortunately, many medical schools nowadays are biased against Caribbean graduates, even St. George. Many large prestigious academic institutions won’t even touch one of these applications unless the applicant is an exception to the rule.

Furthermore, with the AOA (American Osteopathic Association) combination with the ACGME (Accreditation College For Graduate Medical Education), having a DO degree is no longer a disadvantage for getting a residency. DO residents no longer have to complete separate osteopathic internships and osteopathic accredited residencies. So, Caribbean residents have more competition than ever before to get into ACGME accredited residencies. But, at least, the Caribbean schools with a known reputation can help these applicants secure a spot.

And then finally, the new Step I board pass/fail non-scoring criteria will prevent radiology residency programs from assessing incoming students’ test-taking acumen, which correlates with passing the radiology boards. Therefore, residencies will be more wary of accepting a Caribbean student, even from a top-tier program, especially without knowing if they are a good test taker.

Other Foreign MD Schools

For other foreign MD programs, residencies have the same problems. It’s a problem of familiarity. What does a degree from a Taiwanese, Indian, or Iranian institution mean? This problem is even more complicated than the top-tier Caribbean schools (where we are more familiar). How do we know how students compare to United States schools that graduate? Perhaps, a few institutions do break this mold. But for the most part, we cannot figure out where a candidate stands. Nor do we have the time and energy to tease that out. Primarily, we don’t need to when programs have so many excellent United States candidates to choose from nowadays.

Additionally, the ACGME combining the AOA and the new Step I board pass-fail criteria will make it much more difficult for these students to secure a radiology residency slot due to the increased competition.

DO Schools

Today, many MD radiology residency programs still have a bias against DO candidates, especially at larger academic institutions. Nevertheless, all DO schools must meet the same criteria as MD schools since the AOA and the ACGME have combined into one organization. Therefore, even at the most questionable United States DO institution, theoretically, we should know the baseline training of the medical student applicant. We cannot receive this same assurance from a foreign graduate school.

Moreover, getting rid of the Step I board scores will have a negligible effect on these applicants. Why? Because we have an idea of the baseline quality of these US accredited schools.

So, What’s The Final Ranking Of DO AND Foreign MD Degrees For 2022?

From best to worst chance of securing a radiology residency spot:

  1. DO Schools
  2. Top Tier Caribbean MD Schools
  3. Other Foreign MD Schools

 Just a few words of advice, because you may have graduated from a lesser-known foreign medical school does not mean you have no shot of acquiring a radiology residency. And, if you are coming from a top-tier United States medical school, it does not mean you are guaranteed a spot. But, the type of program you are coming from influences the chances of getting in. You were wondering about probabilities, right?

 

 

 

 

 

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Should Radiology Residents Have Workstations At Home?

workstations

One of the most significant changes in radiology in the post-Covid age is the ability for radiologists to “telecommute” to work. The pandemic has hastened the adoption of these technologies, not just for teleradiologists but for almost every practicing radiologist. Nevertheless, most radiology residents still cannot read from home workstations (although I have heard of a few).

So, is it a good idea for residents to have workstations at home? Well, I will go through some of the pros and cons of home workstations for residents. And, then I will give you my conclusion for which if any residents should have workstations from home.

Reasons For Residents To Not Have Workstations

Need Real-Time Consultations To Learn

My best teaching situations are routine phone calls and visits from our physician colleagues at the workstation. And when a resident takes these consults, they are most likely to learn how to practice and communicate in radiology. Working from home decreases these potential connections to the daily consultations that radiology residents will receive.

“No Real Time Teaching”

Especially for first-year residents, there is no substitute for sitting with an attending at a workstation for a bit to learn radiology. Yes, it is possible to make phone calls to your faculty to go over the images. But, usually, only after you have seen the case and without a faculty member by your side. So, you lose out on many teachable moments to learn about normal findings or ask miscellaneous questions on all the cases you see. These questions can be the most thought-provoking.

Reading In A Bubble

Yes. You need to make independent decisions and read by yourself eventually. But, when you are at the institution reading, you can more easily recruit the help of nurses, technologists, faculty, and more. It is much easier to talk to the ultrasound technologists about patients’ histories in person who just completed a case than to catch staff on the phone somewhere. Ancillary staff and fellow physicians add critical information to your findings and interpretations.

Expense

It is a significant additional expense for institutions to allow residents to read from home. Workstations can run in price from thousands to tens of thousands of dollars. And Medicare only indirectly reimburses for resident dictations, so it has low perceived value for the institutions. Therefore, resident workstations can theoretically increase the cost of healthcare.

Reasons To Have Workstations

Sick Residents

Residents get sick just like everyone else. And, sometimes, it’s a mild bug (or even Covid!). Most residents don’t want to infect everyone else. Yet, they still may have the ability and desire to work. Well, with a home workstation, that is still possible. Having a workstation from home opens the possibility of continuing to learn and read without having to take a day off!

Looking Up And Reading Cases Off-Hours

Sometimes, you just want to look at actual cases at any hour. Maybe, it was an interesting case from the day. Or, you just want to learn more about a particular subspecialty, say MR MSK. For that matter, residents (and faculty) are much more likely to learn about these cases and subjects on off hours if they can look them up quickly at home. That power can undoubtedly add to resident education.

More Accessible To Prepare Interdisciplinary Presentations

We often see residents scrambling to get all the cases they need for the next tumor board during the day. This process can often interfere with daily work. If you have a workstation at home, there is no excuse for doing these activities off-hours when you are home. It’s much easier to complete when you don’t have to go to the hospital.

Is It Worth It For Radiology Residents To Get Workstations?

I am certainly one of the biggest proponents for onsite learning as a faculty member. Based on the many reasons above, such as real-time teaching, I tend to learn more when sitting at the hospital surrounded by colleagues instead of reading cases from home. Something about being present with others enhances the learning process. And that is one of the main reasons residents do a radiology residency, to learn.

Nevertheless, there is no denying that the flexibility of home workstations can also help when a “traditional” learning environment is unavailable, whether due to sickness or after-hours work. So, I am not against residents having home workstations if the institution can afford to pay for it. But, home workstations should not replace the residency experience. Instead, workstations can supplement the learning environment for the resident. As an add-on tool, it’s not a bad idea!