Category: Resident Advice

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Radsresident Book Poll

book poll

So, the results from my informal survey of radsresident readers are back! And, I thought it would be interesting to first compare the results of the Saint Barnabas residency book poll to the Radsresident book poll results today. Here we go!

First-year radiology residents from Saint Barnabas and the Radsresident survey agreed that Felson’s Principles Of Chest Roentgenology, Lawrence R. Goodman, Core Radiology,  Jacob Mandell, and Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major are the most popular

Second years from both groups agreed that Core Radiology,  Jacob Mandell is the most popular.

Third years from both groups agreed that Core Radiology,  Jacob Mandell is the most popular.

Unfortunately, I did not get enough 4th years to reach statistical significance to compare with the original poll.

Overall, the most popular book is (drum roll please……..) Yes, you guessed it. The top choice for both polls is Core Radiology,  Jacob Mandell.

Lastly, I also added a few more categories for fellows and attending. Why not get their opinions too? At least, they have had some successful experience with residency!

Check out the results from my informal radiology book poll at the bottom of this blog in order of popularity for each residency year.

The Final Results of the Radsresident Book Poll!

So, now I present you a list of the results from my online poll with links to the same books on Amazon (where I am an affiliate!)

Attending

Brant And Helms’ Fundamentals of Diagnostic Radiology, Jeffrey S. Klein, William E. Brant, Clyde A. Helms, and Emily N. Vinson

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

Core Radiology,  Jacob Mandell

Fellow

Thoracic Imaging: Pulmonary and Cardiovascular Radiology, W. Richard Webb and Charles Higgins

Osborn’s Brain, Anne Osborne, Gary Hedlund, and Karen Salzman

Genitourinary Radiology by N. Reed Dunnick, Jeffrey Newhouse, Richard Cohan, et al.

4th Year

Not Enough Results For Statistical Significance

3rd Year

Core Radiology,  Jacob Mandell

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

Crack The Core Exam,  Prometheus Lionhart

Fundamentals Of Body MRI, Christopher Roth and Sandeep Dehmukh

Radiologic Physics War Machine, Prometheus Lionhart

2nd Year

Core Radiology,  Jacob Mandell

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

Duke Review Of MRI Principles, Wells I Mangrum, et al.

Nuclear Medicine and Molecular Imaging: Case Review Series, Lilja B Solnes and Harvey Ziessman

Neuroradiology: The Requisites, David Yousem, Robert Zimmerman, Robert Grossman

1st Year

Core Radiology,  Jacob Mandell

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

Felson’s Principles Of Chest Roentgenology, Lawrence R. Goodman

Crack The Core Exam,  Prometheus Lionhart

Radiology Review Manual, Wolfgang Dahnert

Weir & Abrahams’ Imaging Atlas of Human Anatomy, Jonathan Spratt, Lonie Salkowski, Marios Loukas, et al.

Neuroradiology: The Requisites, David Yousem, Robert Zimmerman, Robert Grossman

Enjoy the list and most importantly, thank you for your participation!!!

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Why Radiologists Should Consciously Love Subconscious Learning

subconscious learning

Given the opportunity, many of you would jump at the chance to read a new exciting imaging presentation of sarcoidosis or esthesioneuroblastoma. Sounds sexy, right? And I am the first to admit those disease entities seem attractive to me, something entirely different from the usual. But what about the seventeenth case of questionable overlapping shadows from soft tissue artifact versus pulmonary parenchymal disease at the left base on chest film? I mean, who cares about shadows at the bottom of the film, huh? We see them all the time. Or how about the 112th case of seeing a left adrenal gland that happens to have a medial limb that appears a little bit more concave than most others? I mean, this may not even register in our forethoughts as anything. However, I would argue that this second form of knowledge, what I like to call subconscious learning, is just as important, if not more so, than the sexy conscious education we all love to talk about every day- those cases of sarcoidosis and esthesioneuroblastoma. Nevertheless, many radiologist residents poo-poo, the second form of learning. I mean, why even bother with that other stuff when we can talk about that great case of esthesioneuroblastoma?

The Reality Of The Situation

Unfortunately, our reality as radiologists does not match the sexy image of a diagnostician frequently making unusual diagnoses. Instead, first and foremost, we are purveyors of normal findings that we register unconsciously every day.

For example, on any day that we may read a hundred chest films, only a small percentage, maybe 5 percent or less, will have these sexy undercurrents. The majority will have plain old garden variety mundane findings. But, it’s these common findings that we all need to either ignore or understand. If not, you will go down the tubes at your peril.

Why Is Subconscious Learning More Important?

So, why do I believe making these common subconscious findings that we gloss over during readout is more critical? Well, in reality, those findings that we see every day impact patient care more. Knowing whether that shadow at the lung base is significant on any given day may affect maybe 2 or 3 patients. On the other hand, that case of sarcoidosis, you may see a few times a month or year, or that case of esthesioneuroblastoma, you may see once or twice in a career (unless, of course, you work at an esthesioneuroblastoma center of excellence!)

Furthermore, overcalling findings can cause more harm to patients than you might think at first glance. For example, think about that patient with the adrenal gland with slightly increased concavity. You may send this patient to an MRI for an adrenal workup without knowing that this finding is within the normal range. And, of course, you find a nonspecific liver lesion. And guess what? Now you have to do a hemangioma scan. And the hemangioma scan comes back negative. The clinician then orders a biopsy, and the patient develops a subcapsular hematoma. And the complications roll on in “ad nauseum” at a cost to the patient and the health care system.

How Do We Increase Our Subconscious Learning?

I’ve said it before, and I will repeat it because it is that important. We have never found a substitute for sitting down (or standing up) and reading many films. You can only say what is within the normal range after seeing 10,000 livers, 85,000 heart shadows, and 12,000 gallbladders. And we accomplish that by registering these findings over time in our mental databank. No, it’s not glamorous, and our conscious brain may not realize it. But it works.

Conclusion

So, the next time you sit next to your radiology attending, think twice before you say that you will hit the books to increase your understanding of radiology. Truthfully, instead, you accomplish just as much by looking at your next case even though it is “nothing special.” No, you may not realize that you are learning anything new. And, no, it may not prepare you as much for the boards. But, over time, your subconscious learning will eventually win out. It is not only your sexy conscious knowledge but also your databank of common unconscious findings that will allow you to become the radiologist you want to be!

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Calling For Help- A Sign Of Weakness Or Strength?

help

Back in the day (in the dark ages!), when I began taking call years ago, each radiology faculty member brought home the beeper on occasion to cover any resident issues from home. Meanwhile, the resident would give independent reads overnight without the attending help. Imagine no real nighthawk or night-attending coverage whatsoever!

Rarely, if ever, would a resident dial the attending (god forbid!) for some help. Moreover, if the resident spoke to the faculty member past 10 PM, he would place him on a blackball list. (Kind of like the McCarthy era) In essence, this resident’s name would ring throughout the department as “incompetent” and “childish” for having to make the phone call for the next several years.

Nowadays, at least at my program (and hopefully at most), the faculty members encourage phone calls at nighttime. If an event significantly affects the department, I, as a faculty member and associate program director, would rather hear about it at night than have a disaster in the morning. And that goes for all the radiologists in the department. Today, I consider the ability to know when to call an attending a sign of significant strength. But is there something useful about the old-fashioned approach? Or was it pure hazing, no more, no less?

Strengths Of Discouraging Nighttime Calls For Help (The Blackball Era)

Were there any net positives of feeling that you could not call your superiors for fear of a severe backlash? Well, I would like to say that it was all bad. But in reality, several net positives overwhelmed many of the negatives. And unfortunately, newer residents lose out on some of these experiences.

First, once you start having backups, whether a nighthawk, in-house attendings, or senior residents, you lose the independence of judgment. No longer do you worry about missing findings. Instead, you know an attending will eventually find it later.

Moreover, knowing you have a backup makes call a less practical learning experience. Knowing that your decision will make the difference between patient injury and a good outcome, you will treat the case differently.

In that same vein, the learning experience of call was much more intense. One of my attendings used to say, “pressure builds diamonds.” Well, I believe that statement contains some truth. Those evenings I spent making the tough decisions alone stuck with me for years. And I am thankful for that.

Finally, you developed a camaraderie with your fellow residents in other disciplines who were in the same boat. These connections carried through for the remainder of the residency. Today, it’s not quite the same. Each department in the hospital has its backup system. And in a sense, we rely on each other slightly less.

Weaknesses Of Discouraging Nighttime Calls For Help (The Blackball Era)

First and foremost, you can see why a junior resident commanding a whole radiology department cannot lead to the best patient care outcomes. And, rightfully so. I would rather have a seasoned attending reading my films than a junior resident.

That premise leads to the next issue, delays in patient management. ER attendings were less likely to allow the resident to make a final disposition. Often, they would keep the patient in the emergency department to wait for a “final read.” For instance, if a resident reads a case without backup, patients sometimes slip through the cracks. Based on an occasional discrepant radiologist read, an ER attending may occasionally fail to work up the patient appropriately. Or, the ER attending would rarely send patients with appendicitis or ectopic pregnancies home based on a faulty resident read. So therefore, some ER attendings would choose to delay management until the attending radiologist returns.

And finally, does a resident that seeks help from an attending deserve placement on a blacklist? Probably not. It is an unfair practice. I could easily compare it to a fraternity that requires its new members to guzzle a case of beer. It doesn’t make it right.

Preponderance of Evidence

So, which way serves the radiology resident, the patients, and the institution the best? Based on my arguments for both sides, this call is not as easy to make as you might think. However, as much as I learned from being discouraged from calling my superiors, I believe that patient care should take priority. We all took some form of the Hippocratic oath. And therefore, we should try to lower patient morbidity to the best of our ability. Also, decreasing the time spent in the ER improves patient outcomes. Even though today’s residents lose some of the independence we had not too long ago, trainees and faculty have to think of patients first.

So, call your attendings for help if you need it. And, faculty, please treat your residents respectfully after they call. We no longer live in the dark ages. Calling your attending is appropriate for the best patient care. And patient care should come first!

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RSNA 2018 Meeting: What Residents Should Expect From Artificial Intelligence?

By far, the RSNA is the largest and most publicized radiology meeting of the year. But, I usually attend other meetings instead because so much goes on at once at the RSNA that it is next to impossible to concentrate on one area. Moreover, to get from one side of the Mccormick conference center to the other takes almost 10-15 minutes!

In any case, for the first time in eight years, I bit the bullet and decided to attend the RSNA meeting this year. Partly, I needed additional CME credits, but also I was not able to participate in the SNMMI meeting due to timing. But, I am delighted that I did. Why? It allowed me to grasp the most current themes in radiology that exist today. And, for residents, in particular, I thought it was critical to share with all of you what may be coming down the pike.

To start with, if I had to give one overarching theme from the conference, I would have to say that the central idea was artificial intelligence. Some of these revelations about artificial intelligence were not all that critical. But, others will play an enormous role in your careers down the road. So, I will try to emphasize those items from the conference that will undoubtedly influence your career. And, I will briefly talk about a few issues that the AI companies and academic sorts may overhype.

Strong AI Career Influences

Integration

When you pull up your PACS system to read cases ten or twenty years down the road, no longer will you have to pull up your history, labs, pathology, priors, EHR, and films separately. Instead, all hospitals and outpatient offices will have software and systems that will allow you to sort through all the information at once. Right now, some institutions are more integrated than others. For most of you, lack of integration this will become a relic of the past. Walking through the technical exhibits, you could see many solutions today that will allow the radiologists of the future to read films with all the clinical information at your fingertips.

Triage

Imagine having a helper sort through films to determine which ones you should look at first and others that can wait a bit. Well, now they have multiple software packages that use deep learning to create work lists that make sense. And other programs try to detect STAT findings such as brain bleeds to make sure that radiologists read these studies first. Finally, other software programs can make sure that the correct radiologists are reading the appropriate studies. Right now, most practices do not have the staff to scrutinize cases before dictation. So, all these AI solutions, will allow more efficient and appropriate reading of STAT and essential studies.

Reducing noise

Having stopped at numerous vendors, I noticed that most of the big ones were touting deep learning algorithms to increase the quality of images. What do I mean by that? Many had sophisticated programs that mitigated artifacts and increased conspicuity of lesions and vessels. Some allowed you to image patients with significantly lower contrast dosage to prevent acute renal failure. Motion artifact on a CT scan or PET-CT scan may become a rarity. The future in this arena is now!

Increasing Reading Efficiency And Quality

Right now, some companies have created Computer-Aided Detection (CAD) packages that assist the radiologist in reading images. At the meeting, these solutions seemed to emphasize lung nodules and mammography.  I would expect some improvement over the coming years in these imaging modalities. And, I think we will begin to see other imaging modalities that utilize CAD. CAD will continue to reduce the time and effort that goes into reading studies.

One of the new types of CAD that I thought would be of help to the average radiologist was a bone age reader. It’s the perfect place for AI to begin because medical liability is a bit lower.

Additionally, new software packages can integrate CAD functions into the current dictation and PACS systems. We will see a lot more integration to improve radiologist reading efficiency.

Weaker AI Career Influences

Radiology 3.0

As much as the RSNA academics liked to state that we will no longer be image-centric and instead become patient-centric, I don’t see many powerful economic and political factors to drive the current radiology business in that direction. Currently, I am a bit skeptical about the rate of progress toward that goal. I have a feeling we will still have considerable time pressures to get tons of cases out rapidly.  Until fee for service no longer becomes relevant, radiologists will not have the time to see each patient after reading their chest film. It’s just not realistic. However, we will have more information at our fingertips about our patients’ care to make better reports and decisions. But seeing a patient after reading each film is a pipe dream.

Driving Direct Patient Care

In one of the plenary sessions, a computer scientist gave a whole lecture on improving metrics such as hand washing and patient falls with artificial intelligence. She discussed placing sensors all around the hospital to create a virtual environment that can sense these events to improve patient morbidity and mortality. While I agree that we should try to improve these issues since they cause harm to patients, the lecturer did not convince me that hospitals and institutions are ready to spend the money and time to accomplish these goals. For the foreseeable future, I see too many financial and legal hurdles to extrapolate these ideas to a larger scale.

Artificial Intelligence And The RSNA- Final Take Home Messages

Artificial intelligence will have a profound effect upon all of our careers, for better or for worse. But, the younger generations of radiologists have more to gain and more to lose. Therefore, for residents, especially, it is critical to follow the developments within the field. And, the RSNA meeting is just the right place to get a sense of AI and your future. If you have an opportunity to attend a meeting like the RSNA, it is well worth it. Take advantage of the event and learn about how the main themes will affect your career!

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Radiology Book Favorites – A Local Poll

I thought it would be interesting to informally poll my residents to find out their favorite radiology book by residency year and share the information with the readers of the website. Why? First of all, I figured many readers have a vague idea of what books to read, but sometimes they purchase radiology books without checking out what their colleagues liked the most. Second, I performed a brief survey by residency year to get a more specific idea about what you may want at your stage of residency. And finally, I was hoping to find a few patterns (which I did).

Well, these are the basics about what I found. Core Radiology was the only book that all years found to be useful. Brandt and Helms and Felson’s were popular in all years except the 4th year. Otherwise, there is a smattering of favorites throughout all 4 years of residency.

Check out the results from my informal radiology book poll (the first of its kind on this website!) at the bottom of this blog in order of popularity for each residency year.

Let’s Create A Radsresident Favorite Radiology Book Poll!

And lastly, I thought it would be a good idea to also have you, the reader, take a survey to determine which books were your favorites. If we gather enough data, we can create another list compiled from all my readers. I think that this information would also be helpful to decide upon which books to read. So, fill out the survey at the bottom of the page to give your opinion!

The Final Results!

So, now I present you a list of the results from my informal poll with links to the same books on Amazon (where I am an affiliate!)

4th Year

Crack The Core Exam,  Prometheus Lionhart

Core Radiology,  Jacob Mandell

The Requisites: Vascular And Interventional Radiology, John Kaufman and Michael Lee

Fundamentals of Pediatric Radiology, Lane F. Donnelly

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

3rd Year

Core Radiology,  Jacob Mandell

Felson’s Principles Of Chest Roentgenology, Lawrence R. Goodman

Arthritis in Black And White: Expert Consult, Anne C. Bower and Donald J. Flemming

Essentials of Nuclear Medicine And Molecular Imaging, Fred A Mettler, Jr, and Milton J. Guiberteau

Brant And Helms’ Fundamentals of Diagnostic Radiology, Jeffrey S. Klein, William E. Brant, Clyde A. Helms, and Emily N. Vinson

2nd Year

Core Radiology,  Jacob Mandell

Brant And Helms’ Fundamentals of Diagnostic Radiology, Jeffrey S. Klein, William E. Brant, Clyde A. Helms, and Emily N. Vinson

Fundamentals of Skeletal Radiology, Clyde A Helms

Felson’s Principles Of Chest Roentgenology, Lawrence R. Goodman

Duke Review Of MRI Principles, Wells I Mangrum, et al.

1st Year

Felson’s Principles Of Chest Roentgenology, Lawrence R. Goodman

Core Radiology,  Jacob Mandell

Brant And Helms’ Fundamentals of Diagnostic Radiology, Jeffrey S. Klein, William E. Brant, Clyde A. Helms, and Emily N. Vinson

Duke Review Of MRI Principles, Wells I Mangrum, et al.

Mayo Clinic Gastrointestinal Imaging Review, C. Daniel Johnson

Gray’s Clinical Neuroanatomy: The Anatomic Basis For Neuroscience, Elliot L. Mancall, and David G. Brock

Fundamentals of Skeletal Radiology, Clyde A Helms

Fundamentals of Body CT, W. Richard Webb, William E. Brant, and Nancy M. Major

 

Please fill out the survey below if you want to contribute your opinion to the “best of” radiology list of books for all readers of radsresident.com. If you cannot see the survey for whatever reason, you can click on the adjacent link that will take you directly to the survey site. Once again, thanks!!!

 

 

https://www.surveymonkey.com/r/RRLT759

 

Create your own user feedback survey

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What Does It Mean To Be One Of The Successful Radiology Residents?

successfui radiology residents

So, your residency director begins to talk about his most successful radiology residents over the past ten years. But what does that mean exactly? And do you want to be part of that list? Well, maybe or maybe not.

Most of the time, the resident’s and program director’s expectations align precisely. But other times, the definition of a successful resident from a residency director’s perspective may vary widely from yours. In this light, we will talk about the expectations of a residency director and your expectations of the meaning of a “successful” radiology resident. Moreover, we will look into those conflicts of interest that may arise between the two expectations.

Residency Director Expectations

So, what makes a residency director happy with his residents? Well, for many directors, it comes down to reducing the heavy workloads. And, to keep their work to a minimum, most residency directors want their residents to comply with the basic expectations of a radiology residency program during the four years. In other words, these are some of the phrases that a residency director would want to apply to their best residents.

1. Passes the core exam on the first try

2. Completes all the necessary work on his own

3. Doesn’t create too much noise during residency.

4. Is expeditious with his work

5. Gets along well with others

6. Completes fellowship after residency

7. Enters academics and has a radiology career

8. Creates his research projects independently

9. Continues to produce research independently after graduation

 

Radiology Resident Expectations

On the other hand, what does a resident think would make the best sort of resident during his training? Here are some short descriptive sentences.

1. Reads enough during residency to have a good background for his career

2. Experiences and learns about all the procedures and modalities in the field.

3. Gets along well with colleagues and attendings

4. Makes connections for fellowship and beyond

5. Does not get sued

6. Can find a quality job in a desirable location with reasonable income after his residency

 

What Are The Potential Conflicts Of Interest Between The Resident’s and Program Director’s Expectations?

Research

The program gains more clout for a residency director when it produces large amounts of academics. For one, the Radiology Review Committee/ACGME will be much less likely to cite a residency if they have sent many abstracts to national conferences and have written numerous publications. On the other hand, many residents can care less about pursuing research and utilize it only as an avenue to graduate residency.

Making Noise

Often, residency directors like the status quo. To accomplish this, they would rather have their residents go through the motions of completing their work without changing the system. It becomes a less complex pathway with fewer chores to do. However, on some occasions, by not vocalizing educational issues, radiology residents may sacrifice their education and career. So, the resident may not find it appropriate to maintain silence.

Finding A “Good” Job

Sometimes, the program director’s definition of an acceptable career choice differs widely from his radiology residents. For instance, she may expect residents to go on to academic or prestigious private practice careers to maintain the “lineage” of the program. Nevertheless, the best career pathway may not always apply to each resident who comes through the system. Some residents may have business interests or may not have the desire to enter a typical career.

Taking And Passing The Boards

For most residents, completing the radiology boards become a critical step to obtaining a desirable job. And it also adds to the positive statistics of a program. But sometimes, passing the big exam is unnecessary to get the career the radiology resident wants. Perhaps, they want to enter the business world. Or, they have a job lined up in some other area. Taking and passing a board may become less critical to this resident than the radiology program.

Bottom Line About “Successful” Radiology Residents

The program director’s and the radiology resident’s expectations of the “successful” resident usually align. However, occasionally they don’t match up. It’s like parenting. Sometimes, we need to let our residents take an untraversed pathway. We, as program directors, cannot always force our residents down the same well-trodden trails. And radiology residents should not expect that they always need to perform the desired requirements. Instead, radiology residency directors, residents, and the external regulating bodies should redefine their expectations for success with the understanding that “successful” residents do not always fit an identical mold.

 

 

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Why A Strong Department Chair Is Critical To Residency

chair

As an associate program director, I work with all the residents and faculty. But, one role, in particular, plays an even more significant role in the quality of the residency than the others. Which one would that be? (Hint: Well, if you have not guessed it by now, you may want to look at the title again! The Chair)

OK. So, the chair is critical to running a great residency. But what is it about a chairperson that makes the role so important? Well, the importance of the position is what we will run through over the following, oh, say, 8oo or so words!

Backbone When The Going Gets Tough

Everyone, once in a while, events conspire to mangle a residency program. Perhaps, a resident decides to leave for another career, and the hospital wants to take away the residency slot forever. Or, the emergency department determines they no longer want residents to give the final dictations at nighttime. In any of these cases, you need a firm chair to prevent these issues from negatively affecting the residency program. Sometimes you need a leader to fight for your department!

Allocation of Resources To The Residency Program

What would happen if you had a chair that decided to commit more resources to non-residency-associated imaging centers at the expense of a hospital-based residency program? Chaos, of course! You may not have enough physical bodies to teach the residents. Or, the chairperson decides to stop giving the program directors administration time to run the residency program. Either way, the chair controls many of these outcomes. And, if she decides to allocate the resources to the outside facilities instead, the residency loses out.

Carrot And The Stick

In any practice, some physicians have more or less interest in teaching. But, what happens if some of the attendings decide that they no longer want to give conferences? Well, the chair has the practice’s long arm to ensure that does not happen. The chairperson can either decide to provide money or non-monetary incentives to make sure that the faculty performs. Or, she can remove incentives from staff members who do not participate. Either way, the chair’s ability to utilize her power directly affects the program’s quality.

Sets The Tone Of The Department

Let’s say your chair runs the department as a dictator. Or, he is always just trying to appease friends instead of doing what is best. What happens to the residency in these cases? In the first case, the residency program runs on fear and misery. And in the second case, nothing ever gets accomplished. Bottom line: the chair sets the quality of interactions in the department and the residency.

Liaison Between The Hospital And The Program Director

Some departments have a chair who does not communicate the critical issues of the institution to the residency. What occurs in these situations? First, residents may lose out on remaining compliant with national requirements such as hospital ACLS training. Or the radiology program may not fulfill its obligations to stay accredited. Poor communication between the hospital, chair, and the program director can become a nidus for a residency to implode!

The Ceremonial Function

Sometimes, a chair may decide not to attend essential residency functions. The chairperson may not participate in the residency graduation or the annual hospital ball. What does this say about the department? Do you think the hospital will look fondly upon the residency program when its leader is remiss? Probably not. In this case, the chairperson and department will be much less likely to receive the resources they need from the hospital. It’s a “give and take” relationship. So, the chair must step up and set an excellent example for the residency and hospital.

Residency Advisor

We, as program directors, often need to get a feel for how the faculty will respond to a change before implementation. And residencies constantly need to institute new requirements. But will the faculty buy-in so we can implement the new development? A strong chairperson who knows his department well can ensure you can fulfill your change. Moreover, she can guide what works and what doesn’t. Without serving this role as a residency advisor, a program director will encounter many more pitfalls during his tenure!

The Chair As Leader

In any medical department, a chairperson plays a critical role in running the specialty service and ensuring the residency moves along smoothly. So, when you decide to look into a residency department, observe the chair. Does he participate in the interview process? Can you get a feel for how he behaves toward the department? All these factors will affect you long after the interview day. A chair reflects the face and culture of the department!

 

 

 

 

 

 

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The Gestalt Versus Segmental Approach For Radiology Residents (Doximity Article)

gestalt

Ever watched an expert radiologist read a CT scan or an MRI? They gaze at a scan, digest the information in one fell swoop, and spit out impressive findings and differentials with the single Gestalt.

If the world’s greatest radiologists can do it this way, why can’t you?

Well, what if I was to tell you to avoid this expert radiologist’s approach? You might think I was crazy, even though it may be hazardous to your career! But this “Gestalt approach” is most likely the wrong one for you.

But why? Why does this Gestalt approach to films, used by expert radiologists, not work well for the neophyte radiologist? To answer this question, we will define Gestalt and explain why this approach can be dangerous for early radiologists. Then, instead, we will tackle why and how radiology residents should read films using the “segmental approach.”

Defining Gestalt

Let’s start by defining the principles of Gestalt. According to Wikipedia, these are “the idea that natural systems and their properties should be viewed as wholes, not as collections of parts.”

Radiologists use the Gestalt approach when they sense the findings and diagnosis without processing the individual steps. I like to think of the Gestalt approach like The Dog Whisperer, Cesar Milan. He can naturally sense the overall picture of a dog that others cannot. With this sixth sense, he can train dogs to do whatever he wants while mere mortals struggle to figure out exactly how to do what he does.

Why Avoid the Gestalt Approach When Starting?

Since you have not been practicing radiology for long, you will miss half the findings in the film. You don’t know what you don’t know. And, if you don’t look for a finding, you won’t mention it or find it. So, if you read a chest film and don’t know to look at the pulmonary arteries, you won’t find that case of pulmonary hypertension. The Gestalt approach does not allow for evaluating each of the individual sectors of the film to ensure you have looked at it.

How long have you been practicing radiology? At most, for residents, three or four years. Rarely is that enough time to build a network in your brain allowing you to look at a film rapidly once and then create a framework for arriving at a final impression of the study. You have not trained your eyes to search everything in the image in a short period. And, therefore, you will not catch everything.

Take it from me; the Gestalt approach is a fast way for a resident to look like a fool. When you review a case with another clinician, they will catch things you missed. What could be more embarrassing?

What Approach Should You Use?

Instead of the Gestalt approach, the beginner radiologist should utilize a segmental approach. What do I mean by that? The segmental system divides the film into individual parts. You then review the entire image until you have completed your search pattern. In essence, it is a glorified checklist.

In addition, the segmental approach can vary for each reader based on personal preference. For some, you may divide the chest film into quadrants. For others, on the chest film, you may look at the technique, the heart, the soft tissues, the bones, and the lungs. Whatever the pattern, it usually doesn’t matter except that you cover all bases. As a beginning radiologist, this approach will prevent you from missing critical findings. And you will look much more intelligent than the new radiologist that uses a Gestalt approach.

The Bottom Line About the Gestalt Versus Segmental Approach

The Gestalt approach does not work well for beginning radiologists unless they have a tremendous gift. Most learners cannot look at the whole to identify the abnormalities in each part. Instead, the new learner is more adept at looking at all the pieces to determine what went wrong with the whole. Therefore, until you have the experience to identify abnormalities with a glance rapidly, the Gestalt approach is a recipe for disaster.

So, create a great, all-inclusive search pattern to avoid missing individual findings. Who knows? Maybe someday you will become that great radiologist who uses that Gestalt approach!

 

 

 

Want to see the original Doximity version? Click on the following link!

Link to the Doximity Website Version

 

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What Might Happen With A Residency Merger?

residency merger

Throughout the country, businesses grow to keep costs down. One of the ways that they accomplish this task is by merging. And, if you think that residencies are any different, you would be wrong! Similar to many businesses, you may have noticed that residencies have grown bigger and bigger over the years. While it was once rare to hold ten residents per year per class 30 years ago, a radiology training program of that size is no longer unusual. So, what happens if you begin a radiology residency program and it merges during your four years? Will the residency approach you like a second-class citizen? Or, would you notice some fringe benefits from the process? We will treat these issues and more as we summarize the benefits and downsides of a residency merger!

Benefits Of A Residency Merger

More Residency Resources

First and foremost, you may notice that soon after a residency merger, you may be able to rotate through new departments. Or, you may have access to a simulation center that you did not have before. Furthermore, you may find new grants for residents to start research projects. And you may have at your fingertips a more extensive staff to choose from as your mentor or research partner. That doesn’t sound too bad.

Increased Prestige Of The Residency Merger

Before the merger, you might be in a small community program without “name recognition.” Now that you are part of a larger entity, you may find that hiring practices that want graduates from high-powered programs may be willing to look at your resume for your first job. There is more to a name than you might think!

Faculty With More Time To Teach

Sometimes, faculty at a hospital may no longer have the responsibilities to run their program as they did before. You may find that the staff can now dedicate more time to teaching and residency responsibilities.

Downsides Of A Residency Merger

Loss of Special Programs

As programs grow, they relook at areas in the budget that they can cut so that the senior administration can save some dollars. Perhaps, your residency may have had different outside rotations that you no longer “need” since the entity provides the same service. Or, you may have had a foreign travel program that the original institution sponsored. You know what they say in business: “Cut the fat!”

One Program Director For Many Sites

No longer, you can go to the same program director in charge of everything at your one site. Now, you have one program director for an entire system. What does that mean for you? The program director may have less time to focus on individual residents. Instead, they have multiple sites to “keep in line.” So, you may find that the director caters less toward you.

More Bureaucracy In The Residency Merger

On that same note, now that you have a more extensive system, you may find it more unwieldy for the Institutional Review Board (IRB) approval for research projects. Or, you may have more difficulty getting reimbursed by the system for expenses. With a larger institution, you exponentially multiply the “red tape.”

Increased Traveling Distances

Now that you have multiple sites within a more extensive system, you will likely need to travel to each location. If you live in the city, you may need to go to work via subway, train, or bus. You may need a new car if you live in the suburbs across from your original hospital. Unfortunately, you have a new budget item!

Some Disgruntled Attendings

At most hospitals, the faculty does not like change. Moving around resident call schedules and increasing the responsibilities of the staff can induce resentment among the mix. So they may be less willing to participate in the residency process. Or depending on how the system arranges coverage, attendings may have less time to teach. No change is perfect!

Less Intimacy

Remember that three-person class you had before when you learned each member’s quirks and foibles? Well, that is no longer the case. Now, you will have to contend with colleagues and attendings you will not get to know during your remaining years of residency. When your program touted a small program feel during your interview, they didn’t meet your expectations!

Dilution Of Resources

You remember what your teacher taught you in kindergarten- you need to learn to share! Perhaps, you had a fantastic faculty teacher on service. Or, your program had a one-of-a-kind pathology rotation within the institution. Now that you have a more significant residency, you may have less opportunity to use these resources because they need to be utilized by a larger body of residents.

Change And Residency Mergers

Change is hard. There is no way around it. And, when you enter a residency, some alterations from a merger are beyond your control. But, as you might initially think, a residency merger is usually not all bad or good. Instead, it will afford you some new opportunities and come with some additional palpable downsides. So, what is my advice? Make the most of a changing situation. Learn about the new lay of the land. You never know. Now that your program has included you in a more extensive system, you need to know it well. And make the most of its new opportunities even though they may have some downsides!

 

 

 

 

 

 

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Radiology Residency Rank Lists: Are They More Than Just Entertainment?

rank lists

Like many, I enjoy browsing the U.S. News And World Report Medical School rank lists yearly to see which programs are top. (Usually in a line at the supermarket!) Even more so, I enjoy reading the Aunt Minnie and Doximity radiology residency rank lists each year. And I love reading and writing about them as much as the next guy. But, we need to be careful when we rank schools, residencies, and other educational institutions. So, why am I such a “Debbie Downer” when it comes to ranking residencies and educational institutions, and in our case, specifically radiology residency? (And no, it’s not related to my role as an associate residency director at a small radiology residency program). Well, as you guessed, I will give you my reasons for our topic for today!

One Size Does Not Fit All

When you rank multiple programs in one list, you cannot consider all the variables that would make one program great for a particular type of personality and terrible for another. Moreover, looking at the rankings, you will see categories like best teaching, research, and clinical experiences. Some folks learn best on the job, and others retain better in a lecture format. How do you rank that? Or, you want to become a great clinician and don’t take a research interest. Would a Mass General work well for you? It doesn’t do justice to the individual.

A Majority Of Residents Want To Work In Private Practice

Many of the rank lists assume that applicants want the same thing: a high-powered research and teaching program. But, 90% of all radiology residents go into private practice. So, the rank lists usually do not follow the end career results of its participants.

Development of Vicious/Virtuous Circle

Rank lists tend to have a pile-on effect. If a program is ranked highly, it sticks in all the readers’ minds. They will say to their colleagues, “Oh, XYZ school is great.” Likewise, if an article ranks a residency low on the list, that remains in the mind of its readers. I call it a “self-fulfilling proposition,” not based on the truth.

Emphasis On Larger Programs

The larger the program, the more graduates know about it. Therefore, the lists show bias toward bigger residencies just by the sheer numbers. So, if you have a program that contains 20 residents per year, these residents will tend to vote for their programs, right?

Each Site Within A Residency Program Can Be Different

Even within a program, experiences can vary widely. Sometimes, residents barely see each other and do not rotate through all the sites within a system. And one resident may spend more time at the V.A. hospital versus the academic center. So, what may be an excellent experience for one resident may not even resemble the reality for the remainder of the residents within the program.

Residency Experience Is So Dependent On Individual Colleagues/Faculty Members/Mentors

I always like to say the following: if you go to an OK residency program, but like the folks you work with, it will seem excellent. On the other hand, if you attend a program that by all the rankings is fantastic but hate working with all your colleagues, it will become terrible. So, how do you measure one person’s experience versus another when the program’s culture varies widely in any given year?

Do Residency Rank Lists Have Any Merit At All?

Based on these legitimate reasons, residency ranking tends to have very little relevance for the average radiology resident to choose his rank list. Instead, like the U.S. News Report Annual rankings of colleges, it primarily serves as a great way to grab the attention of its readers and create a bit of buzz. Therefore, it performs an essential purpose, but the goal is not necessarily to help out the audience that reads it. So, what is my conclusion based on the evidence? I’m not saying that you shouldn’t read a rank list of the best programs. Instead, take the results with a grain of salt and realize that a “top program” may not be top for you!