Category: Resident Advice

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How Far Should I Take That Procedure?

procedure

The Procedure Situation

Round 1

Your radiology attending tells you to interview a patient and then complete an ultrasound-guided breast biopsy, knowing that it was a large mass and a relatively simple case. You have done this procedure numerous times with this same faculty. So, you go ahead and do it again. No complications. No issues. After you complete the biopsy, you feel immense pride in your capabilities. You show the attending the pictures from the biopsy. The attending congratulates you on a job well done.

Round 2 later that same day…

A different radiology attending wants you to work up another patient and start the subsequent breast biopsy. So, you begin to interview the patient, set up the table and the sterile field, position the patient for the procedure, and place the ultrasound probe on the biopsy site. You begin to numb the overlying skin lidocaine and make a small incision for the biopsy gun. Since the attending still has not shown up, you decide to place the needle right near the lesion, hit the targeted breast nodule, and then subsequently collect multiple samples, placing each one into a little sterile cup on the side to send to pathology. You complete the rest of the procedure without complication. All seems to be well.

You clean up everything and let the patient know that everything went just fine. And, you tell her you are going to consult with the attending before you have her leave. So, you merrily step out of the room and walk down the hallway toward the radiologist’s office to let her know about the patient’s biopsy you completed. You enter the office and state, “I completed the biopsy successfully on patient “XYZ.” The attending stares at you with a stern, angry face and says, “How dare you complete the procedure without consulting with me!!!” You are the talk of the department for the next month!

How To Assess How Much You Can Do

Unfortunately, during radiology residency, you may encounter similar situations such as this one. Different attendings have entirely varying expectations for each radiology resident. Some may expect you to start and finish all procedures. Others may be less likely to allow the resident to have independence, even though he/she may be competent. So what to do? I will go through several guidelines in assessing whether you, as a radiology resident, should complete a given procedure on your own.

Are You Competent In The Procedure? 

Competency should be the first issue that you need to address as a radiology resident. Suppose you do not think you have done enough of a technique independently from start to finish. In that case, you certainly have no business doing any procedure or a portion of a procedure alone. The comfort level is also just as important. Even if you have the numbers of biopsies to back you up, if you do not feel comfortable with a procedure, you should also continue to make sure that you have your attending’s guidance at all times until you have that comfort level that you need.

Are We Doing the Procedure For The Right Reasons?

Before performing any procedure, you need to make sure that it has some clinical benefit. Nurses regularly come up to me and ask should we give intravenous contrast. The first thing I ask them is why are we doing the study/CT scan? It may not need contrast in the first place. Likewise, no matter how “minor” a procedure is, you always need to think about it if necessary first!!!

Level of Difficulty of Procedure/ Potential For Complications

Some procedures, such as an upper GI series, have a much lower complication rate than a complex liver embolization. So, it is essential to assess any given procedure’s difficulty and potential complications before deciding whether you should tackle it on your own. Most liver embolizations, stent placements, and angioplasties should probably be under the faculty’s direct supervision unless perhaps you are about to graduate from an IR fellowship in a few days. On the other hand, a paracentesis can undoubtedly be performed from start to finish by a resident.

Attending Expectations

Some attendings expect the resident to do almost everything and others feel the need to hold the resident’s hand at every step. Much of that decision may be related to the trust between the attending and resident. However, it is imperative to listen to the guidance of your attending before beginning or ending any procedure. Because you are not the physician who signs off on everything, you need to abide by the person’s rules in charge. Always make sure to get the OK from the supervising physician before performing any procedure!

Patient Expectations

Many patients expect an attending to complete a procedure. Always abide by the wishes of the patient. You never want to be caught in a situation where the patient does not want you to be performing a procedure, and you do so anyway. Not listening to the patient’s request is the realm of lawsuits and legal issues!!!

It’s All About Self-Awareness!

The difficulty of residency can be more about self-assessment/awareness and working with colleagues than about the actual day-to-day mechanics of performing cases. You, as a resident, need always to be aware of your strengths and weaknesses as well as your expectations. My advice: make sure to always know in advance that you are performing a procedure for the right reasons, have the abilities to conduct it, and your attending expects you to complete it. Only then should you consider performing a procedure independently!

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Taking Oral Radiology Cases- A Lost Art?

oral

The lights go down as the radiologist in front of the classroom prepares the computer for a case presentation. A switch is flicked on. Suddenly, a black and white PowerPoint case begins to shine brightly on the screen in front of you. The radiologist glances about the room looking to see who would be the best fit for this next case. You begin to sweat and fidget with your hands, praying your faculty will not call on you next. The attending’s glance remains fixed upon you. He says, “Tell me about this patient with a 2-year history of a cough!”. You become flustered and unsure what to say.

The scenario above occurs commonly in radiology residencies across the country. However, since the oral exam has disappeared, I have noticed an overall decrease in proficiency in how residents present each radiological case. The art has been lost. You can blame some of it on poor teaching. Decreased time allotted to education may cause some of it. Some of it can relate to the emphasis on the new board examination system. And, perhaps the new radiology residency culture may be responsible for some of the changes.

In whatever case, it is a shame. Taking oral cases is a crucial step to becoming a well-rounded radiologist. You need to relate to your colleagues’ images in a timely, logical manner, no matter what you are looking at. If you want to look like a star, you need to have this process down cold. To enable you to have the tools to get through a radiological case, I will go through the basics, including determining the kind of study, presenting descriptive findings, coming up with a differential diagnosis, and ultimately determining proper management.

What The Bleep Am I Looking At?

Whenever your attending introduces you to a new oral case, the first thing you need to do is determine what you are looking at. Take your time and think about what kind of images you see. You often lose the case discussion even before you have begun because you never identify the correct study. Is it an ultrasound, CT scan, MRI, x-ray, or nuclear medicine study? Is the examination performed with or without contrast? During what phase?

For nuclear medicine studies in particular, if you can identify the study before going through the case, you have already completed 80 percent of the heavy lifting. You have already isolated the differential diagnosis if you can identify the radiopharmaceutical. If you are not sure, you should start describing the physiological distribution of activity to determine the type of study. Often the act of defining the distribution helps the resident to understand the kind of study.

Also, scan the images for any identifying information. If it is an ultrasound, it will often tell you which organ you are looking at. I have found it can become difficult to tell the testes, ovaries, and kidneys apart on a single image. Usually, the ultrasound technologist labels these studies so you can differentiate among the options.

Finally, make sure to look at the top of the film to see if you can find the patient’s age and sex. This information can also further help you to hone in upon the correct differential diagnosis.

Describing The Findings

This part of the oral case is when the newer residents fall short compared to residents studying to take the oral boards. Residents tend to stop very quickly at the description part of the puzzle and then enter rapidly into a differential diagnosis. Often, a poor quick description leads to a poor differential diagnosis. Again, you need to take your time to describe all the salient points.

So, what should you include in this part of the case? Always describe the location, the size, the intensity (if nuclear medicine), the shape, the density, and borders. Describe its effect upon adjacent structures. Make sure to use buzzwords if available. If you see an angry-looking mass on a CT scan that looks like a star, you may want to use the words spiculated or stellate. If a lesion enhances with rim nodularity and fills in from the edge to the center, use peripheral nodular enhancement with centripetal filling. These buzzwords connote certain types of differentials in the minds of the radiologist listeners. They provide information on the kind of disease entity even before going through a differential diagnosis.

Finally, don’t get happy eye syndrome. Look for other findings that may support or refute your differential diagnosis. I can’t tell you how many times a resident will stare at one section of the film to forget to look at the rest of the images or film. He loses the forest for the trees.

Concise Relevant Differential Diagnoses

A novice and more seasoned resident starkly differ when they give a concise and relevant differential diagnosis. The beginner will have no idea what to say. Or, she will continue to drone on about multiple different possibilities for the final diagnosis. She does not even differentiate between the zebra and the most common diagnosis.

Again, take your time before speaking. Before even starting this process, you should go through broad categories of differential diagnosis in your mind. Is it neoplasm, infection, inflammation, iatrogenic, congenital, etc.? When you have come up mentally with some reasonable possibilities, make sure to talk about no more than three etiologies of the most likely diagnoses. And start with the most feasible and then go down to the least likely. This process will allow you to speak logically. Also, it will enable you to show that you have thought about the differential analytically.

What Next For The Patient?

Three options exist for the further management of the case after you have completed the basics of determining the findings and differential diagnosis. The first possibility: the patient needs no further workup, and you have made a final diagnosis. One example would be an adrenal nodule with a Hounsfield unit of 2. This finding is consistent with an adrenal adenoma—end of story. No further workup is needed.

Alternatively, it may be imperative that you need another step to work up the case. For instance, if you need to determine the matrix of an aggressive osseous lesion on a musculoskeletal MRI without a final diagnosis, make sure to recommend a plain film. Otherwise, you may never determine the final disposition of the patient.

And lastly, you may find a lesion with low clinical significance but needs to be followed over time. This category includes the small lung nodule or the nonaggressive indeterminate liver lesion.

You can almost always categorize your case into one of these three groups. And, it will show that you thought about the ramifications of the imaging upon the clinical picture of the patient.

Final Thoughts: Taking Oral Cases Should Be Fun!!

Taking oral imaging cases should not be a difficult or embarrassing process. It should become something that you should look forward to, building your confidence and becoming a better radiologist. It sums up the essential ingredients needed to make an excellent radiologist: the ability to make the findings, synthesize the data, develop an outcome, and communicate the clinician’s results.

Unfortunately, in many programs, the radiologist just expects you to know how to take an oral case despite not having been taught the process. If so, now you have a framework of the fundamentals of how to take a case outlined above. Like anything else, being adept at taking oral cases is simply a matter of practice and knowing the process. Once you have the process down and the base knowledge, you can more easily build upon your abilities and become better and better over time. You, too, can become a star at taking cases!!!

 

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Radiology Residency Night Float Vs. Standard Call- A Perpetual Controversy!!!

night float

Blurry vision setting in; eyelids drooping just wanting to shut; difficulty communicating; and impending malaise. Rarely would I have any chance whatsoever to lay my head down even once. The films would keep on streaming in. These feelings were typical on that first night of call on a 1 or 2 weeknight float rotation block or the occasional Saturday overnight calls that we would have to do every once in a while. I dreaded those days. But, it is still standard for many radiology residency programs. It is almost impossible not to have at least a few overnight shifts like the ones I just described.

At one point or another, many radiology programs and residents have come up with different schedules and options to minimize this extreme fatigue. Some have instituted night float schedules. Others maintain a standard rotating call schedule Q4,5, or 6. Some have long and short call schedules.

The choice to do one system or another is not so clear-cut. Programs have many considerations before deciding to have either of these systems before implementation. Although I tend to favor the night float system since I remember it mitigated fatigue after the initial day or two of calls when taking overnights, the decision to have a night float program is probably unsuitable for all programs.

So what factors would lead one program to have a night float system and another to have a standard call system? Some of the issues we need to address are the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies, and emergency department requests. I will also review each system’s disadvantages and advantages, allowing a program to decide which approach is best.

Factors For Instituting A Night Float Coverage System

 

Size of the Program

The smaller the program is, the less likely there will be adequate coverage for rotations during the daytime, let alone the nighttime. In fact, at many programs, a small residency cohort prevents the institution of a night float system. In a program with three or fewer residents per year, it may not be possible to have a resident out every night to be on call without severely compromising resident education. Also, many programs cannot cover daytime obligations without a night float system.

Attending Coverage

Institutions with attending nighthawk coverage at nighttime allow more flexibility for scheduling of night float. Some programs do not need full-time resident coverage during the nights and may share call obligations with the attending. Therefore, it is significantly easier to institute a night float system for the residency program.

Resident Preferences/Culture

In some residencies, the radiology residents have instituted a night coverage system because of the preferences of the individual residents. Many residents have fully invested in a given scenario. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or fewer calls than they would have in the old system. So, the night coverage system becomes engrained into the fabric of the residency program.

Also, the program director may set up this schedule to accommodate specific residency daytime programs. A nighttime schedule may allow the resident to maximize daytime educational opportunities. For some programs, that may mean either a standard cyclical call schedule, and for other programs, it may mean a night float schedule.

Program Director/Chairman Preferences/Department Culture

In many programs, the leaders may institute nighttime coverage based on their preferences. The program director or chairperson may believe a night float system or standard call schedule may be better for a residency program. Or, perhaps there are coverage requirements that the department desires. In either case, the decision is not up to the residents.

Number of Studies

Perhaps you are in a residency program that is a level 1 trauma center with significant numbers of ER studies at night time. Some programs are so busy that they may need more than one resident or attending on-call each evening. This factor may allow less flexibility in scheduling a night float system since a program may not be able to accommodate the call coverage at nighttime.

Emergency Department Factors

Emergency departments may have specific requirements for radiology coverage at nighttime. Some programs may only want to have senior residents take call. Others specifically want attendings to cover during the evening. Depending upon the demands of the emergency department, this may dictate the numbers, type, and presence of residents or attendings on call. A night float system or standard call system may reflect the whims of the emergency department.

 

Advantages/Disadvantages of Night Float And Standard Call

Night float

Most people think night float coverage for a week or two mitigates fatigue the most. The body tends to get used to the nighttime schedule over time, allowing the resident to function better on call. Sure, the first few days can be challenging because the body and mind have to adjust. But overall, the experience is much improved.

On the other hand, when you are on a night float system, the resident may lose touch with the “educational” aspects of the residency program. You miss daytime lectures, conferences, and attending readouts for long periods. While the time spent on night float is essential for training, receiving all the benefits of daytime resident education is impossible. You may lose out on understanding the context of the images you interpret. Education, in this sense, may also be compromised.

Standard Call

Sometimes a Q4, 5, or 6-day call schedule integrates better with a program than a night float system, allowing the resident a better overall experience. The resident does not miss all the noon conferences and educational experiences they would miss over a long block on a night float.

The two significant disadvantages to the cyclical call schedule are overnight fatigue and the “lost day.” As I mentioned, I always found it much more taxing to have an occasional overnight than a night float block because my body never adjusted to the system, just like most residents. In addition, the resident loses an extra day of residency experience every time they work because they are obligated to have a day off afterward, “the post-call day.” This loss can significantly decrease the educational opportunities for the resident.

 

Residency Call- Night Float or Overnight Calls?

Nighttime call is a crucial facet of every radiologist’s education. Whether or not you have a say in constructing your program’s night coverage system, you now realize that what works for one program may not work for yours. The decision to have one or another method can be complex, but it is important to weigh each of the factors to come up with an outcome. The key is to make the learning opportunity pleasant and mitigate fatigue. Hopefully, your residency has chosen your institution’s most appropriate night coverage system!

 

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Best Radiology Electives for the Senior Resident

radiology electives

It’s getting toward the end of your 3rd year, and you are studying intensely for your core examination. All of a sudden, you get a phone call from your chief resident. He says, ” We are making the schedule for next year. What would you like to do for your senior year radiology electives?” You realize you haven’t thought this through, and you are not sure what to do. He just assigns you to a standard fourth-year schedule.

Believe it or not, this is a situation that often happens to most residents. Choosing your fourth-year electives is not a decision you should take lightly. You should not have the choice made for you, nor should you choose without thinking deeply about what you want. Your senior year elective decisions can have repercussions upon your comfort zones in private practice. This decision can also influence your practice patterns for years to come. Today, we will discuss what not to do when you decide upon your senior schedule, which standard rotations are the best for senior electives, and finally, some innovative ideas for creating rotations on your fourth-year schedule that will really enhance your residency education and your career.

Which Fourth Year Radiology Electives Should You Avoid?

Don’t Repeat Your Fellowship!

When you create a schedule for your fourth year, I recommend avoiding adding scheduled rotations that duplicate your fellowship. Several times, residents have requested six months in mammography when they have already signed up for a mammography fellowship. What’s the point in that? In most residency programs throughout the country, 90 percent of residents eventually do private practice. And, only 10 percent work in academia. So, chances are you will not be working only within your specialty. In fact, according to many articles (1,2,3), most radiology job descriptions want the new radiologist to not only practice in one subspecialty but also to cover other areas within radiology. So, if you decide to do a half year in your fellowship’s subspecialty, you are also decreasing the opportunity to learn subspecialties outside of your comfort zone. And, you are also reducing your desirability for being hired by a private practice.

For instance, if there are two candidates, one who wants only mammography work and another that feels comfortable reading MSK MRI and being sub-specialized in mammography, which candidate will be chosen by a private practice? It’s relatively simple. It’s almost always the one that can do both. You are missing out on a potential opportunity if you choose to duplicate your fellowship.

Avoid What You Already Know

I would also avoid choosing fellowships that are within your comfort zone. If you feel like you know MSK MRI well, it doesn’t make sense to do half the senior year in the same subspecialty. In private practice, you generally do not want to pigeonhole yourself into only a few areas of a subspecialty. A series of fourth-year electives or “mini-fellowships” in only subspecialties that you are well-versed in will limit your ability to learn other subjects and ultimately prevent you from being comfortable in these modalities after you complete a residency.

The Conventional Fourth Year Elective Approach

If you are going down the conventional route of fourth-year electives, there are two routes I would choose. First, it would be reasonable to select an emphasis in an area that you are interested but in which you are not doing your fellowship. Since you will be completing these electives reasonably close in time to looking for full-time radiologist work, you will have a second area of subspecialty confidence and diversify your competencies when looking for a job.

Second, I would choose electives in areas of weakness. Residency is the time to get to know the different subspecialties and get your hands dirty. The more competent you are in all aspects of radiology, the more desirable you will be for private practices. It behooves the budding radiologist to get to the point of basic competency in as many areas as possible.

The Unconventional Fourth Year Elective Choice

What is the difference between a good and a great radiologist? It’s pretty simple. A good radiologist can generally make the correct imaging calls. A great radiologist can make the right call, understand the call’s deep clinical significance, and predict the subsequent patient outcomes. If I had to redo my residency again, I would choose the unconventional radiology elective approach.  Why? Because correlating imaging with the practical deepens these great clinical radiology qualities.

So, how do you arrange an elective choice such as this? It definitely will take a bit more work on the part of the radiology resident, and you will have to go out of your way to communicate with other specialty directors. Still, it pays to arrange a few weeks or a month rotating on a medical or surgical rotation with correlative imaging.

Example Of The Unconventional Elective Choice

For example, if you are interested in musculoskeletal radiology, I would highly recommend calling the surgical director of orthopedics and ask him/her if you can watch and participate in the clinical workup of patients, orthopedic surgeries, and the subsequent follow-up of patients. Then, when you work up a patient with a medial meniscal tear, you will have seen the surgery and the after-care follow-up of these patients. You will understand how the imaging fits into the equation and the significance of your imaging calls. The learning that you achieve will stick with you for the rest of your radiology career.

I would also recommend washing, rinsing, and repeating. If you can arrange this elective in multiple subspecialties, in whatever specialty area interests you, it would be a highly effective way to have a tremendous diverse overall fourth-year experience that will last a lifetime. Also, you will have clinical knowledge of the imaged patient that most other radiologists do not have.

Final Thoughts About Fourth Year Radiology Electives

The fourth year of radiology residency is a time to explore in more depth the subspecialties that you have encountered during your first three years. Because you are so close to becoming a board-certified practicing radiologist, fourth-year radiology electives take on a vital significance where the learned subjects will make a difference in your clinical practice. So, please pay attention to creating a tremendous fourth-year elective experience. Don’t squander the opportunity!!!

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The Other Struggling Radiology Residents

struggling radiology residents

A radiology residency program is like a family. When one person is afflicted academically or professionally, all of its members suffer down the road. Just as important as it is to be aware of and help the struggling radiology resident, it is also important to remember that one struggling resident can have severe repercussions for the remainder of the radiology residency program. It is not just the program director and chairman that reap the consequences of the struggling resident. Often unfairly, the class members take up much of the additional burden. The result be extra call shifts, less time spent on educational rotations, uncomfortable personality conflicts, or spare time spent educating the failing resident. So, I am dedicating this post to the other radiology residents affected by the struggling radiology resident. First, we will explore how other residents can appropriately identify and help the struggling resident and possibly get this person to the program director’s attention. Then we will go through what a resident should and should not do when a resident is academically or professionally struggling. And finally, we will examine how the residency program should commit its resources toward the struggling resident vs. the other radiology residents.

 

Identification of Struggling Residents by Colleagues

Often, the first residency program members to notice that a resident is struggling are not the program director, chairman, or attendings. Instead, it may be the struggling resident’s colleagues. Fellow residents are more likely to interact with struggling residents socially in a more comfortable setting. Here, the struggling resident is more likely to discuss his/her issues. This interaction is an opportunity to learn more about your classmates’ feelings about residency. They may even ask for your help. My advice is to give your classmate whatever assistance is reasonable so they can perform well. Residency is not a competition; it is a team environment. In addition, the help you give your fellow struggling resident will return to you many times. Whether you decide to teach your colleague or help them out with other residency issues, you will find that you will learn more about your material and yourself. Even better, you may be able to stem a progressive downward spiral to probation. Or, even better, prevent your classmates from suffering more dire consequences.

How To Identify The Resident

Sometimes the identification of the struggling resident is a bit more subtle than a simple comment about their struggles. Unlike an attending that sees a resident on a noon conference or a single day, you, as a fellow resident, may notice a pattern of taking cases and missing all the findings each time or multiple absences not recorded by the program. Or you may see bad habits such as drinking too much, something a little bit off, or a strange affect. These signs can be essential sentinel events. And you may want to address the issue with your program faculty to ensure the struggling resident gets the help they need.

In the end, it pays to identify the struggling resident. Remember, it often affects not just that resident but the entire program.

How Can The Residents Help With The Academically Struggling Resident?

The program directors, attendings, and chairman are primarily responsible for handling the academically struggling radiology residents. But, for the struggling resident’s rehabilitation to succeed, the program often needs to have the participation of all. The role of the other residents can be the key to the stability of the program through this trying time as well as increasing the likelihood that the struggling resident will eventually succeed.

Before any remediation, it is critical to determine if the struggling resident is willing to accept the help of the other program members. So, the role of the other residents can only begin when the struggling resident asks for help from their colleagues. You certainly cannot force a struggling resident to participate in remediation efforts if the struggling resident is unwilling or able.

Interventions To Help Academically

If you remember the previous article- The Struggling Radiology Resident, we discussed how the academically struggling radiology resident might have difficulty coping with the quantity or quality of their work. So, I will briefly review how the other residents should attend to these issues.

What should their colleagues do for a struggling resident who cannot schedule an appropriate time for studying? This dilemma becomes a time management issue. It would be fair to help the struggling resident to create a schedule for themselves. Sometimes it helps to sit down with the struggling resident and show them how you schedule your study time and what you have been reading on each rotation.

For a struggling resident with difficulty with the quality of study time, it would make sense to have group study time and present cases to one another to improve their presentation when reviewing studies. Or, it may be a good idea to go over questions with all the residents to practice testing skills. These processes help the struggling resident and may be good practice for the team.

How Can The Residents Help With The Professionally Struggling Resident?

Regarding a professionally struggling resident, fellow residents must be more careful with assisting in interventions. The intervention will depend on the primary cause of professionalism problems.

The Absent Resident

For the resident that is often absent, it may be possible to address this issue by asking the resident where they have been or why they have not been around in a non-confrontational manner. Sometimes the struggling resident may not be aware of the burden they are placing on the other residents. This interaction may make this resident aware of the issues he is causing and take responsibility for his actions. Again, if this does not work, bringing the matter to the program’s attention may just be as essential.

The Personality Dilemma

You must be more careful with the resident with personality issues, whether an abusive or unengaged resident. If you are friendly with this resident, it may pay to find out the cause of the behavior. But be careful not to be overly intrusive, as getting involved much further may be inappropriate. Indeed, if the struggling resident is amenable to helpful suggestions for conflict resolution within the residency, talk to this person about some of these issues in an appropriate setting. Or, it may be relevant to suggest this resident seek professional help if the resident is amenable.

In many programs, some struggling residents will experience psychiatric issues just like the general population. Or, they may get involved with alcohol or illicit drug use. These situations can be extremely touchy. Many of these residents may not have insight into their problems. And, they are likelier to refuse help from colleagues or attendings. Of course, a few may have an understanding. But, if you notice a struggling resident with one of these issues, it is usually best to bring the issue to the attention of the program director or chairperson of the department so that they can get the resident into the appropriate channels for treatment. Of course, there are exceptions to every rule. And occasionally, the struggling resident’s colleagues may have intimate knowledge of the resident. Therefore, they may be more likely to be able to get the resident appropriate help. But, be careful in this situation because there can occasionally be unforeseen legal and professional ramifications to the caring colleague. A resident without insight into their problems may see this helpful resident as antagonistic and can theoretically pursue these channels.

How to Commit the Program’s Resources

Over my tenure as associate residency director, I have learned that dealing with struggling radiology residents’ issues can drain a program’s administration and resources. The time you usually spend toward improving the residency program instead needs to be placed on the problems of the one resident. Especially in smaller programs with less faculty and monetary resources, the extra time can overwhelm the program directors, chairperson, and heads of Graduate Medical Education. While the struggling resident must get the necessary help and remediation, we have to remember that other residents also need to have a functional residency program. It is easy to forget about the other residents in this process. So, it is the residency director and chairman’s role to place additional efforts to concentrate on not just the struggling resident but the other residents at these times and to ensure the residency program continues running smoothly.

Back To The Other Residents

Every program, at one time or another, will have struggling radiology residents. And fellow resident colleagues need to help out, if possible, with identifying and remedying the struggling resident. But, the other residents often suffer the most from the consequences of a struggling resident’s actions. And the residents can be hurt by the administration’s choices to help the struggling resident. So, everyone involved needs to make a concerted effort not to forget about the struggling resident’s colleagues. Or else, these residents can truly become the “other struggling residents.”

 

 

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The Struggling Radiology Resident

struggling

In any profession or career, some employees lag the performance of their peers. It turns out that radiology residency is no different from any other job in this respect. The key, however, is that the employer can identify the struggling worker or that the employee can recognize that he or she is struggling. It is only when this process happens that interventions can occur. Also, this process of identification needs to be early and effective. The radiology program’s goal is to help these residents along as soon as possible to allow rapid and more effective remediation. Early remediation can prevent a struggling resident’s further downward spiral that could lead to probation, suspension, or even worse, job loss. On occasion, there is no effective remediation for specific individuals, but that is instead the exception rather than the rule.

No matter how you slice it, the loss of a resident is devastating for both the radiology program and the radiology resident alike. So, my goal for today’s discussion is to help the individual struggling radiology resident and prevent him from going down this pathway. We will discuss how to identify oneself as struggling, what you can do to intervene before more severe repercussions, and how to deal with your attendings and colleagues when you are the “struggling resident.”

Self Identification

As is said, you cannot fix a problem unless you know a problem exists. So, self-identification of oneself as struggling becomes crucial. Some residents know from the very beginning that they are having difficulties and have good insight into their situation. Others may be having challenges but are not aware. Additionally, sometimes the feedback that residents get from attendings, technologists, nurses, and administrators can be different from the truth and outright misleading. Given that radiology residents tend to have limited responsibilities during their first year of residency, this issue is more likely to go unnoticed during this first formative year of residency. So, we will first talk briefly about some indicators that you are struggling during residency.

I will also classify the reasons for the struggling resident as either academic or professional, to simplify and organize the discussion. Let’s first start by discussing some of the indicators that a resident may be struggling in academics.

How to Know If You Are Struggling Academically

Noon Conference and Readouts

Noon conference can be an excellent time to discover your position relative to your colleagues. If you notice that you are unable to answer questions that your colleagues quickly answer consistently, that can be a red flag. If you have a hard time describing or making a finding on studies geared to the first-year resident, you may be struggling. Or, if different attendings become consistently frustrated with your answers while giving the noon conference, you may want to consider that you are having difficulties.

Readouts with your attending may help to determine whether you are struggling. Are you able to answer routine questions appropriately? Is an attending that typically accepts resident dictations re-dictating everything you write? Is your supervisor frustrated with you? Do your attendings provide you with some sense of independence during procedures similar to others in your program? These are some hints that all may not be quite right.

Call

Next, think about your experiences on “buddy call.” Do you feel comfortable going over films with your colleagues, attendings, and other clinicians? Is there a sense of frustration from these people with your reads? Are attendings not satisfied when they find out they are on call with you?

Feedback and Exams

How about feedback and evaluations? Is the feedback you receive from attendings routinely negative. Are milestone evaluations always below par? Do you receive comments from attendings that are uniformly negative?

You might think that the in-service exam or Radexam would also be a useful metric of resident performance. It turns out that as an associate program director, I put much less faith in academic evaluations based upon the in-service examination as a sole means of assessment. I have found a weak correlation with resident academic performance. So as a resident, I would put less stake in this form of self-assessment. However, in combination with the in-service exam, if you are underperforming in other residency-based quizzes or examinations, this can be an indicator of real academic issues.

How to Know If You Are Struggling Professionally

This area can be harder to recognize for a struggling resident. Many don’t realize they have a problem until it’s too late. But, we will go through some examples that you may be able to self-identify.

Absences

Absences, in its many forms, is a leading indicator of professionalism based struggles. Are you routinely late to conferences and readouts, and do you sense the frustration in others? Do your colleagues too often have to cover for you because you are not available? Have you been cited multiple times for missing conferences or required meetings?

Conflicts

Conflicts with classmates and colleagues can be an indicator of professionalism struggles. Are there routine yelling matches with your fellow residents? Do your colleagues not want to help you out with call coverage, studying, or other everyday residency issues? Are you routinely fighting with the secretaries, nurses, technologists, or even attendings?

Substance abuse

Substance abuse is all too common a cause for having a problematic residency. Take a serious look at your habits and if they may be genuinely affecting your performance. Are you routinely using alcohol or other illicit substances?

Organic causes

Chronic disease can be a cause of day to day residency struggles. Cancer, hepatitis, infectious diseases are all problems that can cause fatigue and difficulty with concentrating on a long shift.

And of course, there are psychological issues such as depression, anxiety, schizophrenia, and more. These issues are more likely to go unnoticed by the afflicted resident. But some residents, already diagnosed with these disorders, may have better insight. These residents need to take a hard look and see if these problems are affecting their residency performance.

Self-interventions

The next step in the process is to figure out how to remedy the situation before more significant repercussions. If you know your issues are academic or professional, you can certainly take measures to stem the riptide. We will go through several of these avenues.

You’ve decided that you are struggling academically. What do you do? The next step is taking a realistic assessment of why you are having difficulties. For some people, it may be the quantity, and for others, it may be the quality of their studies.

Quantity of Learning

Having been through the residency process and supervising many residents over the years, I have learned that radiology is a reading-intensive specialty. Moreover, to increase one’s knowledge base, a resident needs to create a means to cover all the essential and relevant topics within the residency program. So, the first question is: on what do you base your study schedule? Some residents will use the curriculum guidelines from their residency program. Others will split the ABR core exam topics into bits of information that they can review. Even others may use STATDx/Radprimer to guide their studying. The bottom line is that you need to find some guidelines that will allow you to cover all the topics that you need to know.

The second question: have you created a schedule that allows you to cover the critical topics during residency. And what are some options for the resident? Many residents don’t realize the amount they need to learn to become a proficient radiologist. A schedule, therefore, becomes very important for the struggling resident. Plans can vary from one person to the next. Some people do better with studying for short blocks of time. Others prefer to slog it out for a long block at once. It doesn’t matter how you complete the necessary work, whether you take 2,3, or 4 topics per evening, but the work needs to get finished. A regimented schedule will allow you to get through the appropriate information for each rotation.

Quality of Learning

The next step is to assess if it is how you are studying, that is the problem. Some residents read for hours every night, only to find that their knowledge base is not to par. You would think that by the time one gets into the radiology specialty, they would have a method for studying well. But, that is indeed not the case for many residents. Studying and reading for the radiology resident is different from studying for medical school classes and the boards. Radiology emphasizes pictures. Medical schools emphasize words.

So, if you are genuinely studying for hours at nighttime without meaningful results, try learning differently. I would recommend emphasizing reading the pictures and captions within a book over the general text. Many residents do not realize they need to do this to be a more effective radiology student.

Pictures/Case Series

You may also want to explore case review series over general text reading. Again pictures are the center of the radiologist’s world. I find that a general text helps more when you have experienced a case firsthand during the daytime and want to find out more. On the other hand, a case image with text is more similar to the radiologist’s day-to-day work and will allow many residents to digest the information better.

Discovering Learning Disabilities

There is one last item that I want to bring to light. On occasion, a radiology residency may make a learning disability evident. Because radiology is different from other subspecialties and the methods for studying differ from other areas, some residents have problems with the transition. Some residents have issues looking at a picture and translating it into findings and conclusions. Radiologists do not usually test for this before beginning radiology. If you think that this may be your situation, it behooves these residents to consider psychological testing to find a more effective means of studying. Dollars spent to solve this issue now if you do have a learning disability may pay back itself in spades later on.

Fixing Professionalism

Professional issues and their solutions can vary widely. It may be as simple for the absentee resident as creating and sticking to a schedule to make sure you attend all the important events on time. If you are in constant conflict with your colleagues, you may need to learn to relate to others better, and that may involve sharing more or not taking everything to heart. On the other hand, maybe the conflicts are connected to other pressing issues such as substance abuse or health problems.

The critical thing to remember: there are many sources of help for the radiology resident. Whether it’s your colleagues, attendings, program directors, chairman, the Physician Assistance Program, a psychiatrist, or other individuals, there is someone at your program that can support you. It is crucial to talk to someone if there is a professionalism issue that you need to address. And, there is always help if the situation becomes unbearable.

How to Deal With Attendings and Colleagues If You Are Struggling

OK. So you have identified that you are struggling, and you have created the means to remedy the issues effectively. The next problem is that you may have created an environment where your colleagues’ expectations are so low that it may be challenging to defy their expectations. I like to describe this as the “vicious circle.” Your faculty will now scrutinize everything that you do, much more so than your colleagues. And, even though your performance may improve, they may not recognize the improvement. Unfortunately, they may still perceive you as below par. This “vicious circle” is probably the most challenging part of being an underperforming resident. So, what do you do at this point?

I would recommend continuing with the remediation program at hand. Healing a reputation takes not a few days or months. Instead, it can take years. Eventually, your effort will be recognized, but not without a lot of work and effort. You will have to suffer through some of your attendings and colleagues’ expectations until they realize you are a capable resident. This process takes grit and determination. You are going to have to ignore the expectations of others and create expectations for yourself. Eventually, you will notice a change in how they treat you, but remember, it will not happen overnight.

Summary

Radiology residency is a big transition for most residents, and some may struggle at the beginning academically or professionally. If you are struggling at this time in your life, don’t let these shortcomings define you. The measure of greatness is overcoming obstacles such as completing a radiology residency, a significant achievement. Struggling radiology residents often become radiology attendings with greater empathy for others’ struggles and can become the most successful radiologists!

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Radiology Moonlighting: A Taboo?

moonlighting

Rarely do chairmen and radiology program directors in academia utter the word “moonlighting” to their radiology residents, fellows, and employed attendings. Yet, moonlighting is a mainstay for many neophyte and seasoned radiologists. Why is the subject so taboo? Academic stakeholders want to know that their residents and practicing physicians dedicate themselves entirely to their primary responsibilities as learners and their duties at their daily jobs. To these stakeholders, moonlighting implies that their workers work toward other endeavors that may “interfere” with their primary roles. Concerns such as duty hours and sleepiness during the day job can arise. Even worse, the stakeholders perceive these workers to be competing with their primary business.

Why You Should Consider Moonlighting

But I would like to argue against both of these notions. First, it is unusual that the worker moonlights more than she can handle. Of course, anything taken to an extreme can harm the practitioner. Too much sugar causes tooth decay. Too much water causes hyponatremia. And, too much moonlighting can theoretically distract from the day job or training. However, it turns out that this impression is a widely perceived misconception.

I harken back to my days as a radiology resident and fellow. As a resident, I remember reading CT scans in a quiet room in the evening next to the CT technologist’s workstation. I would preliminarily provide initial interpretations by fax to satisfy the demands of the ER physician and provide coverage that would otherwise would ordinarily not be available. Also, I would rapidly scan the plain films that attendings left from the afternoon shift. We made sure no impending disasters lurked in the morning as we searched for occult pneumothoraces, free air, pneumatosis, portal venous gas, and more.

Instead of interfering with my role as a radiology resident at the time, I found the experience to allow me to read more quickly and accurately. It supplemented my day job and, subsequently, my career. My moonlighting enhanced my performance during my daytime residency position. We can only achieve skills such as rapidly and accurately reading films by having had the experience to do so. Moonlighting experience easily fits the bill.

Second, you will perform most moonlighting gigs at a subsidiary of the primary institution or a local group. Usually, these opportunities may require temporary coverage due to staffing needs. It would be undoubtedly unusual for a moonlighter to “poach” cases from their primary residency program or day job.

Discordant Views Of Moonlighting- Academics Vs. Private Practice 

Even more interesting, practices consider moonlighting a badge of honor for the applicant to private practices, one he can display to his future employers. And, concordant with this view, the typical private practice employer considers moonlighting an asset. When interviewing for private practice jobs, the stakeholders would specifically ask if I had done any moonlighting. For these private practice stakeholders, moonlighting implies that the trainee has the experience and wherewithal to handle the daily pressures of a bustling private radiology practice. The typical skeptical chairmen and residency director’s impressions of moonlighting differ from this view.

Given the importance of moonlighting for a budding radiologist from both a training and future employment perspective, program directors should actively discuss the topic instead of suppressing the information. Therefore, for the rest of this discussion, I will discuss where to find exceptional moonlighting experiences, what to avoid, what you need to do before obtaining your first gigs.

Where Do I Find Moonlighting Opportunities?

First of all, if you are fortunate enough to have a moonlighting opportunity embedded in your residency or fellowship program that the institution supports, I would say this is the best situation. You don’t have to worry about “stepping on anyone’s toes.” And, your institution will likely already insure you for the task. These opportunities are the simplest and best for the trainee.

I am aware, however, that many programs do not have these opportunities on hand. So, I would recommend you ask either former or current residents and fellows about the options in the area. When you interview for your fellowship, make sure to get the phone number or email of the current fellows. Ask them if they moonlight and what exactly they do. Usually, the current trainees know the local environment for moonlighting the best.

Let’s say, however, the current residents or fellows are not moonlighting. What else could you do? You may want to call the local groups and find out if they have any temporary staffing needs. The local group may often need a warm body to “babysit” a magnet or give preliminary reads in the evening. This moonlighting experience would be your opportunity…

Lastly, if all else fails, you may want to either search employment websites or ask a locums company to help you to find moonlighting opportunities. I would reserve this option for last because the companies that use these agencies charge a fee that may lower your pay rate.

What Moonlighting Experiences Should I Avoid?

In the recent past, residents would finish their residency training, take and pass their oral boards. Subsequently, they would be board certified in radiology. No longer is this the case. This fact leads to some new technical issues with moonlighting as a fellow. In the past, I would have said, by all means, go ahead and give final reads as a moonlighting fellow. Instead, as a typical radiology resident or fellow, I would consider reserving final reads until after you have passed your boards. Find moonlighting opportunities to give preliminary reads or work for a senior attending that is ultimately responsible for the final readings.

Why do I feel this way? Well, if you miss a finding and it goes to court, legally, you may have a more challenging time defending your miss. If the plaintiff’s attorney asks you if you were board certified at the time of the reading of the study and you say no, they can theoretically question your judgment at the time of the interpretation.

It is also essential to check that your malpractice insurance for your residency or fellowship is compatible with the moonlighting site. If not, you should obtain the correct insurance, or the opportunity should be off-limits for the prospective candidate. If you provide final reads for a practice or don’t have an occurrence policy, you should consider tail insurance.

Also, make sure you do not commit too much time to the moonlighting job. As discussed before, you certainly don’t want your moonlighting to interfere with your day job.

What Do I Need To Do Before Moonlighting?

1. Months before the prospect of moonlighting, it would help if you started getting the prep work done. The first thing to consider, make sure you get all the necessary state licenses that you may need. It can take a lot longer than thought to get a state medical license. Have all that paperwork ready.

2. Keep your CPR and ACLS certifications up to date. Some opportunities require the applicant to have satisfied this requirement.

3. Before accepting any offer, make sure you feel comfortable with the requirements of the job. If they need someone to overread MSK MRI and do not have experience with this, it is probably not the best situation. Be thorough when you ask the employers about what they require.

4. Let your residency or fellowship program know that you are going to be moonlighting. The program needs to record your hours worked “off-campus” as part of the duty requirements of the ACGME. If the program catches you working too many hours, the ACGME can penalize the program. It’s probably not worth the risk of jeopardizing your residency or fellowship.

5. Once you have pinpointed the opportunity, you need to make sure your malpractice insurance covers the employment opportunity. Also, you must proceed rapidly with hospital credentialing as this process can be very time-consuming. Hospital credentialing also includes sending off the malpractice insurance information to the hospital medical staff office.

Summary

Moonlighting can be a fantastic experience that supplements your residency and fellowship education. It can enhance your prospects for future employment, can allow you to gain speed and confidence at your daytime job, and let you more rapidly pay down your student debts. I highly recommend moonlighting if the opportunity is available, you are so inclined, and it is allowed by your residency or fellowship program.

Good references/links to find out more about moonlighting

Moonlighting for Extra Money: Tempting, but Watch Out

Radiology resident moonlighting: A necessary evil?

 

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My First Real Radiology Job- Do I Want Partnership?

partnership

Every once in a while, a resident or fellow will ask me, “Should I take a partnership track versus an employed position?” Or, “What questions should I ask about partnership when I interview for a job?”. These can be somewhat tricky questions to answer since there are so many variables involved. I will tackle some of these issues here. I will also answer some common questions and clarify some misconceptions.

To make this post somewhat structured, I will first talk about the features of employed positions and ownership/partnership track positions. Then, I will determine whether it makes sense to be a permanent employee or on a partnership track. Finally, I will elaborate on the questions you should ask if you are fortunate (or unfortunate) to be placed on a partnership track. So, let’s begin…

To Be Or Not To Be– A Partner!!!

What are the initial differences between jobs that are permanent employee versus partnership tack positions? First of all, no hard and fast rules exist. Some employed roles have features of partnerships, and others have characteristics of employed positions. For the sake of simplicity, I will ignore these nuances and instead talk about the general features of each type of employment situation. You can further determine how the different components of your particular job offer apply to you.

Employed Positions

Basic Issues

Most practices pay employees a fixed salary that makes up the majority of their income. Some employees also may receive a production bonus of some sort, but it tends to be a small percentage of the salary. Starting salaries of employed positions tend to be higher than partnership track positions at the beginning. But, they remain more stable or gradually drift higher for many years to come. If the partnership or practice has a “banner” year, you will likely still get the same negotiated salary regardless of its profitability.

They also tend to be at the mercy of the employing body, whether a hospital system, partnership, or corporate entity. In general, employees have less control over their situation. Employers make the business decisions. If you don’t like the technologist, nurse, or administrator in your practice, you will still have to live with that person. You may not be able to change your PACS system or to set your protocols. Bottom line. You are at the whim of your employers.

Defined Written Responsibilities

Also, in general, employed positions usually have particular sets of responsibilities written in the contract. If you perform a duty that lies outside the realm of your negotiated deal, the practice does not require you to accomplish that task unless your employer pays for it. Being an employee allows you to concentrate on radiology without dealing with the day to day issues of running a practice.

For instance, you don’t have to worry about hiring, firing, buying magnets, billing, capitalizing on radiology trends, attending hospital events, and more. A lot goes into the management of a practice that is not related to day to day radiology. And as an employee, you will likely be a lot less responsible for these activities. But everything comes with a price. You are selling your ability to control the entity for which you are working.

Risks of A Private Equity Buyout

And most importantly, for some, practices treat employees very differently when there are significant changes. In today’s rapidly changing practice environment, groups are merging; hospitals are buying out imaging centers; large corporations are taking over smaller entities. When a significant event such as this occurs, the employee usually does not benefit as the practice’s employer will. Typically, when a radiology practice is “bought out,” the partners or employers will get a large sum of money to pay for the accounts receivable, equipment, real estate, goodwill, and so on/so forth. On the other hand, the employee will typically get nothing. Or even worse, the employee will be the first to be fired if there is a business restructuring.

Partnership Track Positions

Partnership track positions usually pay a lower amount at the beginning than an employed position until you make a “partner.” A partnership track employee can make a substantially different income than a permanent employee. Many starting radiologists do not understand this concept, but it makes a lot of sense. You are paying for the equity/ownership of the partnership in two ways.

Sweat equity

First, there is a concept called “sweat equity.” “Sweat equity’ is essentially a time commitment. This process can last almost any time interval. Most practices have a partnership track period that can last anywhere from almost immediately (in the early 2000s, I knew one fellow offered immediate partnership before finishing fellowship!) to 10 years.

Time to partnership varies depending on multiple factors. First and foremost, these include location. The more desirable the area, the more competitive the partnership spots. And, the more years to partner the practice will charge the partnership track radiologist. Additionally, the time to partnership can be longer if you own equipment, real estate, and other assets. That makes sense because to pay for that share in the partnership, you need to put in more “sweat equity.” Finally, market conditions also affect time until a partnership. Suppose numerous radiologists are looking for partnership positions. In that case, the practice will charge a more extended period of “sweat equity” because of the high demand for a job and willingness of the partnership track position “to pay” for it.

Buy-ins

Second, many practices expect the partnership track employees to buy-in monetarily to the radiology business at the end of the partnership track term. This buy-in may be related to the accounts receivable and the owned assets of the practice. Furthermore, buy-ins can range from a nominal amount to over a million dollars, depending on the assets owned. It can be paid for directly, by a loan, or by increased “sweat equity.” The amount of buy-in can be a critical factor in selecting a partnership track position.

Practice building

Practices also expect partnership track employees to be involved in practice building. You will not just perform your daily duties as a radiologist, but you will be assisting and learning to accomplish other tasks outside of the normal radiologist purview. You may involve yourself with hospital committees, giving grand rounds, attending events outside regular business hours, and other important “non-radiologist” functions. These events are essential training for the partnership track radiologist to learn the business roles of the partner.

Partnership- Not An Obligation

The applicant needs to remember: Practice partners usually do not want to create a partnership position!!! Why? It’s pretty simple. It dilutes the preexisting partners’ equity (meaning that each partner will get a smaller share of the profits). There has to be a significant need to create a partner. These issues include lack of coverage in a particular subspecialty, need for more practice managers, etc. There is no such thing as an entitlement to a new partnership track position. Also, be prepared to work hard to gain a share of the partnership for that period.

What about the Partners?

Usually, practices pay partners a fixed salary. However, they earn a substantial portion of their income from the practice’s excess profits, usually a bonus. Usually, you expect the compensation of the partner to be higher than that of the employee. Why? Partners assume the risk of the practice and also manage practice issues. If reimbursement decreases, partners are affected first. If there is a loss of an employee, the partner needs to cover that position. Or, if there is a lawsuit against the practice, partners need to manage the subsequent issues.

However, the difference in salary between a partner and a non-partner can vary widely depending on the profitability of the practice. Therefore, it behooves the applicant radiologist to determine what the partners are making before joining the practice. You need to “check the books” or talk to the business manager. You certainly do not want to go through the process of “sweat equity” only to find out that your final income is not much different from your partnership track salary.

Does It Make Sense To Be On A Partnership Track?

Believe it or not, there is no quick answer to this question. It all depends on the individual situation and the job. There are also inherent risks to taking a partnership track position versus a permanently employed position. So, let’s evaluate each piece of this equation individually with different questions.

Are you the sort of person that likes running the show, or do you just want to do your work and go home?

A partnership track individual needs to be interested in business and practice building. There is no room for a partner who does not have any interest in building the practice outside regular business hours or is unwilling to perform different roles during the workday outside the normal radiology purview.

Is the job something temporary for you, or do you want this job to be permanent?

It would be best if you did not put “sweat equity” into a job where you think you will be leaving in several years to be closer to family or other needs. Generally, imaging centers will pay less for a partnership position. So, it’s just not worth it. Or maybe, you just need a position, but the practice job description is not exactly optimal, but it is the only thing available in your desired location. In this case, you may also decide a partnership track is not the correct decision. For example, you don’t want to be practicing women’s radiology when your only desire is to be an interventionist!

What is the current business environment in your location?

In some practice locations, hospitals are converting private practice jobs to employed positions due to mergers and acquisitions. You do not want to be stuck in a partnership track, only to find out that there is no partnership position at the end of the road. You may never make the “partnership” salary, or even worse, you may be out of a job. Remember, in a situation like this: employees are the first to go.

Have multiple recent retirees received buyouts?

First of all, what is a buyout? It is essentially the opposite of the buy-in. A partner that steps down expects to get the equity back that he put into the practice. Every once in a while, a practice may have many former partners retiring with enormous buyouts. Large buyouts can affect the partners’ salaries dramatically depending on the circumstances. It would help if you looked into all the specifics for yourself.

Is there a tiered partnership?

Some partnerships have separate buy-ins for the professional portion of the practice and the practice’s technical ownership. Others may give you only a small percentage of ownership compared to a “full partner.” You may become a partner one day. But, the partnership may not be what you thought it would be. Some practices are more equal than others!!! It is imperative to get all the facts correct before starting that partnership track.

Should Student Loans Affect The Decision To Be On A Partnership Track? 

I will try to tackle this question separately from all the others because it is becoming an important issue for residents/fellows before the partnership decision, given their enormous loan burdens. The difference between an employed position and a partnership track position can also seem substantial at the beginning. It may or may not be more financially savvy to take the initially lower-paying partnership track job. Here’s where it is vital to try to glean the specifics of your future career. And, this decision can be complicated. You have to plug in the numbers for yourself and make the calculations. To show you, we will take a specific circumstance under consideration. I will give you the example below.

Here are the inputs:
  1. You owe 500000 dollars on student loans.
  2. Student loan interest and long-term investment returns are both 6%
  3. The partnership track lasts three years.
  4. The difference between the salary of a partner and an employee is 150000 dollars.
  5. A permanent employee makes 100000 dollars more per year on average than the partnership track position during the partnership track term.
The calculation:

Theoretically, the salary difference can go to student loan payments if you are in a permanently employed position at the beginning. So, after taxes, you will have 66,000 dollars (100,000 dollars *0.66) per year or about 200,000 dollars (66,000 dollars x 3 years) more principal paid toward the student loans at the end of three years. Given that the loan’s interest rate and that the money you will make after you pay the loan is 6 percent, for a 30-year career, that same amount is equivalent to saving 200000 *1.06^30 or approximately 1.15 million dollars.

On the other hand, if you decide to take the partnership track, you lost out on the 1.15 million dollars you would have made if you were an employee. But, how much more, in the end, will you make to compensate for those years of “sweat equity”? So, let’s subtract the salary difference between a partner and a non-partner and take the taxes out every year. That number would be (150,000 dollars* 66 percent) or 100,000 dollars. Let’s take that 100000 dollars and multiply it by the number of years worked. That number would be 100,000 dollars *27 years (30 years of working minus three years of making less than an employee) or 2.7 million dollars. This number does not even include interest!! In this case, it would certainly make financial sense for the applicant to take a partnership track position.

The bottom line: you need to perform the calculations for yourself. It may make financial sense to take the partnership track position even though the initial salary is less than the permanent employee.

Bottom Line

The decision to become a partner vs. a permanent employee may not be simple due to the applicant’s personality, job-related factors, and monetary considerations. If you are thinking about the partnership route, make sure to know your role and get as much information/specifics as possible so you can leap. A partnership is a long-term decision, just like a marriage. Know what you are getting into!!!!

Please leave in comments below. I would love to hear from you!!!

 

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Alternative Careers and Supplemental Income for the Radiologist

Every once in a while, a frustrated resident will say to me, “I’m not sure if I am interested in any of the traditional fellowships in radiology. What else can I do with my life? I am 250,000 dollars in debt and I don’t think I can stomach practicing radiology like everyone else for the rest of my life. I have no choice.”

It is tough to think that after all the money, time, and effort, you have invested into a radiology residency, you may not have a career at the end of the road that you will enjoy. In addition, many radiologists think that if you are not practicing in one of the standard subspecialties, you are a waste to the specialty. And finally, many radiologists do not know all the opportunities out there in the world. Given these biases, it is no wonder this sort of atypical resident would need to address feelings of hopelessness.

Some radiologists and radiology residents just need other outlets for their talents and to find a different path. And, in truth, intellectually rewarding and high paying job opportunities for radiology residents are almost endless. Just remember, it is not an easy journey to get to the promised land of the alternative career opportunity. People that decide to take these alternative pathways may burn the proverbial “midnight oil”. And, it can take years to become an expert in an alternative career. But, if you take an interest in seeking these possibilities, you have come to the right post!!!

Also, some radiologists merely want to supplement their income from other sources in another area they may have interests. We will certainly discuss some of those possibilities as well.

So, I am first going to address where to look for these opportunities. And, in the second half, we will address the opportunities themselves, both the full-time career pathways and the supplemental income pathways.

Alternative Careers- Where to Look?

Dropoutclub.org

All physicians should know that outlets exist for getting information and networking about alternative career opportunities. Let me give you a few that I know. First of all,  check out a website that regularly posts jobs and career opportunities outside of radiology called the dropoutclub.org. This website posts all sorts of jobs that are currently available for physicians. It also contains a forum that discusses different issues for physicians seeking an alternative career.  And, the website contains sections that approach how to interview for certain careers such as consulting.

Seak.com

Also, look out for a website called seak.com that specializes in the area of legal/expert witness testimony. But, the website also contains information on all sorts of alternative career paths. In addition, the website contains links to loads of seminars and opportunities for networking with other physicians in a similar situation.

Recruiters

Some recruiters are actively involved in findings residents and attendings that have interests in other career opportunities. They can sometimes be a helpful resource.  Additional, they may know of available jobs that may be relevant to the physician’s interests. But let the buyer beware! Although many recruiters are legitimate and truly want to help the physician, others just want to make the sale at any cost even though the job or the career path may not be right for the applicant.

Colleagues

Finally, you may know physicians that you work with on a regular basis that perform other activities outside the daily practice of radiology. From my experience, I have encountered some colleagues that have started their own consulting business, invented medical devices, worked as an expert witness. wrote books, or performed other career activities outside of the typical realm of radiology. These people are great resources to learn about how to get a start in some of these alternative careers.  I recommend talking to these people because they will give you a more realistic insight into traveling down these pathways that you may not get from a seminar, website, or recruiter.

What Are Some of the Opportunities?

In the interest of time and space, I cannot go into all the specifics of each career opportunity, but we can certainly paint some broad strokes about many of them. I will divide some of these opportunities into the following sub-segments- Finance, Legal, Political, Consulting/Surveys, Pharmaceutical Companies/Research, Invention/Entrepreneurial. Teaching, and Writing. There are certainly other areas as well, but these are some of the areas that are most familiar to me that I can comfortably talk about.

Finance

Let’s start with finance, an area that lends itself to alternative full-time careers. This area seems to be one of the most “sexy” for many radiologists and radiology residents. You may think high pay, high profile. When you log on to the dropoutclub website, many of the posted jobs are in this realm. There are many hedge funds and large brokerage houses that seek people who can understand how companies operate in the biotechnology and medical world that may not be readily accessible to the typical layperson.

Radiologists have a particular set of expertise in imaging devices and this focus may allow insight into companies that other medical professionals don’t have.  You may be involved in the tasks of research and presenting information to the executives of a company. Or you may be involved in gathering information from clinicians. Some of the positions are geared to the entry-level job and others are geared to the more experienced professional with finance experience. It is important to remember that you will probably be starting out low on the totem pole unless you have a strong finance background. Long hours are the norm. But, there is a very high pay potential. Just like becoming a full-fledged radiologist, it is a long road!!

Legal

Let’s split this career pathway into two parts: becoming a litigator and expert witness work. The first pathway involves a full career change. You may hear of physicians that have also obtained their JD degrees to work in areas such as malpractice defense or even patent work. Both of these areas certainly lend themselves to the expertise of the radiology trainee. Getting a JD, may involve another 3 years of schooling with additional significant expense as well as a long path to a partner within a firm. So, this can be a tough road. Alternatively, you can think about doing this later on in your career after you have paid down some student loans. When you have the will there is a way!

More commonly, many radiologists participate in expert witness testimony as a way to supplement their income and maintain a footing in the legal realm. This pathway involves reviewing cases and providing opinions to attorneys. On occasion, you may even become involved in expert witness testimony or a deposition in court. Some physicians exclusively provide support for the defense of physicians and others may work for either side. It can certainly be interesting work and give you a new perspective on the legal side of radiology and medicine.

Political

Ever thought about becoming the next Ben Carson or Bill Frist? If they can do it, you certainly can too. Some residents enjoy politics. They may like being involved in hospital committees and organizations. Or, they may want to take charge of their residency program as chief resident and get involved in liaison work between the attendings and residents. If this is the avenue you want to take, you can certainly find ways of making your future success more probable.

I would recommend residents to look into the Rutherford-Lanty Fellowship in Government Relations, organized by the ACR. According to the website, “it allows residents to gain an understanding of state and federal legislative and regulatory processes and the ACR role therein. It also informs residents about the governmental factors that play important roles in shaping the future of radiology.” This would be a perfect entree into the world of political action. In addition, you can find annual meetings such as the RLI Leadership Summit held annually where residents can learn about health care leadership opportunities.

I also think this sort of resident should get involved in hospital, regional, and/or national organizations and actively seek opportunities to participate in leadership roles. Half of politics is networking. The bigger your network, the more likely you can get involved in a political career.

Consulting

The word consulting is a very broad term. Consulting work incorporates many different entrepreneurial and employed careers as well as part-time work such as surveys. So, I am going to divide it into two parts.

Consulting as a career

I will begin with the full-time career path. There are some companies that specifically hire physicians to provide expert consultation for businesses. One such well-known company is called Mckinsey & Company. In addition, there are niches in which someone with a unique background may have expertise. If you have prior training and interest in software engineering, for instance, you want to utilize your skills to become an independent consultant in the area of software development, PACS, etc. You can potentially leverage this area of expertise to start your own company or work with large companies to assist in product development, increasing efficiency and customer satisfaction, and more. Consulting work is unique to the individual’s talents, opportunities, and imagination.

Survey work

Many physicians, such as myself, will occasionally participate in telephone or internet surveys. Often times, a consulting company will want to get the input from radiologist about new products or the business/political environment. There are a bunch of different companies to which you can sign up and get involved with their surveys. I make sure when I participate in these surveys that the time spent is worth my while.

I have found the following survey/consulting companies to be fairly reliable, compensate fairly well, and have a decent amount of work for radiologists: GLG Group and M3 Global Research. Be careful not to participate in surveys from companies that only offer prizes for a random winner that participates in a survey. It’s probably not worth your while.  You are a professional and your time is certainly worth something!

Pharmaceutical Companies/Research

There are many opportunities for physicians in this realm. Again, you will be starting at the very bottom. You just have to accept that. But, there have been some very interesting opportunities available for radiologists.

At my former job, I participated in the reading of imaging studies for pharmaceutical clinical trials. Many large companies still want physicians/radiologists reading their images to make their studies more powerful and legitimate. You can also get involved in structuring the studies and negotiating with companies to provide these services when you get to a higher level within the company.

Additionally, if you are inclined toward research, there are many opportunities to run a research department in a large pharmaceutical company, typically involved in imaging research. Many pharmaceutical companies give significant opportunities to radiologists/physicians to climb the corporate ladder. Remember though, there is certainly a bit less stability with a pharmaceutical company career, compared to typical radiology careers. But then again, you are reading this because you are not the typical radiologist!

Invention/Entrepreneurial

Maybe you have the next great idea. And, you just need an avenue to implement it. There are many radiologists who have gone down that pathway. Unfortunately, it does take a lot of work including research/development, funding, marketing/advertisement, salesmanship, and so on/so forth. There are also no guarantees that your product/idea is going to succeed. So, it is best to stick with your first career until the idea/product/company becomes large enough to support you full time. But, the rewards can be immense for the hard-working entrepreneur.

Teaching

Many colleges and large universities need quality scientists to teach their courses. Radiologists certainly qualify!!! If interested in these careers, you may consider contacting a school to find out what are their needs. This can begin as a supplemental income or can become a career avenue. In addition, if you have a particular expertise in a certain area of radiology, there are also entrepreneurial opportunities to begin your own course/curriculum/school and build it over time.

Writing

Welcome to my world!!! I am fairly new to the blogging industry. But, it is a great way to get your name out there. In fact, starting a website and writing is a great platform for other careers and business opportunities, whether it be writing a book, consulting, or whatever/wherever your interests lie. Also, if you have a hankering for this avenue, there are also many opportunities to write for others as a freelancer or work for medical organizations that need writers that can translate medical jargon to the general public. The opportunities are extensive. Of course, you can also decide to write the next great novel and become the next Michael Crichton!!!

All These Pathways. So Little Time.

I bet many of you didn’t know that there were so many alternative careers pathways and avenues for supplemental income for the radiologist. So, for those of you that are not sure you want to stick with the typical radiology career, don’t despair! All it takes is a bit of imagination, time, and hard work, and you too can find an outlet for your talents and your loves, whether it be a part-time gig or a full-blown career.

Would love to hear any comments or thoughts!!!

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The Difficult Radiology Attending

difficult attending

Fortunately, most individuals in the radiology profession have stable, friendly personalities. But, in any room of 100 people, you will have psychopaths(1 out of 100), narcissists, borderline personalities (6 out of 100), in addition to other difficult personality types. And radiology is likely no different. During your radiology residency, you magnify these issues because you have to sit for a concentrated amount of time with this person. It could be for hours at a time. (Although that can be different now with the Covid pandemic!) So, you need to learn coping mechanisms to deal with these difficult people.

Why Difficult Radiology Attendings Are Not All Bad

Ironically, I found that some of these most difficult attending personalities gave me my best and most intense learning experiences. It’s where I learned to develop a thick skin, become more of an independent radiologist, tighten my dictation style, and listen. These were the formative years for me. If you think of this tough individual as another link in the chain of learning experiences, most of these days, weeks, or months you sit with this problematic attending will seem to have more relevance to your overall education. Your time spent will indeed not be perfect but will be much improved.

Personality Types

This segment will go through 12 different difficult personality types that you may encounter during your residency program. We will also teach you how you can use each problematic personality type to add to your body of experience and build you into a thriving radiologist.

The Narcissist

Everyone knows this individual. I personally always think of that main character from Dragon’s Lair(Dirk the Daring), with the perfect hair, the expensive clothes, and showing off their skills (or lack thereof!!!) to the world. As they say, “God’s Gift to Humanity.” These problematic individuals will often appear overconfident, and some will make fools of themselves. It’s going to be the attending that never uses liver windows because he says he can always easily detect all liver lesions in soft tissue windows. He’s just too good to make that extra effort.

What’s great about working with these sorts during your residency training? When you complete a rotation with this individual, you will learn how to avoid being overconfident and look more carefully in places that the narcissist will miss. Most important, it is a great time to learn how to be humble, an essential feature of a good radiologist. Radiologists cannot always be right!!!

The Know It All

If you were in school, this would be the talkative kid that is always raising his hand. Or think of Hermione from the Harry Potter series. This person can be incredibly annoying but smart and well versed. The know-it-all gives the resident a distinct learning experience but usually takes the thunder away from something that another attending or you may have discovered. As a resident, you have a lot to learn from this person. He or she will teach you all sorts of radiology information that others will not and give you a sense of humility.

The Absent Attending

You know this type of individual, always leaving the department at the drop of a hat. He/she expects you to do all the work for them during the day. And, the person is rarely available when you have pressing questions. I have found that this experience is probably one of the best learning experiences you can have as a resident. It allows you to take charge of a rotation that you usually would be merely following. You will need to look up lots of information on google and ask other residents/attendings what to do. When you finish with the rotation with this sort of difficult attending, you will be able to run the department because you will handle most of the day-to-day issues on your own, related to your experience of having the unavailable attending!

The Smitten Attending (With Someone Else!)

So, you are working in your interventional rotation, and your co-resident or a medical student is very handsome or pretty. Your attending does not seem to want to listen to anything you have to say. The “boss” always goes to the other resident to teach them and ask them questions and forgets about you. What do you do? Well, the answer is simple. You work twice as hard to get their attention. Working hard on this rotation may not pay off concerning getting a recommendation from this individual. Still, it will allow you to put your heart and soul into your work and make the rotation an intense work experience. You will live and breathe the subspecialty rotation. When you go into practice, you will be thankful for the extra time and expertise you may not have otherwise!!!

The Obsessively Detail Oriented Attending

When you come back from dictating a case, this is the sort of difficult attending that will mince every word and tell you why each word and phrase should have been different. Don’t take offense at this sort of mentor. Most of the time, they mean well. But, the experience of having to write the same dictation over and over; overcorrecting every statement until you make it the way he/she wants, can be painful. But, dictation is one of the more difficult elements in radiology to master. So, this experience can be invaluable for honing your reports and making them much more robust and exacting. Believe it or not, consider this person a resource to make them that much better!

The Sociopath

Watch your back! He/she will typically seem to be the friendliest radiologist in the whole department. This problematic attending often will tell you precisely what you want to hear. Until wham! At the end of the month, you find out that your evaluation from the program director is not what it initially seemed. The sociopath will not tell you about what he/she thought of you at the time of your rotation and takes pride in stealthily making the lives of the radiology resident miserable.

The good news is the rotation will seem to be just fine when you are there. It is only the afterglow that causes misery. But your experience with this attending will teach you something invaluable, never assume that everything is ok. Always ask and find out what you can improve and how you can do things better. This experience is a wake-up call for the naive resident!

Bizarro

Out of all the radiology personality types, believe it or not, you will find this one to be one of the most interesting. I can remember one of my former attendings telling me about a mentor who was continually drooling when he spoke and whose eyes were incessantly tearing. He stood at the short height of 4 foot 3. But, when you talked to this person, the passion for teaching and his profession shone through everything. These attendings tend to have some of the most diverse backgrounds and interests.

When you treat these folks as mentors/teachers, you find that they have unique ideas and behaviors that you would not learn from the more typical personality/appearance. I have incorporated their lessons into my daily practice. Also, I have found that their teachings tend to stick because of the unusual delivery and presentation. Typically, you will remember the days fondly that you work with these people and have good stories to tell as well!

The Dictator

You will find this problematic attending demanding and harsh. The dictator treats all his staff with an iron fist. This radiologist will appear unreasonable at times and expects everyone- nurses, technologists, residents- to bow toward every whim. Unfortunately, you will need to do the same or wait for his wrath. The environment may, at times, be unpleasant, and you will need thick skin. Still, I have found that these attendings make the residents more rigorous in their approach to running a department, adopting search patterns, and learning radiology. Use this opportunity to incorporate the dictator’s demands into your routine, and I can assure you, you will become a much better radiologist!

The Gossiper/Talker

You will have some of the best conversations with this attending and will learn about every character in the department. This person talks a lot and can prevent staff from getting their work done, And some of the information you may or may not have wanted to know. However, listen to this person very carefully because they can be an excellent source of information about what is going on in the department, a precious commodity. My advice is to reveal only what you want to expose to this attending, or else your story may become publicized as well!

The Inappropriate Attending

Most people know about this type of personality. He/she may yell at the patients, make off-color jokes with the wrong sorts of people, or maybe a little too touchy/feely. To this day, I use these uncomfortable situations to be instructive of what not to do as an attending radiologist. I use these experiences to remember to model good behaviors to my residents by the allegories/stories that have occurred!!!

The Loner

Many residents feel the need to get instantaneous feedback from their attendings. This problematic attending will not only give you refrain from any feedback, but he/she also may not even talk to you during your shared time. You may be “pulling teeth” to get this attending to teach and speak to you. You may feel like you are always being observed and assessed, but with no response. Remember that the world of radiology is not a specialty of instantaneous feedback. You may find out what you have done right or wrong months or maybe years afterward. This attending personality type truly prepares you for the real world!

The Unintelligible Radiologist

Most residents know this type. It’s the attending with tons of typos in their reports. And, clinicians are continually calling this attending to figure out what he reported in his radiology impressions. So what is the significant advantage of having an attending like this? You will need to learn how to field the clinician’s questions about his cases in a thoughtful, intelligent manner without incriminating its author. It’s a great way to solidify your radiology impressions and learn to communicate with the clinicians!!!

Bottom Line About The Difficult Attending

There are all sorts of personalities that radiology residents will encounter during their four years of training. I have probably just scratched the surface. Problematic characters can lead to trying times on a daily, weekly, or monthly basis. However, the experiences that you will have can be invaluable in your development as a radiology resident. Use these personalities to enhance your reputation and skills as a radiologist. Don’t let these difficult attendings get the best of you!!!