Category: Miscellaneous

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Do Radiology Resident Retreats Really Work?

resident retreats

Flashback to 2001 or 2002: Our program director at Brown announces that we are going to meet in the fancy dining room in the new wing of our hospital for a resident retreat. One or two days later, we all had a free meal and shared war stories from the hospital with the guidance of our faculty.

Today: I can vaguely remember only the stuffed chicken from this first “retreat.” And, I can barely remember the war stories. Sure, it was nice getting a break from the regular rig-a-ma-roll of hospital activities. But, did it reduce resident burnout and exhaustion? Moreover, did it create a lasting memorable experience that changed me?

Well, the recent article in the Radiology Business Journal claims that resident retreats may directly reduce burnout. And, this conclusion was explicitly based on another piece which issued questionnaires to residents.  (You can click on it at Current Problems in Diagnostic Radiology here).

So,  based on some of the “data,” as well as my experience, I figured I would attempt to tease out whether resident retreats do mitigate resident fatigue. And, we will look into whether this article is anything more than clickbait. Also, is the resident retreat is just another way to get around the real issues that cause residents to be miserable during their residency without directly addressing them? We don’t want to give this article and the Brigham program (as much as I like it) an easy pass!

The Main Conclusion Of The Study: Improved Camaraderie

Yes, many residents bog themselves down in residency and lose the bigger picture. And a day or two of a retreat can reset your general mindset and outlook. However, giving residents an open-ended questionnaire and expecting the answers to reveal some long term decrease in burnout is a big leap of faith. I mean, sure, you will get positive opinions expressed because it is a day off from work. Who doesn’t want a day off to relieve the mundane parts of your job? I would be happy to answer any question positively after a day or two off with a full belly and a few good conversations with my colleagues.  So, I’m not sure if this format truly addresses whether the resident program is mitigating burnout. Sounds nice in theory, though!

What Is Causing Burnout- Does The Retreat Solve That?

Well, take a look at another article from the Radiology Business Journal. You will see a whole list of factors that cause resident burnout. In fact, they list the following: “counterproductive administrative tasks such as procedure logs and training modules, continuous and long clinical shifts, demanding call schedules, technical issues and lack of feedback and social interactions.” And, of course (based on my current resident experiences), I would like to add student loans/high debt to the equation.

So, what exactly does this retreat address then? Merely just one of the myriad factors that cause burnout- lack of social interactions. Is this enough to tip the overall ship to reduce burnout significantly? I’m not so sure about that. And does it deflect from solving most of the other real issues that cause exhaustion in a radiology residency program? Probably! If you think about it, of all the causes of burnout, this residency neglected all the others in the spirit of making the residents temporarily happy by having a day or two of social interaction.

Bottom Line About Resident Retreats

It’s good PR to create a retreat to provide the residents with an opportunity to fraternize with their colleagues. And it’s certainly nice to have some time to commiserate with your brethren. However, it takes more than one resident retreat with a few fleeting smiles to relieve the myriad causes of resident burnout. Based on this method of data collection, the numerous sources of burnout, and my own retreat experiences, the study conclusions overly simplify the real causes and solutions for treating resident burnout. Although it sounds nice in theory, and may temporarily increase residency morale, a solitary retreat is not the answer!

 

 

 

 

 

 

 

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What The Core Exam Low Pass Rate Does Not Tell Us About This Year’s Test Takers!

low pass rate

In residency programs throughout the country, you don’t need to go far before you hear some chatter about the low pass rate on the core exam and the change from years before. And, then, you take a look at the article on Aunt Minnie, with headlines stating, the ‘fail’ rate is rising. Or, you check out a forum or two or social media, as they rail against the exam and the test takers. It’s no wonder that many residents are on edge. I know that at my residency, the buzz is palpable.

Similar to other years, I have seen sketchy opinions about this year’s exam and misguided words about the residents who took the exam this year. But, given the increased failure rate, these statements weigh more on the residents who have taken the exam. And, unfortunately, many of the assumptions and statements made about this class of residents taking the exam and the test itself are entirely off-base. So, I aim to dispel any misconceptions by telling you what you should not assume about this group of test-takers and the core exam. Here are some of the more common ones!

This Group Of Test Takers Are Not As Smart

I know many residents who took the exam this year. And, although more residents had trouble passing the boards this year, these residents are just as intelligent as others. Perhaps, many are not great test-takers (reflected in the USMLE board scores used for admission to residency). But, by no means, are they going to make radiologists that are inferior to any other year.

Moreover, residents throughout the country in this class practice radiology competently as judged by faculty, chairman, and program directors. This judgment is in spite of the board score results. So, instead, I am forced to fault the exam itself, and some of the reported esoterica and minutia tested, not the folks taking the exam.

They Are Lazy

The residents of the class who just took these boards have worked very hard, if not harder than in years past. In my program,  some of these residents are the best since I started. Indeed, they have studied very hard for the board examination. But, by no means, should anyone call them lazy!

They Have Been Targeted To Fail The Boards

No, no, and again no. The ABR does not seek to fail more of any particular class in general; however, misguided any exam may be. Instead, I believe they have created a test that does not measure what it claims, minimum competency to practice radiology. The ABR did not specifically target this residency class taking this particular test.

There is No Way To Predict Who Will Pass The Boards

Interestingly enough, the Radexam pre-core exam did predict the outcome of the core exam results very well. Percentages on our pre-core Radexam mirrored the real exam almost perfectly. At least in my residency, it turns out that this test is far superior to the old in-service examination. I would love to hear the experience of other institutions as well since the Radexam is so new. Based on our experience, we will continue to take it more seriously. We will do so to make sure that residents have studied enough (and the right way) to pass the core examination.

Low Pass Rate And The Residents Taking The Exam

An exam is only as good as the material it tests. And, competent residents who perform well in my residency tell me about the many esoteric questions and minutia on it. Therefore, I squarely place the blame of the low pass rate on the core exam, and not the residents taking the examination. As I’ve written before, it’s time to start reworking the test and its questions. We need to change the material tested so that residents will remember useful content for years to come, not just spit empty facts on an examination and quickly forget.

And just as importantly, let’s stop putting all the blame on the residents taking the exam. Based on the judgments of our faculty, we already know that they are competent and will make great radiologists. We do not need a faulty test to tell us otherwise!

 

 

 

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Are You Getting Burned Out By All The New Articles On Physician Burnout? I Am!

physician burnout

I don’t know about you. But, between JACR, Medscape, Diagnostic Imaging, Radiology, AJR, JAMA, the New England Journal of Medicine, the New York Times, the Wall Street Journal, and a myriad other radiology journals, the numbers of articles about physician burnout have starkly increased. So much so that you cannot go without one week without coming across a new report on the subject.

And, I acknowledge that burnout is a real problem. Yes, physicians that I know tire of reading increasing numbers of studies. They drown in electronic records. Others complain every day about the lack of control they experience in medicine.  Also, I concede that there is a high suicide rate of physicians throughout the field. These are real events and facts that contribute to a harsh environment.

However, that’s not the whole picture of the dissemination of information about physician burnout. Let’s briefly look behind the iron curtain of the media’s interests in presenting information about the subject.  How does the press affect readers’ perception of reality on the topic? Moreover, is this a topic that should receive so much publicity?

Misalignment Of Media Interests

Sometimes the goals of media and the public good align. And, other times they butt heads. It’s not all altruism. And let me explain why.

In general, what is the goal of the media? It is to increase readership. And how does the press increase readership? By addressing emotionally charged issues. And, what can emotionally charge the public more than seeing how your physician is so stressed that she can no longer function appropriately?

Any subject matter that induces an emotional reaction from the reader can sell lots of journals, papers, and all sorts of electronic media consumption. This positive bias from all types of media affects not only the articles they write but also the surveys they create and the interviews they get with physicians. If you are interviewed or surveyed, you are far more likely to say you are experiencing burnout if someone asks you a leading question than if they ask you the same thing in a different way. And, they have every incentive to do so. It’s their livelihood. Now, these facts may be real to an extent. But, they may also overemphasize the problem to a degree beyond the truth.

#Me Too

Not only can the increased emphasis of media on burnout overstate the problems and issues associated with the condition, but it also leads to the #Me Too dilemma. If you see 20 articles on the same topic within any given month, you are more likely to associate the features of burnout with your situation. Now, this may not be your reality. But, the subtle psychological hints of repeated media stimuli can influence your perception of whether you have burnout.

Burnout: A Real Epidemic Or Pure Perception?

Like always, the truth probably lies somewhere in between. I know the condition does exist. And, I am aware that some physicians that I know meet the criteria for burnout. But when you read your next article on burnout, be mindful of the biases that lead the author to make their assessment of the degree of the problem within the physician population. There may be a hint of truth to their views, but it may not be to the extent you assume. That said, I’m feeling a bit of burnout after writing this article. Time to go back to sleep! (Written at 3 am)

 

 

 

 

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Can You Pass The 2019 Precall Quiz?

precall quiz

Once again this year, I am presenting 10 cases from our precall quiz. These cases will help to determine if you are ready for taking call at your institution. Each of these is the sort of the case you will likely encounter on call at some point. Sixty-five percent is passing. Partial credit is possible. Make sure to write down the answers on a sheet of paper and cross-reference them with the answers provided on the bottom of the page. See if you will be competent to take overnights or if you need to study a bit more before you are ready!

By the way, if you think you can score better the next time or if you want some more practice, check out the previous years’ precall quizzes. The links to the 2018 and 2017 quizzes are right below. Good luck with the exam!

2018 precall quiz

2017 precall quiz

 

Case 1:

 

 

Case 2:

 

Case 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 3:

What is the possible diagnosis?

How would you manage this case at nighttime?

 

Case 4:


Case 5:

Case 6:

 

 

Case 7:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 8:

 

Case 9:

What is the diagnosis?

What else would be of help to increase the specificity of the study?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 10:

 

 

Answers to Cases:

  1. Right-sided ileocolic intussusception
  2. Right perihilar mass with pneumothorax
  3. Possible diagnosis: fetal demise with conflicting images in M-mode, How to manage: scan yourself in real time with M-mode or cine
  4. portal venous gas, bowel pneumatosis, SMA thrombosis- call surgeons
  5. Proximal transverse colonic apple core lesion, suspicious for primary colonic neoplasm
  6. Normal CT brain
  7. Hill-Sachs deformity with a loose body (greater tuberosity overlying the glenohumeral joint)
  8. Mets with multiple levels of cord compression. Abnormal signal within the cord, suggesting ischemia.
  9. Findings suspicious for PE (High probability study- old verbiage), What would increase specificity? A prior V/Q SPECT
  10. Left distal ureteral stone with left-sided hydronephrosis and hydroureter and adjacent inflammatory change, porcelain gallbladder (increased risk for carcinoma)
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Hard Proof That The Radiology Core Examination Does Not Work! Need We Say More?

radiology core examination

I can still remember these words, “All you need to do is to study and attend your rotations. If so, you will pass the core radiology examination.” And also, “Residents should not need additional time off to study for the test. They get all the time they need.” Lawrence Davis, MD, the former head of the Radiology Review Committee (RRC), stated these comments with confidence at an Association of University Radiologists (AUR) meeting a few years back. According to the recent article in Aunt Minnie, ARRS: Residents who passed Core Exam valued test prep; nothing could be farther from the truth.

Here is a direct quote from the article, “survey respondents who passed the Core Exam and got a higher overall score used a greater number of test-prep resources, had more time off to study, and had higher U.S. Medical Licensing Exam (USMLE) Step 1 scores (240 versus 221) compared with residents who scored lower or failed.”

Based on this new information, this group entirely invalidated the former RRC head thoughts in one fell swoop. Furthermore, the data stands directly against the ABR mission to create an exam to test basic competency. Now, the evidence to support my theory in a previous article about the new test is live and “in the flesh.”

But, I am going to take it one step further. The results of this new study signals that the ABR needs to revamp the entire radiology core examination once and for all. And, let me tell you why.

The Core Radiology Examination Is Not Based On Practical Knowledge

One of the stated goals of the ABR is to demonstrate competency of recent radiology graduates. But, how can the ABR test those stated goals if the core exam performance depends on residents needing more study time? All the knowledge that they need should come from day-to-day studying and working alone, not from taking additional time off to study.

Additionally, a medical career examination should test for baseline competency, not test-taking skills or superfluous facts. If you need to buy all these supportive test-prep resources, then you are testing for more than baseline competency. In reality, you are checking for skills outside of the purview of radiology, the ability to take a test. Who do you want to hire a good quality worker/radiologist or a great test-taker?

We Are Supporting The Test Taking Support Companies At The Residents Expense

Once again, the resident is an afterthought when it comes to all the fees that we make them pay. The typical resident has to shell out thousands of dollars to the ABR. And then, the ABR forces upon them the indignity of paying for additional test prep resources on top of everything else. Whether it is books, courses, online question banks, or index cards, each dollar spent on these resources adds to the enormous debt of the typical radiology resident. When are they going to start thinking about the needs of radiology residents?

Now, there are traditional resources such as subspecialty books that residents can and probably should buy. But, are we helping residents by having them pay for the additional resources to pass a test that does not measure what the ABR intends. Who finally wins out in the end? Well, the test taking companies, of course. They earn hundreds of thousands of dollars on the backs of indebted radiology residents.

Let’s Stop Playing Games Once And For All!

The ABR needs to stop deluding themselves that the core exam serves the purpose that the organization had expected. The evidence against the utility of the test is now officially on the table. Let’s now start the process of creating a new examination that works as intended. Back to the drawing board, folks!

 

 

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What Is This Hang Up About Ivy League Applicants?

ivy league

Hovering over the shoulders of program directors throughout the country right after the NRMP match, sponsoring hospital and medical school administration eagerly monitor the match results and statistics from each radiology residency. And, what excites these bureaucrats?

First and foremost, they love it when you’ve matched all your spots, a legitimate achievement. Second, these administrators want to see how far down the rank list you went. Now, I believe this to be a bogus statistic because many of our best residents have been ranked farther down the rank list. But, OK, I will give them that statistic willingly (although I think it’s silly!)

And, finally, they ask to see how many residents came from “Ivy League” institutions. Now, this arena is where I have a real problem. It shows a lack of insight into the residency selection process and medical school training, as well as demonstrates a hubris undeserved of the sponsoring institution. And, let me tell you why.

Medical School Selection Bias

With all this talk about Lori Loughlin and the unfair practices of the university selection process and knowing what I know about the university selection process, I believe that university selection biases also apply to many medical schools. In particular, these issues tend to affect “Ivy League” medical schools more than most because of the aggressive pursuit of applicants (and snowplow Moms!) to get in. Between legacy favoritism and the eternal quest for diversity (not necessarily having to do with the making of a quality physician), these institutions do not necessarily select for the best candidates at our radiology program. Now, don’t get me wrong. There are some great students at these institutions. But, great students sit on the rosters of almost any medical school.

Poor Fit For The Institution?

Many of the candidates that come from “Ivy League” medical school  (not all) want to work in radiology residency programs that have a preference for getting grants and bench research. And, not all programs offer this sort of work. Instead, some residencies provide a solid clinical experience without in-depth bench research. Why would these candidates fit in well with the philosophy of these programs? They do not!

No Difference In Resident Performance

In this realm, I am a bit biased. But, in a look back of all the residents that we have had over the years, our best residents ironically have often come from Caribbean medical schools or have been D.O. candidates. Not to say that the “Ivy League” graduates have been terrible. But, I have not seen standouts of increased performance compared to the other residents in our program.

And this same idea you can also see in the top 20 CEOs in this country. Take a look at the Crain’s Chicago Business article called No One Asks Where The Top 20 CEOs Went To College. (Hint: Only one went to an Ivy League institution) So, why make an increased effort to recruit these applicants when these residents have not performed any better?

Possible Attitude Issues

And finally, as an associate residency director, what is one of the worst things I can do? Well, naturally, recruit residents that do not want to be here. If we are a profoundly clinical residency without that hardcore research component, why would I want to hire an applicant who intends to apply for research grants? These sorts of residents can develop the wrong attitude for a residency program without these resources and will regret being there. Discontented residents make for a miserable residency experience.

The “Ivy League” Applicant

Now, I am not saying that programs should avoid taking applicants from these prestigious medical schools. Indeed, many will make excellent residents. My point is that great residents can come from any medical school. To make accepting these residents into your program as a badge of honor neglects the right reason for the application process in the first place. And what is that reason? It is to find a candidate who thrives and performs successfully over the four years of training!

 

 

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Beyond MOC: Should The ABR Scrap The Core Exam And Find A Way To Assess Competency Objectively?

competency

As physicians, we rely heavily upon our boards to verify that members of our profession can competently practice medicine. Nowadays, physicians are questioning whether the requirements for maintenance of certification (MOC)  provide a valid measure of competency to practice radiology. Even in areas like internal medicine and radiology, a few physicians are taking this mission to court. (1)

But that’s just MOC for attending radiologists. What about the initial exam that the academics created to ensure that residents are competent to practice medicine, the core examination? Did the test creators correlate these board exams with minimal practice competency when residents finish training? And, is it even possible to do so? Moreover, what are these exams testing?  Today I am going to provide a voice for the unloved residents that can’t vocalize their concerns about the examination due to the potential for reprisal from their faculty.

In doing so, I am going to investigate some of the biases that board creators such as the American Board of Radiology (ABR) face. And, then I am going to give some ideas our governing board can objectively use to assess minimal competency, not the current more subjective assessment of what the minimum skill sets should be.

Starting From The Beginning: Who Is Making The Exam

If we think about how the ABR makes its core exam, they farm out experienced voluntary member radiologists of the ABR to create questions for the examination, most of which are academics. Herein lies the first problem. Who are the majority of the radiologists in the country? Are they academic radiologists? Simply put, no.

So, when the initial test question creators formulate the exam, they do not base their questions on the basic competency levels of all radiologists. Instead, these test creators may base their test questions on their own academic experience. This experience may include fairly esoteric knowledge that only the academic radiologist may need. For instance, the question creator may be an academic radiologist that works in an esthesioneuroblastoma center of excellence. Therefore, this radiologist may emphasize a rare disease that most radiologists may never experience. And, you might see this question pop up on your examination even though it does not evaluate for minimal competency.

Also, some of the question designers may practice in a highly subspecialized area. These subjects may not apply to the future practice of a majority of the examinees. Do these questions test for minimal competency? Sometimes probably not. The core examination should more objectively test knowledge that addresses skill levels, not random factual or subspecialty competency.

The Problem With Correlation- Are We Correlating To The Correct Metrics?

According to the ABR, a candidate passes a test if she meets the minimum cutoff that the organization deems appropriate. No, they do not base it on a curve. But, the ABR does need to figure out how to base their minimum cutoff. So, with what exactly does the ABR correlate this minimum competency level? Well, they have to base it off something. To answer that problem, the test question makers assume that they know what the minimal level of competency should be. Well, I am not so sure that is an objective standard based on their different skills compared to the average Joe Radiologist.

Potential Objective Competency Standards For The Core Examination

So, what are some objective standards to which questions should correlate? Well, I can think of a few. Peer review in practice may be one such metric. If the radiologist is entirely off the curve and has passed the board exam, this would indicate that perhaps the examination was faulty. We can correlate the test to that.

What else might be an appropriate metric? Radiologists that cannot hold a job and has been fired by more than one practice. Think about it. If practices continue to let a radiologist go because he does not meet the standards, that is probably a useful measure. Why not use this as a way to correlate the appropriateness of the core exam questions?

Another measurement could be surveying physicians in other subspecialties to assess the competency of the practicing radiologist. If the preponderance of surveys shows poor clinical insight, I believe that would be another useful measure for determining competency.

And finally, perhaps you could use a metric such as multiple lawsuits far about the mean in a particular subspecialty. If a radiologist has been sued five times and the average in her specialty is one or two, that would be a red flag. You can see if the test questions correlate with this endpoint.

These are all potential valid endpoints that the ABR can use to correlation the test that would lend a sense of objectivity. Right now, I am only aware of the subjective criteria of a biased individual examiner of what a passing physician should know. Perhaps, we need to change this concept 180 degrees to assess true competency with objectivity.

Summary: Assessing The Correct Metrics?

Currently, the subjective determined minimum standard of the ABR core examination is not good enough. If we want to create a test that genuinely tests minimum competency, we have to create one with a basis of more objective criteria that associate with the quality of practicing general radiologists that have completed the exam. It will take time and maybe a difficult chore. But it may be well worth it to develop a test that we can rely on to make sure that residents who pass the exam have the minimal competency to practice radiology, instead of being an expert in test taking itself.

(1) https://www.radiologybusiness.com/topics/healthcare-economics/lawsuit-american-board-radiology-antitrust-moc

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Why Can’t Hospitals And Radiologists Just Get Along?​

hospitals

We often hear about radiologist practices and radiologists who cannot seem to get along well with the hospitals with which they work. Perhaps, it is the revenge of the grade C student hospital executive? Maybe, it is the lack of capital intensive resources for the radiologists? Or could it be that some hospitals take every opportunity to cheat radiologists of their next dollar?

Sure, these factors may contribute to a bad experience of working with a hospital. But, I believe that these factors are not the leading causes of conflict. Instead, the answer is simple. Our mission differs sharply with the employers with which we work.

So, how exactly does the primary mission of the employed radiologist or the hospital based radiology group differ from the organization for which they work? And how can we resolve that conflict? Well, these are the topics for today!

Mission Statement For The Employed Radiologist

What is it that radiologists want? Well, let me give you some sentiments from radiologists in the form of some familiar complaints. 

“Constant phone calls are constantly interrupting my workflow.”

“We don’t have enough technologists to keep the workflow going in interventional radiology.”

“The PACs system went down again, and I can’t dictate any cases.”

And finally, of course, “How many times do I have to tell the technologist to complete the study!”

So, what do these complaints have in common? Basically, they are all saying the same thing. Radiologists want seamless workflow. And, if I had to think of the mission statement for a practicing radiologist, it would be, “let me do my work without interruption!

Mission Statement For The Imaging Center/ Hospitals

What about the hospital or imaging center owners? Well, let me give you some of their sentiments in the form of some statements.

“We need to get the SPECT-CT operational so that we can get new patients into the system.”

“Clinicians are continually complaining that radiologists are not getting the reports out in time!”

“We have several obstructionist radiologists that are refusing studies to clinicians. We need to talk to them!”

“The layout of the department is making it impossible for patients to get their tests promptly.”

So, what do these statements from the guys in the executive suite have in common? They all are about the bottom line of the hospital. Or, “how can we maximize revenue for the organization and decrease costs?”

Misalignment Of Mission Statements

Fortunately, most of the time both owners and radiology employees are on the same page. Hospital executives usually want to create a seamless work environment for the radiologist to improve revenues. Likewise, radiologists aim to bring in the most revenue possible for the organization by improving workflow. However, many times these two mission statements will butt heads.

Occasionally, increasing system revenue may mean impeding the workflow of the radiologist. For instance, the hospital sees that picking up the phone while in the midst of a busy rotation makes their clinicians happy. At the same time, it delays the readings of the radiologist. The hospital continues to allow this to happen.

Likewise, increasing efficiency of the radiologists sometimes costs more to the system than doing nothing. Maybe, the reading room is not ergonomic, and the hospital cannot see how the hospital expense will improve the bottom line.

And, herein lies the crux of the problem. How can we reconcile the two missions?

Solving The Employed Radiologist/Owner Misalignment

Both parties need to have skin in the game to solve the misalignment dilemma. Employed radiologists need to have some ownership stake in the operations of the hospital. And just as importantly, owners/managers performance should be tied to improving the seamless workflow of the radiologist. You can’t expect either an employee or a manager to implement changes actively without incentive or experience. In some institutions, minimal incentives exist for these liaisons. Additionally, some managers have little experience with understanding the radiologist’s workflow.

So, how can we allow hospitals and radiologists to have better relationships? Well, we need to align the fundamental misalignments.

First, radiologists should receive some compensation for increasing the revenues and decreasing departmental costs. Tying rewards based on increasing institutional profits make the radiologist more likely to find favor with less radiologist friendly policy but excellent institutional benefit.

Moreover, hospital/practice management should not hire a random secretary within the building at a lower cost to run the business side of the practice. They should find a seasoned business manager who understands the trials and tribulations of the radiologist. How frustrating can it be to have someone who has no clue about radiologist operations?

Additionally, hospitals should tie the business manager to the efficiency of the radiologist practice. How? They can create a reward system not just based on hospital goals, but instead meeting the efficiency goals of the radiologists as well.

Tying The Knot

You cannot expect two groups to be on the same page when some of the most critical goals of each organization differ so widely from one another. Instead, you need to marry the two organizations mission statements into one. Creating a system to align the priorities of both groups should be a top priority. And, hiring the appropriate individuals is critical. Let’s resolve the differences instead of complaining about what both hospitals and the radiologists do wrong!

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Image Wildly!

National organizations that represent technologists, physicists, and radiologists have created programs to decrease radiation dosages called Image Wisely (adult population) and Image Gently (pediatric population). As much as these programs make perfect sense and reduce exposure to patients,  neither program addresses the more pressing radiation dose issue in radiology. Right now, Emergency Departments (EDs) throughout the country have a program that counteracts all of these achievements. I like to call it Image Wildly!

So, what do I mean by that? We, as radiologists, have noticed an epidemic throughout our hospitals. And, no it is not high radiation doses for patients on an exam by exam basis. Instead, we see EDs ordering unnecessary studies indiscriminately. These unwarranted studies significantly increase radiation dose much more steeply than any single exam reduction in radiation dose can achieve. So in today’s rant, I will outline a myriad of factors for the problem. And then, I will identify how we can achieve the goal of reducing radiation dose by decreasing the number of silly studies ordered.

Reasons For Image Wildly

If You Build It, They Will Come

Have you noticed when you either add or replace old imaging equipment with more efficient hardware, the numbers of studies increase accordingly? And, what happened to these patients that didn’t get these studies before the new ED CT scanner arrived? Well, now that the equipment is more readily available to patients, it becomes more convenient for clinicians to order a test instead of waiting to complete an appropriate physical and history to triage patients through the system. But, like many of you, I still believe there is a role for taking a good quality history. It’s the most effective way to reduce exams and also radiation dosage!

Midlevel Providers Automatically Ordering Studies

In some departments, automatic button pushers such as some midlevel providers will sometimes order studies to hasten the final disposition of each patient. The process can become somewhat standardized with any patient labeled with abdominal pain slated for a CT scan. Unfortunately, these formulaic systems do not always work. Not every patient with abdominal pain needs a CT scan. And, the midlevel providers often are just another cog in a wheel run by a larger entity. If only someone would examine the patient well first, the clinician could cancel these unwarranted studies.

CYA (Legal Issues)

Of course, in any discussion of imaging, we need to discuss one of the thousand-pound gorillas, the threat of a lawsuit. Elevated threats of lawsuits lead clinicians to order more studies just to prevent the possibility of “missing” a clinical finding. However, this issue ignores the other complications of imaging- false positives, increased radiation doses, and occasional misdiagnoses. I am a firm believer that the answer often lies in the patient’s history. But, histories are also not perfect. And, how can a clinician transfer the blame from himself? Order a study and make it the radiologist’s problem!

Quantitative ER Parameters (Time To Disposition)

Often, in a busy ED, it takes less time to order a procedure before a patient needs it rather than to have to order a study when she needs it. And, what is the metric that many Emergency Departments use to measure quality? Well, that would be time to disposition! So, what happens? Patients get additional unneeded studies that rack up increased radiation over time in order to minimize ED time. Statistics like this one emphasize time over quality. And, who suffers? The patient, of course!

How To Solve Image Wildly

Unfortunately, I do not have one straightforward answer to solve every problem that leads up to the Image Wildly phenomena. Instead, we need to tackle each reason for the problem individually. Indeed, if you address the legal issues with tort reform that will not correct the reliance of quantitive parameters that many EDs utilize. And, if you prevent the ordering of unnecessary new studies with clinical information systems, you would still have to solve the problem of having mid levels creating formulaic diagnoses of patients so that the hospital can move them through the system more rapidly.

Slowly and deliberately, we need to take a hard look at each of the issues that can cause the problem indiscriminate imaging. Only then, can we significantly reduce radiation dosage of patients and end the problem of Image Wildly!

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Top Ten Radiology Resident New Year Resolutions

It’s the beginning of another year. And, the average Joe off the street creates a list of new year resolutions. Some of them he will keep, and others he will forget. Perhaps, he will try to begin to clean up the house or start to eat right.

Well, as radiologists in training, you have a different set of wants and desires that would appear foreign to the average chap. (And perhaps, a bit bizarre!) I mean who in their right mind would want to read films, do procedures, and see patients. Shouldn’t we concentrate on living life? In any case, here is a list of the top 10 resolutions I would think are most important for the radiology resident for 2019!!!

The Top Ten Radiology Resident Resolutions

  1. Reading more hours every night- One hour is just not enough!
  2. Completing your study logs on time- Be kind to your program administrators…
  3. Paying off student debt interest- Don’t let those debts rack up as much by the time you graduate!
  4. Reading more films and completing more procedures- You can never know enough normal variants!
  5. Staying awake and listening at noon conference– Who knows? You may remember a few tips for when you are practicing as a radiologist!
  6. Always checking for prior films– Don’t get burned later on in your career. Avoid lawsuits!
  7. Arriving on time to work every day- This can get you in trouble later on in your career and may get you fired!
  8. Traveling when you are off- Seeing new places is crucial for maintaining sanity…
  9. Maintaining calm when you receive unreasonable requests for a study- Losing your temper can lead to adverse outcomes!
  10. Standing up instead of sitting down at readouts- Burn a few extra calories while you are at it!

Let me know if you agree or disagree with these top resolutions. Comment below!