Category: Ask The Residency Director

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What Are Some Valuable Tech Skills To Have As A Radiologist?

valuable tech skills

Valuable Tech Skills Question:

Hello,

I am a 3rd-year medical student interested in radiology (especially the tech side of the industry). I’ve heard that 4th year allows for some more free time, and I’d like to put some of that time towards learning a new technology-related skill (like coding, software design, etc.) In that vein, what are some tech-related skills/hobbies that you think would be valuable to focus on as someone interested in radiology? I’d love to bring a unique skill set to my future residency/career.

Any advice is much appreciated! Thank you.

Answer:

Great question about valuable tech skills! If I were a medical student today, I would become well versed in the world of PACS and EHR. I would want to know how they work, the programming languages they use, and all the information tech related to it. Even though not directly a reason for hiring a new candidate, I think it would be extraordinarily useful to know. Why? It would be great to help out your future practices to choose which of these systems to use. But also, you would be able to customize the packages to the needs of your site of work.
What else? Well, I would get to know all the physics and mechanics of the hardware that we utilize in radiology. This hardware entails the CT scanners, the MRIs, the ultrasounds, and the fluoroscopy equipment. Again, if you want to be the “go-to” guy for choosing these pieces of equipment, it would be better than relying upon a sales representative that sells the same things. It would even be better than relying on a physicist because you would know the direct needs of the radiology practice better.
You could also concentrate on the website and social media production. Do you want to be able to help your private practice to create an excellent website, “on-the-cheap”? Well, that could be incredible cost savings for the practice. Plus, it is always helpful to have someone computer and internet savvy to fix it. That would involve learning HTML, WordPress, etc. Also, you would know how to attract customers to your practice.
However, all of this depends on what you want to do when you get out there. Do you want primarily to work in IT, or do you want to be more clinical? Regardless of the decision, you will have a lot of clinical tasks before getting to these points since radiology residency, even at the most academic places, is primarily clinical. So, don’t forget to learn your clinical basics as a medical student!
Regards,
Barry Julius, MD

 

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Have A Professionalism Violation: Can I Still Get Into Radiology?

professionalism violation

 

Professionalism Violation Question:

Hi, I don’t want to give too many details, but I’m finishing up my last year at a top 25 med school w/ step 1>240, multiple pubs, and a mix of honors and high passes except family medicine which is a pass. I have a professionalism violation by my school that will appear on my MSPE – how do I deal with this and move forward in the best way? The breach was for missing out on several clinic days without approval from my dean. What are my realistic chances for matching DR?

I’m pretty crushed because it seems like my goals are no longer within reach, so I need some honest advice on how to proceed

Thank you in advance,

Crushed Radiology Dreams

 

Answer:

A professionalism violation can be more difficult to remedy than a lousy grade or mistake that you made with a patient. The only way to increase your chances of acceptance into radiology residency would be to own it. What do I mean by that? The professionalism violation will show up on your application. And, that is the first item that most residency directors look for on the ERAS forms. So, you need to be ready to explain the offense, whether in person or the personal statement.
Additionally, you should be able to show deep-seated remorse. But, most importantly, you need to be able to say why this was a “one-off” event. And, you must convince the faculty why it will not happen again.

Biggest Concerns For The Program Director:

What would be the most significant concerns for most residency directors (from my end)? First, this person will not show up for rotations. Or second, this resident will try to weasel out of his obligations because he doesn’t like them. Most residency directors have had residents like this, and that is the last type of resident that they would want to take. In truth, many residency directors would rather have a resident with some academic deficiencies than a resident with recurrent professionalism violations.

Potential Solutions:

Therefore, you need to reassure your interviewers that you follow through with all the activities that you accomplish. How can you do so? Well, some places in the application that may help would be: comments on your Dean’s letter from your rotations, or other letters of recommendation testifying that the event was atypical for your personality. Regardless, you need to make sure not to cast any further doubts on your application and your character. If the readers of your application sense that you have a recurrent pattern of professionalism violations, you will not receive any interviews or rankings.
Bottom line: you are not going to be able to make the issue magically go away. But, you can mitigate some of the damages. All is not necessarily lost.
Hope that gives you some insight,
Barry Julius, MD
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DR Versus DR-IR Application Questions

DR-IR application

Question About A DR Versus DR-IR Application Dilemma

Hi! Love reading your blog, you’ve been a great source of information,

I’m a current M3 interested in both DR and IR. I genuinely like both fields, but it seems like there is a growing sentiment in both areas to define themselves as separate. I’m currently working on research in IR with my IR faculty, but I don’t want to lock myself out of DR programs, which is what I’m noticing has happened this cycle for some of my M4 colleagues. Applications IR weighted are not receiving much love from DR programs even if they do quite well for IR programs.

What thoughts do you have about the growing divide between fields, and what advice can you give for a medical student interested in both? Should I also do some DR research? I like the way IR is currently practiced, where IR folks will do a mix of IR and DR, but it seems like most IR leadership and PDs are interested in furthering the distinction.

Thank you!

DR And DR-IR Application Weary

 

DR Versus DR-IR Answers:

How To Apply

Having gone to the recent APDR/AUR meeting, I can tell you that you are right about some of your reported sentiments in some programs. Some programs/program directors take it in stride that many folks will be applying to both IR/DR and DR programs. But, other DR program directors did not have such favorable opinions about those applicants that are applying to both. I believe that if you are not sure about which program to choose at this point (as is normal!), the best bet would be to apply to a DR program that has IR/DR and ESIR slots. Applying to DR programs that also have both will allow you to hedge your bets a bit and give you the most flexibility. In these programs, they can usually flip a DR spot to DR/IR or ESIR or vice versa. Also, it doesn’t lock you into the IR pathway if you are not sure you want it. DR/IR is a big commitment and works if you are sure about it. If not, you can regret your decision because you will have less diagnostic radiology, and it will be a tough slog.
Also, DR research can never hurt an application and can only serve to enhance your chances of getting into a program. It demonstrates an interest in the field. And, it gives you a bit of radiology research experience. Who doesn’t want that?

The Growing Divide Between DR and IR

More and more practices are indeed allowing or requiring the interventionalists to do only interventional. However, some imaging companies still have the model of doing DR and IR work (that’s the way our practice works). It is hard to tell how difficult it will be to find a job in a practice with DR and IR in the future. But, I would imagine there should still be a role for these folks in more rural and smaller less subspecialized practices. But if corporatization of radiology takes root everywhere, that model could become rare. It remains to be seen.
My 2 cents,
Barry Julius, MD
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Off Cycle And Need Funding: Can I Get A Fellowship I Want?

off cycle

Question About Off Cycle Fellowships And Funding:

Hello Dr. Julius,
I hope all is well. Thanks very much for creating this site. It shares a lot
of very valuable, helpful information that is difficult to find elsewhere.
I have a few questions I was hoping you could answer for me.
I matched into a categorical Internal Medicine residency last year, during
which I realized I wanted to pursue radiology because it better aligns
with my interests, strengths, and personality. I discussed this with my
program director, who fully supported my decision. I completed my
internship a few months ago and left the program on good terms, receiving
strong references. I am now involved in radiology research at an
academic medical center. I recently became aware of an unexpected PGY-2/R1
residency opening for this year, which would start shortly, as
an off-cycle position.
1. Does completing an off-cycle residency limit fellowship opportunities?
Would fellowship directors be less interested in a candidate if he or
she finishes residency training after July, thus complicating the schedule
for incorporating a new fellow into the schedule at later point?
2. Since I matched into a 3-year Internal Medicine program, do the
remaining two years of my funding follow me to the next residency?
3. Is it possible to have more than one source of funding for a single
resident? For example, could one theoretically have funding remaining from
the first match and then also have partial funding through the military
or a foreign government? I’ve noticed there are positions on ERAS
dedicated for external financing through the military or international
sponsors. I am just curious if sources of funding can be combined.
Thank you very much for your time! I appreciate it.
Best Regards,
The Off-Cycle Resident

Answers:

You posed some interesting questions about particular issues that residents of mine have encountered in the past. So, I can help you based on my experiences.

Off-Cycle Issues

Let’s start with the problem of being off-cycle. Yes, most program directors would rather have a resident that is on-cycle. But, life happens, and it does not always work. For personal reasons, we had one resident who started residency three months later than the typical July 1 beginning. In his case, we were able to get a dispensation from the ABR to allow him to start his fellowship on time. On the other hand, if you are way off-cycle, you may not be allowed to do so. In that situation, it would make it a bit more challenging to find a fellowship position that can conform to the timing that you need.

That said, since the market for fellowship now favors the applicants, many programs would be willing to create a spot that allows you to start a fellowship soon after finishing. Right now, I know of many 6-month fellowship positions that would be happy to take an off-cycle resident at almost any time. It might be a bit more difficult if you were interested in a more competitive fellowship like interventional radiology.

Funding Issues

In terms of the funding for residency, typically, the government bases it on the amount of time completed in residency, not the expected time in a residency. So, if you only have completed a year or two of a three-year categorical spot, you will still have as many options as those that did a one or two-year preliminary program.

For those that have completed more than two years of a government-funded residency, you can also get foreign or military funding to supplement the rest, if available. And finally, some spots I know are entirely privately funded, so it does not matter how many years have been supported by Medicare.

Most programs, however, will utilize the government Medicare program for funding. So, if you are in a residency and have used up government Medicare resources, the program can rely on other sources of financing afterward, if your residency can find it and if it is available.

Thanks for the great questions,

Barry Julius, MD

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Radiology Fellowship Interviews: What’s The Difference?

radiology fellowship interviews

Question About Radiology Fellowship Interviews:

Hi Dr. Julius,

Thanks so much for the great piece about writing a fellowship personal statement. I recently went through the process myself and can appreciate the truth behind the points you stated.

As a follow-up, do you have any tips when preparing for the fellowship interview, after being shortlisted?

Thanks once again for all the high-quality posts. 🙂

Yours sincerely,
A Concerned Fellowship Applicant

Answer:

 

Thanks for the excellent question. It turns out that I have never delved into the differences between residency and fellowship interviews. And, there are a few significant differences between the two that I should mention. So, I thought that in addition to answering your question, it would make an excellent post.

To begin with, I highly recommend that you take a look at my original posts on residency interviews called How Important Is The Interview, Really? and Ten Ways To Sabotage Your Radiology Residency Interview. These rules still apply. And, once you have gone through some of this essential advice, take a look at some of the other specifics below about what you should look out for on your fellowship interview trail.

Radiology Fellowship Interviews: What’s The Diffference?

First of all, you will notice that different from a residency interview, most fellowship interviews tend to be more intimate. Most of the time you will be the only candidate at the site at this time. So, you will get to know the few interviewers much better than on a typical residency interview day because you will no longer be just another one of ten candidates. In that sense, it will often be a bit less nerve-racking. However, the general rules for interviewing still apply!

Next, the interviewer will expect you to have a background and a specific interest in the fellowship field of choice. So, you cannot have makeshift answers to why you are choosing to train in the field of radiology in general. Instead, you need to get down to brass tacks and come up with specific reasons for choosing this area of specialty.

Moreover, you will need to know more about the individual program to which you are applying. It is not enough to say that this will be a well-rounded program for your radiology training. No. You need to say why this particular fellowship would be an excellent fit for you. So, you should verse yourself in the specific equipment and unique training that this program has.

Also, make sure that you can talk about specific areas of research that may interest you. Fellowships, more so than residencies, tend to expect that you will perform research. So, talk intelligently about some projects that might interest you in this specific facility.

Other than that, it comes down to the same rules for interviewing in general. Be enthusiastic, conversational, well-dressed and groomed, etc.

So there you have it: some additional rules of the road for the residency interview. Let me know how it all goes.

Regards,

Barry Julius, MD

 

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Should I Address My USMLE Step II Score Drop In My Statement?

score drop

Question:

Hello – I’m actively interested in applying for DR residency, but I was let down yesterday after receiving a Step 2 score which dropped 11 points from my Step 1 (230 –> 219). I’m a DO student, and I’m afraid this will be a red flag that will become detrimental to my application for a radiology residency. I planned to address this score drop in my personal statement, as I’m sure programs will wonder why it happened. I believe my Comlex Level 2 exam went very well. However, I haven’t received that score yet, and I’m not sure PDs even care about it. Do I need to apply to a backup specialty?

A Worried Candidate

 

 

Answer To How To Deal With The Score Drop And More!

I wouldn’t throw in the towel quite yet. You have to remember that there are so many factors other than board scores to add to the equation of getting into a radiology residency. Moreover, many residencies use a cutoff of 220 or higher on the step one exam. So, you will most likely get a decent number of interviews as long as your other application credentials are OK. (not having those I could not tell you where to apply)

Also, you are right about the COMLEX scores. Most programs do not care much for those scores because it is harder to compare to everyone else taking the USMLE examination. So, I don’t believe that it will change your chances of acceptance all that much.

Finally, being a DO does not hurt your application as much as it had in the past. Now, the ACGME and the AOA are one organization, so you are no longer as much of a “second class medical citizen.”

One more critical point about your personal statement that you mentioned: I would not be so keen to address the score drop. (unless there was some major life crisis that could have affected your entire application). It would call more unnecessary attention to your board scores. To begin with, really, your step I score was not so bad. Instead, it shows that you have the potential to pass the core exam. (what most residency directors care about) Your personal statement would better serve you by talking about all the other issues that I discuss in my blog called How To Create A Killer Radiology Residency Personal Statement. Make sure to read or reread it before submitting your residency personal statement.

 

 

Let me know how everything goes,

Barry Julius, MD

 

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Fellowship Quality Training Trumps Name (Most Of The Time)

fellowship quality

Question About Fellowship Quality:

 

Hi Dr. Julius,
I have a follow-up question on fellowship.

My situation is a little tricky. My wife just started a three-year fellowship, as I’m beginning my R4. Having a kid, I would hate to leave my family, and there’s no big-name program where I can do my fellowship within a driving distance. So, I signed up for a body fellowship in an excellent facility. However, it does not have a shiny name. Do you think it makes a big difference in the long run if I did my fellowship now, in this place, vs. after completion of my wife’s fellowship at an Ivy League Program?

Regards,
Confused About Fellowships

 

Answer:

Thanks for the excellent question!
In general, fellowship quality trumps name. Why? It is more important that you feel comfortable in the subspecialty you have chosen and have learned what you need to know to become a well-rounded subspecialist radiologist. However, in a depressed job market or regions with stiff competition for jobs, sometimes name recognition does help. Also, academic places tend to weigh name recognition a bit higher. So, the more critical question is: Where do you ultimately plan to practice? If you plan on staying in a more rural area, it probably does not matter one lick. More so, in today’s market, even on the coasts, name recognition does not carry as much weight as it did five years ago. However, if you plan to practice in academia or Manhattan/San Francisco, it probably does.
Another item to remember, it is always possible to complete a second fellowship later on down the road if you wanted additional experience. (unlike residency)  So, I don’t think it is a bad idea to complete this fellowship now and come back later to do another one if you decided on a career with more stiff competition.
Hope this aids in your quest,
Barry Julius, MD
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Informatics Vs IR: Should I Enter Digital Heaven Or Perform Manual Labor?

informatics

Question About Informatics Versus IR:

 

Dear Dr. Julius

Thank you for this amazing blog; there are many useful topics that we don’t cover during our training. As I am finishing my second year of radiology, now is the time to choose the fellowship. I will be happy to hear your opinion as I am debating between two pathways.
I am making some bullet points for each as pro and cons.

1. IR
• ( + )Higher salary, further as it becomes more competitive, I can imagine that it will become more exclusive and the pay will keep rising.
• ( + )Now, with the introduction of the direct IR residency path, it might be the last time to join, and I should seize this opportunity.
• ( + )With all the hypes of artificial intelligence taking over diagnostic in a decade, this seems to be the long term responsible choice.
• ( – )I like from time to time interventions, but I hardly see myself enjoying it for life, especially considering overnight calls when I have a family.

2- Informatics and diagnostics-

• ( + )I am personally fascinated with all the current potential of informatics. Maybe naively thinking that we are still very early in the artificial phase of our profession, I could enjoy diagnostic, perhaps enjoy the creativity phase of this upcoming technology, and maybe also become a leader in this field.
• ( – ) Diagnostic salary will probably decrease in contrast to IR, and there is a chance in a decade that I might be obsolete
• ( – ) 2 years fellowship without any short term financial benefits
The rational choice will probably be to go to IR, but I feel that I should take a chance with informatics,
I will be happy to hear your opinion.

Answer:

Once again, some great questions. I love my audience!!!!
 
Anyway, to answer your specific questions, I am going first to give you my general gestalt about the two fields. Then, I will go through your sentiments for each bullet point (some of which are correct but others are a little off the mark)

 

My Opinions About IR:

 

 

So, when it comes to IR, it is the type of field where you need to invest your life toward that end fully. What do I mean by that? It has more “surgical subspecialty like” qualities than the rest of radiology. If you decide you don’t like to do PICCs and Ports or you determine later on that you are not interested in seeing patients, it can become challenging to extricate yourself from the specialty. And, as you mentioned, it can be hard on the family, not necessarily because of less vacation time (usually interventionalists get more), but instead, you can expect to leave earlier and come home later on a typical workday. Additionally, you may be taking overnight call a bit more often than other areas of radiology. 
 
Furthermore, especially in the beginning, if you decide you want to learn more about informatics independently while doing IR, it will be more challenging to make the time to do so. You need to establish yourself in the Interventional first to become the “go-to” person in the field. That said, anything is possible if you put in the time. It’s just a matter of how much time you want to spend with a family versus work. On the other hand, if you were to decide on another field in radiology, it would be a bit easier to learn more about informatics on top of your regular diagnostic radiology career.

 

My Opinions About Informatics:

 

In terms of informatics, I would recommend you first have some idea about what you might want to pursue within the field before you begin down that rabbit hole. The career options vary more widely than any other subspecialty in radiology. Do you wish eventually to become a CIO of a practice or hospital? Or, maybe you want to become an entrepreneur or work for a private company? Perhaps, you want to be the key “tech” guy within the practice that can fix the PACs systems? I would say before thinking about the specialty as a whole; I would first target a specific area so that you can hone in precisely what you would want from the informatics training before you start. It would be best if you had an idea about what you want before you begin or else the training you receive in informatics may not be as helpful for your career. 
 
As much as I love the specialty of informatics as a career choice, this specialty seems to me to be more like an MBA. It gives you the tools to help you in your career. But, if you don’t know what you are doing, it’s just another title!

 

Addressing The Bullet Points:

 

 
Now for the answers to the bullet points:

 

IR

 

1. IR usually has a higher salary because they work more time, not because they make more per unit worked. The reimbursement for IR procedures is overall worse than many other subspecialties in radiology. Salary is a function of supply and demand. As more people enter the field, you increase the supply and decrease prices.
2. I agree that doing the direct pathway now would save you an extra year of training if you decided to go that route. However, it is more important that you like what you do. So, that would not be my first consideration.
3.  I don’t see AI taking over any subspecialty within radiology during your or my career lifetime. AI is just as likely to take over interventional as any other subspecialty in the field. (you can refer to some of the prior blogs on the topic- especially the one from the RSNA last year)
4. The most valid consideration that you mentioned is the time issue/overnight calls. I agree with that sentiment entirely
 

 

Informatics/diagnostics

 

1. Interest in the field is the most important factor for deciding on a career path. If you enjoy what you do within a radiology subspecialty, you will be successful regardless of the field. Fascination and curiosity are great reasons to enter a field. (especially when you can get paid well for it!)
2. I don’t believe that you will become obsolete in any area within radiology as long as you keep up with the changes. Moreover, it is hard to predict where the salaries will be decreasing the most within radiology. Don’t be so sure that a salary for an interventionalist will be higher in the future than someone who is involved in informatics. It all depends on what you do.
3. From what I have read, you can do a one or two-year fellowship in informatics or any variation in between. Moreover, you can certainly moonlight during the time that you are completing the fellowship to increase your salary for the year or two that you are there.
 
So, there you go. My final summary:  I believe that for interventional radiology, you have to be “all-in.” It needs to be a calling more than any other area in radiology or else you will regret choosing the field. And yes, informatics is only as good as how you choose to use it. Have an idea of precisely what you want before you pick that route.
 
Hope this long-winded summary helps!
Barry Julius, MD
 
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Full-Time Practicing Primary Care Physician: How Do I Get A Radiology Residency Slot?

primary care

Question:

 

Hi.
I am a physician in a primary care specialty looking to go back to residency, specifically in radiology. I have been in practice for ten years and have realized that I do not want to practice primary care for the rest of my life. Have you had a resident in a similar situation? What factors do I need to consider? How does Medicare funding for residency come into play?

Thank you so much for your blog and the book. I realize this is a rather late stage to make a change, and I would appreciate your input.

 

Answer:

So, this is the deal: I would love to have physicians that have previously trained in other specialties. They make the best radiologists because they understand the clinical implications of diagnostic imaging. Some of my best radiologist mentors had completed another specialty first.

However (and this is a big caveat), it does become more challenging to obtain a slot because of the Medicare funding situation. Once you have graduated from a U.S. residency and start to practice medicine, Medicare does not fund the additional years of training.
But all is not lost. If I were you, this is what I would do. Some residencies throughout the country have their spots funded by private sources in addition to Medicare. For instance, I know in New Jersey that University Radiology Group supports several residency slots privately for the Robert Wood Johnson program. These are the slots that you would need to find. You may want to try calling the departments up individually to find out if they would take a previously trained physician. Otherwise, you will potentially waste your time and money applying to places that would not enroll you regardless of how excellent your application.
And finally (and perhaps most critically), you need to be ready to go through the mental and financial hardships of repeating another residency. Depending on your family situation, you need to make sure that all members are “on board” with the change. It’s certainly not an easy four years. But, I can tell you that going into radiology was one of the best decisions I have ever made!
Good luck with the decision process,
Barry Julius, MD
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What Are The Best Resources For Learning Ultrasound?

learning ultrasound

Question:

Hi! I was wondering what source you would recommend as the best to teach ultrasound to radiology residents?
Thank you!!

Answer About Learning Ultrasound:

So, I did a little bit of “market research” for you. And, I asked a few of my best radiology residents what they preferred to read to learn ultrasound. I did this because the best ways to learn regularly change. So, this is what they told me.
When they first started, they used the Ultrasound Requisites to get a solid background on the topic. Afterward, they would use what they would like to call the big blue book- “Rumack”  (Diagnostic Ultrasound) to look up additional information about any specific case. Most importantly, however, each of the residents said it was most critical to go inside the room to scan at the beginning to experience how they get the pictures and to understand the basic ultrasound anatomy. And, I have to agree with this method for learning ultrasound. I utilized a similar approach and it worked for me.
One of my great radiology mentors always said the following: “Ultrasound is not a spectator sport.” That was one of my favorite phrases. And, I continue to tell the same to my residents. You need to go into the rooms at the beginning and learn how it all works to get to know the world of ultrasound. Otherwise, all you will see are a bunch of disconnected grainy pictures!
Let me know if you have any other questions!
Barry Julius, MD
(All links are to books are at Amazon where I am an affiliate)