Category: Resident Advice

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Should Residencies Ever Rehire A Resident That Previously Left?

rehire

What is so special about the radiology resident when it comes to rehiring? Moreover, if a resident finds himself in a situation where he leaves and subsequently wants to go back, is it ever appropriate for a residency to rehire this individual? To answer these questions, let’s first discuss why residencies are so different from a regular job when rehiring.  

Why Rehiring Is So Different For Residencies?

Rehiring at a typical job and residency is not the same. For residencies, each post-graduate year has a distinct service role and responsibility that the program needs to fill, different from most jobs. Additionally, since residency is not just service (unlike a typical job), the resident also needs to meet educational qualifications in any given year. For some programs, that might mean passing specific procedural and cognitive activities. Finally, residents may need to fulfill designated milestones of differing responsibilities at each institution. So, residents are not easily interchangeable, and rehiring during residency can be challenging.

Additionally, when one leaves and wants to come back later, your program may not have the educational or financial resources to compensate the resident. For example, if you complete a different residency year and then return to radiology residency, Medicare may no longer fund your position. Or educationally speaking, a first-year most often cannot substitute for a third-year resident spot that might be open and vice versa. All these issues can also stand in the way of a rehire.

When Can A Residency Program Rehire A Former Resident?

Now that you can understand why rehiring might be so tricky, let’s discuss some of the situations that residencies might encounter that would enable the residency program to rehire a former resident. Three of these circumstances are a coincidental fortune, grants and opportunities, and institutional policies. We will go through each one of these in particular.

Coincidental Fortune

Sometimes all the stars align that allow a program to rehire a resident. Let’s take the example of a resident that was let go because of failing the Step III USMLE. At some institutions, residents need to pass the test before they reach their PGY-3 year. So, hospitals are not obligated to rehire individuals who do not pass their Step III boards after starting their PGY 3 year. 

But, let’s say the resident who failed initially was in good standing up until the boards and then passed their boards well into their PGY-3 year. Then, suppose the residency program has not filled that spot, and the former resident applied to it again after passing. In that case, the resident could be fortunate enough to retake their place (albeit possibly graduate later.) The story could have also ended without the resident able to retake their spot if it was no longer available. It was luck that enables the resident to get their job back again.

Grants And Opportunities

Other times, different programs have opportunities built into them to rehire residents after a specified amount of time. Perhaps, it is a year of international volunteering as a radiologist. Or, a resident may take off a year to complete a permissible research project in the institution. In these specific situations, programs can rehire their residents after they fulfill their time.

Institutional Policies

Finally, some institutions may have specific policies that forbid a resident from being fired. Perhaps, a residency suspends a resident but has done so without the appropriate documentation to do so. Other by-laws may force due process before termination (as long as it does not jeopardize patient care!) Specific policies in place at the hospital such as these can cause the rehiring of a resident.

To Rehire Former Residents: Not So Simple!

Residencies are much more than a typical job because of their education as well as service requirements. Therefore, rehiring former residents can present multiple obstacles due to the nuances of radiology residencies. Given these obstacles, don’t expect to regain your former position unless you do your due diligence to ensure that you still have a spot. Rehiring at a residency program is not the norm!

 

 

 

 

 

 

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Service Exceeding Education At Your Program? Do Something About It!

service exceeding education

All radiology residencies have an Achilles heel. In the pursuit of creating an excellent education for all radiology residents, programs need to balance the “service obligations” with the “educational” environment. Now, there is a lot of debate about service exceeding education. But, we all know of rotations where the service obligations seem to outweigh what you may learn on rotation. You may have a mammography rotation where your attendings need you to complete all the needle localizations at the expense of learning diagnostic and screening mammograms. Or, perhaps, you have an interventional rotation where you can’t get into cases because the technologists need the residents to consent all the patients. Regardless, what do you do when you find yourself not receiving the education you think you should receive?

How To Improve A Rotation With Service Exceeding Education? A Playbook!

Step 1- Be Specific About The Problem Of Service Exceeding Education

The first thing you need to do is to be specific and write down the particular problems in the rotation. In other words, what are the educational circumstances that your program is not meeting? If you believe that the residents don’t have enough paracenteses, write that down. If you find that the nuclear medicine attending is never in the reading in the room or is not giving enough lectures, make sure to add that onto the list. Make sure you enumerate each of those problems. Eventually, you will want to address the issues with the educational committee.

Step 2- Cross-Reference with The ACGME Program Requirements

Next, check the ACGME program requirements. See if the problem is one that directly contradicts the philosophy and regulations of the program requirements. If so, write down how the issue interferes with the program’s goals. This step is critical because programs must fulfill their educational objectives to their residents. If they do not, programs can meet repercussions from the ACGME. At worst, the ACGME may not reaccredit your program until they comply. Some corrections can be costly. You can expedite change if you document how the issues may prevent the program from meeting the ACGME bylaws.

Step 3- Document The Issues And Provide Data

Now that you have the specific issues and why they may interfere with the program’s goals, create a data trail. For example, if you are not receiving the right number of conferences every week, document all the faculty’s conferences. Or, figure out what number per week you have been receiving or the rate of cancellation of lectures every week. You will need to have some hard data when the time comes to present the issues. Objective data helps because you can eventually factually show that the fix can improve the problem.

Step 4 – Create A Plan To Fix The Problem

Come up with a financial or educational plan to solve the problem. Say your program lacks a statistician and you need one to satisfy the research requirement, come up with the potential costs of hiring one for the hospital or the program. Of course, it is a good idea to meet with your faculty to figure out satisfactory solutions. As a resident, you may lack the experience to know some of the costs and problems that the institution may encounter when they attempt to fix the problem. So, gather a team of folks that do know more about the area you wish to improve.

Step 5- Formally Meet With The Program Director, GME Committee, Etc.

Since you have already enumerated the problems, figured out how they interfere with the program education/requirements, provided accurate, objective data, and created a plan to fix the problem, now is the time to meet with the appropriate committee. You should submit the initial run through to the education committee or the program directors at the program level. Here the committee can discuss the issues and enact a plan. If the solution is not amenable to being fixed at this level, the education committee can submit the plan to the GME level, hospital level, etc. Nevertheless, you need to formally present a plan so that the program or hospital can make a solution.

Step 6- Implement The Plan

Now that the institution or residency is backing the solution, you should be part of the team that seeks to implement the solution. Make sure that the plan is working as stated and followup to check for a positive outcome. Most of the time, you will find a reasonable solution for the previous issues. (But not always!)

Step 7- Document Outcomes

Now that your institution has “repaired” the problem, you still have more work to do. Make sure that the fix is not worse than the problem itself. It is therefore vital to objectively document how the changes to the program have affected the outcomes. If the hospital institutes a policy that faculty members that miss lectures will receive a pay cut and the lecturers continue to miss giving noon conferences, the fix was not an adequate solution. So, this step is crucial to show that you have a viable solution to your original problems.

Why Bother With All This Extra Work To Remedy Service Exceeding Education?

Well, the answer to this question relatively simple. Your radiology residency program is the foundation for your future career. And, if your education is not adequate, it will reflect in your future employment.

Furthermore, this learning experience is not only good for learning how to fix your residency. It is also a great way to learn the principles to enact change in any career stage. You can adapt the same steps to almost any situation where you want to enact helpful change. So, figure out those areas in your program where service requirements overburden learning and think about ways to enhance your residency rotations using this seven-step guide. It is an exercise worth the effort!

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How To Succeed In Neuroradiology

neuroradiology

In the last part of the “how to be successful” series, we will finally discuss the ultimate rotation, neuroradiology. In our department, most residents go through MRI at the hospital as a neuroradiology rotation because most hospital-based MRI cases image the brain. Most hospital departments throughout the country work the same way.

So, what are the critical baseline keys to being successful in neuroradiology? Well, it comes down to primarily one main area of knowledge, anatomy. Location allows you to hone your differential diagnoses. So, let’s go through the primary reading material best suited to learn your anatomy. Then, we talk about a few other sources that are helpful for residents. Finally, we will discuss additional useful hints for being successful in neuroradiology with a year-by-year systemic bent.

Resources For Neuroradiology

The Best Anatomy Book

To learn your anatomy, one of the best tools is a book that many of you have read in medical school, Sidman and Sidman, Neuroanatomy. A few days ago, I found the same book, an older edition from 1965, sitting on my bookcase. The publisher again updated the book in 2007. But, the principles of programmed learning remain the same. It is very repetitive, but repetition is worth the pain. By the time you complete the book, you will remember your neuroanatomy and the terminology cold. And, you will be ready for everything else that the neuroradiology rotation can offer.

Other Valuable Resources

Several of my residents touted RadPrimer as a great way to conquer neuroradiology reading once you know your anatomy. But, if you want a great review of neuropathology, I would also check out the original edition of Osborn’s Brain. I have been hearing from several resident sources that the newer books are a bit too long. However, although a little bit dated, her original book is an excellent concise review of MRI brain pathology. It feels very thick. Once you start reading it, you realize that it contains mostly pictures with brief explanations that she organized rather well. So, look for that book if you can find it. You will not regret it.

Head and neck imaging has always been a difficult area to find excellent resources. Anatomy tends to be a bit more complicated. And, there is wide-ranging pathology. You can try the book called Imaging Anatomy: Head and Neck to help get you started along your way with the anatomy. Some of my residents liked the website headneckbrainspine.com to review head and neck pathology as well.

Year By Year: How To Succeed In Neuroradiology

Year One

As I said before, you need to learn your anatomy starting day one of the rotation. You should finish the Sidman and Sidman Neuroanatomy book as soon as possible, if not even before the rotation, so that you have a basic understanding of what you will need to know.

During the beginning days of this first-year rotation, my recommendation would be to sit down next to the neuroradiology attending and watch them dictate the cases. Initially, neuroradiology may seem like a foreign language because you will not be accustomed to the MRI lingo, sequences, and images. But, by watching the neuroradiology attending in action, you will fill in most of these gaps. By the end of the first week, you should start dictating the cases. Dictating cases will help you get the language under your belt and enable you to begin to understand how neuroradiology works.

It would help if you were emphasizing the bread and butter neuroradiology cases at this point. These include all the different types of imaging that is key to nighttime call- once again, those entities that will kill patients or are more common. So, this year you should be emphasizing bleeds, infarcts, masses, cord compression, and so forth. Although necessary eventually, the rare pediatric metabolic neurodegenerative disease should not be your focus. 

For head and neck, think about learning similarly. Again, foreign bodies, mumps, and tonsillar abscesses should take precedence over rare head and neck tumors. Also, make sure to emphasize and head and neck anatomy with all the spaces. Head and neck anatomy can be challenging for the novice MRI Neuro reader. Know not only the primary diseases, but that you can also make the findings real-time. That involves reading lots (and lots) of cases on the PACs. Don’t be a bookworm without coming out to read on a work station. (A widespread mistake!)

Years Two And Three

Now you are in “Full Metal Jacket” mode. You have the basics under your belt. And boards are a stone’s throw away. So, make sure to fill in all the gaps. You should worry about all the non-lethal, less common diseases. Read through the more significant books (like Osborne), or you should have completed the RadPrimer. Regardless, you need to know “everything” for the boards. Therefore, know your less common differentials, diseases, and more.

Also, try to take some of the cases before your attending grabs them. Then, be sure to dictate them. Pre-dictating will get you in the habit of becoming an independent reader. Don’t be a wallflower and wait. You will lose out on the critical skills of becoming an attending.

Year Four

Hopefully, you have passed your core exam by now. So, try to emphasize learning about all the other areas that you may have missed studying for call and your core exam. I would check out subjects like MR Spectrography, tract mapping, and those areas you may never see again if you do not pursue an MR neuroradiology fellowship. Here lies your last chance to learn about these more esoteric areas that you will not come across as a general radiologist. If you decide to do an elective this year, try to also work with either a neuro interventionalist or a neurosurgeon to see their perspectives on the rarer vascular cases. Bottom line: Check out all those areas you may not see again once you graduate. You never know when this more esoteric knowledge will come in handy!

How To Succeed In Neuroradiology: A Whirlwind Tour!

So there you go, anatomy once again is key to your success as a resident. (check out the books in the first section!) Localizing lesions is often the key to unlocking the differential diagnoses that you need. And, the only way to learn that is via anatomy! Of course, remember once again, take cases as much as you can because studying books by themselves will only take you so far. Finally, make sure to start your neuroradiology rotation with the most common and deadly diseases. Then, expand your repertoire on a year-by-year basis from there. With all this strategy, you will be sure to succeed on your next “tour-of-duty” through neuroradiology!

 

(I am an affiliate of Amazon and get a small commission if you click on the links to the books!)

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Teaching In Radiology: How Can Residencies Help To Prepare?

teaching in radiology

Question About Teaching In Radiology

Hi Dr. Julius,

I am an MS3 who is planning on going into radiology, have always loved teaching, and want to make it a large part of my career. I was hoping to hear your take on how radiologists can teach and any tips to shape my career with this goal in mind.

 

Answer

“What kind of teaching opportunities do you have?” is a common question that I get from my interview candidates for residency every year. Teaching is a large part of learning in most radiology programs. Almost all programs have some form of teaching opportunities. These may manifest as teaching medical students, junior residents from different specialties rotating through your department, or interdepartmental tumor boards. Regardless, you will find many opportunities to teach.

Community Vs. Academic Teaching In Radiology

So what is the difference between programs and the different teaching opportunities? Well, it comes down to the sort of teaching. More community programs tend to give you less opportunity to teach students because they may not be affiliated with a medical school. Instead, you will have more opportunities to teach technologists, nurses, and fellow physicians. And, the options tend to be less formal. 

On the other hand, academic programs give you more formal opportunities to teach and mentor research projects and other academic members within your residency, such as students, observers, fellows, and more that you would not get at a community program. And, teaching can be in larger forums. The bottom line is that teaching opportunities are not unique to one type of program or another. The styles just depend on your inclinations and your choice of program. 

Stop And Smell The Roses (And Teach!)

I believe that each resident that comes through a program should stop and take the opportunity to teach others. Teaching others reinforces what you know and helps your fellow man or woman. Plus, you wind up hearing or asking questions that you may never have thought about in the first place. These questions make for promising research projects or take you to places that will make you understand ideas more deeply than you ever thought possible. The rewards are invaluable, and the time it takes to do so is relatively negligible. 

Then, when you finish your residency, you can decide for yourself if you want to take more opportunities to teach either in academic or private practice. They are all around you. It’s a matter of what you want to pursue in your career. 

 

My forty-three cents on teaching,

Barry Julius, MD

 

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How To Be Successful On CT Rotation

CT rotation

CT imaging is often by far the busiest radiology rotation at many hospitals. Emergency departments order more studies every day to reduce disposition times and cover themselves. Physicians of all sorts bombard you with multiple phone calls.

With all these pressures for increasing attending output and less teaching every year, how can you succeed on your hospital CT rotation? Well, I will tell you the reading materials that will help you get through this rotation. Then, we will go through a year-by-year analysis of the processes you should take to succeed in this rotation. Finally, we will summarize the most critical components of having a successful hospital CT rotation.

Reading Materials On CT Rotation

There are so many areas to cover with so little time for CT rotations. Therefore, efficiency is the general theme for CT learning. You need materials that are concise and easy to understand. I am going to provide you with some of those resources.

Let’s divide the hospital CT rotation into four different areas to cover what you need to know: CT anatomy, CT chest, abdomen, and pelvis (body imaging), CT head (neuroradiology), and CT extremities (MSK). Of course, you will need to know all of them. But, the details you need to know will not be the same as the in-depth dive into MSK, neuroradiology, and chest rotations you might have. Therefore, I would start by limiting myself to materials that cover those topics that are most efficient and that are essential: cross-sectional anatomy basics, the basics of CT scans, disease entities that will kill or severely injure patients, and finally, common disease entities. Reading summary books and case review series will most likely give you the most bang for your buck in reading.

Anatomy Reading

I recommend you check out one of the cross-sectional atlases to cover the basics. I often use Cross-sectional Anatomy CT & MRI to review anatomical structures if I have a question. If you are a more junior resident, I would recommend going through this book cover to cover and looking through all the CT cross-sectional correlative images. This atlas will get you up to speed so you can make the findings for your rotation.

Body CT Reading

Next, I recommend going through a short book called Fundamentals of Body CT by Webb for your chest, abdomen, and pelvis basics of interpretation. Universally, all my residents recommend this easy-to-read summary of the key elements you need to know to understand how to read body CT scans. I used the same book (albeit an older version!) as a resident eons ago. The Emergency Imaging Case Review Series can also give you cases with acute diseases that you must know on rotation and call.

Neuroradiology CT Reading

A lot of neuroradiology comes down to knowing your anatomy. So, check out the programmed text called Sidman’s Neuroanatomy. Residents consistently hail this book as a great way to review the critical anatomy you will need to interpret brain CT scans. Additionally, many of my residents recommended Radprimer to learn the basics of neuroimaging. Finally, you may want to have Osborn’s Brain around to read about more specific disease entities. I recommend reading this book cover to cover, not as much while on CT (because of lack of time) but rather when you are on neuroradiology rotation.

Regarding head and neck cases, consider going through the Head and Neck Imaging: Case Review Series to review the morbid and familiar disease entities. It is hard to go through an entire textbook on this rotation because of the wide variety of diseases and the complexity of anatomy. However, this book will allow you to learn what you need to know about this topic. One of my residents also recommended headneckbrainspine.com as a great way to review anatomy and disease entities that you will find on this rotation. Check that website out. You will like it.

MSK CT Reading

Finally, you will need to know the basics of MSK to interpret CTs of the extremities. Once again, I would refer to Fundamentals Of Skeletal Radiology (as I discussed in the How to Be Successful in MSK blog) to cover the basics of what you will need to know at night. Many residents also touted the MSK section of Core Radiology as a great way to review this area.

Spine CT has also become much more common since I was a resident. So, it also pays to review lots of real-time cases. In particular, if you want a book, you may want to explore the Spine Imaging: Case Review Series: Expert Consult to cover your bases.

Year By Year Summary Of The CT Rotation

Year One

During this first year, you should be emphasizing anatomy the most. So, I would suggest cracking open the atlases as I described above. Anatomy will be the key to your success.

In the beginning, try to sit with your attendings and see how they interpret and dictate cases. Shortly afterward, no more than a week later, you should start reviewing and dictating cases. The more you see and do, the more confident you will be on call. So, make sure to read out as much as you can.

Also, especially in the first round through this rotation, you will need to understand the mechanics of reading CT scans. Out of all the resources provided above, the Fundamentals of Body CT is probably the best for this purpose. It will help if you read this book before you have finished the first week of your first rotation. In addition to body imaging, make sure you also read some neuro-CT materials because CT brain work is prevalent.

Finally, review the diseases and CT scans of the critical disease entities that will kill patients or cause severe morbidity and common disease entities. You need to know all these CT appearances and make the disease findings before you start taking calls in year 2.

Years Two And Three

Now that you have completed your first year and are most likely already taking calls, you must take responsibility for the cases you read. So, it would help if you pre-dictate as many cases as possible. It would also be best if you compare your reads with your attending. By reading the images first, you will get practice making your own independent decisions. This independent streak is critical for becoming a great radiologist. 

Also, start reading less common disease entities than before. Now might be a great time to explore and review head and neck CT cases, spine CT cases, and more complicated MSK CT cases now that you have more than likely become competent in essential body imaging and CT brains. It would also help if you considered reading the case series and the more detailed books to round out your education in the different areas of CT imaging.

Building speed is also a critical part of these “middle years.” You should ramp up during your four years of residency so that by the end of your time in radiology, you should be able to read as quickly as an attending. 

Year Four

At this point, you should be honing your craft. Dictations should be very accurate and efficient. You should be reviewing the source materials for all the areas of CT, just like an attending. If I have questions, I regularly look up the diseases/questions I need to know for a case. Often, it is the original paper on the topic. It would be best if you were doing the same at this point in your career. This process is called practice-based improvement. It is critical to become a great radiologist. As a fourth-year resident, you should be all about practice-based improvement!

Succeeding On CT Rotation

The knowledge base is daunting since you cover so many organ-based areas on CT scan rotations. Following the general precepts of learning your anatomy, finding suitable summary materials, and going over lots of real-time cases with case-based series books for reinforcement will give you what you need to know during your four years of CT rotations. Books are essential for this rotation, but reviewing many cases is even more critical. So, plug away and read as many cases as you can. It is the cornerstone of becoming an excellent radiologist!

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How To Succeed On Pediatric Radiology Rotation

pediatric radiology

One of the statements that you will often hear when performing pediatric radiology is the following, “Children are not just little adults.” And, nothing could be further from the truth. Many of the rules and diseases you have learned for the adult population do not apply to kids. You will find a whole new vocabulary and subset of conditions that are unique to this population. So, what does this mean for residents trying to learn pediatric radiology? Well, there is a lot to learn! So, as in the other “how to be successful” series, let’s go through some of the reading materials you will need to know, and then we will delve into what you should be doing and learn on a year-by-year rotation basis.

Reading Materials For Pediatric Radiology

Reading, like in other modalities, is critical to performing well. Therefore, I wanted to give you what I think are some of the best resources. Overwhelmingly, our residents recommended the Cleveland Clinic Pediatric Modules. And, having checked out the site myself, I have to agree. It is an excellent resource with useful summaries and pictures. Moreover, at the moment, it is free! So, I would recommend you to take a look at the site. 

If you are interested in a more traditional book, you can try the Pediatric Requisites. However, having seen the website and the online information’s high quality, I am more biased toward the modules. Plus, the modules give you excellent pre-and post-test questions. What more can you ask?

Year-By-Year Summary: What You Need To Do

Year One

Pediatrics has more procedures than you may have thought. Of course, you will need to know how to do the basics such as VCUGs, barium work, intussception reductions, and g-tube placements. Plus, you need to complete all these procedures on babies and children, some of which are very scared. And you must also deal with their parents. All this is part of your first year’s introduction to pediatric radiology. So, get familiar with these procedures and learn how to handle the interpersonal situations you will encounter. The attendings will want to have a “go-t0* resident that can help them out during the day. Learning these skills is what it takes to become part of the team. It is all key to having a successful first month.

Also, you will need to learn the basics of pediatric chest and abdominal x-rays. The litany of diseases and findings markedly differs from the adult population. Moreover, there are tons of these films you will need to interpret. So, get cracking! Also, be sure to read lots of pediatric trauma films. Fracture patterns in pediatrics do differ from adults. So, make sure to learn these. Most residents will spend the majority of their time on these plain films.

However, also get to know the disease entities in other modalities that you will encounter on-call that you will need to interpret. These include ultrasound and CT scan for pediatric appendicitis, ultrasound for intussceptions, and ultrasound for pyloric stenosis. Indeed, you don’t want to miss these pathologies at night time. So, you will need to know these entities and findings cold.

Years Two And Three

Now that you know some of the basics, concentrate on other pediatric radiology areas, you will need to know. Start getting to know the other critical disease entities that you may encounter on CT scan and MRI. I’m talking about hepatic tumors, pediatric cancers such as neuroblastoma, Wilm’s tumors, lymphomas, and more. You will need to know these disease entities for the boards.

Become more adept at pediatric ultrasound. For kids, pediatric ultrasound is a critical tool for making all sorts of diagnoses. Why? Because kids are much smaller than adults, it’s a lot easier to see delicate structures that you cannot penetrate in an adult. Pediatric radiologists, therefore, tend to play a more hands-on role than ultrasound in adults. So, be sure to watch how some of the more senior radiologists do their exams and make their more complex diagnoses.

Year Four

Esoterica should be the theme for this last year. Make sure to try to see and participate in cases that you may never see again. Maybe it is brain ultrasounds or pediatric neurointerventional workups. By the way, if there is a pediatric interventionalist, stop by the interventional radiology department and follow some of the compelling cases you started to work up in pediatric radiology. Hang out with the pediatric surgeons for a bit, especially when they workup unusual congenital abnormality cases. You may also learn a lot about new and fascinating disease entities from these folks.

Make sure to also learn about some of the other areas you may have skipped over the years. Check out the unusual congenital abnormality cases. Pediatric radiologists love them. And, most pediatric departments have collections of these either on film or on PACS. Bottom line. You should fill this year with all the gaps that you would have missed out on otherwise.

Learning Pediatric Radiology: Like Starting From Scratch!

Learning about pediatric radiology differs from the rest of radiology because the disease entities are so different. But, all with the online resources, procedures, and hands-on experiences, you will be sure to learn most of them. Additionally, clinical acumen and bedside manner will go hand in hand on this rotation. It is more critical than ever. So, don’t expect only to sit by the PACS workstations. Instead, roll up your sleeves and be prepared to get up and work. Only this way will you succeed in this excellent rotation experience!

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How To Succeed On Hospital Plain Film Rotation

plain film rotation

Even with all the more sophisticated modalities, most radiology residencies still have a plain film rotation. Sometimes this rotation goes by the moniker chest. Other times, it is more generally called plain films and includes both chest and musculoskeletal x-rays. Regardless, since we are generally modality-based and not organ-based at my institution, today, we will go through how to succeed in this rotation’s more generalized version. To do this, we will start with some of the recommended readings for this rotation. Then we will delve into some more of the specific year-by-year recommendations for achieving success.

Recommended reading for the Plain Film Rotation

Overwhelming, upon surveying my residents, one book was the clear winner for learning the basics of reading chest films. It was easy to understand and logically arranged, using the programmed learning style. Check out Felson’s Principles Of Chest Roentgenology. (I am an Amazon affiliate and receive a small commission on any purchases through the links!) When you complete this book, you are ready to start reading films. On the other hand, for those of you who prefer an online tutorial, some of my residents like the University of Virginia chest tutorial to help with the learning process.

As I had mentioned previously in a discussion of how to succeed in MSK imaging, I would also recommend Fundamentals of Skeletal Radiology to learn the basics of reading films on this rotation. Specifically, it has a reputation for helping out with trauma and fractures. But, it will get you started reading with what you will need to know on this rotation. Finally, I would also advise you to have a copy of the Keats Atlas of Normal Roentgen Variants That May Simulate Disease: Expert Consult by your side to help you distinguish normal variants. Knowing normal vs. abnormal is probably the most challenging part of being an excellent plain film reader. And, most departments have a copy of this book lying around somewhere in the dark!

Finally, I want also to emphasize that reading is supplemental to looking at films on rotation. It will never replace sitting down and reading studies at a PACS station. So, don’t disappear to go reading books during the daily rotations. You will only be hurting your residency education!

Year By Year Learning Recommendations For Hospital Plain Film Rotation

First Year

Learning By Doing!

In the world of x-rays, reading books is not enough. Every first-year resident should be immersing themselves in reading cases live on a PACS. Even better, during the first few days to a week on this plain film rotation, they should sit with an attending and watch how they make the findings, interpret the images, and dictate cases. In the times of Covid, this exercise may be a bit more complicated. However, it is critical to read x-rays in this way and return to a semblance of normalcy, especially after the pandemic ends. (It will eventually!) You need to go through this exercise to understand the mechanics of how your faculty reads the films.

Soon afterward, all residents should dictate the cases themselves after going through the images with an attending. Remember also to try to take notes on the relevant cases before dictating. You don’t want to forget the findings that the radiology faculty told you to add to the dictation. Residents should try to get through as many cases as they can.

How Much To Read

Back in the day, we would measure the number of cases read based on boards. (I’m dating myself!) Each electric panel would have around 20-30 cases. First years would go through up to one full board of films each day on rotation. That number is a reasonable goal for most first-year residents when they finish their first rotation in plain films.

Second And Third Years

Now, it is time to take the proverbial bull by the horns. Since you have learned the basic mechanics of looking at and dictating films, it is time to mix up the equation a bit. Try to read some cases independently and then go over the results with an attending afterward as she is signing off the reports. Reading cases first by yourself allows you the independence of making decisions and gives you insight as to what you missed and what you can do better. It is the ultimate way to get feedback on every one of the cases that you read. I would also recommend occasionally sitting with an attending, especially ones that you may not have worked with as much, to get to know each faculty member’s style. You can still learn a lot about watching how each reader operates the plain film station.

At this time, you should be able to get through at least the equivalent of two boards or up to 60 films at the end of this rotation. That would be an entirely reasonable goal.

Fourth Year

During your final year, you should be reading cases entirely independently. Of course, your attending will need to sign off on the cases at the end of the day. So, at this point, you should pretend that you are the attending, except that you should check the results of your dictation with the final read. Of course, if you find a complicated case or you have a question during the day, you should ask your attending what you should dictate/do. But for the most part, you should be able to the cases entirely by yourself. As a fourth year, you are very close to reading cases independently as an attending, and you should act like one!

Plain Films- Still Part Of The World Of Radiology

As much as we love to read all the more complex and sophisticated radiology modalities, most practices have their radiologists read plain films. Chest films and basic trauma radiology serve a critical need. And, we have not found any reasonable way to replace them. So, don’t poo-poo the plain film rotation. As an attending, most practices will expect you to read lots and lots of films, even in the 2020s. So, get cracking. Start learning to read plain films well during residency so you can hit the ground running when you begin your first job!

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How To Succeed In Fluoroscopy

fluoroscopy

Since at least I was a resident, radiology faculty considered fluoroscopy to be one area in radiology that residents just learned “on their own.” Books never helped all that much with the mechanics of completing an upper GI series or barium enema successfully since it is more like a technical skill. Additionally, only a few attendings were willing to teach the mechanics a GI workup. Each one had their way of completing a study. And like a snowflake, no two attendings would ever have an identical method of conducting a fluoroscopy study. Many of us would resort to learning the specialty from other residents instead. So, to say learning fluoroscopy was difficult is an understatement!

Fast forward to today, and I believe it has become even more challenging for residents to learn. Why? Because fewer and fewer attendings take a keen interest in the art of fluoroscopy, even more so than before. Most faculty would rather be elsewhere interpreting and performing the newer modalities, whether MRI, nuclear medicine, or interventional radiology. Moreover, books about barium slinging have not changed much in the past 20 years or so. And after surveying my residents, they are still not so comprehensive or easy to understand. Nowadays, fluoroscopy has become more of a hodgepodge of studies than ever before. We have more bariatric studies, presurgical cases, and fewer and fewer bread-and-butter upper GI series and barium enemas. In the state of New Jersey, they don’t even sell the equipment for double-contrast barium enemas anymore!

I’ve ranted enough, incoherently! So, with all these obstacles in your way, how can you succeed on a fluoroscopy rotation? Let me give you a few pointers, including some so-so books that you will need, some general guidelines, and some more specifics using the usual year-by-year format about what else you need to do to succeed. I will emphasize year one because this is by far the most challenging year of them all.

Fluoroscopy Reading Materials

I will make this section relatively brief because after surveying multiple residents and knowing what I know about fluoroscopy, no one book is adequate for learning what you need to know. Nevertheless, here are a few suggestions from the peanut gallery. A few of my residents liked a book called Introduction To Fluoroscopy For Residents & Professionals Alike. (I am an affiliate of Amazon when you click any of these links to books on this page) It teaches some of the basic techniques of fluoroscopy, and they found it somewhat helpful. Again, it does not replace the experience of watching a colleague perform a study.

Additionally, some residents recommended Mayo Clinic Gastrointestinal Review for those who want to learn more about the pathology itself. This book is beneficial when you have a case with a specific pathology, and you want to learn more. Finally, you can always use other resources, such as Google and Radiopedia, to look up information. But, if you desire to read books, these are some of the best options.

Basic Guidelines For Performing Fluoroscopy

Listen, Watch, And Take Notes

The first and most critical item on the “to-do” list is to watch and listen carefully to your fellow residents or attendings who will show you the mechanics of what to do the first time. Take notes about exactly how they administer the barium, position the patients, snap the x-ray spot views, and turn them on the table. You want to have all this information in your working memory to emulate your teacher when you do your first study by yourself. So, you want to recite these steps for each procedure ad nauseam so that you can repeat them in your sleep. Furthermore, the books don’t cover all the technical information you need to know, as I said above. You can’t look up a fact or technical issue while the patient is drinking oral contrast!

Take Adequate Histories

Fluoroscopy studies are tailored examinations to identify something specific that both the ordering physician and patient want to be answered. I can’t tell you how many times I see first-residents going over a study only to realize that they skipped over the critical part. For instance, with a patient with dysphagia, you need to look at the upper esophagus and swallowing mechanism more closely. An esophagram that does not look at the upper esophagus is useless with this history. If you don’t know the problem, you will focus on the wrong information.

Complete As Many Procedures As You Can (Don’t let others do them for you)

Like in interventional radiology, the key to becoming an expert in fluoroscopy is to do lots of studies. Two or three barium enemas do not make you an expert. You need to understand the nuance of the techniques and how to tailor examinations to patients. The only way to do this is to practice. And, the more, the merrier!

Dictate All Cases And Remember Relevant Priors

Finally, whenever you complete a procedure, the person in the suite real-time needs to dictate it. Even though the attending may understand the case more than you do, she was not there at the examination. And, she will never be able to describe all the events that happened there. So, the performing resident must dictate the case.

Also, it is vital to remember to compare to relevant priors. Anytime a patient comes in for a GI examination, I always look for the prior chest, abdomen, and pelvic CT scans. I can’t tell you how many times I uncover why the patient is coming in for the procedure when no one else knows. Sometimes, even the patient does not know. It could be a questionable diverticulum or a leak that the radiologists saw on another exam. The only way to know for sure is to look at the priors!

Year By Year Outline Of How To Succeed in Fluoroscopy

Year One

By far, year one of fluoroscopy is the hardest. You have no clue what to do, and the surgeons and physicians that order these tests are unforgiving. Moreover, the patients themselves can be challenging. Some GI patients (more so than other patients) have other psychiatric ailments that can make cooperation difficult at best. So, how do you proceed? And what should you be focusing on this year?

For the first week or so, you should be watching and listening very carefully. And then, you should be performing as many cases as you can. Get to know the technology and fluoroscopy tower. Familiarity is key.

Especially during the first year, you also need to focus on taking histories and basic techniques. Also, practice improving your bedside manner. Patients will appreciate it! 

By the end of this rotation, your goal is to become entirely independent to perform your studies before the second year. No studies in fluoroscopy are off-limits. Remember. Although not impossible, it is hard to hurt a patient with a bit of barium. (although I’ve seen it happen!) But, if you have any questions, be sure to ask your seniors and faculty.

Year Two

You should be focusing on more than just technique at this point. Instead, you should tailor the exams appropriately for the case at hand. If there is stomach pain, look for gastric and duodenal ulcers. And so on. Your goal should be to become a valued consultant to the ordering physicians. It is much more challenging to do this during your first year because of the focus on the technique. It easy to forget everything else!

Years Three And Four

During the last couple of years of fluoroscopy during residency, you should concentrate on continuing to refine your technique to get patients on and off the table quickly and efficiently. You should also spend time teaching your fellow junior residents. Teaching reinforces all of what you had learned the previous years. It will also make you much better at fluoroscopy as an attending when the time comes. At this point, you should feel comfortable with almost any study that comes into the department. 

Summing Up Fluoroscopy

Although many folks consider fluoroscopy to be one of the ancient and dying arts in radiology, it continues to have critical patient care uses. Accordingly, you will still need to learn the techniques and skills to become a great fluoroscoper. You will need to sharpen your history taking skills, hand-eye coordination, and dictation abilities. It is still a great way to learn radiology. But, no one said it was going to be easy! 

 

 

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How To Succeed In Interventional Radiology

interventional radiology

No. I am not an interventionist by any stretch of the imagination. But I do have a clue about how best for you to succeed in this rotation. Let’s call it years of experience and intuition based on our interventional radiology rotations’ best residents. On this note, we will return to the How To Succeed series this week again, this time in Interventional Radiology.

When we compare interventional radiology to other subspecialties, it has less in common with other radiology areas. Why? Because it overlaps more with many of the features of other surgical subspecialties. So, it would help if you changed your mentality to succeed on this rotation. Let’s delve into what you need to succeed on this rotation and how you can adapt to the new expectations. First, we will discuss reading materials and the basic mechanics of what you must do. Then, we’ll talk about when you should learn the different aspects of interventional radiology.

Reading Materials 

Fortunately for some and unfortunately for others, reading plays a little bit less of a role in this subspecialty rotation in the traditional sense. Of course, you must read about cases and how to perform them. But, most of what you need to know for this rotation is experiential. For example, using the wires for a fistulogram is the best way to learn about them. The most salient way to understand the angle you need to use to approach a liver biopsy is to do it.

No amount of reading will allow you to translate everything you need to know to a successful procedure. You need to watch, perform with guidance, and finally complete a technique independently. There is almost no way around it. Therefore, your goal on this rotation should be to get into as many cases as possible.

Background Reading

Even though reading is not the central focus of this rotation, I will give you some background reading resources that some of my successful interventional residents have used. These include readings in the newly written book Vascular Interventional Radiology- A Core Review. Our residents also use Core Radiology and the Vascular and Interventional Case Review Series. Finally, one of my former residents (now an interventional resident) recommended looking at a book called Image-Guided Interventions. This book would be more for the gung-ho budding interventional radiologist, but it is another option. You can click on any of these Amazon links to purchase these books (I am an Amazon Affiliate and get a small percentage).

Other successful residents will google all the devices, wires, and other hardware every time they use one. All successful residents will look up information on significant cases the day before they perform them if they can!

Fundamental Doctrines Of Interventional Radiology

Here are some general guidelines for interventional radiology residents to maximize their interventional radiology experience.

Consent All Patients Early

Every single one of my successful interventional residents has said the same thing, “You need to make sure to consent patients as early as possible before a procedure!” If you cannot consent your patients before the procedure, you will not have the appropriate history that you will need. And your prep time will be taken by having to consent these patients. This consenting process will interfere with your getting into other procedures during the day. And a vicious cycle ensues. What does this mean? It would help if you got up early to start the process before the day’s procedures begin. There is no way around this!

Build Trust With Your Attendings

In interventional radiology, you will need to build trust with your faculty more than in almost any other specialty. And the reason is self-evident and straightforward. These radiologists are the key to allowing you to do more and get more “hands-on” experience. If a faculty member does not trust you, you cannot perform procedures. So, listen carefully to what your attendings have to say. And follow their instructions. Most importantly, do not forget to do something that they ask. I guarantee that being lackadaisical will ruin your entire experience!

Get Into As Many Interventional Radiology Cases As Possible

If you want to perform well in interventional radiology, your days will be non-stop. You will need to get involved in almost all the procedures you can. The experience counts, and there is no way around it. Why? Because to understand how to complete cases, you need to see and do them. You do not want to become an attending and perform a manual procedure you have never seen or performed!  

Therefore, you may not want to pause in the break room for too long for this rotation. There is time for that when and if you become an interventionist. Now is the time, however, to keep the department moving so that you can get into the next case! So, help get patients in and out of the department, take histories, and get consents. It’s the only way to maximize your case time!

Read The Night Before

Finally, any interventionist worth their salt will tell you that you must read about the procedure and the disease entities the night before. Look up the disease entity, the history you need from the patient, the technique, the wires required to complete the procedure, and how to finish it. You will enjoy what the interventionist is doing more the next day because you will understand the whole process. Furthermore, your attendings will be impressed with all that you learned. Even though you may be exhausted the night before, you should never skip this step!

Guidelines For Each Year Of Interventional Radiology

Year One

Just like surgical interns, you need to know the basics before getting heavily involved in the procedural aspects of interventional radiology. The first year is the best year to learn how to consent, take an appropriate interventional history, make orders, do tube rounds, and discharge patients. You need this background to get to the next step! 

Of course, many of you will get to start doing some procedures, but there is a lot more to interventional that you need to know. As a background for the rest of your time in interventional radiology, you should learn all these other tasks in your first year. Reading about procedures or learning about cases the night before is also vital, even though you may not get to help out as much with the manual techniques this year.

Years Two And Three

You should learn the “bread-and-butter” interventional radiology procedures during these two years. Get involved in biopsies, PICC lines, catheter placements, and nephrostomies. These are the procedures your attendings will allow you to do more, especially if you have established their trust. And you will build up your repertoire slowly. You should be able to perform these procedures as a general radiologist when you leave residency. Make sure to learn them well and execute them many times!

Year Four And Beyond

Year four is the time to get involved in the bizarre, complex, and engaging. Help with oncology cases, stent placements, uterine fibroid embolizations, and neurointerventional procedures. Get a sense of some of the more intricate techniques. These rotations may be the last time you will see the more esoteric aspects of interventional radiology. But the experience will be invaluable!

Completing Your Interventional Radiology Rotations Successfully

Anyone who says their interventional experience was easy will probably not maximize their opportunities to learn the subspecialty. To understand what you need to know and be successful, you should be busy in interventional radiology. You should actively take histories, consent patients for procedures, read up on patients/diseases, and get into as many cases as possible. There is no way around it. Experience is the crucial element of this subspecialty, and you desperately need it to succeed. You can not get ahead by sitting back on this rotation. So, take advantage of the opportunities that your residency affords you. Regardless of whether you go into interventional radiology as a career, this experience will go a long way in making you a well-rounded radiologist!

 

 

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How To Be Successful In MSK Imaging

successful in msk imaging

We’ve been through the first two parts of the how to be successful series, nuclear medicine, and breast imaging. Part three, today, is all about how to be successful in MSK imaging. Like the previous weeks, I will talk a bit about the reading materials for this rotation and discuss when you should learn what. All the text links to books in this summary will lead you to Amazon, where I am an affiliate. Afterward, I will give you some more final thoughts about MSK imaging in general and how you can succeed in this rotation.

MSK Reading

MSK reading is a bit more varied than some of the other rotations and more decentralized. Different books are better than others for various topics. Because you need several different books on this rotation, it can be a bit more expensive. If you can try to borrow some of the books, you can save a bit of money. But if you decide to purchase them, they are good references to have nonetheless. Either way, using multiple books on this rotation will be much more efficient for studying MSK than using just one because no one book is comprehensive and intelligible enough for both the core examination and real-world practice.

In the following sections, I will divide what you need to read by each year of MSK. We will cover the following topics: trauma MSK, arthritis, musculoskeletal MRI, bone tumors, and other miscellaneous topics like musculoskeletal ultrasound.

First Year

First, you need to learn bone and joint plain film anatomy. So, in the beginning, especially, you will want to know about normal anatomy to get a better sense of how the different sorts of fractures look. If you are a first-year resident, review your anatomy books again from medical school (i.e., Netter’s or a cross-sectional atlas like Cross Sectional anatomy CT & MRI). You will then want to start with a book of the basics about common types of fractures, especially in an emergency setting. One of the resident-recommended books for this stage as a first-year resident would be the Fundamentals Of Skeletal Radiology. I used something similar many years ago. This book gives you some of the essentials of what you will need to know.

First Or Second Year

After knowing the critical information about MSK injuries, you will want to continue staying on the plain film theme and learning the arthritides. This topic is more about outpatient MSK imaging, but it is also critical for learning to become a consummate MSK imager. One classic book that I found very helpful is the book called Arthritis in Black and White. It is a classic, but it briefly summarizes the findings and distributions of different types of arthritides with pictures to help you out as well. You can read this one also during the first year of MSK or early in your second year.

Second Or Third Year

As a second and or third year, you also need an intelligible MRI MSK book that will give you all you will need to understand and interpret MSK MRI, a common area of difficulty in residency because of lack of exposure. Be careful not to buy the wrong book because many books make this fairly intuitive topic into something more complicated than necessary. So for this subject, check out Musculoskeletal MRI. I found this book “way back when” to be an excellent source for elucidating MSK MRI’s mysteries. It was one of my all-time favorite books in radiology because the author’s style is easy to read and logical. My residents still like it to this day.

Final Year

Finally, toward your last rotations before the core exam, you need some resources to fill in the blanks like bone tumors and MSK ultrasound. For these topics, many residents will look at MSK Case Series Review. Cases are the key to knowing the different types of bone tumors. If you want a more generic overall summary of these miscellaneous topics, you can check out the Musculoskeletal Requisites book.

All Years

Be sure to use a reference tool to check out normal variants, especially for the bones. Have a copy of Keats Normal Variants Atlas available when you read cases. You can also google your images, but it is easier to have a normal variant book handy. I often use this book when I am unsure if what I am seeing is pathological or normal.

Other Thoughts About MSK Imaging

In MSK imaging, especially, you need to be a little more definitive than other areas in radiology. If you see a fracture, call it a fracture. Don’t beat around the bush. You will find that Orthopedists and Emergency Physicians alike will need your final diagnosis to make their final treatment plans or surgeries. So, saying that you are not sure won’t cut the mustard unless, of course, there is real uncertainty in what you see on imaging.

Also, try to get to know your Orthopedists and ER physicians to determine how your calls correspond to what they see clinically or in surgery. Or, even better, examine the patients yourself after making a call. It is a great way to get to know if your diagnoses are correct.

And finally, for those who don’t have as much exposure to MSK MR, I would try to look at the cases that your attendings read on your own time. Then, compare your conclusions based on the history and images to the dictations of your attending. It’s a great way to learn what you need to know.

How To Be Successful In MSK Imaging

To become successful in MSK imaging, you need several ingredients. First, you need the right books (unfortunately, a lot of them for MSK!). It would then be best if you had the right attitude (coming down a little bit harder on diagnoses than some other subspecialties!) And then finally, you need a good point of reference for your calls (correlate with your patients, ER physicians, and Orthopedists.) If you utilize these resources, you are bound to become an excellent MSK imager!