Category: Ask The Residency Director

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Will Mini-Fellowships Replace Fellowships?

mini-fellowships

Question About Fellowships And Mini-Fellowships:

Hello,

Why is it that it is practically required to do a fellowship these days? Is there no value in being a general radiologist?

With many residency programs now moving towards offering “mini-fellowships” at the end of R4, could this trend change?

Sincerely,

Future Radiologist

Answer:

As you hinted, fellowships are not technically required, but they are very desirable. Why? Because most groups want someone that can help out with the studies that most others in groups cannot do. It could be interventional work, breast MRI biopsies, or high-end neuro cases. However, groups also want radiologists to be able to perform some general work. So, having the accompanying skill set of a general radiologist is very desirable. These are the most wanted radiologists, and you can call these sorts of radiologists generalists even though they have a specialty skill set. You will be sure to find an excellent job in this situation.

However, it is still possible to find work without a fellowship as a true general radiologist, especially in less popular places such as rural places in the USA. Herein lies the problem: If and when the job market changes, having no fellowship can put you in a bind if you decide you want to leave and find a job in more competitive parts of the country. So, my recommendation is always to do a fellowship just in case. It is for only one year.

Finally, mini-fellowships in a residency are excellent opportunities. But, they usually don’t provide the same in-depth dive into the subspecialty as a true fellowship. Usually, the mini-fellowship also lasts several months instead of a full year. So, I don’t see the trend of completing a full year fellowship changing so fast with the advent of these mini-fellowships. Furthermore, mini-fellowships have been around for five or more years. And, full fellowships remain much more desirable for practices than a few mini-fellowships during residency. Once again, if the job market changes and you only have mini-fellowships, you will be at a disadvantage. 

Great question,

Barry Julius, MD

 

 

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How To Keep Up The Momentum For Residency?

momentum

 

Question About Maintaining Momentum For Residency

Hi Dr. Julius,

I’m a first-year DO, and I am just finishing up the final exams for the first term. I’ve done very well so far and am on track to be near the top of the class, if not first (Though it is just the first term, much can change). I’ve had a strong interest in radiology before medical school, much of it due to my physics background as an undergrad.

I wanted to ask, how can I keep the ball rolling to make for a successful radiology application? I’ve heard conflicting answers about research. Some say that research isn’t as important in the eyes of PDs, but most of that advice I hear is towards MD candidates and may not necessarily apply to me.

I have two publications from undergraduate in my specialty field of physics. Still, I am a little lost on finding opportunities in radiology research, given that my school does not have a radiology department. Is it unprofessional to reach out to nearby departments to see if residents have any ongoing projects?

The Momentum Chaser

Answer About Maintaining The Momentum:

Hi Momentum Chaser,

I’m glad to hear that you are starting your medical school on the right foot. However, remember that the first couple of years are very different from your school’s clinical portion. Many students who do well during the first two years do not repeat the same grades when they make it to the clinical years when the medical school evaluates you on some of your softer skills. (Although some do) So, try to play nice in the sandbox to keep the momentum when you get to your clinical years!

Importance Of Research For Residency

Regarding research, the importance of it to residency programs differs widely depending on where you apply. And, I don’t believe it changes anything if you are DO or an MD. Some highly academic programs rely on their residents performing research during the four-year residency program. So, a Mass General type of program is going to want to see lots of research. On the other hand, a community program will not care to the same extent about the research you have conducted already. They will worry a lot more about having a good quality clinical resident. Specifically, they want one that can handle the overnight call and the residency workload. So, the answer to your question about the importance of research is it depends.

What To Do If Your School Doesn’t Have Radiology Research Opportunities

To answer your last question, it is certainly appropriate to ask other departments within your school or other sites for ongoing research opportunities. You may also want to consider finding a project within your school that may overlap with radiology, although not radiology specific. For example, there may be an internal medicine project that requires some imaging. I mention this because it can be more challenging to find projects outside your institution (although possible). To also answer your question, it is also professional and appropriate to ask about projects in nearby departments. It may be helpful to continue the momentum for your application and career!

I hope that helps a bit,

Barry Julius, MD

 

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What Is The Difference Between Categorical And Advanced Radiology Positions?

categorical and advanced radiology positions

Question About Categorical And Advanced Radiology Positions:

Dear Dr. Julius,

I wasn’t sure of the difference between categorical and advanced radiology positions. What should I tell the applicants this year? Could you let me know the differences?

A Confused Program Coordinator

 

Answer:

For some reason, I have been receiving this question about categorical and advanced radiology positions a lot this year. Perhaps, it has something to do with how ERAS lists our residency program on its website. In any case, I had to look it up to make sure to give you the correct answer!

Definitions

First of all, some of you know that an Advanced residency, according to ERAS, is any residency that begins after the postgraduate one year. On the other hand, a categorical residency is any residency that begins at PGY-1 year. This categorical spot must continue for subsequent years until the end of the training. 

In this situation, how is it possible for some radiology programs to have a categorical spot when radiology training begins during the PGY-2 year? Well, some radiology programs have an affiliated prelim year at the same institution. And, usually, there is some form of agreement between the two programs. This combined prelim year could be any of the approved PGY-1 slots for radiology, including Prelim surgery, Prelim medicine, transitional year, etc. Therefore, if you are not applying to the prelim spot at the same institution, you should not apply for a categorical slot in radiology.

If Interested In A Prelim Spot At The Same Place As Radiology Residency, Ask!

Also, if you are interested in completing the PGY-1 year at the same institution as the radiology residency, make sure to ask the radiology program director if they have a categorical connection with the same institution’s prelim year. Some do, and others don’t. If they do, sometimes the radiology residency can make a phone call to the prelim program. In this case, this connection can give you a better shot of getting the prelim year slot at the same institution. Why? Because programs want to make sure that you will have an ACGME accredited prelim year before starting residency. Likewise, it’s harder to ensure that outside the institution.

However, if you apply to prelim and radiology spots at the same institution, you may or not be applying to a categorical position! It all depends on the residencies and agreement among the programs. Bottom line, make sure to check with the program director or the graduate medical education office.

Hopefully, you now know what you need to know about categorical and advanced positions!

 

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Failed Course And Switched Schools: Is It Possible To Get Into Radiology Residency ?

course failure

Question About Failed Course And Acceptance To Radiology Residency:

 

Hello Dr. Julius,
I am an applicant for this year’s DR residency cycle. I’m in a unique position and would value your opinion. I began medical school at a DO program but am now graduating from a foreign MD program. In essence, I was not able to satisfactorily perform osteopathic manipulations. And, I couldn’t pass the final lab at the end of year 2. Instead of repeating the year, I transferred to an offshore school with US-based rotations on my original four-year timeline for graduating.

Nonetheless, I have otherwise satisfactory pre-clinical grades, clerkship scores, and decent board exams, without any other failures or professionalism concerns. My failure of the class and switching school is a large red flag in my profile. I’m very candid about all of this in my application but would like to know your initial impression as a program director if this scenario came across your desk.

Thanks for your time!

 

Answer:

Unfortunately, I have to say that you will have an uphill battle after your failed course, not to say that getting into residency is impossible. One of the red flags that most radiology residencies look for is why you have changed schools. And, if you couldn’t pass a particular class, most residencies will want to know why.

In radiology residency, you will need to perform procedures in interventional radiology and body imaging. You will need to develop a reasonable explanation of why you can perform these technical procedures competently even though you had a failed course of osteopathic manipulation. Maybe, you can demonstrate that you performed well in another technically based rotation and get recommendations in that area. That would certainly help your case. Nevertheless, your goal should be to explain to residencies why you can safely complete procedures, especially since that seems to be the reason why you were unable to complete your DO degree.

Hope that helps a bit,
Barry Julius, MD

 

 

 

 

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Pros And Cons Of Emergency Radiology!

emergency radiology

Question About Emergency Radiology:

 

Hi Dr. Julius. I have recently developed an interest in trauma radiology. I like it because I would get to work from anywhere. And, I don’t have to deal with patients and people in general, aka no tumor boards (I’m an introvert). Moreover, I read somewhere that there is a significant demand for fellowship-trained emergency radiologists. The salary is on par with other specialties, although I don’t understand how they can track RVUs for an emergency radiologist. I was wondering if you can discuss the CONS of the job. I know it is a one-week night float system with two weeks off (which I love). The night shifts are long, from 10 to 12-hour shifts. Maybe malpractice is higher? But I am not able to think of any other CONS. My ideal job would be a private practice in a suburban area (not in a big city). Would you recommend doing a dedicated emergency radiology fellowship or instead do an MSK/Neuro fellowship focused on emergency? The residency I am in gives an EXCELLENT exposure to body trauma causes.

Kind regards.

Answer:

So, what do I think about emergency/trauma radiology? Well, to start, let’s first say that the job can vary widely from one worksite to another. If you are doing teleradiology ER work, that is very different from an in-house radiologist. To say that it is an excellent job for an introvert also depends on what your job entails. I know some trauma radiology jobs that need extroverts to present cases to the emergency department, highlight their research, or examine patients!.

Night Work

Night shifts can be a bummer for some folks. (I found it a little quiet and depressing during my residency) For others, it can be the ultimate in convenience (imagine being able to go shopping at 11 AM when no one is there!). 

My Take On Emergency Radiology

Although what floats your boat can differ widely between you and me, I never really had a craving for trauma type cases. I found them a bit more repetitive than cancer or a rare disease. But, I came from a level one trauma center during my residency, so I had extensive exposure to the trauma experience (perhaps too much!)

Fellowships For Emergency Radiology

Regarding what to study to become an emergency radiologist, I would consider the MSK/Neuro route. Why? Because it gives you a bit more flexibility when you go out and find a job. You can become an emergency radiologist with those specialties under your belt. But, you can do other work in general radiology and some subspecialty work as well. From my experience, trauma radiology is more comfortable to practice, and almost anyone can do it. On the other hand, Neuro and MSK work is a bit more subspecialized, so I like that option as a fellowship a little bit better. (unless you want to do academic ER radiology as a career choice.)

 

Those are some of my random musings about emergency radiology!

 

Regards,

Barry Julius, MD

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Thinking About Owning An Imaging Center? Tread Carefully!

owning an imaging center

Question About Owning An Imaging Center

 

Hi Barry, I received a call from a group of radiologists looking to sell an imaging center. We are a primary care group of 20 PCP’s. Can you direct me to resources to better understand the current pros and cons of owning an imaging center?

Thanks, 

Opportunity Knocks

 

 

Answer:

That is an excellent question!

Although I don’t own an imaging center myself, I can tell you some of the general pros and cons of owning one, having worked in many during my working lifetime.

Owning an imaging center is essentially like owning a second business. You will be responsible for a large team of employees. And, you will be critical to managing the property itself, whether it’s rented or owned. Moreover, you will collect the full payments from insurance companies, Medicare, Medicaid, and self-payers. Unfortunately, the reimbursements for current procedures continually drop over time, so you have to expect to provide some wiggle room when you purchase buildings and equipment. Be very careful not to overspend.

Furthermore, you need to run an efficient team or know how to find someone to run an efficient team. If not, your competitors down the street will run you out of business. It is not good enough to want to run an imaging center. Instead, you need to know the intricacies of how to run an imaging center. It is never has been and never will be a sure thing. (As many physicians think before owning one!)

And it isn’t straightforward. These skills include knowing how to negotiate with insurance companies, understanding how to get patients on and off the table quickly, when to provide new procedures/modalities, how to get your radiologists to work efficiently, and what furniture offers the best outcomes for patients. Therefore, your team needs to be extremely knowledgeable and experienced. Don’t just go into the process, thinking that you know what you need to do! Most importantly, why do you think you can run a better center than the radiologists that came before you?

That said, there is a reward if you can manage the most efficient/well-run practice in town. If not, I would stay out of the imaging centers’ business because it is very competitive, and the margins are tight.

If you want to find out more about running an imaging center, you can go to the ACR website, and they will provide you information and courses on how to run a practice. While you are there, check out the Radiology Leadership Institute, where they have entire classes on this subject. You might want to consider that as well.

 

Hope that helps,

Barry Julius, MD

 

tomatoes

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Is Nuclear Medicine A Dying Field?

dying field

Question About Nuclear Medicine As A Dying Field:

Hi Dr. Julius!

What is the future of nuclear radiology? I have seen some programs that offer dual certification pathways within their DR residencies. Is that worth it? I’ve also heard it’s a bit of a dying field, thoughts?

Also, is therapeutic nuclear radiology becoming a feasible pathway for radiology grads? On paper, it sounds fantastic to use radionucleotides to not only diagnose but also treat patients.

Thank you!

Answer:

Once again, an excellent question from one of my readers!

Well, I have a lot of opinions on this topic since I am first and foremost a nuclear radiologist. And I am happy to share them with you!

Nuclear Medicine History/Background

You first have to start by understanding the history of the specialty. Nuclear medicine is one of the oldest subspecialties in radiology. It came about before ultrasound and was once the only other high tech modality for radiologists other than x-rays. So, back in the old days, probably around 50 years ago or so, a lot of really smart radiologist went into the field. And, at that time, the area was distinct from the rest of the radiology field. So, they formed a separate board society and training programs “unattached” to radiology residency in addition to a fellowship after residency. Fast forward to our time, and you have a bit of a mess. Most applicants to nuclear medicine would prefer to get into radiology because you can do so much more. You have much better job prospects because the radiology training is so much more diverse.

The Split

But, this current organization of two separate radiology and nuclear medicine creates a problem. Generally, the folks that are only nuclear medicine need more to do than just reading nuclear medicine studies during the daytime. Most practices do not have enough work to support a nuclear radiologist. So, enter the new dichotomy. There are those nuclear medicine physicians who train primarily in radiology that, in general, prefer to do the diagnostic radiology work along with diagnostic nuclear medicine. And then, some are only nuclear medicine trained that need to create a new livelihood for themselves. And one of those areas is the realm of nuclear medicine treatment. In general, right now, these procedures do not pay well and are very time-consuming. However, these nuclear medicine physicians provide an essential service by administering the radioactive pharmaceuticals and following up the patients over time.

I believe in the future; the specialty will split into these two entities- diagnostics and treatment- because of the current mechanics of reimbursement and what procedures that nuclear medicine docs and nuclear radiologists can perform.

Is Nuclear Medicine A Dying Field?

Finally, to complete the answer to your question, diagnostic and therapeutic nuclear medicine are very active in research and new radiopharmaceuticals coming in for clinical use. So, nuclear medicine is certainly not a dying field. But, who performs what is changing. Of course, there is some overlap. For instance, I perform radioactive iodine treatments and do pretty much all diagnostics. But, I don’t do any of the Lutithera or Xofigo treatments or others available to the public. And, there are all variations in between. Nevertheless, nuclear medicine is an excellent specialty for someone who wants an exciting radiology subspecialty and likes to practice general radiology (Which is what I do!)

That is my long-winded answer to your question (I could have even gone on for longer but had to stop somewhere!)

Dr. Barry Julius

By the way, for those of you interested in a book for nuclear medicine, I would highly recommend the Mettler book. I used it to study for my recertification examination! (I am an Amazon affiliate and receive a commission)

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How Do I Find Hybrid Model Radiology Practices?

hybrid model radiology practices

Question About Hybrid Model Radiology Practices

 

Hi,

I just read the “Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money“?“. I am interested in the hybrid model for the same reason you mentioned and I love money :-). Also, I love teaching the residents. But I am not big on research, publishing, etc.

But I do not have any idea, and I do not seem to find any information about the hybrid model. Is it a rare breed? I am a PGY4 resident and working in one of the hybrid model radiology group led residency training on the East coast.

Any ideas about some of the hybrid radiology groups along the east coast or anywhere in the US?

Answer

 

Great question!

 

There are probably more hybrid model radiology type jobs than you might think at first glance. However, not enough such that it can potentially limit you when it comes to living circumstances/location. You may need to be flexible on where you eventually want to settle down if this is the type of practice you want. It worked out well for me at Saint Barnabas in New Jersey (Imaging Consultants of Essex), and it happened to be in a place that I wanted to live.

If I were to start looking for places with a hybrid business model, I would start by looking at community residencies throughout the country. Or, you can look at “minor” affiliate hospitals that have residents rotating through the department. These sorts of programs are more likely to house hybrid model radiology practices as well. Not all of these are private practices; however, Some will be hospital run practices, and others will be purely academic.

You can certainly give these folks a call and find out what kind of business model they follow. I believe that this sorting method will provide you with the most excellent chance of finding hybrid type practices. Like your residency, my old stomping grounds at Brown University/Rhode Island Hospital used to be a hybrid model practice. But, I think it has changed to more of a hospital-based imaging practice if I am not mistaken. Unfortunately, some of these hybrid practices have become hospital-owned for a myriad of reasons.

 Regardless, try this method out. I think it will help you find some of these sorts of practices.

 

Regards,

Barry Julius, MD

 

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Non-Traditional Student: A Disadvantage For Radiology Residency Application?

non-traditional

Non-Traditional Student Question:

 Hello, Dr. Julius!

My question is regarding the perception of non-traditional medical students during the radiology residency match process. I am a current MD student who is ten years older than the average admission statistic for my school with class rank and scores well within the published ranges for a successful match. Should I expect my non-traditional status to be an extra hurdle during residency interviews? If so, what advice can you offer to help ease residency directors’ concerns? Also, would you recommend addressing it in my personal statement?

Your thoughts on the subject would be much appreciated!

Regards,

Non-Traditional Student

 

Answer:

From my experience and I believe from most program directors’ experiences, your older age will be a plus at application time. I have found that non-traditional applicants tend to be more mature, precisely know what they want, and are more conscientious than their younger peers. Additionally, they tend to become less distracted by the minutia of a residency and are more goal-driven. You should never apologize for your additional years of wisdom. Instead, embrace it.

When you write your personal statement, you should expound on your vast experiences that a younger resident does not have. Remember, also, to check out my blog called How To Create A Killer Radiology Personal Statement. Honestly, though, I would not worry about your age either when you write your personal statement or at the interview time. If this was an average job on the street, age could be a detriment. But, in the world of radiology,  it is a plus, not a minus!

 

Respectfully,

Barry Julius, MD

 

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How Can I Prevent Low Imaging Volumes From Causing Me To Lose My First Job?

low imaging volumes

Question About Low Imaging Volumes:

Hi. I am an R2. I’ll most likely do a fellowship in body imaging (mostly because I haven’t felt a click with any particular specialty). I keep reading about practices firing radiologists because of low imaging volumes due to COVID. I’m concerned that this will affect me when I apply for jobs because I am only interested in private practice. I want to position myself with some advantages, and I need your advice on how to do this. I particularly enjoy the IT aspects of radiology (troubleshooting PACS, EMR, making software more efficient, automation, computer hardware). In my residency, there is a faculty member who is the “Director of IT.” And, I might be interested in a role like this.

My question is, do you think this is something that is even an advantage if you are seeking private practice? If so, how can I enter this space? Is there a course? Do I do research? If this is a bad idea, are there other things I can do during residency to give myself an advantage when it comes time to apply for a job in private practice? 

What should I do?

 

Answer:

Armaments To Prevent Job Loss

These are excellent questions, and I have a few answers! Let’s start with the first one about practices firing employees because of low imaging volumes. First of all, this Covid situation will most likely all but disappear by the time you graduate residency. Nevertheless, one of the best protection against getting canned is to become invaluable in whatever area that you practice. That niche can be informatics/IT. However, it all depends on the type of practice where you work.

If you aim to work at a small private practice somewhere, it will probably not help all that much. If you work for a larger institution or an academic center, it can help a lot, depending on what you do. In an educational sort of setting, if you are pumping out tons of papers and creating lots of programs/IT solutions for your colleagues, no one will want to let you go. Alternatively, if you are in charge of a massive corporate IT program, and the business cannot function well without your knowledge, they will not fire you. On the other hand, if the IT services you provide are just a little help, and the clinical work that you provide to the practice is not so much. Well, then you will not have the same job security.

At this stage of your career, work hard, and perform well in residency regardless of your fellowship. Learn about all aspects of radiology as much as you can so that you can establish a niche for yourself when you leave your residency. To repeat, most folks that are good at what they do will be the last to be fired.

How To Get Into Information Technology

Next, how can you enter this IT space? Well, some of it depends on how much experience you have in IT already. If you don’t have the knowledge that you would need to take over the IT at a practice, you would probably want to look into the Informatics fellowship. This fellowship will give you the basics of what you will need to know about IT for radiology practices. There, you can establish connections that you would need to find a career. Additionally, research in your area of specialty is never a bad idea during residency or fellowship, especially if you want to follow the more academic path.

Final Advice

So, there you have it. Work hard, learn as much as you can about radiology, consider an informatics fellowship (if that is what you want), and perform a niche in a practice that others have a hard time filling. These are the ingredients that will keep you in practice regardless of the Covid or any other unfortunate situation that may arise to lower imaging volumes for radiologists.

Good luck,

Barry Julius, MD