Category: Ask The Residency Director

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Disrespect From A Surgical Attending- How To Deal?

disrespect

Question About Disrespect From A Surgical Attending

The Situation

Hello, I am a radiology resident berated by a surgeon with disrespect in the reading room in front of my colleagues and attendings. An outpatient had imaging findings of small bowel obstruction. I sent a secure electronic message via EMR to the aforementioned surgical attending who ordered the CT scan, an unexpected result that could potentially affect management. I did it out of courtesy even though the hospital policy does not include this as a critical diagnosis that radiologists need to convey immediately. My radiology attending signed the report a couple of hours after I had sent the message. 

However, the surgery attending did not see the message/report until later that afternoon and started to ask me via chat if I had contacted the patient or another surgeon. As per my hospital policy, I did not do that because this is not a clinical diagnosis requiring immediate notification to the clinical team, such as a stroke or pulmonary embolism. The surgery attending took the time to come to the reading room soon after. First, he asked me if I was a resident or an attending; when I answered that I was a resident, the surgery attending started to yell at me for not reporting a critical finding directly. He made it sound like the patient was going to the OR urgently (at the conversation time).

Surgical Attending Disrespect, Exaggeration, And Bluster

Furthermore, he was threatening me that the patient could have died due to the delay in communication. Later, I found out that the surgery attending had already spoken with the patient on the phone. The patient felt perfectly fine/refused to go to the ER and would wait until Monday to go to the clinic (documented in the EMR). Even though we caused no harm to the patient, the surgery attending was very contentious. He made a public scene and stated that I did not do enough to communicate this finding in the middle of the reading room. 

Also, if I had not messaged, the surgery attending may not have found out about the SBO until after the weekend, as the patient felt perfectly normal. The surgery attending cared more about displaying her power over a resident. Her display of power was not for resident education. Is a new SBO on an outpatient a critical enough finding to call the patient directly or attempt to reach the inpatient surgical consult within minutes? What do you think is the best course of action to combat what I perceive as bullying and disrespect? Thank you for listening to my long story.

Answer

There are two main issues in your question. First, let’s first start with the facts about small bowel obstruction. Second, I will discuss the reasons for this public display of power and disrespect and the right course of action.

A Little Bit About Small Bowel Obstructions

Small bowel obstructions without other emergent ancillary findings such as portal venous gas, pneumatosis, free air, bowel wall thickening, SMA thrombus, free fluid, or focal fluid collections are typically managed clinically and are not “emergent.” As your hospital policy dictates, this reason is why radiologists do not usually have to make a phone call to the surgeon at your institution. And, you did more than required by sending the text message. 

Additionally, if you are talking about a plain film diagnosis, these findings are even less specific. I can’t tell you how often I have seen a plain film with dilated bowel loops and air-fluid levels. Then, we get a CT scan, only to see not much happening. A CT scan is a lot more specific for the diagnosis but is by no means perfect. 

Nevertheless, in a pure small bowel obstruction without complication, our role is less diagnostic than management-related. Usually, the surgeon wants to know if it is better, worse, or unchanged. This decision tree, along with the surgeon’s clinical assessment, should factor into the equation of whether they need to pursue the case/management further. The surgeon’s responsibility is to look at the plain film or CT scan with or without the radiologist and decide if further steps are necessary. This role is regardless of however the radiologist reads the study.

More About The Surgeon And What To Do

Based on your story, I suspect that the surgeon is at fault for negligence with the patient. And, I believe that the surgeon is transferring her inadequacies onto you. In my history of dealing with surgeons, the least confident ones unnecessarily tend to take their anger out on others. Unfortunately, you were a target because you are “lower” in the hospital hierarchy. This surgeon is trying to feel better about her faults by displaying her power over you.

If this bullying recurs or you feel that it was egregious, I would refer the case to your faculty in a situation like this. It is wholly unprofessional to berate and disrespect anyone in the middle of a public forum such as a reading room. I don’t care if it is a janitor, technologist, resident, or attending.

Also, it would help if you precisely documented what happened with any other witnesses. That way, it takes the situation to a faculty level with some objective facts. The attending staff can then can decide to talk to the surgeon based on the case. Unfortunately, as a resident, you are not in a position to reprimand or talk back to the surgeon.

On the other hand, your faculty can undoubtedly do so. This way, it should not happen again. And, maybe the institution can change this surgeon’s inappropriate behavior.

I would be very interested to know what you have decided to do,

Barry Julius, MD

 

 

 

 

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How Do I Gain Confidence To Read Complex Cases Outside Subspecialty?

confidence

Question About Confidence About Reading Outside Subspecialty

I will be completing a neuro fellowship in one year. Still, my potential job opportunities require that I read everything, including MSK and Body MRI, which I don’t have the confidence about for one reason or the other. I need to learn to read these studies; how do I do this? Would I have to do a second fellowship?

Not quite sure how to proceed!

Answer

Yes, many of the great radiology opportunities indeed involve generalist work with the ability to do your subspecialty (in your case, neuro). And, from my experience, most general radiology practices expect that their neuroradiologists cross over to all sorts of other subspecialties within MRI in addition to the sophisticated neuro cases. So, the big question here is how you get the confidence to read other complex subspecialty cases outside your wheelhouse. And, I believe in your situation, a second fellowship is most likely not the answer. How do I know that? Well, I have already been there.

So, what did I do to ensure that I would feel confident enough to read MSK MRI on the job even though my primary specialty was nucs? During my residency training, I made sure to read extra cases in the modality when I was on site. I accomplished some of this just before my fellowship in nuclear medicine. And, this was in the days just before PACs started. So, it was much harder to do back then.

Nowadays, it’s much more manageable. Start picking up cases from the PACS, read them, and then look at the dictations afterward. This method is a simple way to gain confidence and familiarity with other specialty areas you usually don’t read. You can even do this at your up-and-coming neuro fellowship since most are affiliated with a hospital or outpatient center that does MSK MRI. So, I would try this first. How do I know this will work? Well, it certainly worked for me. I feel reasonably comfortable with reading MRI MSK to this date.

Of course, your confidence will continue to build even after you start working. However, at least you will give yourself a head start if you begin the process. I hate to say it (because I’m not too fond of the ABR jargon), but this skill is what the ABR calls practice-based improvement in a nutshell!

That’s some advice that has worked for me!

Barry Julius, MD

 

 

 

 

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What Are The Best Extracurriculars For Radiology?

extracurriculars

Question About The Best Extracurriculars:

 Hello Dr. Julius. I am an incoming MS1 interested in radiology, and I wondered if you had any recommendations for medical school extracurriculars that radiology residency directors highly value. Having talked to several medical students about their extracurriculars, there seems to be a wide variety of options. I know that I will be swamped in medical school and only have time for a few activities. I would love to know if any extracurriculars would be particularly helpful in preparing me for radiology. Thank you!

 

Answer:

Radiology Relevant Extracurriculars

There are two types of extracurricular activities that radiology program directors like to see. The first are those that are relevant to radiology. These would include research, participating in national radiology specialty conferences, etc. These show a depth of interest in radiology and not just taking a two or 4-week rotation.

Non-Radiology Relevant Extracurriculars 

The second of those extracurriculars that you do that may have nothing whatsoever to do radiology but are something that you have explored profoundly and have been successful performing. It could be music but not just strumming a guitar. Maybe you have played in Carnegie Hall or were doing vocals for a cover band. Or, if it is astronomy, you don’t just look at stars at nighttime. But maybe you are actively involved in searching for new planets and found one that has your name!

I am trying to point out that we like to see that you have other interests outside of radiology that make you not just another number but also an interesting person. And that you want to do things, not just superficially, but will work at it to get better and better. These second sorts of interests are so important because we can sit with you for hours at a time. And, we want to make sure that we will like the person that is by our side and have a person there that will work hard for the residency program. 

The Crux Of The Matter 

So, get involved in some radiology-specific research or organizations if you can. But, also explore things that interest you like to do on the side. Doing too much and mastering nothing does not mean much. But, someone that pursues their interests to the nth degree, now that is special.

Even after all this discussion, more important than all the extracurriculars in the world, is doing well in your medical school and getting good grades for the Dean’s letter and good board scores (correlated with passing the core radiology examination). So, don’t forget about the basics!

 

Good luck,

Barry Julius, MD

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ABNM-ABR Pathway Completed: Do I Need A Breast Fellowship?

abnm-abr

Question About ABNM-ABR Pathway And Breast Fellowship

Hi,

I am a 4th-year radiology resident graduating from the ABR-ABNM 16-month dual certification pathway in June. I matched fellowship in breast imaging starting July. However, I am liking nucs and am considering bagging the breast fellowship and working in nucs.

Can you help me think through if this would be advisable?

Thanks,

Nucs Versus Breast

 

Answer

Dear Nucs Versus Breast,

 

If you are graduating from an excellent ABNM-ABR dual certification program, you have completed a “fellowship.” So, if you can find a job in nuclear medicine or nuclear radiology that you like, I don’t think it would be unreasonable to forgo the breast fellowship. Especially nowadays, the market for all sub-specialist radiologists is excellent (nucs included).

 

However, some breast fellowships rely on their fellows a lot. So, bailing out just before the start of the fellowship year may not be the best way to make strong connections in radiology. Of course, this is especially the case if you have already committed and signed on the dotted line. So, make sure to discuss the issue with the breast fellowship director if that is what you want to do. See if they can find another fellow easily and if it will be a hardship on the program if you decide to leave before starting. But before you do anything, make sure you have a job (with a contract in hand) before you talk to anyone about canceling the breast fellowship!

 

Also, just because you are not doing a breast fellowship doesn’t mean that you can’t practice breast imaging when you leave. I have been reading screening mammos and diagnostic mammos for some time now without a fellowship. And, you will likely have the opportunity to do interventional mammo as well if you want to go in that direction, with or without a fellowship. Completing a fellowship only implies having some additional expertise. It does not mean that other radiologists cannot be excellent breast imagers!

 

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Can I Use Psychiatry As A Clinical Year Before Starting Radiology?

psychiatry

Question About Psychiatry Clinical Year

Hi Dr. Julius,

I initially matched into Psychiatry residency. However, I decided that Psychiatry was not for me and left after an intern year (which included two months of IM wards, one month of outpatient medicine, two months of Neuro, one month of ER, and six months of inpatient Psych) to serve as a GP for four years in the Air Force. I now plan to apply to Radiology. Will I be expected to repeat my intern year?

 

Answer

You posed an interesting dilemma about using psychiatry as a clinical year. If you look at the Radiology ACGME statement, which is as follows:

To be eligible for appointment to the program, residents must have successfully completed a prerequisite year of direct patient care in a program that satisfies the requirements in III.A.2. in emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pediatrics, surgery or surgical specialties, the transitional year, or any combination of these.

This statement does consider psychiatry as an appropriate substitute for an internship year. However, it appears that you did spend a good chunk of the year on clinical care.

So, I would recommend the following: Give the ACGME a call and determine if you could count that year toward the program requirement (especially since you did have substantial non-psych months). On occasion, they do grant exceptions if you could prove that you spent the year performing direct clinical care. It’s worth a try.

If they approve only part of a year, that could be a problem. Why? Because it leaves you with half a year that you still need to complete. It may be hard to find a residency slot to fill up half a year of requirements only. Nevertheless, you never know what they will say. I would be interested to know how it turns out!

Regards,

Barry Julius, MD

 

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What Electives Are The Most Marketable?

marketable

Question About The Most Marketable Electives

Hello Dr. Julius,

I’m having difficulty deciding what electives to do during my last year of radiology residency. I will be doing a fellowship in body imaging, and I’m considering finding a job in a private practice (outpatient, ER, private hospital). I have a total of six electives. I thought of three neuro, two MSK, and one mammo versus three MSK, two Neuro, and one mammo. What would you recommend? What would make me more marketable?

I appreciate your help.

Thanks a lot for all the info you’ve provided us!

 

Answer

 

Your marketability will depend on multiple factors. But, the specific number of each of the rotations you provided is not so critical. More importantly, you should feel comfortable in whatever areas you want to practice when you finish your residency program outside of your fellowship.

For example, you may have done a lot of mammo before coming to fellowship. So, in that case, I would opt to do that elective less. Or, if you are weaker in MSK and are interested in practicing in that area as a radiologist, go for it. Each elective you choose should help you when you leave the academic world and start a real-world radiology job. And, if you want to be more creative, you can check out my previous blog on creating electives as a senior!

Let your experiences and desires to practice different subspecialties dictate which ones you should choose as an elective. At most job interviews, they are usually not going to delve into the details of how many rotations you have done. But they might ask you about mini-fellowships (since they are all the rage!). And they are surely going to ask you what you feel comfortable reading!

 

I hope this helps,

Barry Julius, MD

 

 

 

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Can High Step III USMLE Scores Compensate For A Bad Step I And Step II?

step III

Question About Step III USMLE Scores:

Hello,

Would an excellent Step III score offset bad Step I and Step II scores? My Step I was 226, and my Step II was 219. Thank you!

 

Answer:

You have posted an interesting question. But, first, let’s talk about your scores. Your scores are not in the “bad” category. Typically, at our institution, a score of 226 on Step I can get you a foot in the door for an interview if everything else is OK. The step II score was a bit more marginal. But, the Step I score has shown that you have the potential to pass the core exam.

I agree that if diagnostic radiology becomes more competitive and institutions continue to use them for selection screening, they may slightly raise the bar. (although the score for Step I will be disappearing) That could make your scores not cross the threshold for acceptance for interviews. But, for now, I think many programs would accept those scores.

A Strange Situation Indeed

First of all, what is interesting, strangely enough, is that in the 12 years of working as an associate residency director, I have never seen the situation where both Step I and Step II are below 220 and step III is around 250 or so. And, I think I have a sneaking suspicion why.

First, very few people who score lower than the Step I and Step II thresholds will ever ace the exam in Step III. Additionally, we typically use cut-offs of 220 for either Step I or Step II. So, Step III is usually not on the radar because many residents typically don’t take this exam as “seriously and therefore we, as faculty, don’t either.” Why? Because the folks taking the exam are traditionally interns that don’t have as much time to study for it. So, the scores are not so critical. Instead, typically we care only that the resident has passed the Step III exam.

It’s Not About The Exam Itself

Again, to remind you, I am not a big fan of any of the USMLE exams. However, it is one of a few items that correlate with good core exam outcomes in radiology. And good core exam outcomes affect residency credentialing. So, unfortunately, all this talk about scores has nothing to do with being a good radiologist. Instead, it has only to do with the probability of becoming a board-certified radiologist. And, therefore, we are forced to use these scores as a screening tool for interviews.

Final Determination About Step III

In brief, to answer your question, Step III is the least influential of all the USMLE exams for receiving interviews. An excellent step III score will most likely not compensate for feeble Step I and II scores (which yours are not!)

I hope that answered your question,

Barry Julius, MD

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Considerations For An Internal Medicine Resident That Wants Radiology!

internal mediicine resident

Question From An Internal Medicine Resident:

 Hi,

I am an internal medicine resident and want to switch to radiology. I’m also a DO and didn’t take the USMLE. I realize most programs require the USMLE exams. I am thinking of taking the exams and applying to advanced or R positions or completing an internal medicine residency and applying to radiology as a 2nd residency. What are your thoughts regarding taking the USMLE while in residency and switching residencies? Any words of advice regarding how to get letters of recommendation from radiologists? Thank you

 

Answer:

First issue For An Internal Medicine Resident

I would consider applying to radiology as soon as possible. Why? Because the longer you spend in an internal medicine residency, the more likely medicare won’t fund your entire radiology residency. That can deter residency programs from choosing you when you apply for a radiology residency. So I would not delay. After two years of other residency/internships, you lose a good chunk of funding!

 

Second issue

It would help if you took the USMLE before applying to radiology. Most programs use this as a screening criterion. And you will be screened out of most programs. You should take the USMLE exams if you want to significantly increase your chance of getting into a radiology residency program. It would be best if you took this as soon as you can. The COMLEX just does not hold as much weight in radiology residency circles.

 

Third issue

Letters of recommendations from radiologists are not necessary if you have great letters. Although desirable to have at least one letter from a radiologist, most programs would understand if you do not have access to a radiology program at your institution. The quality of the recommendations counts the most, not the recommending physician (unless it is some famous name somewhere!) Of course, if you can rotate through a radiology department somewhere and get a LOR, that would be good too!

Regards,
Barry Julius, MD
Radsresident.com
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Teaching In Radiology: How Can Residencies Help To Prepare?

teaching in radiology

Question About Teaching In Radiology

Hi Dr. Julius,

I am an MS3 who is planning on going into radiology, have always loved teaching, and want to make it a large part of my career. I was hoping to hear your take on how radiologists can teach and any tips to shape my career with this goal in mind.

 

Answer

“What kind of teaching opportunities do you have?” is a common question that I get from my interview candidates for residency every year. Teaching is a large part of learning in most radiology programs. Almost all programs have some form of teaching opportunities. These may manifest as teaching medical students, junior residents from different specialties rotating through your department, or interdepartmental tumor boards. Regardless, you will find many opportunities to teach.

Community Vs. Academic Teaching In Radiology

So what is the difference between programs and the different teaching opportunities? Well, it comes down to the sort of teaching. More community programs tend to give you less opportunity to teach students because they may not be affiliated with a medical school. Instead, you will have more opportunities to teach technologists, nurses, and fellow physicians. And, the options tend to be less formal. 

On the other hand, academic programs give you more formal opportunities to teach and mentor research projects and other academic members within your residency, such as students, observers, fellows, and more that you would not get at a community program. And, teaching can be in larger forums. The bottom line is that teaching opportunities are not unique to one type of program or another. The styles just depend on your inclinations and your choice of program. 

Stop And Smell The Roses (And Teach!)

I believe that each resident that comes through a program should stop and take the opportunity to teach others. Teaching others reinforces what you know and helps your fellow man or woman. Plus, you wind up hearing or asking questions that you may never have thought about in the first place. These questions make for promising research projects or take you to places that will make you understand ideas more deeply than you ever thought possible. The rewards are invaluable, and the time it takes to do so is relatively negligible. 

Then, when you finish your residency, you can decide for yourself if you want to take more opportunities to teach either in academic or private practice. They are all around you. It’s a matter of what you want to pursue in your career. 

 

My forty-three cents on teaching,

Barry Julius, MD

 

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Postponed COMLEX Due To Covid: What Do I Do?

postponed COMLEX

Question About Postponed COMLEX:

Hello, I am DO third year medical student interested in radiology. However, I worry about the current situation that I put myself in. During this COVID summer, exam dates got thoroughly messed up to the point where my COMLEX was pushed back two times, leaving me with the decision to delay the beginning of my third year to take Step I or to leave it and focus on COMLEX 1. I chose the latter decision because I was thoroughly exhausted from studying due to my postponed COMLEX. Unfortunately, I received a low score and have dug a relatively large hole for myself.

I know that trying to take Steps I, II, and COMLEX 2 is not an option in my third year. But I wanted to ask you if I had to take a year off, would it be worth taking Step 1 since by then it would be a pass/fail exam? And if I did not take Step I and significantly improved on Step 2 and COMLEX 2, what would my chances be for matching into DR after 4th year? What are other things that I can do to optimize my chances of matching right away or, if not, matching after taking a year off?
Best

Answer:

For most programs, the COMLEX exam holds much less weight than the USMLE. If you score well on the USMLE and don’t score so well on the COMLEX, it does not matter as much. That said, if you decide to take the new pass/fail USMLE Step I, the scores for the USMLE Step II become much more important, especially coming from a DO school. So, it will become a much more critical exam to do well on. I would go as far as to say that a good USMLE Step II score will become a requirement for you to get in since programs will most likely use this score as a screening criterion for interviews. (in the past, you only needed Step I.)

Taking a year off to take an exam is a red flag from a program director’s perspective. Why? Because it shows that you may not be able to multitask well. And, radiology residencies involve lots of multitasking. So, if you are taking off an entire year to take exams, it raises lots of questions from a program director’s view. If you decide to take that route, you need to do something else that will add to your CV for getting into a radiology program, such as a relevant radiology research year/fellowship. Taking off a year just to retake the exams would be a disaster for your application.

My two cents,
Barry Julius, MD