Category: Resident Advice

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Canceling A Procedure? Call The Clinician!

Not all ordered procedures make sense. Perhaps, the clinician decided on you performing a biopsy based on an incorrect typographical error in a report from the radiology department. Or, even though the clinician thinks that a carotid stent would be helpful, you conclude that the risks of a procedure outweigh the benefits. In the end, these decisions to perform or cancel a study are ours to make, not the referrers. And, sometimes, canceling a procedure for a good medical reason is the best we can do for the patient, end of story. You can feel good about yourself, doing right for the patient. Plus, you have one less procedure for the day!

But wait. Is that all? Well, you have not completed your work yet. What is the one way that you can get yourself into loads of trouble even though you canceled a procedure for a good reason? Hint! You can look at the title above, or instead, check out what I am about to tell you in capital letters: CALL THE CLINICIAN! And, let me tell you why.

It May Delay Clinical Treatment

Even though you serviced the patient well by canceling a procedure, it may not have benefited the patient as you thought if you do not notify the ordering physician.  Let me give you an example. You were planning on performing an angiogram to determine the location of a GI bleed. And now, you have canceled the examination because the GI bleeding stopped. And let’s assume you did not contact the ordering physician. Well, perhaps, the treating physician had delayed treatment for hyperthyroidism based on the assumption of your administration of intravenous contrast material. Look what you did! Now, the patient had her treatment hindered for many weeks by your lack of communication.

Potential Increasing Risks To The Patient

Sometimes patients temporarily stop necessary medications before a procedure. For instance, many patients take Coumadin as preventive medicine for stroke if they have a prosthetic valve because they are at increased risk for blood clots. Therefore, typically, you need to withdraw the patient from anti-coagulants to prevent bleeding during or after a procedure.

And, when you cancel a procedure, many times, the patient will not return to their regular scheduled regimen until the doctor reorders it. Moreover, the patient’s risk for stroke can increase each day he does not receive the medication. Therefore, it behooves you to let the ordering physician know. Why would you want to enhance a patient’s risk for further morbidity?

It’s Offensive Not To Notify The Ordering Physician

One of our prime roles as physicians is to communicate results (or lack of results) to our colleagues and patients. By withholding critical information from the ordering physician, you disrupt the link. And, yes, canceling a procedure counts as “critical information.” If you want to make sure not to get repeat customers in your department, be sure not to pick up the phone and call!

You Can Ruin Your Reputation

Technically, you may be the best neuro angiographer in the world. But, if you cannot let your colleagues know that you decided to cancel that stent placement procedure, then, who cares about how good you are? You are not giving patients the best medical care. And, you certainly do not want to establish that reputation.

There’s More To Do After Canceling A Procedure!

Practicing quality radiology involves more than just making quality clinical decisions and performing appropriate procedures well. Just as importantly, we also need to maintain the links of communication with our clinical colleagues so that we can give the best possible care to our patients. And, if sometimes, the best decision for the patient is to cancel a test, make sure to contact your fellow physician. Don’t spoil your excellent patient care with a lack of communication!

 

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What It’s Really Like To Be Pregnant During Radiology Residency!

Dear Dr. Julius,


I am writing in response to the post that I recently saw on the Radsresident.com blog regarding pregnancy in radiology residency. While I commend you for your efforts to assist aspiring radiologists in their search to balance the stresses of training with life-altering decisions such as family planning, I must admit that the responses seem overly simplified and downplay the stresses that one faces while enduring this transition.

Having entered radiology residency with a child, who I had given birth to at the end of my third year of medical school, I certainly am not an expert on the stresses of having a first-time child during this portion of the training. I did, however, decide to have my second daughter during residency training. And, she was born towards the end of my R1 year.  If you were so kind as to indulge me, I would like to add some insight into the questions previously posed now that I am about the finish my R4 year keeping in mind the lessons I have learned along the way.

Is pregnancy in radiology residency doable?

Short and long answer: Yes. Starting or expanding a family in residency is ultimately a choice.  It is doable, but that doesn’t mean, you will not have to make sacrifices. Some days you will feel like a great mom and other days you will feel like a great resident. Every once in a while, you will feel both. Your time will be stretched; your attention will be split. You will have to work hard just like anyone else who has personal issues they are dealing with at home. If you commit though, you can make it work and not just survive residency but also thrive. I would also argue that my children have helped me keep perspective through this all, and I don’t believe I would be as good as I am if not for my desire to show them the rewards of working hard.

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

The answer to this question depends but generally the answer is yes.  Most programs have some form of leave for residents. However, this does not mean that the program will pay for the entire time off. The Family Medical Leave Act (FMLA) should guarantee that you receive up to 12 weeks of time off if you need/want it, but this does not mean that you will be paid for the entire time. Additionally, the program may expect you to use your vacation time during your maternity/paternity leave. So, consider this when planning.

Some programs like mine have built in time for new parents (both male and female), which is up to 6 weeks PAID leave in addition to any vacation time you want to use up to the 12 total weeks off. However, standards may vary, and the best people to ask would be the residents themselves. As per the NRMP, programs cannot legally ask you about your family plans during an interview unless you ask questions that open the door to this subject. However, this doesn’t mean you cannot probe the current residents about their experiences (and honestly you should).

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

As Dr. Julius said, the only potential for significant exposure you will face is during fluoroscopy or interventional radiology rotations. If you find out you are pregnant, you can alert your radiation safety officer and officially declare the pregnancy. Once a pregnancy is declared, you will receive an additional radiation badge that tracks the radiation you receive over your pelvis (the badge goes UNDER your lead). The badge measurement should represent an estimated amount of exposure to the growing fetus.  The most important time to avoid radiation exposure is during the first 12 weeks when organogenesis and rapid cell division is highest. However, you do not have to perform IR or fluoro duties later in the pregnancy if you don’t want to.

I had my IR rotation early on, so it wasn’t an issue. But, I ended up shifting my fluoro rotation to another academic year because I didn’t want any unnecessary exposure. Your program and the chiefs should be willing to work with you. If you feel comfortable talking to the chiefs ahead of time, you may even be able to coordinate those rotations earlier/later to avoid having to cause scheduling changes later on. Of note, some women choose not to declare their pregnancy and continue to work. I know of IR attendings who worked during their pregnancy the entire time. But the point is, it is your right to decide how much potential exposure you will receive. You need to feel comfortable.

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

I think this sincerely depends on the program and how it distributes residents among services. I would agree that the R4 year may have more flexibility due to elective time. But, R1 year is also relatively light given the lack of call. In my hospital, R2 year is especially difficult and demanding, but the toughest year can vary depending on the program.

I tried to time my pregnancy on purpose towards the end of my R1 year. By doing this, I was able to take advantage of the six weeks of paid leave offered by my hospital. In combination, I was also able to take two weeks of vacation from R1 year and tack it on to 2 weeks of vacation from R2 year for a total of 10 weeks off. I will be finishing on time. And, I did not have to remediate any rotations except the few weeks of fluoroscopy I missed during an R4 elective.

Timing is not always doable, and you may experience stresses related to just trying to get pregnant during training – just something to keep in mind. I even met a girl last year who was eight months pregnant while taking her boards examination. She passed. Life goes on. Ultimately, there’s no perfect time to have a child, and the program should help you work through your needs as you encounter new challenges.

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

I can only speak from personal experience that I had very supportive co-residents. But, I believe this stems from the underlying culture of my program/hospital. I believe that resentment may be a little harsh to describe the sentiments of the other residents. Certainly, if additional/compacted call falls on your colleagues, they may be anxious for your return to mitigate the stress of call.  Not one of my co-residents ever questioned my dedication to the program during or upon my return from my leave. If anything, you may have some challenges with the attendings once you come back. And, you may find yourself having to prove your knowledge in light of a prolonged absence.

I would argue that as long as you are meeting milestones and keeping your major/minor change percentages on par with your colleagues, you should not have to worry. You need to understand, however, that your choice to take time off will require dedication and discipline. Upon your return, you will make up for the time you lost to “catch up.”

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

I would advise asking the residents during your time with them on interview day or during pre-interview dinners. Don’t single yourself out, but ask general questions like, “How many residents have families?”; “What’s the program’s family leave policy? Is it paid? Do you have to use your vacation?” As Dr. Julius mentioned, having support nearby or having a supportive partner is probably the most important thing. Radiology residency may be less demanding in terms of physical time in the hospital. However, you will need to read and study during your off time to excel. You will be preparing case conferences during off hours if your program doesn’t give you dedicated time. You will need to carve out time for yourself and your well-being. All this work requires the support of others.

Feel free to allow your readers to contact me directly with questions on Twitter @KVincentiRad.

Thank you for your time.
Kerri Vincenti, MD
Chief Radiology Resident
Pennsylvania Hospital of the University of Pennsylvania
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What Radiology And IR/DR Programs Don’t Tell Applicants About Interventional Radiology!

IR/DR Programs

After all of the hype about the new IR/DR programs, I am not surprised that it has become so attractive for medical students. However, most applicants don’t realize what happens to the typical resident’s desire for interventional radiology after they begin their residency. Of course, these programs don’t tell them that! It’s bad for business. So, I will give you the lowdown.

On the interview trail, at least since when I became a program director, and before the new IR/DR programs existed, a large percentage of medical students have always claimed interventional radiology was their top choice for fellowship. But, as soon as they would arrive at the program, some of these former desires became a wist of memory. And, the other rarified few would make it to their first, second, or third year and then suddenly drop off of the IR bandwagon. Very few who initially wanted interventional would make it to the end of the residency. Why did that happen? Well, I have some theories.

Constant Consents/Too Much Patient Contact

One thing most residents like to complain about (myself included back in the day): scut. And, in the world of interventional radiology, you can find no lack of scut in any corner. Patients need consents. They complain about their symptoms.

Moreover, as a “real” IR doctor, you need to listen. That can become real old quickly if you cannot stand performing these critical patient duties. It’s not why most residents signed up for radiology.

Lifestyle Is Not What They Thought It Would Be

Overall, which radiologist subspecialist awakens the earliest in the morning? Well, that’s easy- the interventionalist. And, who often leaves the latest? The same. Also, some interventionalists may get called in for all hours of the night at any time on their lonesome. Now, radiology may not be the lifestyle specialty that it was years ago in any subsegment of radiology, let alone interventional radiology. Regardless, this sort of long day in interventional does not attract many radiology residents to the field. You may be the only one in your residency!

Risk Of Needlesticks

In any medical field, you will encounter physical dangers. But notably, the interventionalists have a higher likelihood of bodily injury. Most critically, these folks use lots of sharp needles. And, guess what? When you utilize lots of needles, you increase your chances of a needle stick and the good stuff that comes with it- Hepatitis, HIV, and more. Many residents think about this only after they start their residency. And, walla, they make their decision not to enter the field!

You Can Perform Procedures As A DR Graduate

No. Interventionalists are not the only ones that can perform procedures. If you decide to take a rural job or practice as a general radiologist, you will likely be responsible for some of these. I know of many “non-interventionalists” that perform all sorts of biopsies, vascular work, and interventional oncology. So, why bother if you don’t need that extra certificate of qualification?

Not As Glamorous As They First Thought (PICCs and Ports)

Nowadays, most interventionalists perform all sorts of procedures. And, most likely, it will not be many of those stent placements in the neck or embolization of the liver. Most techniques are much more mundane. You will probably have done a lot more PICC lines and Portacaths than any high tech complex procedure out there. Yes, you will be a critical member of the team. But no, you will most likely perform more garden variety interventional procedures than complicated ones.

Heavy Lead

In some “fancy” institutions, they have made sure that each interventionalist needs to wear anti-gravity lead before any procedure. But, more likely than not, you will need to wear a regular lead uniform most of the time. And, unless you maintain yourself in excellent shape, many lead garments tend to cause back and muscle pain. In fact, at a certain age, it is not uncommon for many interventionalists to switch to a DR specialty because of the wear and tear on their bodies. Most new radiology residents do not realize the long term consequences of wearing a heavy uniform until they hear the complaints of their mentors.

 

Bottom Line: What Does This Mean For The Future Of The IR/DR Programs?

After all of these issues, and as much as I like the field of interventional radiology as a profession, I find it fascinating that the IR/DR residency has become one of the most popular and competitive specialties out there. I think many residents have not done their research and have fallen for all the hype.

Now, call me crazy, but I believe that one of two things may happen since residents are signing up early before they get to know the specialty. Either, the attrition rate for these IR/DR residencies may become more significant than the founders realized or the programs will have created lots of disenchanted and unhappy IR/DR clinicians. Only time will tell. I hope I am wrong!

 

 

 

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Can I Discuss Lifestyle On Interviews?

lifestyle

We all want to know about lifestyle when we interview for residency, fellowship, and beyond. But, many of us are afraid we will offend the sensibility of the interviewer. Will he think I’m lazy? Will she believe I will take too much vacation if I work here? I’m sure at one point, or another, these thoughts have crossed your mind.

So, in what context, can you ask these questions? And, is it ever appropriate to grill your interviewer about the lifestyle that she leads in her job? I mean that likely is one of the reasons why you are taking the position there. Or, at least, you don’t want to let on that is the reason why you are taking the job, right?

Once again I aim to please. Accordingly, I am going to delve into the hornet’s nest of the discussion of lifestyle on an interview. At what point should you avoid it at all costs? When is it appropriate to discuss? And, finally, how should you address it and what should you say?

When To Avoid Discussion Of Lifestyle

In general, unless under special circumstances, you should not broach the topic of lifestyle on that initial outing when you interview for an attending job. Think of the first interview as a “get-to-know-you” session. First and foremost, you want to discover if the place of work matches your expectations for what you want. Typically, once you introduce the subject of lifestyle issue during that first interview, you have opened a can of worms. You are saying; essentially, lifestyle is more critical than the working environment. Most likely, you do not want to relay that message on first sight!

Likewise, as a resident, most often it is inappropriate to ask an attending about lifestyle issues as a resident. First, faculty tend to know less about the day-to-day lifestyle issues of residents. So, it shows poor insight when you ask the attending about how and where they live. Try to direct these questions to a more appropriate source, your future colleagues, the residents within a program.

And finally, sometimes, you discover that you are interviewing with a person who does not seem to want to answer questions about lifestyle. Perhaps, this person is awkward or is a bit off. Is that the sort of person, you want to ask about lifestyle anyway?

When Is It Appropriate?

Of course, as an attending interviewing for a job, you need to find out more information. So, wait a bit. Get a feel for the practice. If you have already had your first interview, then you can start thinking about lifestyle questions. Vacation and call issues become more important once you have established that this place may work for you.

Or, perhaps, you are sitting down at the table at lunch with future resident colleagues. This time would be perfect for broaching the topic of lifestyle. Do residents always eat together? That’s certainly an appropriate question at this point in the day.

And then finally, sometimes the interviewer may ask you a question that can lead you into discussing a lifestyle issue. For instance, he may want to know how you tend to enjoy your vacations. That could appropriately stimulate discussion on the topic since the interviewer essentially permitted you to discuss it.

Best Way To Address The Issue

Once you have established that you think that you will fit in with a residency or practice, it pays to be tactfully forthcoming. At that point, you can ask the interviewer if they receive extra “administration” or half days. Or, you can find out about which days may lead to easier rotations. The information that you collect from this place may further inform your decision down the road to choose where you want to work. Use your best judgment. You have gotten this far!

If you feel less comfortable, you can also always sidle your way into the conversation. A statement like the following For instance, after you see a picture of the radiologist in Bora Bora on the reading desk, the following statement would undoubtedly work- “I see that you like to go away to Bora-Bora. How often do you take that trip?” That would be a non-offensive way of beginning to broach the topic. And, it can lead to more detailed information.

Another non-intrusive question that I like and can work to get a feel for the “corporate culture”: “Do the partners/residents like to go to dinners together?”. This question establishes whether or not the partners get along well enough to host events together.

Bottom Line About Discussing Lifestyle On Interviews

Understanding the corporate lifestyle is a critical piece of data that you need to decide whether the radiology practice or residency works for you. Nevertheless, it can become a sensitive topic. Delivered at the wrong time, it can relay a lousy impression that may prevent you from getting that next great position.  So, be sure that you mention the subject at the appropriate time to the correct individual. And phrase these questions non-offensively. Tread lightly, my friends!

 

 

 

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Minimal Effort And Maximal Gain: A Targeted Residency Approach

minimal effort maximal gain

Radiology residents, especially, are under the gun to complete their work efficiently. I mean, to learn what you need to know for the boards you have to read through umpteen books and a gazillion films, right?  So, who has the time to go through the motions of a bland long-winded study routine to get you through all the material? That would take way too long. Therefore, I want to give you some suggestions to guide you efficiently through all the subjects you need for radiology residency. So, here are some the basics you need to get through residency with minimal effort and maximal gain!

Targeted Reading

I can’t remember the number of times that I have talked about targeted reading in my posts. But, I will repeat it for the ten thousandth time. It’s that important. Every resident should read radiology books differently from other subjects. Remember. Pictures first, then captions, and then text. If you start from the text and go to the images, much less information will stick. So, please do yourselves a favor and do this the right way.

And, just as critically, make sure to emphasize case review series in your review process. Radiology without cases is like peanut butter without the jam (sorry for those of you that are allergic to peanut butter!). It just does not feel right!

Reinforced Reading

How do you get information to stick around in your brain? Well, you need to look at the same item from different angles. What do I mean by that? If you find a meningioma on a CT scan at work, first of all, make sure to look it up that night. Then, look at the same case on multiple imaging modalities. Perhaps, check it out on an MRI, a contrast-enhanced CT scan, or even a skull series if available. The more ways that you look at the same findings, the more likely you will recall the case when you need it!

Lots Of Questions

Don’t let the texts that you are reading become merely a bunch of random words. Just like any other time that you had to study for tests, make sure to phrase the text into the form of questions. And, I have some great ideas to help you along your way. My residents reported using several test question bank companies for study, especially around board time. But, it may not be a bad idea to use these question banks at any time during your studies to emphasize the materials.

The two companies that I hear assist the residents with fairly comprehensive question banks are as follows: Board Vitals and Quevlar. Both of these companies give you some great questions for the Core Examination. Now, you need to make sure to have learned the basics before. But, both Board Vitals and Quevlar will enable to get through the material that much quicker to get you where you need to be before the boards.

Group Learning

You certainly need to read a lot independently to learn the material that you need to know. However, you should also utilize your colleagues to maximize your knowledge. Going over questions or cases in groups with your fellow residents adds new perspectives on the same information. And, by golly, here you have another neural pathway to maximize what you retain!

Board Review Courses

I believe in learning from numerous different angles. And, therefore, I need to put a pitch in for Board Review Courses. Not all program directors believe in this approach. However, sometimes, it helps to step out of your familiar residency conference world and to get a fresh perspective. Different instructors and different points of view create distinct neural pathways for information recall. That is the reason I believe a board review course can work. I think it’s not a bad idea to attend one or two.

Minimal Effort And Maximal Gain

Don’t get me wrong. To be a great radiologist, you need to put in the hours. However, make sure that you utilize your time as effectively as possible. Why spend time that you don’t have? So, follow this approach to get through the material logically and efficiently. Who doesn’t like minimal effort for maximal gain?

 

 

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Why Residents Should Take Charge Of The Worklist

worklist

By the time you start your first radiology attending job, you should feel comfortable getting through a typical day’s work. So, how do you arrive at this point of comfort? Well, it is not via magic. Most successful starting radiologists will have adopted a formula for getting through a day’s trials and tribulations. Moreover, they know how to manage the worklist. And, the easy way to do so? You should have that experience during your radiology residency.

Now, not all residency programs work the same. Some residents plow through whatever cases the attending tell them to go through. In these sorts of residencies, the attending maintains the responsibility for the worklist. They make sure that either the resident or the attending read through the cases that they need to complete.

And at others, the resident starts the day by gathering the necessary cases together and dictating. Attendings will intermittently arrive at the department to read out the studies with the resident. However, the attending charges the resident with the responsibility of getting through the worklist for the day.

I would argue that the latter programs tend to be more helpful for starting in practice. Let me tell you why.

Most Practices Are Run By Radiologists

First of all, in most practices, who is in charge of the worklist? No, it is not the nurse, the technologist, or the radiology assistant. Instead, usually, the radiologist manages the worklist to determine who he should read first, second, and third. Even though artificial intelligence may one day take over some of this process, radiologists should have the background to feel comfortable owning a worklist.

Teaches You How To Get Help From Others

Let’s say that you start on your worklist and you find a case where you are not sure of the diagnosis. Who do you approach? And, how do you contact that person? Do you call or walk over to the other room? Do you interrupt their train of thought or do you wait until they finish up? Or, do you find a clinician in another specialty? These skills only come when you have to manage cases outside of your purview. And, these cases are much more likely to arrive when you control your worklist.

Learning How To Triage Work

In the same vein, when you have an unsorted worklist, how do you know what needs to be read first, second, and third? Sometimes, you arrive at a decision best when you have had the experience to make that conclusion. It takes time to figure out that you should read certain physician’s cases first or a specific type of STAT indication sooner. What better way than to manage a worklist as a resident?

Time Management Skills

Of course, when you learn to control your worklist, in the beginning, you may not realize how much time you have to complete all the work for the day. Unfortunately, you may find that you had less time than you initially thought. So what is the best way to hone your time management skills? Manage the worklist! You’ll eventually learn the ropes.

Patient And Physician Phone Calls

During the day, you are bound to receive multiple phone calls from both referring physicians and patients alike. How do you deal with them in the confines of a busy day when you have a whole bunch of studies to read? Well, when you manage your worklist, you get to figure that out. Do you spend an inordinate amount of time on the phone or do you hurriedly give them an answer? To determine how you should proceed, take charge of the work for the day!

Taking Charge Of The Worklist

It’s more than just lip service. Owning the worklist allows budding radiologists to hone their skills. Whether it teaches you to work with others, time management, the art of triage, or more, it will enable you to get through the day in a timely fashion. More importantly, when you learn all the skills of managing a worklist, you can hit the ground running at your first job. That’s where you want to be!

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Should Radiologists Focus On Helping Our Clinical Colleagues Or The Attorneys That Read The Reports?​

attorneys

Radiologists create dictations with two audiences in mind, for the clinicians that read the report, and also for the lawyers that may interpret the record if the case turns sour. Depending on the radiologist, he might attune the report mostly toward the clinician or may create a dictation primarily for the attorneys. Every radiologist emphasizes one audience or another along a broad spectrum.

However, walking too far toward either extreme can become problematic. Forgetting about legal issues can lead to lawsuits. And, wholly concentrating on the attorney in your dictations can lead to angry clinicians.

In the situation of radiologists who write solely for the attorney, the report impact patients negatively. Why? They dilute the effect of our reports to care for our patients. Moreover, they send the wrong message to our trainees while neglecting the Hippocratic Oath. These radiologists are essentially saying that the legal importance of our reports trumps the clinical care of our patients.

Neither do I believe that we should ignore the legal aspect of our dictations entirely. That would be professional suicide.

So, we should think carefully about for whom we are writing and how it affects both the trainees and the clinicians. Therefore, today I am going to talk about how creating reports for clinicians or attorneys can impact your message. And, then I am going to give you some guidelines to compose a balanced dictation.

Problems Of Writing For The Attorneys

So, what happens if we create dictations with the attorney as the primary reader? First, it dilutes the message that we want to give to the clinician. These dictations tend to emphasize all possibilities for the diagnosis versus the most likely diagnosis. We overemphasize findings for our attorneys instead of the clinicians that read them. In the end, clinicians are less likely to pursue the correct avenue.

Next, our reports become wordier and harder to understand. When you write for the legal system, you tend to add more caveats. We use terms like cannot be excluded. I find these reports less straightforward and much longer to read.

And finally, when we write for the legal system, we tend to recommend additional tests to protect ourselves. Perhaps, that 22-year-old female with a probable hepatic hemangioma on ultrasound will receive a full workup that she does not need in the interest of protecting our hide.

Problems With Writing For Only Our Fellow Clinicians

On the other hand, what happens when we write only for the intended audience, the treating physician? Well, first we tend to de-emphasize the less likely diagnoses. So, if the clinician does not make the rare diagnosis, and it was not in your report, an attorney will more likely find fault with your dictation. Some of these “clinical dictations” may neglect the zebras entirely.

And, more importantly, by neglecting the attorneys we expose ourselves to the possibility of a lawsuit. By mentioning an appendicolith in a normal-appearing appendix and not talking about the rare outcome of early appendicitis, you may go down the proverbial tubes.

Striking A Balance

Like everything else in this world, the key to making something useful is to strike that perfect balance. To create a reasonable mean between the two extremes you can create dictations referencing the most likely diagnosis with some mention of the more uncommon etiologies, emphasizing the different probabilities.

Moreover, make the dictations easier to understand without using too many caveats. Wordiness does not necessarily protect you from having an attorney use your report against you in a lawsuit.

Finally, you should strive to recommend further workup for the most likely diagnoses that will significantly impact patient care without going overboard, using the clinical data to help make the decision.

The bottom line: We need to remember in every report that a patient’s medical care is at stake. And, that battle, for us radiologists, is worth the fight. So, think twice before you create your dictation for only the referring clinician or the attorney that might read your report!

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Five Dictation Styles To Avoid At Your Own Peril!

dictation styles

As you get along in your career, you will see thousands upon thousands of dictations. And as you would imagine, most reports are useful to clinicians and fellow radiologists.  However, others should never make it to the medical record. To top it off, some of these dictation styles make me bonkers. Often, they waste my time and increase my workload. Therefore, I can only imagine how the clinicians feel that order these studies!

So, in the interest of altruism, I have decided this week to give you five examples of different dictation styles to avoid and one format to use. Some of these dictation styles are too wordy. Others are non-objective. And, others are merely careless. To show you different ways of creating the same report, I have made each dictation similar with a history of shortness of breath (So, you won’t see it at the beginning), and with the same overall findings of right lower lobe pneumonia. Now, you will know how you can get that information across the easy way or the hard way!

The Five Dictation Styles To Avoid!

Style 1- The Cut And Paster (It’s A Struggle To Figure Out What You’re Thinking!)

Comments:

PA and lateral views of the chest demonstrate right lower airspace disease that obscures the right hemidiaphragm. Follow up to resolution is recommended. Cardiac silhouette is within normal limits. Skeletal structures are intact.

Impression:

PA and lateral views of the chest demonstrate right lower airspace disease that obscures the right hemidiaphragm. Follow up to resolution is recommended. Cardiac silhouette is within normal limits. Skeletal structures are intact.

Style 2- The Emotional Dictation (It’s Not A Novel Guys!)

Comments:

PA and lateral views of the chest show patchy opacities at the right base that are compelling for either the diagnosis of atelectasis or pneumonia. I believe that a mass in the right lower lobe is unlikely. However, I would desire to follow up in 6 weeks to make sure it resolves.

The cardiac silhouette is within normal limits. Skeletal structures are unremarkable.

Impression:

Findings compelling for right lower lobe pneumonia or atelectasis

Desire follow up study in 6 weeks to check for resolution.

Style 3- The Indecisive Dictation (All Things Being Equal!)

Comments:

PA and lateral views of the chest demonstrate probable right lower lobe airspace disease. The differential can include pneumonia, atelectasis, pulmonary edema, pulmonary infarct, sequestrum, drug-induced inflammatory changes, fungal infection, atypical lymphoma, or other neoplastic entities. Followup to resolution. The cardiac silhouette is within normal limits. Skeletal structures are intact.

Impression:

Probable right lower lobe pulmonary parenchymal disease.

Consider pneumonia, atelectasis, pulmonary edema, pulmonary infarct, sequestrum, drug-induced inflammatory changes, fungal infection, atypical lymphoma, or other neoplastic entities.

Followup to resolution

Style 4- The Overly Technical Dictation (No one cares and what a waste of words!)

Comments:

PA and lateral views show slight underpenetration of the film with minimal patient rotation rightward.  At the right lung base, the right hemidiaphragm is partially obscured by patchy airspace opacities. It encompasses a segment of the right lower lobe measuring 2 cm and overlies the right 6th through 8th posterior ribs. The airspace opacities extend to the right heart border but does not obscure the silhouette. These findings are most consistent with right lower lobe pneumonia. Followup to resolution is recommended.

Cardiac silhouette is within normal limits. Osseous structures are intact.

Impression:

Right lower lobe pneumonia
Follow up to resolution.

Style 5- The Unchecked Dictation (If you like phone calls, this one is for you!)

Comments:

PA and lateral views dem straights right lower lobe air space disease consistent with pneumonia. Folloup to resolution is recommended. Cardiac silhouette is normal. Osseous structures are intact.

Impression:

Left lower lobe pneumonia.

Followup to resolution.

One Style That Works For Me!

Comments:

PA and lateral views of the chest demonstrates right lower lobe air space disease consistent with pneumonia. Followup to resolution is recommended. Cardiac silhouette is normal. Skeletal and soft tissue structures are intact.

Impression:

Right lower lobe pneumonia.

Followup to resolution.

Summary

So, there you have it: five of the some of the more common annoying dictation styles that you will see and one that works for me. Please, please, please… Try to avoid the usage of these horrible styles. Regardless of whether you create them or read them, they will waste your time and efforts. At least, consider trying to develop good dictation habits before it is too late!

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How To Pick Up Speed In Radiology

When starting as either a resident or beginning attending, commonly, radiologists worry about whether they are reading quickly enough to meet the demands of the residency or practice. Sometimes, we self impose this construct of the “truth” about our speed. And, other times the fear may be legitimate. In either case, how can you achieve the point at which you are interpreting cases fast enough to feel like you are producing quality dictations without fumbling too much (everyone misses something no matter how quickly you read!) at a reasonable speed? Well, that is my goal for today!

Read Lots Of Cases

First and foremost, I have never found a substitute for reading tons of cases. When you have seen the same finding for the seven thousand three hundred and forty-sixth time, it will stick. Eventually, as you read it so many times, it becomes part of your autonomic system. It becomes so entirely reflexive that it never quite makes it into your consciousness (which will slow things down!).

Create A Master Checklist

Every great radiologist creates a master checklist. It may get to the point that you subconsciously check everything because you have done it so many times. But, it is still there. If you continue to use the same checklist, time after time, it will become second nature. One day, you will make all the findings and won’t even remember that you have one!

Minimize Interruptions

Sometimes, you have to shut the door and focus on the work ahead. Don’t allow your chatty colleagues to stop you from doing your work. If they need to talk to you and you are in the middle of a study, have them wait until you are done. A few seconds of delay can significantly backtrack the progress you have made on your report!

Use Templates Well

Templates can become a major time saver if used properly. If you are dictating a CT scan, having the technique section automated will save you countless hours throughout your career. But be wary. Make sure to take items out that do not apply to your current case!

Use Your Residents Wisely (If an attending)

If you are fortunate to work for a practice with a residency program, you need to make sure to utilize the residents to your advantage. What do I mean by that? Well, they usually have better access to histories than you do (as long as the resident is good!). So, make sure to copy and paste these into your report. On the other hand, if your resident makes lots of typographical errors, you would want to make sure to redo your own report so that it comes out readable! How you go about utilizing the reports varies on a case by case basis. But, using your resident appropriate can save loads of time!

Listen To Your Attending (If a resident)

Say you are on at nighttime and your attending likes a report a certain way (i.e the impression before the findings), make sure to create reports the way she likes it. Or, if you are sitting next to your attending and he tells you to dictate a case an include a statement about the kidneys, remember to do so. You don’t want to have the report bounce back to you!

Don’t Perseverate On The Small Stuff

We can obsess over liver and renal cysts, pulmonary granulomas, and ovarian follicles. Or, we can learn to minimize the verbiage that we use to describe these findings. At some point, when you get too busy, you have to remember to include only what is truly important. Don’t go crazy with the minutia!

Limit Your Differential

Almost every finding can theoretically have 10 differentials. But, what is really going on in the case? In the real world, you only have time to discuss those differentials that are really likely or dangerous. You don’t have time to discuss the unlikely zebras!

Knowledge Is Speed

Believe it or not, reading lots of radiology books augments your speed. Why? Just because it tends to boost the confidence of the reader. The more you know, the less you perseverate and the quicker you become. Thems are the rules!

Don’t Be Too Speedy!

And finally, a word to the wise. After all this talk about increasing speed, don’t forget that sometimes you need to slow down. Missing findings is bad for patient care, increases the likelihood of lawsuits and will ruin your reputation. Therefore, there is a point of no return. So, back it up a bit, will you?

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Great Teachers And Radiologists: Not Always One And The Same!

great teachers

Have you ever heard of the phrase “those that can’t do, teach”? Well, if you think about the words, you can find a modicum of truth. (Not for all radiologists but some!) I’m sure that some of you have worked with a radiologist/former teacher who gave the most terrific lectures on a topic. And then, when you sat down with them for the first time to complete some work, you realized that something was not right? Maybe, they missed all the significant findings. Or perhaps, the dictations they created were so long, to be almost unreadable. I certainly have worked with some of these great teachers in the past. And, you will most likely too.

Does It Matter?

The simple answer is yes. But, why? Well, residents and students tend to follow excellent teachers to the end of the earth (and they fall over the cliffs with them). In essence, they form the same bad habits and eventually perform the same way. If your favorite attending that gives those great lectures lackadaisically ignores the liver windows on a CT scan, you are likely going to follow suit.

Moreover, we tend to give those mentors that we like a pass. In essence, these attendings perpetuate these bad habits because their teaching sways their students to ignore their foibles. And, programs are less apt to remediate these faculty members.

It reminds me of that friendly guy who was not so great at his job but continues to get promoted because he can never complete his work well. Everyone loves him. He eventually becomes the CEO of the company because no one has the guts to fire him!

How To Prevent Yourself From Falling Off The Proverbial Cliff?

Similar to the Reagan era when the United States made agreements with the Soviets to decrease nuclear weapons, all students need to trust but verify. What do I mean by that? We can’t always rely on what our favorite mentors say and do. With even our best teachers, we need to check on what they say. Even the best radiologists and mentors make mistakes. And, you certainly do not want to incorporate these mistakes into your practice.

Also, remember that sometimes your best teachers are not the most charismatic. Many times, that boring lecturer has excellent advice and maybe a better radiologist. You need to listen to all your faculty members to learn how to practice our specialty. I like to say that teaching is a team effort. If you learn from just one individual you will likely miss out on the best way to practice.

And finally, think about how your favorite mentor’s practice affects patient care. Does it make sense to ignore the liver windows on a CT scan when you improve your sensitivity for the detection of metastases in a patient with colon cancer? Probably not. Sometimes, we, as students, need to use some common sense.

Great Teachers And Radiologists: Not Always The Same

We love to ascribe positive sentiments to our favorite mentors and teachers. While true for some, not everyone is great at everything. Sometimes, we have to step back and decide for ourselves if our most entertaining and best lecturers are teaching everything that we need to know for our future. If you want the best experience from residency, learn from all your faculty, whether “charismatic” or “sub-par.” You will be happy that you did!