Category: Resident Advice

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Gaining Recognition When The Odds Are Stacked Against You

recognition

For medical students and residents, at times, it can be tough to gain recognition for your work. I want to give you a little vignette of one uncomfortable experience with a difficult attending I had as a former medical student. Then we will discuss how to counter a poor evaluation. Although your stories may differ from mine, many of you will experience something similar as you traverse through residency.

The Background Story

I was a fourth-year medical student subintern during a medicine rotation. And my group consisted of myself, a pretty female third-year medical student, an intern, a resident, and a balding senior medicine attending in his late sixties or early seventies. The attending physician assigned us to review compelling cases that presented themselves the prior week. We were then to discuss the medical topics that arose from these cases.

First, the 3rd year medical student began to discuss a patient with severe onset of hypertension. And she went through an appropriate workup of the patient with hypertension and delved into the physiology and management of patients with hypertension. It wasn’t a bad presentation. Unfortunately for me, the attending would not stop affectionately staring at the third medical student. It was a bit creepy.

Next off, it was my turn to present. I had a great case of a patient with Histiocytosis X/eosinophilic granuloma of the spine that I thoroughly researched. I knew the case and the topic cold. Therefore, I rehearsed the presentation many times at home. So, I was excited to present. What could be wrong about presenting a rare, fascinating case I knew well?

So, I began to present the case and then went through the process of coming up with the diagnosis with history and imaging. Again, I noticed the attending continuing to ogle the third-year medical student inappropriately. As soon as I started to discuss the topic, WHAM… He shut me down by saying, “We don’t need to discuss this topic because it rarely occurs, and you will probably never see another case like this in your lifetime. What a waste of everybody’s time!”

Problems With Gaining Recognition In Clinical Education

All too often, something similar to this scenario occurs in clinical medicine, whether you are in radiology or another field. Perhaps, you are a foreign medical student, and the mentor won’t give you the time of day. Or, maybe, you are rough around the edges, and your teacher doesn’t like your personality. In all these situations, favoritism for reasons other than merit and quality often trumps a great job. No matter how you change the grading system to include milestones or different innovative ways of evaluation, bias can interfere with gaining recognition for your work. In the end, the final grade often comes down to the evaluators’ quality. (Don’t take it personally!)

At the same time, there are many positives about the experience of having learned about the topic of eosinophilic granuloma, regardless of my evaluator. First of all, in my line of radiology work, the diagnosis of eosinophilic granuloma has come up in my experience several times. Second, from my studies on the topic, I have used the information from that presentation for the betterment of my patients. And finally, the subject arose on some of my radiology board examinations, and I knew all the answers to the topic cold. So yes, there was something educationally valuable from this experience.

How Can We Align The Evaluator With The Recognition Of A Good Job?

That brings us back to the crux of this post. What can you do to get the attention of your evaluators about your quality work when they don’t want to give you the time of day? I do not claim it is going to be easy. It certainly isn’t. But there are a few workarounds.

Get What Makes The Evaluator Tick

First, ask your evaluator what it is that interests them. Now, I am not asking you to be a brown-noser, but sometimes to garner the attention of our seniors, we have to find out what makes them tick. A person like this is more apt to listen to you when you are on the same wavelength. Admittedly, in my case above, if I had changed my topic, I think it still would have been difficult to change this attending’s opinion of me. But, at least, I would have presented a case that would have been more likely to get his attention.

Defy Expectations

Next, go above and beyond the expectations of the evaluator. For instance, perhaps, I could have begun a quality initiative study to improve the outcomes of patients on his service and put his name on the paper. My story above might not have ended differently, even if I had provided the “ogler” with something distinct and memorable. But, it would have increased my chances of garnering recognition for my work.

The Nuclear Option

And finally, sometimes you need to go to the top. Things can be, on occasion, so bad that you cannot even fathom doing anything that will change the opinion of your senior. But be very careful. Heads of departments will often side with their staff before they side with a resident or medical student. So, if you use the nuclear option, ensure you have objective evidence that this person is unfair to you without trying to get your evaluator into trouble. And, also make sure that the director is willing and able to help. Sometimes, they can pair you up with someone else who can evaluate your work.

Gaining Recognition For Your Work

We all encounter people in positions of authority who may not be “fair” to their subjects. It is part of what we experience in medical school and residency and part of the real world. Most of us are somewhat sheltered from the real world through the beginning of medical school because our teachers’ primary evaluation method is exams. As we enter the clinical years and residency, evaluations become more subjective. So, learning how to successfully interact with difficult attendings who may unfairly evaluate your work is vital. Don’t be another technicality of a poor mentor. Be proactive in your education and obtain the recognition you deserve.

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Should I Take A Leave of Absence During Residency?

leave

 

Sometimes events beyond our control interfere with radiology residency. It may be a personal situation, a new business opportunity, mental illness, or severe burnout. I outlined some of these issues in my previous article called The Struggling Resident. And perhaps, one or many of these reasons have you thinking about taking a leave of absence.

But, what does this option entail? Many residents don’t know the details about taking a leave of absence. So, we will talk about the potential consequences of what can happen after a leave of absence and why you need to take the option only as a last resort. Then, we will discuss what situations merit taking a leave of absence, a circumstance where you might want to think about taking a break (but very carefully!), and finally, situations where it is seldom appropriate to take a leave.

Truth or Consequences

What is so serious about deciding to take a leave of absence from residency for some time? Maybe it’s six months, a year, or more. There are so many reasons why it can become a significant issue.

1. It will potentially take you off schedule for getting into a fellowship. Many fellowships will not consider residents who begin in the middle of the year.

2. You will likely have to start paying your health insurance and benefits. Believe it or not, it can cost tens of thousands of dollars for health insurance for a family. You may pay a few hundred dollars out of pocket per month when you are employed, but it can run over a thousand dollars per month when you are not. Can you cover those expenses?

3. You create a reason for future employers not to hire you. Many employers become very concerned when they see a gap in your employment history without an excellent cause.

4. It can cause irreparable harm to your residency program and classmates. You can no longer take call. Additionally, the rest of the class needs to shoulder the responsibilities. It does not set you in the light of a team player.

5. And finally (and perhaps most importantly!), you may be legally required to start paying off your massive debt load. That can be a real bear!

I Can’t Do My Job

So, when should you unconditionally take that leave of absence? It comes down to one situation: you cannot perform your job duties safely. If you can complete your residency duties, radiology residency is a temporary affair (albeit four years). And, believe it or not, many physicians would love to be in your shoes. So, if you are able and healthy, you should put all your efforts into completing your residency.

That said, if you have a mental illness, severe disability, or significant trauma, by all means, take that leave of absence. You took the Hippocratic oath and may not be able to abide by it in these circumstances. So, these conditions necessitate a departure. My advice: If it is some reason that does not involve breaking the oath, do what you can to pursue other endeavors until after your residency. You will have a great field to fall back on.

A Once In A Lifetime Opportunity

A confluence of events occurs from time to time, leading a resident to consider a job opportunity in another field. Perhaps, you just got that call to anchor a TV show. Maybe you created an invention, and a large company wants to buy out your patent for 5 million dollars; that will take a long time/lots of work to seal the deal. Or, you’ve been dancing for years, and a director in Broadway wants you on his show.

As I began brainstorming about what issues may eventually allow a resident to take a leave without regrets, some of these reasons could potentially cause a resident legitimately to rethink a radiology residency. I get it. Just remember, for those of you with significant debt, if you don’t pay your debts, the IRS can garnish your wages for the rest of your life. And these unique situations are not always a means of securing a lifestyle for years to come. (although occasionally it can be) So, those residents in this unusual situation need to think long and hard about taking a leave of absence.

Situations That Do Not Merit A Leave

If you are thinking of starting a business, quitting medicine, or needing some time off to relax and travel the world, this is not the time. You’ve already been through 4 years of college, four years of medical school, and a year of internship. What is four more years or less in the scheme of things to complete a radiology residency?

So what are some other situations that you should not use to take a leave of absence during residency? These would include taking a break to pursue another subspecialty (why can’t you just wait it out to apply, so you don’t have a gap in employment?) Or, maybe you have mild burnout (better off talking to a coach, colleague, or physician.) Perhaps, you want to start a new business (can you wait until after residency?). Attempting to train for the next Ironman triathlon is not a bad idea (you want to jeopardize your future?), and so on.

Final Thoughts

Taking a leave of absence is a huge deal. Many residents may dream of taking a break at one time or another to go for something they never had a chance to do before. However, think twice, my friends. Often, it sounds good in principle, but the practicalities behind it don’t make much sense!

What do you think? If you have any opinions, please leave a comment below!

 

 

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The Art And Science Of The Lowly Addendum

addendum

Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most crucial part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the essential parts of our report simultaneously? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.

The Lowdown On The Lowly Addendum

OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…

Addenda And The Legal World

First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation.” Sometimes it is the only documentation in the chart that the radiologist took the time to give the caring physician the report results.

On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the report results on your patient with appendicitis? It is only the supplement that documents this vital information.

When Absence Of An Addendum Is Legally Important

Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write a supplement, a communication never occurred.

How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that they discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told them not to order a leg film to look for a fracture. Since the physician did not request the test at your hospital, it turns out the patient went to another hospital for additional imaging three days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!

Addenda And The Medical Record

Addenda can also be necessary for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate the cause of a disease/illness.

Alternatively, frequently we will issue a supplement as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report.” Placing an addendum, in this case, becomes medically essential. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, they may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).

Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the true history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A lousy history can lead to a denial of care payment for a patient. An addendum as a correction can be a lifesaver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!

Ethical Obligations To The Addendum

We, as physicians, are ethically obliged to abide by our Hippocratic oath to do the best for our patients and do no harm. Based upon some of the examples above, we fulfill a moral and ethical imperative to improve patient care by creating addenda. So even though overlooked by our readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!

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The Midnight Radiology Resident Discrepancy

discrepancy

If you haven’t had a discrepancy with the covering morning radiologist as a resident on call, then one of you encountered one of three outcomes. You either haven’t read enough cases. Two, you are the long-lost great-great-grandson of William Roentgen; Or finally, perhaps your name is Watson, the artificial intelligence computer, and you work for IBM!!!

The truth that very few attendings seem to admit is that everyone, including themselves, will miss something every once in a while. One study reported radiologists clinically miss something important between 2-20% of the time. (1) From my experience, that number looks pretty high, but the rate is significant enough. So, when, and notice, I don’t say if you miss something and have a discrepancy at night, you are an ordinary radiology resident. I would even go as far as to say that you are fortunate, in a sense, because you didn’t miss the finding as a full-fledged attending. You have someone to back you up, and hopefully, you will never forget that finding again.

Accepting The Inevitable Discrepancy!

The first step, of course, is to prevent major misses. The cases you need to study leading up to taking calls are the cases that are common and lead to significant morbidity and mortality. You want to view hundreds of different types of appendicitis, aortic ruptures, pulmonary emboli, and so forth so that when the time comes for you to take a call, the chance of missing the critical finding is significantly lower. Unfortunately, however, we can’t prevent all the inevitable misses, and frankly, we have to admit to ourselves first and foremost that this will be the case.

So, what do you do when you have a significant miss? Maybe you sent a patient home with acute appendicitis or a patient with a ruptured ectopic pregnancy. Perhaps you missed an early retroperitoneal bleed. There are specific keys to making the discrepancy in any of these cases, not just another horrible encounter, but rather a learning experience that is valuable for the remainder of your career. We will go through a few rules that you need to follow in the rest of this chapter.

Don’t Perseverate Over The Discrepancy

The first important point is how you emotionally react to the discrepancy. It is also a life lesson. We can’t undo what you did. You need to move on… Perseverating on a miss is counterproductive at best and, even worse, can cause future misses. Remember, just because you made a significant miss does not mean you are or will be a horrible radiologist. So, you need to get over it. The same rules apply to questions on written exams, future failures, etc. One miss does not a radiologist make!

Make Sure To Follow-up The Patient In The Morning

When you find out about the bad news, it is inappropriate to leave the department sulking, not attempting to make good on the miss you made. Try to do what you can to make sure that the physicians in the emergency room know there was a discrepancy. Or, you may need to call the patient back yourself, if need be. Bottom line… You need to make an effort to clean up your mess. It is partially your responsibility.

Read All You Can About the Miss To Not Make the Mistake Again

Reading about the disease, reviewing the films, looking at other similar cases: These are all the things you should be doing soon after the miss. This miss is a real opportunity to understand and fix the incomplete knowledge you had on the subject before, and, of course, to never make the same mistake again.

Teach Others

One of the most rewarding ways of compensating for the discrepancy is to make your fellow residents and junior residents aware of the miss. Teaching your colleagues protects them from making the same mistake that you have made. And, even better, it reinforces the knowledge you have, thereby making it much less likely that you will repeat the same mistake. Just like lightning, it rarely strikes twice!!!

Learning From Midnight Discrepancies

Midnight discrepancies are part of the everyday learning ritual for a radiology resident. It is not the discrepancy itself that is a problem. That is expected and is part of the typical routine residency learning experience. But instead, the issue is how you as a radiology resident learn and grow from the experience. Make the best of a challenging situation!!!

 

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How to Choose a Radiology Fellowship

radiology fellowship

For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!

So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.

Personality:

You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.

I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.

Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology

Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology

Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology

Jack of all trades- Body Imaging, MRI, Nuclear Medicine

Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging

Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology

Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine

And so on…

Lifestyle:

So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.

Body Imaging/MRI-

Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.

Cardiothoracic Imaging-

Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.

Informatics-

Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty

Interventional Radiology-

Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours

Musculoskeletal Imaging-

Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic

Neurointerventional Radiology-

Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.

Neuroradiology-

Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty

Nuclear Medicine-

Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.

Pediatric Radiology-

More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty

Trauma/ER radiology-

Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.

Women’s Imaging/Mammography-

Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.

Money:

Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.

Location:

Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.

Application Competitiveness:

Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.

Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.

Trends/Countertrends:

So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.

Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.

Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.

On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.

Summary About Choosing A Radiology Fellowship:

Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!

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Dictating- Tips for the Radiology Resident

dictating

dictating

Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.

Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.

Resident Versus Seasoned Dictating

So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.

Residents Need More Formalized Guidelines To Learn Dictating

To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.

Templates:

When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.

In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.

Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)

Important Pitfall

However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.

Histories/Priors:

Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.

One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.

Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.

Technique:

I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.

Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!

Comparisons:

The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.

Comments:

If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.

One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.

Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!

Impressions:

The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.

In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.

Beware Of Technical Jargon

Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!

Stick To The Answers

Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely. MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.

If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.

What terms are most frowned upon in the impression?

Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.

But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.

Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!

In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!

Structured Reporting Dictating Versus Prose Dictating

Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.

I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!

Dictating Tips: A Final Conclusion

You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!

 

 

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Radiology Call- A Rite of Passage

call

Every year around the beginning of July, I see some of the most haunted radiology resident faces, right around 10:00 pm, just after the attending evening shift ends and the resident night shift begins. It is almost always a second-year radiology resident who happens to be starting their first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And most importantly, will I kill someone?

The resident only unlocks the answers to these burning questions on the first night. Only after this event does the resident and the program director know whether or not they can handle the burdens of a radiologist. Everything in the first year leads to this point: the precall quiz, the intense reading, the conferences, and the studying. It’s crunch time.

Just before the first night of the dreaded call, my famous last words are: you begin the night as a kid, and you will end the night as an adult. Why do I say that? Because I think the truth lies embedded in that statement. You can never become a full-fledged radiologist until you are responsible for independently making patient decisions. It’s like all those ancient traditions in all religions/cultures, like hunting that first wild boar, the confirmation, the bar mitzvah, etc. The residency now allows you to function as an independent, freethinking human being who can make decisions on your own. Until then, you are merely an observer, not an active participant.

Since taking night coverage is such an intense and essential experience, you must follow certain tenets to make it valuable and safe. I will enumerate eight simple golden rules of call I wish I had known before beginning those fated first nights to come. I urge that you follow all of them to enrich your education safely. Do not stir the wrath of your fellow staff members and program directors in the morning by breaching these rules!

Look at every film with these primary thoughts- what will kill the patient, and what is common?

I can guarantee that if you look at every film with these thoughts at the forefront of your brain and have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. If you see a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think of acute appendicitis. And so forth. Thinking about badness will prevent undiscovered horribleness in the morning.

Likewise, when you look at films, always think about the most common diagnoses first, and you will be right much more often than wrong. For instance: Opacity on a chest film- pneumonia, not Hampton’s hump. Restricted diffusion on a brain MRI- infarct, not ependymoma. Abnormality on a GI bleeding scan, think primary GI bleed, not Meckel’s diverticulum with bleeding gastric remnant. I can guarantee your attending faculty will look at you funny if you come up with too many zebras!

Always, always, always maintain your search pattern in every study.

In the radiology world, one of the main ways to miss something is not to look for it. Sometimes in the middle of the night, the pressure will seem impossible, and you must deliver an answer at that second. Perhaps, a team of 4 angry surgeons comes down and asks, “What is going on with the film?” and needs to know now! Or, an inpatient resident shoves a chest film in front of your face and says, “What’s going on here?” Maybe, the emergency medicine doctor calls incessantly to get a read on that CT chest for dissection.

In each of these cases, I don’t care how emergent and immediate they need the answer, always step back and go through your search pattern. Everyone makes this cardinal error at one time or another. Avoid it! Step back and say give me a moment. Go through each organ or region rigorously. You will look much less stupid than blurting a diagnosis/finding out only later to realize it was wrong because you haven’t thoroughly analyzed the study. One of the worst feelings is finding the doctor who just left your department with the wrong answer, who is getting ready to begin an unnecessary surgery on a patient, or a doctor who will discharge a patient that needs to stay in the hospital!!

If there is no harm to the patient, it is easier to do the study than to fight it.

Most residents take a while to learn this one piece of sage advice. At nighttime, you will have limited time for everything. Interruptions will pull you in fourteen different directions at once. You will receive calls from the emergency department, the floors, the surgeons, etc. And often, these events tend to happen all at once. So, I urge you that if a study is reasonable, do it.

You will spend more time and energy preventing a study from getting done than just completing it. Of course, if it significantly harms a patient, then obviously avoid it. But that is the exception rather than the rule. That fluoroscopy study to rule out a foreign body that you try to block after the resident ordered it: I can guarantee it will come back hours later when you are either exhausted or have lots of things going on at once. So, just do the study!!!

Don’t let your temper get the best of you. You will hear about it in the morning!

Every resident encounters a curt gynecologist, a rude surgeon, a loud, demanding resident, and so on at some point. You are likely going to be grumpy and tired as well. It may seem like a good idea to talk back to that person similarly rudely and unprofessionally. Or, you may want to take a swing at one of these annoying chaps. But don’t do it. One of the most common complaints at nighttime is a letter written by an attending or a resident colleague saying this radiology resident was unprofessional and handled the situation poorly under pressure. This complaint will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident’s file/record. Don’t let that be you!!!

Residents best handle resident matters. Attending matters are best handled by attendings.

At nighttime, many times, a clinician may need an attending radiologist. So, make sure you don’t go in over your head. Call your attending when necessary. The worst thing you can do in the morning is to perform a procedure that your attending should have done or make a phone call that really should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town in the department, not in a good way. An attending should always read a brain scan because of litigation issues. A faculty radiologist should always be present for an intussusception reduction. And so on. Don’t go over your head!

On the other hand, if you have a resident issue at nighttime, try to handle it yourself. If the Emergency Department asks you whether to give the contrast, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the more minor decisions by playing the role of a radiology resident.

Ask for help if you can’t handle something at nighttime.

Sometimes, the job may be too much to bear for one person. (A disaster happened with every patient getting a total body CT scan) Perhaps, it is a question that an expert needs to answer. (A subtle abnormality on an emergent Neuro CTA) And, other times, administrative issues that only your chair or program director can handle. (The MRI broke – should we recommend sending patients to another hospital?) If such problems arise at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it is a patient question that you are not sure about, ask your chief resident. Then, if they can’t answer the question, you may want to ask the assigned attending on-call. And, up the chain, it goes.

If you decide to handle everything yourself and it is inappropriate for your level, you can almost be sure that repercussions will occur in the morning. So please, ask for help when it is needed and appropriate!!

Always answer your beeper/phone/pager.

Occasionally, we hear about a resident sleeping and not answering their pager at nighttime. Unfortunately, those residents will often get written up in the morning for lack of timely dictation. So, jack up the sound on your beeper/phone/pager. And, take all calls!!!

Look at the films. Don’t rely on the ER or Nighthawk reads.

Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. So, do not repeat a dictation or reading that is already present. You should do everything de novo/from scratch, although you should look at their reads afterward. It also seems silly when the resident’s dictation matches the Nighthawk dictation verbatim and hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes that a resident used to check the cases even though others have looked at the study. And, it is not infrequent that our residents catch essential findings that the nighthawk didn’t notice. So please, do your independent reads/dictations!!!

Summary statement

Call is a challenging but integral part of raising a radiology resident right. It is a time of trials and tribulations. You can and will make it through this harrowing trial if you follow the golden rules. Good luck!

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Need some help with what you need to learn before taking call? Check out the following books on Amazon!

Emergency Radiology Case Review Series

Core Radiology

 

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This article is featured on auntminnie.com!!! Click here for the Aunt Minnie version of the article. 

 

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How to Make a Good Impression as a First Year Radiology Resident

impression

It may be your first day, your first month, or maybe you started residency several months ago. Perhaps, you want to make that great first impression on your program director. Or, maybe things are not going as well as you might have liked during your first year. Having worked with numerous first-year residents rotating in our residency and having completed a full four years of residency, I have learned the ingredients you need to become a great first-year resident. As a former resident, I wish I had a list of tips on how to start my radiology resident experience on the best footing possible.

Well, now it’s here. I have a list of 12 ways to improve your radiology residency experience starting in the first year of your diagnostic radiology residency program. Also, I will give you examples of what not to do (these scenarios are real!). Then, I will explain how to make the best of each piece of advice. To all- ENJOY AND HEED THIS ADVICE!!!

Be Enthusiastic

On your first day of radiology residency, you walk into the reading room for the first time, and you are nervous and hesitant. You begin to yawn, mouth wide open. An attending sits in the corner about to read films. You slink back and worm your way into a corner. You don’t introduce yourself for fear of disturbing the attending radiologist. Instead, you start talking to your resident colleagues. Is that a way to start your career? By all means, NO!!!!

My words of advice:

Always make sure to put on your best face forward toward your staff. What does that mean? Well, it’s pretty much common sense. Always introduce yourself. Always ask how you can help. And, always volunteer to participate in a readout or procedure. You have only one chance to learn the things you need to know before practicing as an attending, and that way is RADIOLOGY RESIDENCY. Make it the best learning experience you can, and that involves going that extra mile to show your enthusiasm/interest.

Be On-Time

You wander into the reading room, and it’s 10 AM. When you see your attending radiologist reading out films, he pauses for a moment. You decide to say, “When can we start reading out together?” The attending looks at you with a confused quizzical face. Was I supposed to have a resident today?

My words of advice:

When you arrive in the morning, always let your attending know that you are today’s resident. If you have to step out for a few moments, let him know that you need to leave. It is a sign of respect to let your attending see that you are going to be around to help out, learn, dictate, and ask questions. It will go a long way to establishing a rapport between yourself and your residency staff!

Be Nice to Everyone

It’s your first day, and you walk into the residency coordinator’s office. You sit in her chair, never having seen or met her. And then, you start playing games on her computer. The coordinator walks into the office and stares at you and is thinking: who the heck is this guy?

My words of advice:

Make sure when you are beginning that you are kind to everyone!!! I don’t care if it is the residency coordinator, janitor, technologist, attending, senior resident, or nurse. We are all part of the same team. Moreover, we always hear about our resident’s behavior, good or bad. As residency director, we receive 360-degree evaluations, reviews of the residents from potentially all these sources, and more. I can tell you that if you want to destroy your reputation as a resident, the worst thing you can do is misbehave with your team members, especially the residency coordinator!!!!

Dress Appropriately

You are upstairs on the floors in a t-shirt and ripped jeans. Your ID badge sits in your back pocket with the list of patients to consent. In your morning haze, you stumble up to the door of the 3rd patient with informed consent in hand. You introduce yourself to the patient, and she gives you that look- who are you really, and what are you doing here? You go through your pat explanation of the procedure, the risks, and the alternatives. The patient warily signs the consent form. Great! The last consent of the morning.

Later that afternoon, the program director calls you into the office. It turns out, the patient was the wife of a hospital executive and called the emergency hotline. The program director now has two complaints about this resident, one from the patient’s husband and another from the doctor in the hallway. Both are furious because they did not know who you were and felt uncomfortable confronting you. The program director states, “Go home and change immediately!”

My words of advice:

Always make sure you look and play the part of a physician. Some patients and physicians are easily offended by an inappropriate appearance/uniform. In our world, radiology is a service-oriented profession. Furthermore, appearances fortunately or unfortunately lend credence to your skills, personality, and the department. Please make sure to represent your department in the best light!

Play the Role of An Attending From Day One- Take Responsibility for Your Patients and Department

You roll on into the nuclear medicine department and arrive at the department early. Briefly, you look at the list of patients in the computer. A bone scan and a gallium scan lies waiting as unread. You think to yourself, I know those topics well. I also know it would be much more productive to read a nuclear medicine book on a new subject. As you are waiting for your attending to arrive, you pull out your text and learn about nuclear medicine. The attending walks through the door a few minutes after you started to read and says, “Have you looked at the cases from last night?” You reply, “I was hoping to get my reading done for the day. Didn’t get a chance to look at the cases.”

My words of advice:

When you are on any service, good learners become great radiologists by reading lots of cases. You may know a given topic well, but you can only learn normal from abnormal by reading thousands of cases in different contexts. Unfortunately, you cannot learn this from merely reading a book. The only way to get that experience is to look at lots of cases every day. Take an active role as if you are an “attending.” Radiology is not a spectator sport!

Be Knowledgeable

You are in the second week of your first CT rotation. So, you sit down with the CT attending to go over the day’s work. The attending goes through each of the cases slowly. Finally, she happens upon an abdominal CT scan. You stare at the images, and she asks you about an ovoid cystic density structure just inferior to the liver. You blurt out, oh, that’s easy. It’s an aorta!!! Your attending begins to shake her head slowly and becomes silent. She doesn’t say much for the rest of the day.

My words of advice:

There’s an old radiology adage. The difference between a bad, OK, good, and great radiology resident is the amount you read every night. A bad resident doesn’t read. An OK resident reads 1 hour a night. A good resident reads 2 hours a night. And, a great radiology resident reads 3 hours a night. Don’t be that bad radiology resident! When you start, I encourage you to read a lot, especially emphasizing the basics and anatomy!

Read a Lot, but Make Sure to Study the Images

It is your first day on the new chest film rotation. You have just finished reading an entire textbook on chest radiology. As you start looking at the cases with your attending, you figure that you will try to impress him with your in-depth knowledge of the findings associated with sarcoidosis. So, you start going through a small presentation about your newfound knowledge based on the textual information. After your serenade, he begins to look at the first few cases of the day. Then, he pauses as he starts on the third case of the day.

He asks, “What do you think about this chest film in front of you?” You stay silent as you search the film up and down, left and right. Nothing seems to register as abnormal ton the film. Your attending points out a significant opacity obliterating the vessels behind the heart and obscuring the left hemidiaphragm. He then asks, “Where is the opacity located?” You realize that you have read tons of information on pneumonia but never looked at the pictures. Uh oh! You cannot identify the location based on a mental reference point. Your heart sinks as you realize you have more reading to do…

My words of advice:

Reading a radiology text differs dramatically from reading an internal medicine book, a novel, or other sorts of written information. The most important features of a radiology textbook are usually the pictures and captions below the pictures. So, it behooves the resident to concentrate on these films, often more than the text itself. Of course, you need to understand and remember the disease entities, but radiology is most often about the images!

If a Radiology Attending Asks You a Question, Always Look Up the Answer

So, it’s the end of the day, and you are sitting with your favorite attending. For the few days that you have worked with her, she has a habit of teaching interesting topics while taking cases. It feels like you just read an entire book without even touching a page. She enthusiastically asks you a question about a patient with breast cancer. She says, “I wonder what a sclerotic metastasis would look like on a PET-FDG scan? Maybe you can look it up, and we will go over it tomorrow.”

You go home exhausted and fall asleep slumped over your computer, without even getting a chance to read a word about the topic. You get up in the morning and realize you are running late. Hurriedly, you grab your stuff and arrive barely on time. Sweating profusely, you run into the reading room. Your attending almost sits down at her workstation. And she says, “Did you look that topic up for me?” Unfortunately, you don’t have a satisfactory answer. For the rest of the day and weeks afterward, she barely spends time on her cases with you. You’ve lost many opportunities to learn with your mentor.

My words of advice:

You sow what you reap! When someone, specifically a radiology attending, takes the time out of the day to teach. And, she goes over cases with you out of his/her own free will, it is essential to pay back that person with attention, diligence, and care. By under-appreciating the attending’s time, you change the willingness of a teacher to teach. Remember, most hospitals do not pay radiologists stipends for their time with their residents. Teaching emanates from the goodwill of the staff!

Always get a good history

It is late in the day, and you are about to read the last hepatobiliary scan of the day. But you have to do it quickly because you need to get home to your family. Instead of entering into the electronic health records, you promptly peruse the one-word order on the top of the dictation page. It says pain. So you start reading and dictating the case promptly for the attending with that one-word history. In a few minutes, you finish the dictation.

You walk back to the reading room and begin to go over the case with your attending. Subsequently, he opens the case, looks at your history/dictation, and begins to look at it as the surgical team walks by to get the radiologist’s interpretation. The surgeon asks, “What do you think?” The radiologist says, “With a history of pain, it looks like the gallbladder fills nicely without findings suggesting cholecystitis.” The surgeon responds curtly, “We just took out the gallbladder!!”

My words of advice:

Always take the time to get a great history. As a resident, you should take the time to gather all the information. Without a good history, trust me, you will get burned. So, avoid the inevitable, take your time, and always get all the necessary information!!!

Establish a search pattern for all modalities

The day’s attending sends you out of the room to read a new CT scan of the abdomen. The patient has right lower quadrant pain, and the emergency doctor wants you to rule out appendicitis. So you look through the CT scan quickly and ramble into the Dictaphone about the case. Your eyes move here and there without any specific pattern. Finally, you see some terminal ileum wall thickening and put in your impression- findings suspicious for terminal ileitis/inflammatory bowel disease. Happily, you trot back to your radiology attending to go over the case. Within 10 seconds, your attending says, “You missed the 4 mm obstructive stone in the right ureter!”

My words of advice:

Believe it or not, almost every experienced radiologist has a rigorous search pattern and mental checklist in every case. With this checklist, they don’t miss any findings that may be relevant to patient care. You might not know they have a search pattern/checklist because they have been doing it for so long. And, they rapidly read the cases. But, I can guarantee you will miss plenty of significant findings if you do not go through an organized approach to looking at a film. It happens all the time!!!

Always check for priors

The radiology attending just left the service for the day. You are now on call for the night. The emergency department continues to call the nuclear medicine department every 10 minutes to get the result. Annoying, isn’t it? It is time to give a STAT interpretation of a pulmonary V/Q scan. So, you look at the scan and the associated chest film. And, you see three large mismatches without corresponding findings on the chest film. You call the ER and tell them the scan is positive for pulmonary embolus. You feel good because you think you made the right call for sure.

The next morning at the readout, your attending starts to look at the case. He notices that you didn’t compare to the prior scan. It seems the same. His interpretation- no findings to suggest new pulmonary embolus. He says, “Call the ER right now to make sure the patient doesn’t get more anticoagulants.” You feel like an idiot for missing the correct diagnosis!

My words of advice:

I can’t emphasize enough how important it is to compare priors. Priors will bail you out many times. And, comparing with them makes the difference between shoddy and outstanding patient care. If you want to become a resident star, always make a concerted effort to check for prior studies!

Learn about things that can kill a patient or are common first. Zebras can usually stay at the zoo!

You are taking your first independent call and start to look at your first ultrasound of the evening. It is a 2-year-old pediatric patient with right lower quadrant pain. Looking through the ultrasound images, you see a target like structure in the right upper quadrant. You recently read a large text and saw a case of Henoch Schonlein Purpura affecting the bowel. It happened to look just like it. Your differential reads Bowel thickening from Henoch Schonlein Purpura before anything else. Ten minutes later, the pediatric surgery team trots up the stairs toward your workstation and says, “What are you talking about? We were looking for a large bowel intussusception!”

My words of advice:

Stick to the most common two or three items within the differential diagnosis. You will often be right more than not. As I said, zebras can usually stay at the zoo!!

Making A Good Impression

I’m sure almost all of you want to make your best impression on the staff that you are going to work with for four years. One or two mistakes toward the beginning of your stay can make your life very difficult for the rest of your radiology training. Unfortunately, it is effortless to leave the wrong impression on the staff, but it is harder to correct. To avoid these blunders, I highly recommend you follow these rules. Don’t be the brunt of your residency’s jokes!


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How To Artfully Communicate Uncertainty

uncertainty

Many of you know the oldest radiology joke in the book: What is the national plant of radiology? The Hedge! In truth, we as radiologists have to face more uncertainty in our profession than most. Diagnoses of 100 percent certainty are rare. And, we need to communicate this information to our fellow clinicians reasonably. So, how do radiologists do this without infuriating our clinical colleagues? To investigate how, I will divide this post into multiple sections, each one with a meaningful discussion to help you decrease uncertainty for the clinician. Welcome to my world!!!

Don’t Beat Around The Bush

Say what you mean and mean what you say. Don’t hem and haw about your insecurities. Even though we cannot come up with a final diagnosis at times, it is important to say just that. Make sure not to put in too many caveats and extra words. If you see a liver lesion and it could be an atypical hemangioma or hypervascular metastases, don’t use flowery language or multiple qualifiers like the words: however, compelling, of course, and so on. Just say the differential diagnosis includes hemangioma or hypervascular metastasis.

Excommunicate Cannot Be Excluded

One of my most hated phrases in radiology is (drum roll please…) “cannot be excluded.” But, it is not just my least favorite phrase; it is also the clinicians’. Why? It has the potential to force a clinician to investigate further an unlikely diagnosis. 

If you think that a renal lesion is most likely a hemorrhagic cyst, you should say the renal lesion is most likely a hemorrhagic cyst. Suppose the possibility of a renal cell carcinoma is slight. In that case, you can say that the features are not characteristic for a renal cell carcinoma and the likelihood of the lesion to be a renal cell carcinoma is exceedingly rare. On the other hand, if you use the term renal cell carcinoma cannot be excluded; you give the clinician no sense of the actual probability of renal cell carcinoma. The phrase cannot be excluded often causes the unintended consequence of additional unnecessary workups related to your dictation.

Correlate Clinically

Another way to reduce uncertainty is to find additional clinical information on the patient. If you are not sure, look up the laboratories, the prior studies, the actual clinical history, the vital signs, or the accurate ER report to add more certainty to your report. Think of it this way. You have one report that says: chest film shows right lower lobe pulmonary parenchyma disease, possibly pneumonia, atelectasis, or pulmonary edema. On the other hand, you have another report stating the following: Given the elevated white count of 20 and the patient’s elevated temperature of 106 degrees, the right lower lobe pulmonary parenchymal air space disease is most likely pneumonia. You can see that the increased certainty of diagnosis in the second report is significantly more helpful to the clinician that ordered the study.

Specify Probabilities

If you are not sure of the diagnosis, why not just say the probability of the diagnosis? At least, this will help the physician on the other end of the report know how far to work up the patient for other possibilities. Giving a laundry list of diagnoses x versus y versus z helps no one. But, if you know the chance of x is much greater than y, which is greater than z, that opens up a whole new way for the clinician to proceed next with the patient.

Describe The Findings Well

Finally, if you are unsure of the final disposition, make sure you describe the findings well. For instance, if you see bulky adenopathy in the right hilum, make sure to say the size and shape, whether it narrows the mainstem bronchus, and if it causes post-obstructive atelectasis or pneumonia. You may not know the diagnosis. But, the clinician can now decide whether they can get to the abnormal lymph node by bronchoscopy or proceed to the next step. By describing the findings well, you ensure that the physician will work up the patient appropriately.

Communicating Uncertainty Well!

Our specialty is fraught with uncertainty. That is OK. It’s just the way it is. More importantly, good skills to communicate uncertainty can save your reputation and the reputation of the specialty. Suppose you follow my advice about directly saying what you mean. In that case, avoiding cannot be excluded; looking up clinical information while incorporating it into your report; specifying probabilities, and describing the findings well, you can at least drive the clinical physician to the appropriate next step. See. Uncertainty is not that bad!!! Just like always, it is all about good quality communication.

 

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Radiology Residency Chain of Command

radiology residency

No, we are not the military, but there is a radiology residency chain of command! Lots of different entities in radiology residency are responsible for your day-to-day activities and training. It is more than your faculty and program directors. It is a whole hierarchy. And, it is was not until later on in my career that I understood the roles that each of these entities played in managing a residency program. But, it would have been nice to understand it all from the very beginning and know who to address for each radiology residency issue. To that end, in today’s post, I am going to define each of the different titles and offices in charge of your radiology residency training and describe the parts that they play. For fun, each role I will associate with a military position! Let’s start at the bottom and work our way up.

Radiology Resident (Private)

A radiology resident is the “lowest” but the most integral part of the chain of command. It is his/her responsibility to be trained in the art and science of diagnostic radiology during the four years of residency. To become a member of this club, he/she needs to graduate from medical school and complete one year of clinical training. After that, he/she answers to all the other “higher” positions listed next!

Radiology Chief Resident (Corporal)

Typically selected by the residents and program directors, this person is the first rung in the ladder of the radiology residency command (also previously discussed in a prior post). When there is a fundamental residency level issue or problem, he/she rises to the occasion. The chief resident is often responsible for scheduling, board reviews, interclass conflict, drinks with peers, performance issues, and noon conferences. In addition, any residency program issue that does not need to go to the attending is under the purview of the chief resident. And, the chief resident is also responsible for communicating faculty-related issues to the residents.

Radiology Residency Coordinator (2nd Lieutenant)

He or she is responsible for the day-to-day running of a residency program but is typically an administrator and not a physician. Most residency coordinators make phone calls, transcribe letters of recommendation, report issues to the faculty, send out evaluations, deal with class conflicts, ensure that the learning portfolios are complete, arrange end-of-the-year parties, and more. Some play a significant role in admissions committee screening. And, the coordinator is often the first-line resource for radiology residents when they have issues with colleagues or attendings. The radiology residency coordinator is an integral part of a radiology residency. (I think of this person like the Class Mom/Dad)

Radiology Faculty (Captain)

Full-time faculty members are responsible for the direct and indirect supervision of residents. The ACGME guidelines require all faculty members to teach. In addition, there are specific minimum numbers of faculty members that are necessary to run a residency program. Teaching involvement, however, varies widely by each faculty member. Residency programs expect all residents to follow the faculty lead when it comes to reading, procedures, and training in any of its forms.

Radiology Section Chiefs (Major)

This designation can be a bit technical. Theoretically, the radiology section chief for a radiology residency program can be different from the head of the section in a department. However, these individuals run the individual subspecialty rotations for a radiology residency. Individual faculty members answer to their respective section chiefs in one of many academic areas. The section chief may also perform many other duties such as setting up protocols for technologists, introducing new procedures, signing off on resident competencies and curriculums, ensuring that the subspecialty curriculum is appropriate, and more.

Associate Program Director (Colonel)

Although not an official designation by the ACGME, the Associate Program Director is the second in command for running the residency program. Suppose there are issues that the radiology chief resident, faculty, coordinator, or section chief cannot take care of. In that case, these problems fall into the lap of the Associate Program Director. He/she is also responsible for curriculum planning, enforcement of residency rules and regulations, maintaining education quality, dealing with residency conflicts, answering both the program director and the residents, and more. The Associate Program Director shares these responsibilities with the Program Director.

Program Director (1 Star General)

The ACGME designates this individual as director in charge of the residency program. He/she is ultimately responsible for most issues that occur during a radiology residency. In addition, the radiology Residency Program Director signs off on each resident that he/she is competent to practice diagnostic radiology after graduation. Clinical activity for this individual varies widely depending upon the program’s size, but most have some clinical duties. However, all Program Directors are responsible for monitoring the clinical teaching in the residency program and administering the radiology residency. So, this person is ultimately accountable for a radiology resident’s training.

Radiology Department Chairman (2 Star General)

The Radiology Department Chairman is the head of the entire radiology department. This person is responsible for dealing with all faculty issues and indirectly will usually help with radiology residency administration issues. When there are complaints about individual faculty members, new radiologists to hire, budgeting, and high-level resident problems, this person steps in to help manage the situation. Frequently, the program directors will consult with the chairman before making important decisions. The chairman sometimes holds the purse strings for some residency programs.

Designated Institutional Official (DIO) And The Graduate Educational Committee (GME) (4 Star General)

The DIO is the head of the hospital GME Committee. The radiology residency program director answers to the DIO for program-level issues and high-level resident issues. The types of problems that a DIO will often work with include accrediting residency programs, monitoring pass rates for programs, dealing with probation and suspension of individual residents, checking residency action plans, adding complements to residency programs, and more. In addition, he/she often gets involved in legal residency issues. And, this is just the tip of the iceberg. Typically, this is a full-time administrative position that is very busy! Individual programs bring many of these issues to the DIO’s attention, and they are subsequently voted upon by the GME Committee for approval.

American Board of Radiology (ABR) (Military Service Chiefs)

The ABR is a private organization in charge of testing for minimum competency for the individual radiology resident. All radiology residents need to pass the boards administered by the ABR to become board-certified radiologists. Although they are not directly in charge of residency issues, they play an essential role in determining the curriculum for the individual radiology residency program since they create the board exams (the core and certifying examinations more specifically).

Accreditation Council For Graduate Medical Education (ACGME) (Chairman of the Joint Chiefs of Staff)

Now we are talking high-level!!! The ACGME is a governmental-run body that is the watchdog of residency programs, a diagnostic radiology residency program. This organization accredits each radiology residency program. They have the power to put a residency on probation or suspension. As part of the ACGME, other committees, such as the Radiology Review Committee (RRC), are responsible for setting up the individual radiology residency guidelines and requirements. They are responsible for making the maximum duty hours, faculty requirements, and more. Overall, most residents do not have direct contact with this organization. However, it is crucial to follow the ACGME rules for the individual radiology resident to graduate from an accredited residency.

Now You Know The Hierarchy

That just about covers the basics of the different levels of responsible parties for a radiology residency program. Even though some institutions have additional positions that also play a role in managing a radiology residency, the ones I described are usually the most important. (Just don’t tell that to the research manager or the radiology liaison!) Of course, additional levels can get quite complicated. But at least you have the basics of who to turn to when you have a specific issue or question. So now you know your ABCs of the chain of the radiology residency command!!!