Category: Resident Advice

Posted on by

How To Learn Buttonology As A Radiologist

buttonology

When starting in radiology, the trickiest items to learn are often not the images, procedures, or concepts. Instead, figuring out what buttons to push to find what you want can be the most challenging. Electronic health records, PACs (picture and archiving systems), dictation software, and internet access and use can vary widely from institution to institution in quality and useability. And you may find that figuring it out can take a very long time, especially learning it efficiently. So, how do you set yourself up to learn the ropes when you need to figure this all out? Let me give you tips on how to go about learning all this technological buttonology.

Set Some Extra Time To Play Around With Buttonology

Time is your friend. Spending time practicing with the dictation or the PACs system is the best way to gain familiarity. Anyone can show you the buttons to press, but the chances of remembering how you did it can be close to zero. Only after manipulating the controls can you get used to how the software functions. And, it’s even better when looking at real-world cases. For me, software like Tera Recon has only become relatively easy to use after the tenth time I have processed a cardiac CTA. Also, I remember spending extra time trying to create templates on Powerscribe for dictation so that it was easy to do and could serve me well later on with numerous dictation templates. Time spent now will save oodles of time in the future.

Get To Know Your IT Specialists

Most institutions have dedicated staff to maintain and support PACs, RIS, and the internet. Suppose you want to get to know a function or filter better. Sometimes you have to ask them. I have found that I will sometimes spend three times the duration compared to an IT specialist to figure out how to overcome or improve an issue with the PACs station. So, be nice to these blokes!

Ask Your Fellow Residents And Faculty

When learning the buttonology of your systems, this point is not the time to be shy. I have always said that if we put the heads together of all the faculty, we would have the most comprehensive knowledge of how our electronics and software work. We all seem to know bits and pieces of these systems that can increase our efficiency. But, not everyone knows the same things. So, please, also ask your colleagues if you are unsure what to press or when. It can make all the difference.

Don’t Miss The Training Sessions.

Most of us don’t enjoy these training sessions. They usually interfere with our day (and even prevent us from eating lunch!) Nevertheless, take these sessions very seriously. They can enhance your daily efficiency in spades. I still remember when our hospital acquired the new PACs system; I spent a ton of the time making sure the hanging protocol for plain films and priors was suitable. Fast forward to today, and the couple of days I spent with a personal PACs trainer years ago have magnified my daily efficiency by a significant multiple compared to those who didn’t attend. It pays to stick around for the additional attention even though you may experience pain!

The Magic Of Buttonology!

The quality and efficiency of every day depend on much more than just reading films. We need to be aware of how we can slog through the technical work of each day most efficiently by clicking the least amount of buttons and technological obstructions. But, it would help if you spent the time to learn the buttonology. So, give yourself some extra time to get to know each of the systems, ask your colleagues and staff if unsure, and do not miss any additional training sessions. Missing out on any of these extra steps will divert you from your ultimate target of maximizing your efficiency!

Posted on by

Don’t Skimp On Sensitivity!

sensitivity

In radiology, almost anything can change our sensitivity to detecting disease. Problems with electronics and hardware such as PACS, the RIS, imaging software, or even dictation software can cause us to miss out on information. Phone calls and texts can interrupt our train of thought. Many of these problems can be beyond our control. But, there are also ways that we are directly responsible for our daily reads that can affect our sensitivity. So, what are some main ways radiologists can knowingly skimp on sensitivity to negatively affect patient care?

Not Getting Priors- A Template For Decreasing Sensitivity

Out of all the ways we can negatively affect patient care, this one likely has the most bang for the buck. Whether we need to search for changes that can affect chemotherapeutic regimens or determine if a pulmonary embolus is acute or chronic, we can severely decrease pathology detection and change patient management when we neglect priors. It is certainly worth the extra time to look at the prior studies!

Not Reading The Prior Reports

Just as critically, it is not just about searching the priors but also about reading the previous reports. I can’t tell you how often I have discovered items in the information that are the reason for performing the following study that may not be so obvious if you don’t read the prior dictation in addition to looking at it. It could be an incidental tiny pancreatic cyst or a subtle rib sclerotic rib lesion that you might not realize by just skimming the previous images . In either case, you must also make sure to peruse the prior reports to maximize sensitivity.

Using The Correct Software For Imaging

It is effortless to skimp on interpreting images when the programs are slow or unwieldy. However, we are obligated to look at studies in a way that will maximize sensitivity. That may involve looking at a PET scan on the appropriate interpretation platform or using the reconstruction software for coronary artery CTAs. If you skimp on this step, you are much more likely to miss disease that can negatively affect patient management.

Windowing/Protocols

It is much easier to go through a study if you don’t take the time to go through bone and liver windows on a CT scan or neglect the diffusion-weighted sequences on an MRI of the abdomen. However, by forgoing these steps, you are also sacrificing sensitivity. Sure, it’s nice to get home a bit earlier. But is it worth the outcome of missing a liver lesion or a hidden enlarged abdominal mesenteric lymph node?

Not Waiting For All The Images To Arrive

I get impatient when the computer sends the studies over slowly. That happens to almost everyone once in a while. And, it is very tempting to interpret the images based on the images that you have alone. But, for instance, axial CT scans images without the coronals, and sagittal can cause you to miss compression fractures, renal masses, and more. Don’t skimp on the waiting for these last images to cross over.

Skimping on Sensitivity!

We, radiologists, have taken a Hippocratic oath. This oath obliges us to do no harm. Although we are under pressure to complete all our cases, we must best answer the clinical question appropriately without sacrificing sensitivity. Or else the study can become worthless or, even worse, harmful to the patient. So, make sure to cross all your t’s and dot all your i’s by checking for priors, using the correct software, looking at all the windows/sequences, and not being impatient before interpretation. These are simple ways to increase our sensitivity and ultimately improve patient care!

 

 

 

 

Posted on by

Great Expectations For The Radiology Resident

great expectations

The wait has finally arrived. After years of biding your time in medical school and residency, you are finally en route to what you want to do: begin training as a radiologist. And radiology residency begins. But, is it all that you had expected after all these years? Are you getting unadulterated teaching from your faculty as you had hoped? Is the learning at noon conferences with enthusiastic and engaging staff? Do the fellow residents live up to the great expectations that you had in the first place?

Well, there is a good chance that any residency program that you choose will not entirely live up to your great expectations. So, coming from an associate program director, what are reasonable expectations for your residency program when you start? And what are some unreasonable expectations for your newfound position? Let’s discuss these expectations by expounding on what is reasonable and limited. Then we will summarize the best way to treat these expectations overall.

Reasonable Anticipation

Reading Alongside Attendings

Any program worth its salt needs to have some time dedicated to having residents listening and reading along with attendings. At the beginning of the residency, the only way to know radiology is to listen to how your mentors interpret films and dictate. And this means some dedicated time to watch, listen, and learn the ropes in real-time with a radiology faculty member. A residency cannot survive for long without this factor.

Ability To Ask Questions

If your faculty shuts you down or insults you whenever you ask a question, you cannot thrive in residency. We learn by asking questions. And in the beginning, there is no such thing as a stupid question. Heck, you don’t even know what to ask! But, if your faculty scolds you for asking questions from your mentors, this would be an example of a malicious program to residents and learning!

Monitoring Your Dictations

Any residency should ensure that its residents are dictating and interpreting films appropriately. It is the currency of radiology. The only way to do that is to assess the outcome of the radiology process. And that is the final report or dictation. All residencies should have a system for attendings to review resident dictations. This process is an essential factor for learning.

Feeling Safe

If you feel like faculty members threaten you or fear for your sanity (or life!), you have a real problem. No person can go through such a stressful learning situation in addition to the stresses of radiology residency (and yes, radiology training is considered stressful!). Nor should any resident have to encounter a problem such as this.

Unreasonable Expectations

Unadulterated Attention From Attendings At All Times

Whether you are in a research institution, University program, University-affiliated program, or community/private practice residency, you will not be the priority of most faculty. Most have research to publish, work to complete, and families to come home to. So, if you are too idealistic that you will receive the attention of all the faculty all the time, you will never feel satisfied.

Expectations That Everything Will Be Taught

Yes. For some concepts, it does help to have a teacher. But, no matter what anyone says, most radiology is self-taught. We need to see 100 cases of appendicitis, thousands of routine chest x-rays, and perform hundreds of paracenteses before we get it all right. No one but yourself can do that for you. And, that does not include all the concepts you need to reinforce and remember by reading in every area that radiology covers.

All Teachers And Colleagues WIll Be Your Friend

Just because we are all radiologists does not mean everyone will be your buddy. Similar to the “real” world, we all have different personalities and desires. And, not all people mesh well together, no matter how much we want that to happen. On the other hand, we all can learn from one another. If you apply every person in your program to this concept, regardless of how they feel about you, you will begin to appreciate them for who they are.

Great Expectations

We all come into new situations with great expectations. But, check for yourself. Are these expectations realistic or not? Any program should fulfill the basic requirements, such as working directly with attendings in a safe environment. But, you can’t expect any program to pull all the challenging weights for you. There is just some work you need to do for yourself. It’s the only way to become an excellent radiologist!

 

 

Posted on by

Are You Ready?

ready

The middle of June begins the annual season of change for radiology residencies. The first graduates start to move out as they have held their last few weeks of residency vacation to dedicate this time to move. And new residents prepare to find housing in the area and prepare for the new academic year. Even the first-year residents have an enormous transition from readers and observers to active participants in night shifts and calls. Since so much happens now, let’s discuss a checklist of some items you may not think about or forget before starting the new year. Don’t worry. I have you covered!

Bone Up A Bit On The Basics To Get Ready Before Starting

Whether you are about to start residency, call, or fellowship, why not take the time to read a bit before starting. Many fellow interns and residents say not to do anything before starting your new phase. But, many of them are not radiology trainees. We have more reading than most other specialties out there. So, get cracking. 

Suppose you are an intern. Read some anatomy atlases (if you haven’t done so already!). If you are about to take overnight call, consider some case review series, especially for ER radiology. And, if you are a fellow, start reading about some of the critical areas within your newfound subspecialty. Any bit of reading can give you a headstart.

Find Housing Close To Your Residency Program

You have limited time to get out there and find housing with all the pressures upon you. But, if I have to give one sagely piece of advice, you are usually best off living fairly close (optimally within a ten-minute radius)—the less time in the car or some form of transport, the better. You will have more time for studying and, perhaps just as importantly, more time for yourself. This advice comes from someone who has lived near and far from their line of work. It’s not worth the pain to live farther away!

Remember To Start Up Your Savings And Investments

Some of you will have the option of starting up 401ks with matches or making automatic contributions to Roth IRA. Regardless, before starting, don’t forget to automatize all these investments. As residents, you will not have as much time for a hands-on approach. So, start up those automated investments into those stock index funds before beginning. Trust me. Your future self will thank you many years from now!

Start-Up Car And Renters Insurance

Many of you are moving. So, don’t forget to change up all your insurances. Sure it can be a pain in the neck, especially if you are moving to a new state. But, it is a necessary evil. The last event you need is to start residency after a theft that you can’t recover or have issues with your car once you have already started. Make sure all these insurances are in place before you start.

Make Sure You Have Your Medical Licenses And Credentialing Ready To Go

Some of you will need your state medical license before beginning residency. Others will be able to use the hospital license. Either way, you will still have much to do to ensure that you get it processed and ready to go. Credentialing in all forms can be more arduous than you might think. And, it pays not to worry much about it after you start. So, get everything in as soon as possible, so you will not worry about the details during your residency!

J1 Visas, Etc…

Finally, for foreign graduates, don’t forget to ensure that all the paperwork you need to stick around is complete and ready to go. We have seen a few folks that had a problem getting back into the United States because they did not finish their paperwork. It happens!

Are You Ready? Get Psyched For The Change!

So many errands to do before starting and so little time to do them. Here is a bit of a nudge to get you going so you can start the year with a bang. Before starting, take a gander at this list and ask yourself, what did I forget? This list can help you recall what you need. But, most importantly look forward to the next academic year. Change is exciting and will be here before you know it!

 

This website is an affiliate of Amazon. A percentage of the items purchased through Amazon through the links on this site are paid to the radsresident.com website.

 

 

Posted on by

Why Radiologists Need To Protocol Cases

protocol

Like many institutions, we perform cardiac CTA studies at the behest of our emergency medicine, internal medicine, and cardiology colleagues. They say do the study, with or without a protocol, and the technologists jump without a reflexive thought. For example, one patient had a chest CT scan a few days earlier for shortness of breath. It turned out that the patient had enough calcium in their coronary arteries to make their vessels look like lead pipes. For those who know anything about cardiac imaging and CTAs, tons of calcium within the coronary arteries make it nearly impossible to interpret them for stenosis because of significant beam hardening artifact, limiting evaluation of the lumen.

Nevertheless, without batting an eyelash, the technologists completed the coronary CTA, which was uninterpretable for detecting coronary stenosis. It had a calcium score of over 4400! Now, if only someone had looked at the CT chest, we could have avoided the CTA chest at the cost of unnecessary contrast, additional radiation, and of course, the financial cost to the patient.

This case is a microcosm of what is happening to radiology. Scans come through fast and furious, making it difficult to vet the protocol and the priors on everyone. But, by letting cases get through the system without forethought and protocols, we expose our patients to subpar medicine. In light of these facts, here are some of the critical reasons why radiologists need to protocol cases.

Avoid Unnecessary Studies

How often do we get the wrong orders for the indication? Very frequently! Daily we get orders for CT scans that ask for contrast when none is needed and vice-versa. Of course, a patient with flank pain should not generally get contrast on the first scan if they are looking for stones. But, wrong orders for studies with contrast happen all the time, causing unnecessary exposure to radiation and contrast that is not needed. Protocoling can prevent most of that.!

A Protocol Can Make Sure Studies Are Done For The Right Reason

When technologists and nurses come up to me and ask if they are performing the correct study, the first question I always ask is, “why are we doing the study?” There is a reason for that. We get orders that are not necessarily for the indication that clinicians want. It could be a white blood cell scan for when a simple gallium scan is warranted. Nevertheless, we can correct most of these potential errors before they get to the table!

Protocols Can Add Information To The Case

Protocoling can add critical information to the case. It may help find a relevant prior like the cardiac CTA above. Or you might find a valid reason for a study that might not be evident initially. Perhaps, the doctor is looking for a fistula and needs rectal contrast. Sometimes, you can only figure that out by digging deeper. You know what they say… Garbage in. Garbage out!

Prevent Patient Discomfort

Many radiology studies are uncomfortable and difficult. A CT scan on a patient with severe back pain can be a nightmare. Imagine going through a CT scan in this situation when you could have avoided the test if the radiologist had protocoled it beforehand. Well, this issue happens all the time. We owe it to the patients to prevent additional harm!

Prevent Angry Clinicians

When we do not protocol cases before imaging, we do not get the answers that the doctors are looking for. This cycle leads to unhappy referrers that do not receive the intended study. And, we get these irate phone calls afterward. Do you want your clinician to send patients back to your department again? Well, if you consistently deliver the wrong studies for the patients, that will not happen!

A Protocol Can Decreases Costs

The costs to image patients are immense. And simply one incorrect study can cost the patient and the institution thousands of dollars. Protocoling is a tremendous backstop to ensure that health care costs are more reasonable. Sure, we may not have much time in our busy schedules. But, protocoling can certainly decrease costs to the system!

Protocol: An Easy Way To Prevent Bad Medicine

If your attending asks you to take a stack of patients and ensure the protocols are correct, it is not a waste of time. With all the benefits of eliminating waste and practicing good medicine, it is something that we should all do regularly. So, look at those orders before the hospital performs the studies. Protocoling can make a huge difference in patient care!

Posted on by

The Magic Of Priors

magic

As I was scrolling through the worklist, I came across a case with priors that significantly changed the disposition of a patient, emphasizing the magic of priors. A chest CTA showed numerous pulmonary emboli sitting in multiple branches of the pulmonary arteries. At first glance, any radiologist would be ready to pick up the phone and call the ER to let them know about the pulmonary emboli. Of course, this patient would most likely need anti-coagulation and possibly thrombolysis. But then, at the very end of the list of prior studies, I noticed a previous chest CTA from 2017. To my surprise, the images looked the same. Those bilateral pulmonary emboli were most likely chronic! No new treatment would likely be necessary. If you want to talk about why priors are so important, this is an excellent example of why. It entirely changed the management of this patient. And it is the proverbial tip of the iceberg. So, if you ever get that feeling of laziness, here are some reasons it pays to take the time to press on and look at the patient’s prior studies.

Increases Sensitivity

No, it is not cheating to look at the prior report. Instead, it is excellent patient care. Some lesions, for instance, pancreatic lesions, can be very subtle. And, if you don’t look back at the prior report and the prior study, you are much more likely to miss it. You may neglect to recommend follow-up on this sort of lesion. And, in this case, you never know what can happen next. It can grow and need further treatment or not. Regardless, why not increase your chances of picking up significant findings?

Increases Specificity

Let’s give the example of that lowly nonspecific liver lesion that we always seem to find. The second time around, the diagnosis can become a lot more specific. If the lesion has been stable for the past ten years, it is highly likely to not be malignant. And, you have made of critical management decision of leaving the lesion alone. Otherwise, a whole workup can ensue, wasting health care dollars and causing potential psychological discomfort to the patient. These issues happen all the time, so don’t forget to compare to the priors.

The Magic Of Priors Changes Patient Treatment

I can’t tell you how often I get calls from oncologists that fail to give us the most recent priors, subsequently add them to our system, and then request an addendum. Why is that, you might ask? Well, most oncologists know the value of comparing to priors. How would you know whether to continue on a chemotherapeutic regimen or not? In an imaging study, learning if there is improvement, stability, or progression takes the guesswork of how to treat the patient next. And this is not to mention the potential life-saving acute issues I mentioned with the chronic PE case at the beginning!

Increases Referring Physician Confidence

Knowing that you have an eye on the previous study on all your reports allows your referrers to feel comfortable that you are safely and methodically correctly interpreting images. Of course, this step can lead to a virtuous circle. You get more patients referred because you increase clinician confidence and patient well-being. And, you earn a better living. It’s all good!

The Magic Of Priors

One of the big life lessons of practicing radiology for so many years is to avoid neglecting prior studies. I have seen one too many cases slip through the cracks, and I certainly don’t want the same to happen on my watch. And, I am sure that you probably don’t want that on yours. So remember why the magic of priors is so essential- increasing sensitivity and specificity, changing patient management, and increasing clinician confidence. And, you should make it part of your standard protocol never to forget to look at them too!

Posted on by

Let’s Go Back To The Fundamentals Of Radiology

fundamentals

Yes. I lived in a different world from residents today. We didn’t have all the electronic resources such as virtual flashcards, digital ebooks for almost everything, Radexams, Case stacks, Radprimer, question banks, and other online electronic resources. In addition, there were fewer texts for every topic than what we see today. And, we had only one general review text for the boards (Dahnert). But, as I remember, almost all radiology residents back in my day would read these topic-based physical textbooks to understand the fundamentals of radiology. We needed to read this material to grasp the essence of what we needed to know. Many of today’s residents no longer ascribe to this philosophy and jump right into other ancillary electronic material. 

Moreover, without reading the textbooks that I did when I started, I would never have had the fundamentals I have today to synthesize findings and differentials quickly. By skipping out on reading the fundamental texts, residents build knowledge layered upon a flimsy thin base. They can’t answer the why and how of what we do. And they are much less likely to pass the written board examination. This result is precisely what we ultimately find. So, let’s talk about why returning to reading primary physical textbooks is critical before jumping into all the electronic resources.

Active Learning With A Physical Textbook Is Better For The Fundamentals

Reading with a physical textbook rather than electronic reading material is more efficient. If you are not convinced, take a look at my former article, eBooks vs. Printed Radiology Books- A Death Match Part II. In this article, you will find evidence that using physical texts is better than electronic material for learning material. Holding a book in your hand, highlighting, and taking active notes on flashcards, is more efficient for remembering the material. So, although more portable, electronic resources may not give you the same bang for your buck.

Putting Your Money Where Your Mouth Is!

I know. Many of you have tons of debt from medical school. However, when you pay for something, you establish an unwritten commitment to it. So, when you buy your textbook, you are much more likely to feel like you have to use it, read it, and mark it up. Sharing ebooks with your colleagues is just not the same. Therefore, you should consider going back to the old-fashioned concept of owning your textbooks to increase your retention and maximize the possibility of passing the written boards.

Much Better To Have Conceptual Learning Than Learning Lists!

To this day, I can still remember where and when I learned certain concepts, such as features of extra-axial vs. intra-axial brain tumors (check out Osborn!) or patterns of arthritis (Arthritis In Black And White). When you go directly to the electronic references without reading these source textbooks, you are much more likely to see random lists without knowing the why behind the finding. And, you are much less likely to remember the key concepts that will help you make diagnoses later on. You know what they say – give a man a fish, and he will eat for a day. Teach a man to fish, and they will be able to eat for a lifetime! It’s true! So, make sure to learn the concepts from the text first!

More Difficulties With Complexities And Artifacts

It is much easier to figure out complex problems that don’t follow the rules if you know the basics. And, in radiology, very few cases are precisely what the literature describes. When you know the concepts behind the images, you can adjust your ideas to suit the case and allow you to make the appropriate differential diagnosis because you understand why it can fit what you are seeing. When you are reading electronic material distilled down to the bare bones, you lose out on this ability to make the diagnosis when it doesn’t necessarily follow the rules!

Getting Back To Fundamentals!

I am a purveyor of electronics. It is fun to play around with cell phones, computers, and gadgets. But, based on real-world experience with resident success, I implore residents from the first through third years to opt into reading primary textbooks to establish foundations in their knowledge base. Electronic media does play a role in learning. But, residents should consider delegating that role to the reinforcement of knowledge and not as a place to start. In the end, it is your choice. But, residents that read the introductory texts do better on the boards and make themselves better radiologists!

 

 

As an Amazon Associate I earn from qualifying purchases if you click on the links!

Posted on by

Am I Efficient Enough?

efficient

The ACGME requires all radiology residents to fill out a log of studies that they have reviewed in all radiology residencies throughout the country. Unfortunately, though, the onus is on the resident to assess for themselves if the numbers mean that they have learned enough to build their skills to the appropriate level. And, as most residency directors are aware, that number can significantly deviate among residents. Some residents fill out numbers that may reflect a glance at a study. Others give in the number of studies that they have dictated. These numbers can be high or low. Regardless, the gross number maybe not be so critical if you still cannot get through as many cases when you start in practice. In that case, how can you tell how efficient you are right now? And, where should you be at any stage of your training? Let me start by talking about rotation goals and objectives (because you might think that would help), and then I will give you a few guideposts that you may be able to use.

Can Goals And Objectives Tell You Where You Are?

Every program has written goals and objectives for each rotation that you should aim to complete before you finish it. As you scan through this list, you will probably notice a list of bullet points that you are supposed to do and know during any year. You can use it to figure out what information you have learned and where you need to focus. Nevertheless, I am the first to admit that it may not be all that helpful to determine efficiency. Additionally, the goals and objectives are often outdated. Or even worse, the residency program has copied it from other residency programs! So, the utility is equivocal for determining your efficiency.

Fundamental Ways To Tell You How Efficient You Are At Any Level During Residency

Clocking Speed To Become More Efficient

Clocking your reading speed can be an effective tool to determine how fast you are. But I bet many of you have never tried it. Take ten cases in any modality and read them like you usually would. And measure how fast you read them all. Then, compare with your peers. This technique can be a starting point to determine your actual speed. You may be surprised to learn that you are faster or slower than you initially thought!

Do You Have A Search Pattern That Is Second Nature?

If you are a long-time reader of my blogs, you have probably seen a pattern where I mention search patterns a lot. But, there is a reason for it. A search pattern is a primary tool that radiologists do to make the findings. So, think about your search patterns. Do you know them cold? Or, are always forgetting one or two parts of a film or CT scan each time you read. By the second year of your residency, the search pattern should become ingrained in your psyche. If not, think about reviewing them repeatedly until they become second nature.

Comfort Level Is Critical

If you dread reading certain studies or doing particular procedures, there is probably a good reason. Either you haven’t done the background reading for them. Or you have not participated in reading or doing them. So, assessing your comfort level in any rotation is an excellent way to determine if you are efficient at this point.

Can You Dictate Rapidly?

At this point in my career, when I have a dictaphone in hand, I will often go into a “holy chant.” It is a snappy banter that gets my point across in a relatively short amount of time. Most of you are probably not at this level because you have not read as many images. But, if you struggle to dictate a case at the end of your second year, there is a pretty good chance you are not all that efficient yet!

Am I Efficient Enough?

Anyone who poo-poos or ignores efficiency will have a problem when they get into practice. You will not be able to meet the hospital or imaging centers benchmarks. So, there is no better time than the present to measure how efficient you are.

Remember, you typically will want to avoid using goals and objectives as a primary resource. On the other hand, consider clocking speed, determining if your search patterns are second nature, and assessing your comfort levels and dictation speeds. Think about using these recommendations because efficiency is essential. Efficiency becomes more and more critical as you continue through residency and eventually on to your first job!

 

Posted on by

The Art Of Benign Neglect In Radiology

benign neglect

One of the most formidable skills in radiology is the art of benign neglect. Knowing when not to complete a request can be as important as finishing a test rapidly. It is a critical skill to learn in radiology when on call, running a department, or covering a rotation. With benign neglect, what you don’t do right away often resolves itself. It is a powerful tool. Although we usually like to be direct, sometimes, it can improve patient care by decreasing hospital stays and ensuring the patient gets the correct diagnosis and treatment. So, when does it make sense to practice this technique? And, how can you make sure that these requests are changed, tabled, or canceled?

Orders/Requests That Benefit From Benign Neglect

Redundant Orders

Technologists will often come up to you and ask you if an order makes sense at nighttime. For instance, a patient will get an order for a VQ scan with a normal CTA for pulmonary embolus. And, you have to decide whether to call the technologist to perform the study. Yes, there is a remote possibility that the new VQ scan would be positive, but highly unlikely. And the patient will receive more radiation when another test has made the diagnosis. 

Orders With Marginal Utility

Frequently, in fluoroscopy, you will receive an excessive order. For instance, a physician orders an upper GI series for a patient with a history of upper esophageal dysphagia. Usually, performing the upper GI series, which includes the stomach and duodenum, does not make sense when you only need to analyze the swallowing mechanism based on the history. Looking at the duodenum will not add much to the patient’s workup!

Orders That Clinicians Don’t Want But Ask For

In this category, let me give you the example of a patient with a right-sided breast lump but an order for a bilateral mammogram/ultrasound. Reflexively, many clinicians will send a patient in for a workup of a lump with a script for a bilateral mammogram and ultrasound when they only need a workup on one site based on having additional recent studies. Most clinicians don’t necessarily want the workup of the other side, especially when the patient recently had another negative test.

Requests To Look At Ancient Films Without Current Benefit

Especially on call, every once in a while, you will get a request to look at films from 2 weeks earlier because a resident has a research project or presentation. It is very appropriate to ignore these requests when you have a gazillion other tasks to complete that have a meaningful impact on patient care. In fact, by attending to these requests, you would be delaying urgently needed care!

Orders That Will Open A Can Of Worms For The Clinician

Referrers will sometimes order studies that can open up a whole new set of problems for their patient without solving the initial reasons for the order. Let me direct your attention to ordering an MRCP in the case of a patient that has an indeterminate test for cholecystitis on an ultrasound. Instead, the patient needs a hepatobiliary scan to make the diagnosis. First of all, by complying with the order, you may find additional irrelevant findings such as hepatic or adrenal lesions. And, of course, it will not be as specific for diagnosing cholecystitis as a hepatobiliary scan.

Techniques To Be Successful At Benign Neglect

What are some basic techniques to ensure that you are performing benign neglect for good patient care? First, you can table those orders with less significant clinical impact to the end of the shift. This technique works particularly well on a busy night when you have loads of orders and not much time to get them all done. Additionally, delaying a return phone call in the situation of an unreasonable attending can help ensure that the doctor does not place the order in the system. And finally, make sure to limit a study for the right reasons to limit additional exposure to yourself and the patient. 

“Benign Neglect” As A Tool To Achieving Good Radiology Patient Care

With all the redundant orders, requests that don’t make sense, unruly referrers, and time sinks for completing critical patient care; benign neglect is sometimes the best option to ensure a patient gets the best care possible. Sure, it is not optimal. But, it can work to make sure patients receive the proper test at the right time. It’s a tool to consider when others do not work!

 

 

 

Posted on by

Coping With The Disruptive Study

disruptive study

Ever notice how one or two studies can become the focal point of any night?. Hordes of surgeons, medical specialists, and more come down every fifteen minutes to look at or discuss the case with the radiologist. And, you become the “most popular physician in town.” Sure, it can feel good to be so popular. But, you will find many costs to the disruptive study. On a busy night, you cannot get to the next case. And, the tick-tock of the clock becomes more ominous as the weight of an ungodly list of additional studies piles up. Most critically, you become unable to read everything else. So, how do you prevent a disastrous outcome with unread studies, unhappy doctors, and a nightmarishly long shift? Here are some tips for decreasing the suffering that a disruptive study can cause.

Make Preemptive Phonecalls!

If you know that a case will be “interestingly” positive, make sure to call all the relevant parties beforehand. Although not a guarantee, this polite maneuver will often prevent a group of surgeons or ob/gynecologists from asking you about the case while you are in the middle of dictating something entirely different and complex. Plus, it will make it seem like you are on top of everything.

Don’t Be Ambiguous

Sometimes cases are like magnets to the clinicians because your dictation or what you tell them is not clear. It could be a nodule that you measured as 2 cm in the body of the report, but you stated it was 2 mm in the impression. Or, perhaps, you were not straightforward with your differential diagnosis. Ambiguous reports lead clinicians to find out what is going on by searching for you, especially while dictating something else!

Dictate The Disruptive Study As Quickly As Possible

Cases have a shelf life. If you don’t dictate them on time, the shelf life will end, and you will have a clinician coming down to review the case before you know it, interrupting the workflow for your day. So, as a rule, I try to dictate the “interesting: report as soon as possible. You significantly decrease your colleagues’ chances of stopping you in your tracks.

Tell Your Junior Resident About The Case

Sometimes you are on buddy call or have another radiologist help you out. This opportunity is perfect for teaching your junior resident and then having them go over the case with everyone else! Firstly, this will prepare the resident to learn about a radiological finding or a disease entity. But, it will also teach your junior resident how to go over cases. And the fringe benefit is that you can get the rest of your work done!

Worst Case Scenario- Batten Down The Hatches!

Sometimes the night can get extremely busy. And, you have no time to beat around the bush. As a last resort, sometimes you have to tell the doctors that you are in the middle of doing something else. And that you don’t have the time to go over the study. If you don’t have the time, it’s not cruel to delay a third interpretation of the same case. You do have other cases to read!

The Disruptive Study- Not The End Of The World!

The disruptive study is simply part of our job. Bizarre and challenging cases spark the interest of our colleagues, and they will want to address the issues with you. Nevertheless, we can mitigate the interruptions that it will cause by calling clinicians, increasing clarity, reading cases efficiently, or telling other junior radiologists about them. And worst-case scenario, you can ask them to come back when you are ready. The disruptive study can be painful. But, at least, you have some ways to decrease the potential for it to ruin your whole day!