Category: Ask The Residency Director

Posted on by

Breast Versus IR- The Ultimate Choice

breast versus ir

Question About Breast Versus IR:

 

Hi Dr. Julius,

I am a PGY4 resident and currently ranking my fellowship programs. Right now, I am still debating between an IR and Breast imaging fellowship. I am an active person who likes to deal with patients (within limits) and do procedures. Also, I am a family guy who likes to spend time with family and travel together besides social activities. I love IR, and I see myself in IR, but everyone is warning me of the stressful lifestyle and crazy calls. I know it depends on the practice that I will join. But, sometimes I think about it differently. I mean why I would spend two years in IR fellowship (Non-ESIR) to perform mostly central lines and biopsies. Plus, people tell me that IR will become routine, and I will lose the exciting part and left with the scraps.

On the opposite side, breast imaging is a good lifestyle. I will see patients (I enjoy seeing patients) and perform procedures. Also, I am willing to do 50% breast and 50% general radiology after fellowship if I complete a breast fellowship. I don’t want to regret not going to IR. Should I risk it better than regretting it? I have to submit my ROL by the end of this month; I appreciate your help.

Thanks

Breast Versus IR

 

Answer:

What you do in IR depends upon where you decide to practice. If you choose the option of working in a highly academic large center that is on the cutting edge, you can be performing many other procedures other than central lines and biopsies. But, of course, you might sacrifice salary if you have a lot of debt. (not all the time but most).
And for the most part, if you are doing IR, you will have more weekends and nights. It is true that you will not be able to leave the department as smoothly during the daytime to take care of issues at home. Albeit, you may get more vacation overall to compensate for the extra time on call. When you are working in IR, you will generally work on your feet a lot for long hours.
On the other hand, breast radiology does allow you to work fewer weekends and nights as well as being able to occasionally escape to do other things during the day if you are reading screeners. And, you can perform procedures (even cutting edge procedures depending on the institution) But, in general, as breast radiologist, the procedures that you complete will be less involved. In both career paths, however, you will get to work directly with patients (and be a real doctor!)
So that is my little summary for you. There is a sort of lifestyle/procedure decision that you will need to make. What I’ve discovered over the years: no field is going to meet every one of your criteria. Those folks that are the happiest can decide which track to choose based on their life priorities.
Hope that helps,
Barry Julius, MD
Posted on by

No Procedures Please! I’m Sick Of Interruptions In My Workflow

no procedures

Question:

I’m happiest when I’m just plowing through cases at the workstation, as I find procedures are a considerable nuisance. Unfortunately, there seem to be in every subspecialty, but which ones give me the best opportunity to find a job with few/no procedures required?
Regards,
The Anti-Procedure Student

Answer:

Specialties Without Procedures

Fortunately for you, lots of areas within radiology require minimal to no procedures. Here is my list of the career paths I would be thinking about: Non-interventional neuroradiology, MSK outpatient radiology, heavily weighted academics, teleradiology, emergency radiology (depends on the hospital and their requirements), and informatics. Also, body imaging with an outpatient bent could be non-procedural weighted as well. (assuming that there is no fluoroscopy on site).

Non-Procedure Weighted Specialties

Moreover, let me give a pitch for thoracic and cardiovascular imaging. Many of those rads do not perform manual work. However, at some academic institutions, the thoracic imagers will perform the biopsies. And, at other places, you may get interrupted to supervise Cardiac MRIs and CTAs. That all depends on the workflow.
Nuclear medicine (my specialty) does involve iodine treatments and radiotherapies for other cancers. So, you will need to sit with patients and play doctor. And, you may need to perform lymphoscintigraphies. (Our residents do most of them!)  Also, at some institutions (not mine), you will need to stand and monitor the cardiac perfusion scans. However, you will find that we do not perform that many long involved procedures. Manual work is not our thing!

Procedure Heavy Specialties

Hopefully, you have figured out that breast imaging and interventional radiology does not work well for someone not interested in procedures with all the biopsies and/or vascular work. Also, women’s imaging, in general, is not a place for you with hysterosonograms and HSGs. And, finally, pediatric radiology is also chock full of procedures as well. You have intussusception reductions, VCUG, barium enemas, hands-on ultrasounds, and more. I would avoid that specialty!

My Final Summary

Now that I think about it a little bit more, about half of radiology does not emphasize procedures. You can easily find a path that will take you in that direction when you decide to pursue your career!
Good luck following your “procedureless” path!
Barry Julius, MD
Posted on by

Is Radiology Falling Apart Or Will It Continue To Thrive? I Need To Know!

radiology falling apart

Question Theme: Is Radiology Falling Apart?

Hi, thanks for doing this blog, it’s been an excellent resource for me as a medical student interested in radiology.

As a medical student, there is a lot about radiology as a field that appeals to me; the short “patients”, the diagnostic nature (you give your interpretation, and you finish w/ the patient), the fact that work doesn’t come home, the essence of medicine being radiology, the flexibility of the field in having non-medical interests, etc. However, as someone who wouldn’t be practicing for the next 7-8 years at least, and as someone who wants ideally to have a substantial long career, there are a couple of things that give me pause that I hope you can clear up.

1) I’ve heard a lot of conflicting thoughts about the radiology job market and the increasing “race to the bottom” for salaries along with w/ increases on workload. Can you comment at all on this and how you see the trends for several years out?

2) I have always leaned toward being a private practice physician. And, I know the direction across all specialties is increased consolidation (practices being bought out by hospitals, venture capitalists, etc.), but it seems like radiology is more prone to this than other fields. Do you see this trend holding for the near future?

3) Re: increasing workload; how flexible are practice options still? Is going to Hawaii or New Zealand for weeks at a time to do remote reads even feasible? What are the main practice options viable for a starting radiologist outside of being an academic/private radiologist?

4) In a similar vein, do you see radiology going down a comparable path to EM, where you have many shifts at odd times and holidays? With the push towards 24/7 coverage, I’ve heard rumors this could be the future of the field, and I do not like the schedules EM physicians have at all.

5) Finally, as more of a fun question, what are some of the most exciting things on the horizon for radiology as a field? I know we hear a lot about AI, but I’m assuming there’s more in the pipeline besides that. Perhaps any new modalities altogether? Or whatever else is exciting to you personally.

Thank you so much for helping out a “jaded” and burnt out M3! Continue being great!

 

Answers:

Great question(s). Each of these queries can be an entire blog! But, I will try to answer each of these in short order.

Will radiology be involved in the “race to the bottom” for income? Well, I do agree that over time, the workload has been ramping up due to increasing efficiencies created by technology. And, I see that trend continuing. However, the pattern will take a slightly different path. But, let me start with a little radiology history.

Initially, the first expansion of work for radiologists was multiple new modalities  (ultrasound, CT, and MRI.) Then, the next revolution was the PACs system and the digitization of images.  Now, we are about to experience a new generation of efficiency, that would be the software and AI revolution to assist you with your work. So, yes, you will be continuing to read more studies quicker. And, the government will not be adding new money into the system. Therefore, we will be much busier over time, and the money reimbursed per procedure will decline. However, with AI, it may not be “harder” to read these studies because AI will help you with things like triage, dictation, and detection. So, if you like technology and anatomy, radiology will still be the best field in medicine!

What about consolidation? Unfortunately, I believe that this trend will continue for a while. Economies of scale will continue to make larger better. What does that mean for you? You will more likely need to work for either a large private practice group, a corporate entity (i.e., large teleradiology company), or a large academic center. The days of 2-10 person private practices are slowly drifting away! (I was thinking about writing on this topic in an up and coming blog as well!)

How flexible are the options to practice? Well, here is where radiology takes the cake. Again, it depends on your debt load and your desire to work. But, all the options that you mentioned are still available. Hawaii and New Zealand are more than possible. And, you can work any number of days per week. Just like any other field, however, the less you work, the less you will make. So, you need a financial backstop if you want these options! If you desire a more atypical area to practice in radiology, that is available too. Try informatics if that suits you! Or, consultation work is possible. The sky is the limit in terms of flexibility!

Will radiology work turn into ER shift work? I believe you will have several choices and that it depends on how you choose to practice radiology. As I mentioned in the last paragraph, I think we will continue to see lots of options to decide how to practice. But, for many young graduates, you are right, some may be forced to do shift work depending on their debt level and where they want to live. But, by no means, will you have to do shift work. Clinicians wish for the presence of a physical radiologist in their hospitals. And, day time work will still be available.

What do I find exciting about radiology? That can also be an expansive answer. However, I am a nuclear radiologist, and I am fascinated by the new varieties of diagnostic radiopharmaceuticals coming down the pike for all sorts of diseases. Additionally, I see loads of new cancer treatments with new radiopharmaceuticals as well. Moreover, PET-CT and SPECT-CT  technologies are markedly improving, making visualization, and diagnosis more straightforward and quicker. In terms of other areas, MRI is a continually developing field with new sequences and contrast agents in numerous different fields (MSK, Breast, etc.) And, these technologies are expanding on top of an AI platform. So, is the future of radiologist exciting and bright? Certainly, yes!!! And, once again I can’t emphasize enough the answer to the theme of this letter, “Is Radiology Falling Apart?”, a firm no!

I hope this (briefly) answers and alleviates some of your questions and concerns,

Barry Julius, MD

Posted on by

What Are The Best Radiology Blogs Out There?

radiology blogs

Question About Radiology Blogs:

Dear Dr. Julius,

Here I am again, this question may not fall under ‘ask the residency director‘ category, but it can fall under ‘ask the radiology director who aims to spread knowledge about everything related to radiology.’

So my question is, what would be the best radiology blogs you can recommend? In your blog, I saw your posts about social media, and from time to time you mention other good bloggers such as Eric Postal, etc. but I believe we can highly benefit from a list of recommendations processed by you and your years of experience in this field. Addition to that apart from blogs, what other websites/MOOCs can you recommend for learning Radiology?

Thanks in advance.

Answer:

Favorite Large Radiology Blog Websites:

Once again, an excellent question. I had to think about this one for a while because I don’t see that many regular radiology bloggers that write a lot. (Most radiologists don’t have the time or inclination!) But, if you are talking about websites with musings about radiology in general and the social media/blogging angle, my favorites are auntminnie.com, Medscape, and Doximity. (In full disclosure, I am a Doximity author as well!)
Occasionally, I used to log on to sermo.com for additional articles and community interest. However, I have not recently been to that website.

Favorite Individual Radiology Blog Website:

I also happen to like a blog called Benwhite.com. He is one of a few individual radiologists that I know of with a blog and an individualized website that writes many quality articles geared to residents. However, he has a mix of non-radiology and radiology relevant articles. Also, if you happen to have student loan debt, he has written a book on that too. (Medical School Loans:  A Comprehensive Guide) The White Coat Investor reviewed his text and gave it a thumbs up. Off the beaten radiology path, Ben also created a nano-poetry forum, definitely unique.

Favorite Online Radiology Blog Magazine

In terms of online bloggish magazines, I get Diagnostic Imaging sent directly to my email. That is how I got to know of Eric Postal and his writings. He stuck out in my mind because of his stories and distinct quirky style. (He reminds me a little bit of Andy Rooney from 60 minutes without the hard sarcasm!) However, there are very few regular radiology bloggers that I know of who write on topics similar to the general interests that I write about with a resident bent. Hence, my blog niche!

Hardcore Radiology And Educational Websites

On a more hardcore radiology note, I have the ACR and AMA updates sent directly to my email. Occasionally, they have some articles and information about the business side of medicine and radiology that interests me a bit. Or, they have state-of-the-art scientific updates and news.
Toward the pure educational side of things, I tend to go to radsource.com and radiopedia to look up information in a pinch. And, of course, I often use the standard Google search for images, articles, and additional information when needed. If I want to go in depth or can’t find the information on these sites, I find specific publications on PubMed!
Let me know if I can help you with anything else,
Barry Julius, MD
(In full disclosure, I am an affiliate of amazon.com!)

 

Posted on by

Brains Versus Breast: Which One To Choose?

brains versus breast

 

Question About Brains Versus Breast:

Dear Barry,

I hope you are doing well. I am PGY4/R3 radiology resident, hesitant between breast imaging and Neuroimaging. And, I have a concern about lifestyle and job market in the next couple of years. Which one do you think, will have a better job opportunity?

Answer To The Brains Versus Breast Question:

Both areas can make for an excellent career, but it all depends on what kind of environment, pressures, and lifestyle you want. To help you out I can give you a little summary of the critical factors about I would be thinking.
First of all, let’s start with the general pressure of work. In Neuroradiology, if you miss something in a film, it can be the difference between immediate life and death. On the other hand, if you miss cancer, the results are not as immediately devastating. However, the patient is more likely to sue you for your mistakes. So, I think that your choice in this department depends on what you feel you can handle. Moreover, you will be more procedure and patient-oriented if you pursue the mammography angle since you will be performing biopsies and seeing patients. As a non-interventional neuroradiologist, most see very few live patients and do fewer procedures.
Next, the lifestyles for both specialties can overlap. However, the mammographer can find more jobs that tend to be five days a week or part-time gigs without call. For the neuroradiologist, most do some inpatient hospital work, so it leads you to find a career with more weekends and nights. Indeed, this lifestyle does not apply to all neuroradiologists, however.
And finally, the job market for both specialties is relatively hot. Both neuroradiology and breast are the most needed radiologists out there. There is no lack of jobs at present. And, if I use my crystal ball, I don’t see any significant change coming through the market shortly. Of course, radiology job markets do change with the economy and macro-factors that I can’t predict. However, as long as the economy remains vigorous and radiologists continue to retire, you can expect a continued hot job market. If we look out to the more distant future, when that changes, so does radiologist job availability.
That’s my little summary for you!
Barry Julius, MD

 

Posted on by

What Do Interventional Physician Assistants Do?

Interventional physician assistants

Question About Interventional Physician Assistants:

Hello!
I am a physician assistant student at a large American University. Presently, I’m in the middle of my clinical year, and I’ve just completed my 4th rotation. I have spent the last four months in and out of hospitals. Recently, I have been exposed to interventional radiology. Moreover,  I was very impressed with the role that physician assistants play in this field of medicine.

Until recently, I had never even considered interventional radiology. However, I want to work in a field that is procedure driven. To that end, I am good with my hands and spent 13 years as a firefighter/paramedic which is very procedure driven. So naturally, I found myself very intrigued about interventional radiology as a possible career for a PA. Is there any way you could put me in contact with someone to answer some questions about a PA’s role within IR?  Thank you for this website. It has been incredibly helpful, and I hope to hear from you soon!

Regards,

Future Possible Interventional Assistant

Radsresident Answer For A Future Interventional Physician Assistant:

I agree that the best resource would be to talk to a PA that does interventional radiology. We do not have an interventional PA in our program to which to refer you. However, I have worked with a few interventional physician assistants during my residency and at a previous job a while back and I could shed some insight into what they do.

Both of the PAs that I had worked with functioned as an assistant in complex cases. Also, they were the primary operators in procedures such as PICC lines and ports. Moreover, they would see patients in “tube rounds.” If you haven’t heard of this term, it means they would talk to the patient and provide updates on the status of their catheters and interventions after the procedure. And, they would write the formal notes in the chart to document the condition of the patients. Also, they involved themselves in morning rounds before seeing the patients for the day. And finally, they performed the consents for procedures to reduce the workload for both attendings and residents during the day. Both PAs that I worked with served an invaluable role in the practices and became a critical part of the team.

Hope that gives you a little bit better insight into what they do,
Barry Julius, MD

 

Posted on by

Can I Practice Radiology With Color Blindness?

color blindness

Question:

Does having partial red-green color vision deficiency hamper the chances of a resident to pursue Interventional Radiology? Or will it even prevent me from applying for the post of a professor after completing MD Radiodiagnosis?

Color Blind Future Radiologist

Answer:

Dear Color Blind Future Radiologist,
Fortunately, most interventional procedures, you can view in black and white. And, that same rule also applies for most of the radiology field, interventional and non-interventional. Usually, we look at images without color overlay when reading CT scans, plain films, MRIs, and fluoroscopy.
Moreover, you can change the color settings on the software of most equipment such that you can avoid the pitfalls of red-green color deficiency. Even color doppler ultrasound and nuclear medicine (the most color driven modalities) usually have different color settings. In these colorful modes, you should be able to set it so that you see the information appropriate for your eyes.  So, you should be able to get around the problem.
However, there is one caveat. It is critical to notify your faculty about your color blindness to ensure that they change the settings on the equipment. Don’t be shy about bringing this issue to their attention. You will only be hurting yourself. If you let them know up front, you can look at the images in a color scheme that you can read. In the end, it is possible to become a full-fledged radiologist with a partial color blindness deficiency!
Instead of worrying about color blindness, most importantly, now you can concentrate on improving your application. Since IR has become so competitive, you can spend your time on what matters, garnering a spot in a field with few positions. And, no longer do you have to worry about how partial color blindness will affect their selection of you as a candidate!
Regards,
Barry Julius, MD

Posted on by

Pregnancy In Radiology Residency

Question:

 

Hi Dr. Julius,

I have a few questions for you about pregnancy during radiology residency that I wanted to know.

Is pregnancy in radiology residency doable?

Are programs supportive of students who expand their family during residency?

Are there radiation exposures that I would need to avoid in a diagnostic radiology residency?

Is there a typical year of residency easier to have a baby than others?

With radiology being a male-dominated specialty does this cause strife between residents during maternity leave? (Is there maternity leave?)

How do you decide if a program is family friendly and future-family friendly?

Thank you!

Sincerely,

Future radiologist

———————————

 

Hi future radiologist,

I have to say I have been getting some great questions from my audience and yours is no exception!

So, let’s start from the beginning… Is radiology residency doable for a pregnant resident? My quick answer is undoubtedly yes. Many have done it before.

But, let me give you a bit of the more detailed response to your inquiry. It’s not whether it’s doable, the question is, do you want to do it at this point in your life? By no means is it a cake walk.

So, what changes? Typically, many pregnant residents will lay off the fluoroscopy and the interventions that involve ionizing radiation. And, depending on how your pregnancy goes, you may feel tired and nauseous at times. But, most get through the residency just fine.

And, of course, you are entitled to pregnancy leave which I believe is usually three months. Depending on how much time off you take, that may extend your residency a few months. Moreover, the additional time can delay the timing of your fellowship.

Then, finally, you will probably need some help with the kids once you do restart your residency after the pregnancy.

Is it easier or harder to have a baby during rads compared to others?

Comparing radiology to other residencies, I believe it is more doable than some and harder than others. Those long nights with a reversal of sleep schedule can be tough on typical residents let alone pregnant ones. The hospital will constantly bombard you with images with no time to sleep. Psychiatry and derm are some specialties that don’t have those tough calls. But then again you are practicing psychiatry and derm, not where I would want to be!

And, perhaps it is not as grueling as surgery. But, it all depends on what you want.

So, what year would be best to have a baby?

If I had to choose within the current system, I would have to say in most programs the 4th year (after you have passed your boards) would be the best time. It is the least demanding in most residencies (but not all!) Usually, you can fill it with mini-fellowships, electives, and less call shifts than other years (although some have 4th-year weighted call).

Does pregnancy cause resentment?

I will say the following; Whenever you have one person with different sets of requirements from the others, you will have some resentment. Call shifts will increase for your classmates in spurts.  You will have to give them back afterward, so it eventually evens out.

But, in the end, this is a personal decision to make and regardless of what others think it is probably not best to put it off too long because of the increased risks of waiting too long.

Which residency should I choose for a possible pregnancy ?

So, if I were looking for a residency for my wife where she would have the best situation while pregnant, I would say, most critically, pick one near family members that can help out. Next, I would want to find one where the call might be a little bit lighter.  Or, one that has a decent 4th year if that is when you want it. And finally, find a program director that you believe will be able to commiserate with and support you during residency.

I hope this answers some of your questions!

Barry Julius, MD

Posted on by

I Am A Foreign Grad And Want Interventional Radiology… Help!!!

want interventional radiology

Question For Residency Director

Dear Dr. Julius,

First of all, thank you for writing up this excellent blog. I found the ‘choosing fellowships’ section to be of highly beneficial to me. But even after that beautifully written post, I am still undecided. I am currently a radiology resident in the UK. And, I am keen to apply for a fellowship in the USA(I have completed my USMLE). I like working with my hands. Moreover, I think that I am talented. I understand that the traditional interventional radiology fellowship will no longer be available by the time I am eligible to commence my fellowship (2021).

Now, I am quite interested in neurointerventional radiology. By 2021, I would have completed a five years residency in the UK (3 years in general radiology and two years in neuroradiology). Realistically speaking, what are my chances of getting into a two-year fellowship in neurointerventional radiology being a foreign medical graduate? I understand that it is a competitive fellowship. Also, what kind of interventions do I get to perform by doing a body fellowship?

Many thanks for your help!

 

Answer:

Azygos Lobe,

Unfortunately, all those years in the UK are not directly transferrable to the United States requirements. So, you are stuck with one of two possibilities in the United States. First, you could look to satisfy the alternate pathway requirements. However, interventional fellowships of any sort have become the most competitive of them all in the United States. Even though you may want interventional radiology, getting a slot as a foreign grad may be next to impossible. And, if you were to find one, you may not satisfy the requirements for licensure in many individual states within the U.S. when you completed your fellowship and looked for work here. Therefore, that would be a tough road to choose.

Second, you could theoretically apply to repeat your clinical and radiology residencies in the USA. But, that would mean an additional five years of training.  And, then you could ask for a fellowship in interventional for a year or two (Depending on whether the program has ESIR)

And finally, the most unlikely option, you can apply directly to the IR/DR residencies. But again, only a few accepted applicants were foreigners because it has become one of the most competitive residencies in the match.

To sum up, your options are a bit limited. For your best chances, I would apply to the US residencies and start anew. That would involve many years but would be the most likely scenario to succeed. It would be a tough road to follow.

Body Fellowship For Interventional Practice

In terms of the body fellowship, depending on the location, you may encounter a bit of interventional variability. Some programs do more biopsies and drainages. Others may have a mammo/breast component. And, even others may have a small interventional/vascular element. It comes down to the individual program practice patterns. So, you need to ask around before committing to any particular body fellowship.

Let me know if you have any other questions,
Barry Julius, MD

 

Posted on by

I Didn’t Match In Radiology! What Do I Do?

match

Question:

Thank you for providing great information. I have been utilizing it throughout my residency application process and have found it to be an invaluable resource. Currently, I am in the process of SOAPing (Supplemental Offer And Acceptance Program) to match into a position and was hoping to get your input on applying for research fellowships in radiology as an alternative to SOAPing into an undesirable program/alternative specialty. I am a US MD 4th year with a 230-240 range for both USMLE1&2 and with previous research experience in genetics and interventional radiology.
Thank you for your time and consideration,
A Worried SOAPer

Answer:

Sorry to hear about having to try to SOAP into a position. I would continue to try to get into a slot in radiology if you can. Getting a residency slot in a marginal program is better than not getting anything if radiology is your chosen field. I believe that you can always make the most of your experience regardless of the residency that accepts you.
However, I would imagine that there are not that many empty slots in the SOAP this year. (Only ten programs did not fill as of the time I am publishing this article). So, if you do not match into an opening, I think doing a radiology research program would be a great way to make yourself more desirable the next time you apply. I would probably opt to find a clinical program this year first as well (if you have not done so already), so you have that clinical year that you need under your belt. But, getting a research year afterward would be an excellent way to stay immersed in the field. It is the closest you can get to remain in radiology without completing a residency year.  It will also demonstrate your interest in the programs when/if you reapply.
Good luck with the SOAP,
Barry Julius, MD