Category: Resident Advice

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Do CAQ Fellowships Add Any Additional Benefits?

caq

Have you ever wondered why some subspecialties have a separate certificate of added qualification (CAQ) while others don’t? Are there any advantages to getting these added certificates? Or is it just another degree? If you hate taking additional tests, why would you even bother with another examination to get one? I know that these are some of the questions that I have thought about a bit. And this is a great forum to answer them!

The Main Subspecialty Certificates Of Added Qualification

What are the officially recognized CAQ specialties by the American Board of Radiology (ABR) certificate of added qualification? As listed in the link above, the three most common that radiologists typically complete (from most popular to least popular) are neuroradiology, pediatric radiology, and nuclear medicine. The ABR also lists Vascular and Interventional radiology as a CAQ specialty. But, in reality, it is now a distinct full-blown specialty with a separate board and residency program. And then finally, it also lists hospice and palliative medicine as well as pain medicine as two more options. I don’t know of any radiology residents who have completed these subspecialties CAQ after a radiology residency. But, I am sure there are a few out there somewhere.

How Did Some Subspecialties Become CAQ Subspecialties And Others Did Not?

For the CAQ subspecialties, an academic cohort of individuals decided to make specific qualifications for their subspecialties. Sometimes, it was to limit encroachment from other specialties upon their turf. Or, it was to protect the subspecialty’s interest and maintain minimum standards.

Other subspecialties that do not have a CAQ, never had enough members to put in the effort to create a CAQ. It takes a bit of work and money to create an entirely new CAQ exam and all the bureaucracy that accompanies it!

What Are The Privileges/Disadvantages That CAQs Provide?

Financial/Job Advantages?

Sometimes, practices and hospitals ask to have certain subspecialists on their staff. And, in particular, they often want CAQ subspecialists. Why? Well, because frequently, other physicians or hospital administrators demand them. This demand may give you a slight advantage when you eventually go out into the job market. You may find that these subspecialties can add a few dollars to your starting salary when you begin to look. For instance, interventional radiologists and mammographers have commanded a higher salary in the recent past out of the starting gate.

Moreover, some hospitals require credentialing in specific subspecialties for their staff members. You can often see these in job board descriptions if you look at any online radiology job site. If you don’t have these credentials, you will be unlikely to get that job!

Legal Advantages (Or Disadvantage)

As a CAQ holder, you have the privilege (or disadvantage!) of the legal world considering you an expert in these fields. What does that mean? First of all, the courts hold your reads to a higher standard than other Joe Shmo general radiologists out there. In a positive sense, your subspecialty read will carry more weight in the court of law. On the downside, it also means that there will be a lower threshold for misdiagnosis than a typical diagnostician.

Additionally, the CAQ will allow you to have some “street cred” if you decide at some point to go ahead and perform expert legal work. Lawyers love having subspecialists on their payroll to convince jurors one way or another in malpractice lawsuits.

Pigeon Holing

If you are neuroradiologist and hold a CAQ, you are more likely to work at the facility, and complete neuro reads. Of course, this work can be great if it is the lot that you have chosen in life and you are happy doing it. However, it may pigeon hole you into becoming a neuroradiologist even if you are not so fond of the subspecialty work. So, beware of the subspecialties that you choose!

Surveys

If you like making some extra dough on the side, becoming a CAQ subspecialist opens up a few doors to get these subspecialty surveys. Typically, these surveys pay a little bit better than more general ones because of the laws of supply and demand. You are now less one of a fewer number, so you are needed more!

Bragging Rights

And, then, of course, you have the added benefit of bragging rights. If you happen to work at an academic facility, these bragging rights become more important to maintain your status in the field. And these institutions base promotions on their credentials. And, yes, the CAQ counts as another hoop in this game!

Testing

Finally, you will need to pass a qualifying exam in whatever CAQ subspecialty that you choose. For those of you who have had enough testing over the years, this added test may be more than you can bear.

Do Non-CAQ Specialties Have Any Meaning?

With all these inherent characteristics of CAQ specialties, do fellowship specialties without any CAQ have any meaning? Of course, they do! The point of any added subspecialty training, regardless of subtype, is to get additional training in areas of interest. And if you are telling me that a fellowship in Cardiac MRI holds no value because there is no ABR CAQ, you are suffering from CAQ delusions of grandeur. Fellowship training with CAQ or not is only as useful as what you learn during your fellowship. And, there are lots of imaging procedures to learn with or without an official CAQ!

My Whirlwind Tour Of The CAQ World

So, there you have it. Now you know what you need to know about the basics of the CAQ subspecialties. Being CAQed certainly has its privileges and its downsides as well. Make sure to enter this data into your choices when/if you decide upon a fellowship!

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Forgot To Look At The Priors? Disasters Can Happen!

priors

There are a few tenets in radiology that are unbreakable. One of these doctrines is to always look for priors. So, what are some real stories about what can happen to you if you forget them? To bring home this point, I will give you four examples of what can happen if you leave out the prior exam. The results speak for themselves. And these are just the tip of the iceberg!

The Phlebolith That Just Gets In The Way

New radiologists, especially, will often have a disease called happy eye syndrome. They make a diagnosis and forget about everything else. One of these critical steps they forget is remembering to look at priors. And, one such resident happened to do just that. One night, a resident saw a calcification probably in line with the ureter. And the urinary tract collecting system was slightly prominent. And, she called it an obstructing 6 mm stone.

The next day, the overnight attending looked at the case and saw the same calcification at the same location four years ago on a previous with and without contrast CT scan. And, it was not even associated with the ureter!

So, what happened to the patient? The surgeon sent the patient for surgery. But fortunately for the patient, they never got to operating suite. A well-placed phone call from the morning attending prevented an unnecessary operation. But, that was surely a close one!

The Overnight V/Q Scan- Not Just A Harmless Test!

Very commonly, the resident at nighttime use the V/Q scan as a means to sharpen their skills. But, it is not necessarily a safe test if not used the right way. One night, a resident called multiple mismatches at both lungs with a negative chest x-ray as a study highly suspicious for pulmonary embolus. And, correctly so, of course, if they didn’t have the priors!

So, the overnight physician started the patient on a course of coumadin. Guess what? The next day before the attending came into the hospital; this patient developed a change in mental status. And, the CT scan showed a focal hemorrhage. Now, whether the cause of the bleed was this coumadin dosage is debatable. But, once again, it demonstrates the power of the prior!

The Angry Oncologist (And Patient)

Typically, oncologists order studies to decide whether or not their patients should get a change in chemotherapy. In one such case, one attending read a lung cancer oncology chest, abdomen, and pelvis. There were lesions in the bone, liver, and lung. He reported the results, never bothering to check the script and the request for comparison to priors.

It turns out this patient was on an experimental protocol that demanded precise timepoint interpretations compared to the previous study. Due to the lack of description of change on the CT scan compared to the priors, the oncologist could not determine what to do next. Since the new results did not come back until after the deadlines, the study removed the patient from the treatment protocol! Bye-bye successful therapy!

The Thyroid Nodule From Hell

Thyroid nodules seem to be a common indication for a thyroid ultrasound. And, many of us consider ultrasound to be a relatively benign informative examination. But, so not so much for this next unfortunate bloke.

One radiologist interpreted an ultrasound thyroid examination as a suspicious 1.5 cm nodule at the right lower pole of the thyroid. And, he decided to recommend a biopsy. Of course, in small letters at the bottom of the technologist’s report, the technologist said the patient has two different MR numbers, and please compare these to the priors. Unfortunately, the radiologist missed this statement.

So, the endocrinologist sent the patient for a biopsy. Also, unbeknownst to the interventional radiologist, the patient never knew that the patient had priors. Well, what happened? Of course, the radiologist completed the biopsy, and the patient developed a large hematoma in the neck with associated complications. And, only afterward, the referring physician realized that the patient did have another study. Guess what, the nodule was stable all along and didn’t need a biopsy. The patient was stuck with a needless nasty hematoma!

Priors: Don’t Forget Them!

I think you get the point. But as painful as it may be to hear the same recommendation again, it is worth repeating over and over, don’t forget the priors. These are just a few of the potential disasters that lie in wait for you if you break this tenet of radiology. And, it’s a great way to disrupt the chain of excellent patient care!

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Passed The Radexam Precall Quiz? You May Still Not Be Ready To Take Call!

radexam precall quiz

Ask ten different program directors on how they decide if their residents are ready to take calls and place them in the same room. You will most likely get ten different answers, plus a heated debate (maybe a fistfight or two!) But, I have witnessed some residents who have passed the Radexam precall quiz perform poorly on call. Likewise, I have seen residents with borderline or failing scores on Radexam make a stellar performance when they start overnights. So, what is it that the exam is missing? I think I have it all figured out!

When we look at the skills that you need to succeed at nighttime, there are three general categories: reading, picking up findings, and professionalism. The Radexam tests the first part, knowledge, and I believe it is acceptable for this purpose. But, it leaves out the other two essential categories. Fortunately, most residents are professional, and you can observe their professionalism during their first year, so that category is not usually difficult to assess. However, the ability to pick up findings is a whole other kettle of fish. Some residents can have a vast knowledge base, yet have a tough time making the calls on a film. If you don’t test for it or observe it, you may miss these prospective call-takers. Houston, there may be a problem!

What Can You Do To Improve Your Finding Skills?

If you think you might be in this boat, what can you do to improve your finding skills? Well, several different techniques can help to improve your skills. The first and most obvious way to improve this skill is to read through lots of cases without knowing the answer beforehand. In today’s environment, in some programs, it is effortless for some residents to slide by without having to make any decisions on their own during the first year. These residents will typically either sit by the attending and watch them make all the findings. Or, they will continue to read books during the day without being an active participant in the case. If you want to learn the skill of making findings, passive learning techniques such as these don’t cut it. You need to flip through the cases on your own!

Additionally, you need to use materials that use lots of images. Now, this is a widespread first-year mistake. Many first-year residents continue to study like interns and read lots of materials without looking at the pictures. In radiology, you need to do the opposite. You need to look at lots of pictures and then read the content. To find appendicitis, you should see at least a hundred different cases before you can readily identify it. Some instances are subtle, and others not so much. Looking at all different sorts of examples of a particular disease entity will eventually get you to the point where you can easily make the findings without as much mental effort.

And finally, there is a subgroup of residents who have not read one lick during their first year. If you don’t know what the different disease entities are, how will you find them? However, this group overlaps with the lack of professionalism and lack of knowledge groups. Most residency directors can pick these folks out. And then, it’s a natural remedy. Read more!

How Should Program Directors Test For This Skill?

Direct observation is the key. Just utilizing a test like Radexam only tests the knowledge component and cannot substitute for observing a resident taking real cases.

Now, at some programs, the faculty may not have much time. But that is not an excuse. Testing residents before overnights is the moral and ethical thing to do. How can you allow a resident without the proper tools to take care of patients? It is unjustifiable!

To test residents for finding skills, I typically take a series of 10 reasonable overnight sorts of cases and watch how they perform when looking for the findings. Usually, I make sure that the residents can get about 2/3 of them right. I’m sure there are other ways to do the same thing, but I have found it reasonably simple to find a group of typical on-call cases.

Also, in the real world, you do not have the luxury of infinite time. So, we make sure to limit the amount of time per case. This simple process can quickly identify residents that are falling off the bell curve because they take to long to look at a case.

Are You Ready To Take Call After Passing The Radexam Precall Quiz?

Well, for those of you that are finishing up their first year, right about now, make sure that you continue to go through cases even after taking the Radexam Precall Quiz. If you don’t have a formal method to check whether you are ready in your residency, please make sure to ask your faculty or a senior resident to observe you. Sometimes you need a second set of eyes to ensure you are on the right path. If you want to get an idea of some of the cases for testing in our residency program, I will refer you to the previous years’ pre-call quizzes on this website for a nominal fee. Check them out! Otherwise, make sure to go through your institution’s classic cases without knowing the diagnoses beforehand. This process works to make you a better on-call radiologist!

 

 

 

 

 

 

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How To Do Remote Learning The Right Way

remote learning

Not all programs are alike. Some have advanced IT departments that will create whatever materials the faculty wants. Others have barely entered the digital era. Regardless of how far along the curve your program or hospital sits, we’ve all been thrust into this brave new world, now that residency programs and radiologists demand social distancing.   So, let’s look at the requirements that remote learning tools should satisfy to be successful.

If you are looking to apply to programs, ask whether the residency has these tools. Or, if you are a resident or faculty member in a residency program, try to push the residency to get them. Residencies that do not have most of these remote learning tools are way behind the times!

What Do Programs Need  For A Successful Remote Environment?

HIPAA Compliant Online Meeting Places

As much as I am a fan of Zoom, it  does not allow for safe discussions about sensitive subjects. Just take a look at this Forbes article from the end of April 2020. We certainly cannot entrust private conversations about patient cases in this environment. Residents and attendings alike need to discuss patients in a setting where they don’t have to worry about hackers entering a meeting. If your hospital or imaging center insists on your radiologists using Zoom or other insecure remote viewing tools to look at patient images and information, it can put the patients and radiologists at risk.

Remote Application With Ease Of Use

What good is a remote tool if it takes you 2 hours to get on the network? We need to be able to reach our intended colleagues and fellow residents rapidly. Sitting in front of a computer and waiting a half hour to get past the initial page is not acceptable. All the remote tools must be quick  use for anyone to logon.

Also, remote access tools need to be turnkey. We should be able to rapidly learn how to use them and have our colleagues respond accordingly. Moreover, hospitals should have networks to enable easy access to these resources.

Attendings and residents alike should use these online tools to go over cases and procedures together. Any faculty member or resident should contact each other with them at any time during the workday for learning.

Online Radiology Library

We are no longer in an era where we should need to have one resident wait for someone else to finish reading a radiology text from the library. All residents should have immediate access to both standard textbooks and relevant radiological periodicals online. Any hospital that does not allow for this needs to get with the times. A well-read resident should have all the reading materials that she needs.

Remote Noon Conferences/Scheduling

In addition to HIPAA compliant meeting places, all residencies should have their attendings ready to give noon conferences on the remote access tools. And, that implies all faculty members that provide lectures. It is no longer acceptable to have lecturers unable to give a noon conference because they do not know how to access or utilize the remote meeting applications.

Remote Attendance/Check-ins

Many programs have their residents digitally check-in in the morning or at the start of a noon conference to document that they have attended. Additionally, programs should have the online logs of cases that residents have performed or watched, not just for the six-month resident evaluations, but also for the program itself. This documentation helps with compliance to show that the residents have completed the appropriate requirements of residency. If public schools throughout the country can utilize remote attendance, radiology programs can undoubtedly do the same!

Acceptance Of The Remote Learning Environment

Finally, and probably most critically, all programs need to create a culture where we embed these tools into the fabric of the daily work. All attendings and residents alike should feel comfortable using these remote learning tools. And, they should make use of them whenever possible. There should be no excuses as to why the players within a residency program can’t work with the remote learning tools!

Remote Learning: The Way Of The World

Remote learning is no longer just a fancy accoutrement or add-on to a residency program. It has become a requirement that all residencies should  satisfy to maintain the health and welfare of the residents and faculty alike. These factors should be the bare minimum for a successful residency experience. My advice: make sure your program takes remote learning seriously. It is a necessity for radiology learning today!

 

 

 

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Get Back To Work Now, Will You!

work

Many of us have experienced a recent hiatus from our regular radiology activities related to decreasing imaging volumes. It has been not uncommon to work one, two, or more days less per week than before. Although you may not have wanted this pathway to less work, it has had some positive effects. We have more time at home. Many of you have restarted long begone projects unrelated to the radiology world. Others have begun to re-experience their family life after years of being pulled this way or that.

But now, if your practice or hospital is anything like mine, we have begun increasing our workload. For some, this may be a bitter pill to swallow. We have experienced a taste of an alternative life, the life we could have had if we had an alternate career, or have worked part-time. And, I have a sneaking suspicion that for some radiologists out there, this change may eventually become permanent. But, most of us want to get back into the swing of things. How can we get back to a more regular working existence in radiology after such a long break in the action? Here are some suggestions.

Remember Why You Went Into The Field

Most of us, residents and attendings alike, can think of a time that we made a finding or came up with a differential diagnosis that changed a patient’s life. Or maybe, you can remember a time when you put that stent into a patient’s leg, and the patient could walk without pain afterward. Picture how these moments felt. Think about how they had attracted you to the field of radiology.

Find Some Great Cases And Discuss With Colleagues

Maybe we are no longer on top of one another in the reading room. But, there is always room to pick up an unusual case and share it with some of your colleagues, residents, and attendings. Nothing sparks more interest in the field than a great imaging dilemma with twists and turns.

Read About Areas That Interest You

It’s not an unreasonable time to start picking up a book or two to learn a new area in radiology that you have not studied recently. Or, brush up on some other topic areas that interest you. As we start to become busier again, you will become more versatile. And, you may save time in the long run. Moreover, learning something new can rekindle your interests in radiology.

Teach Others

Although you may not have the option to do close one-on-one teaching at the same reading station nowadays, there are many opportunities to teach others. It could be remote, on the phone, or across the room. Regardless of the method, get involved. I can think of no better way of sparking interest in yourself and others.

The Hiatus Is Over. Get Back To Work!

It’s time to start up again. And, we need to get our heads back in the game. Make the most of the time you currently have. Whether it is reminiscing about our greatness, going over fascinating cases with others, learning about new areas in our field, or imparting our knowledge, we all need to latch on to those aspects of our field that we enjoy. It is mission-critical to be excited and mentally prepared to get back to a full day’s worth of work once again!

 

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No Longer Practicing Radiology During The Covid Crisis? How To Keep Up!

practicing radiology

Many hospitals and imaging centers throughout the country have recruited radiology residents to help out with the Covid crisis. But that leaves many of these residents in a bind. Some residents may feel that they may be losing some of their hard-learned skills. And many have not had time practicing radiology, the main point of completing their residency. So, I am going to outline some steps to make the next several months more relevant to your training. I will do this by going through each residency year and what you should do to keep up your skills. And, I will divide what residents should into First Years, Second and Third Years, and Fourth Years as each of these groups are in different boats.

First Years

For many first years, you are probably not getting the same case experience as you did before. However, for those of you lucky to have some extra time outside of an ICU rotation, I would go through essential books in each subspecialty section. You will find some ideas for books that you may want to read through in my books and links section of this website. (as recommended by my residents) Make sure to read through some of the recommended reading materials at home, now that you may have more time (or even if you don’t!) The key to a successful first year is reading as a basis for the rest of your residency. Don’t squander this opportunity.

Also, if you are interested in interventional radiology, I would recommend participating in some of the procedures that a clinical rotation like the ICU may offer. Volunteer for lumbar punctures, central venous lines, and paracenteses, if possible. These are some procedures that overlap with radiology and will help to maintain what you have learned.

Second And Third Years

Second and third years are years to practice and learn the art of Radiology. So, in addition to reading like the first years.  I would make sure to emphasize radiology cases over only reading raw reading materials/textbooks. So, make sure to go through the case series. Also, when you have the chance, go to the PACS systems and review older cases from the year in different subspecialties, now that some of the regular imaging volumes have dried up. For instance, pick up some of the earlier MSK MRI and make your interpretations and match them up with the final dictations. This action will help to keep your skills and search patterns fresh in your mind since many elective sorts of cases have probably dried up a bit.

Also, even though the ABR has delayed the core examination, it is likely at the forefront of your mind. Make sure to continue to review test questions from sources like RadPrimer and others. (Check out a great post called Up To Date Book Reviews For The Radiology Core Examination from a former resident for some ideas) You certainly want to reinforce this information when you do take the test. Rinse and repeat as much as you can.

Fourth Years

Finally, we need to talk about the fourth year separately. Fourth-year is the best time to learn practical radiology. So, during this time, you should be reviewing areas of practice that you may feel less comfortable with. Especially now, more than ever, I would recommend doing this since the job market will most likely be changing. (Check out my recent post What’s In The Cards For The New Radiologist Job Market After Covid?). So, make sure to read cases in your weaker subspecialties to keep up or learn new imaging skills. (PACS is a godsend!) You may be using some of these skills at your next job!

Keep Practicing Radiology Skills: You Have Worked Too Hard To Lose Them!

Just because some of your radiology training has been canceled does not mean that you should stop practicing radiology. Now, more than ever, you should be making a concerted effort to hone your skills. Whether you are just starting as a first-year radiology resident and need the basics, or if you need more practical training in your final year, allowing your reading and procedural abilities to slip away would be a shame. Reading books and reviewing cases on PACS now is vital. Even though you may be busy outside of radiology with Covid patients, make a concerted effort to stay in the game. Don’t lose your hard-earned skills!

 

 

 

 

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How To Mitigate The Next Pandemic: Encourage New Physicians To Get Business Training!

pandemic

Crises have a habit of magnifying gaps that we could not have imagined beforehand. And, this Covid pandemic reveals these large cracks in our healthcare system by the dozens. We have seen hospitals and imaging centers functioning without physicians receiving the appropriate personal protective equipment (PPE). We are witnessing a lack of ventilators for our sickest Covid patients. Moreover, we are beholding our healthcare system, reliant on lucrative elective procedures, go sour. Practices, hospitals, and imaging centers temporarily are almost empty (other than Covid patients) and dependent on our government to stay afloat. And, these issues are just the tip of the iceberg.

Did these misfires have to happen? Could leadership have prevented the dramatic shortfalls that we are experiencing now? How can we have known our future? Well, it’s a matter of ill-preparation.  And, this pandemic was not on the radar. But why? For years, many intelligent folks have been warning about preparations for pandemics. (check out this TED talk by Bill Gates) And, it is not just him. Other brilliant scientists and doctors have warned us about preparing for the next pandemic. No one listened.

Reason For Health Care’s Poor Preparation For The Current Pandemic

Why did hospitals and our healthcare system ignore prescient information sitting right in front of their noses? Well, it has to do with the model of healthcare that we follow in this country.  We have been treating healthcare as just a business for years.  And if you think about it only in these terms, the situation that we are in makes sense. Why would you prepare for calamity if it’s going to decrease your short-term and intermediate-term profits? Preparations reduce your bottom line.

But herein lies the crux of the problem. We can’t just think of healthcare as a business, but also as a way to protect and serve people. To accomplish this task, we have charged the wrong leaders with the responsibilities of running our healthcare system. Having only a JD or MBA, although helpful for understanding the business of medicine in the short term, is not enough. We need leaders in charge who have also been in the trenches and understand what our physicians and patients need in the long run. They need to understand the science and art of medicine. For these reasons, I would argue that we need more MDs and MD/MBA types in administrative leadership positions. With physicians in charge, hospitals could have prevented many of these issues.

Examples Of Why Physician-Hospital Administrators Would Make Better Health Care Administrators/Leaders

Let’s take some of the examples I provided above. PPE and ventilators are examples of two expenses that make no sense for a hospital to buy if you are thinking only about the business of medicine. First of all, buying such equipment would attract patients with infectious diseases to your institution because you have the equipment to manage only the sickest of patients. These patients cost more to the hospital. Additionally, why buy ventilators or PPE if you don’t need them now?. For-profit and non-profit institutions lose money off of their balance sheets, thereby decreasing bonuses given to their leaders. We can no longer think in these terms.

Or, let’s think about elective procedures as a way for hospitals to make money. Does it make sense? No. In a pandemic, the profit centers of a hospital shut down, causing the government to have to bail them out. Instead, healthcare profits should be made based on treating patients for sickness and making them well. Who better than a physician with some business sense to change this system so that we begin to treat patients and not just increase short term hospital cash flow?

The Answer: Encourage More Physicians/Radiologists To Receive Business Training

I want to underscore that we do need folks with business minds in charge of our healthcare institutions. However, these folks should be the doctors as leaders who can understand both business and medicine. To know how to run a healthcare system, you need experience in the trenches, both in the corporate world and medicine.

So, we, as program directors, mentors, and faculty, should encourage our residents to learn more about hospital administration. Instead of dismissing those residents that are not following our clinical footsteps, we should guide these new physicians on how they can begin this new pathway. Business courses should not be just an afterthought or tack-on to the radiology curriculum.

We need to start thinking differently about what and how we teach about the business of medicine. Let’s start taking more seriously some of the excellent curricula that the ACR or other physician societies offer and create mandatory externships to learn more about healthcare administration. Or maybe, just like informatics or MSK, all specialties should have fellowships dedicated to hospital administration. Now is the time to create easy-to-follow health care administrative pathways for our residents. It’s more than just creating another silly specialty pathway; it’s the future and viability of the entire healthcare system at stake!

 

 

 

 

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Should Hospitals Force Radiology Residents To Work In The ICU During The Covid Crisis?

ICU

Radiology residents are working in the ICU or the wards to meet the increasing demands of an influx of Covid-19 patients, sometimes having little to do with their training. And, most residents have graciously accepted their new duties, in the name of helping a higher cause. But why must residents comply with these demands? Are hospitals treating these physicians fairly? Is it ethical for h0spitals to require residents to participate and forego training in their desired subspecialty? And, what must the hospital ethically provide in return? Let’s answer some of these burning questions as it reveals some underlying issues about residents and residencies themselves.

The Government Indirectly Hires Residents

Once you sign your residency contract on the dotted line (or solid line!), you are receiving a salary from not just the healthcare system that employs you, but also indirectly from a pool of money provided to the hospitals by Medicare. And, most residents receive these government funds in one way or another. Therefore, you are indirectly working as the Government’s servant. In this setting, residents must comply with the Government and the hospital to receive a salary. So, hospitals do have the right to set aside educational objectives for the moment (even though it may not be what you bargained for!)

Residency Has Service And Educational Obligations

It’s not all about take, take, take! There are two components to any residency, educational and service obligations. Not too long ago, in an attempt to get back Social Security taxes from the Federal Government, residents sued the IRS because they claimed that medical residents were students and not employees. (Check out this article) In the end, the Government returned taxes to residents because the Government never clarified the definition of a resident. However, nowadays, the definition of residency changed. Today, the Government/IRS considers residents to be employees, not just students. And, for that reason, all current residents pay Social Security taxes as well as need to comply with government/hospital demands for service. (That includes time in the ICU!)

What Do Hospitals/Government Need To Provide In Return?

Hospitals have a moral and ethical obligation to provide a safe environment for resident trainees. Any institution that does not offer such a setting violates the spirit of a resident’s contract with the institution. What does that mean? Well, hospitals should treat residents like any other employee. In the case of this epidemic, hospitals should provide residents with the protective equipment they need to stay safe. No resident should risk life and limb without the appropriate accommodations of the institution in return.

And, hospitals should continue to pay their residents at their negotiated salary. Understandably, hospitals are struggling with the lack of revenue from canceled elective procedures. However, the amount that they receive for maintaining residency programs remains fixed by the Government. Therefore, it is only fair that residencies should continue to receive their salaries without furlough or pay cut. They are not the same as general employees whose wages can be subject to market forces.

A New World Order For Radiology Residents: Time In The ICU

No. ICU work is not what most residents signed up for when they began their radiology residencies. However, radiology trainees are still, first and foremost, physicians with service obligations. Part of these requirements is a duty to do no harm and help patients. Moreover, hospitals also have ethical and moral responsibilities toward their residents. Therefore, when both the resident and hospital meet these conditions, radiology residents can and should play a role in meeting the new needs of the healthcare system. Hey, when did you ever sign up for something that was as you exactly expected?

 

 

 

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Is There A Deadline For A Final Radiologist Interpretation?

deadline

Ever notice that there is always at least one or two cases that stick around on the worklist day after day? Perhaps, it was a complicated case for which someone is waiting for a consult. Or, maybe the technologist took the wrong MRI sequence and needed to bring the patient back. Regardless, you will see this all-too-familiar case on the worklist for what seems like eons at a time. But, at what point does the case become a hazard to the patient, institution, or radiologist? Is there a formal deadline for a final interpretation? Can radiologists even get paid for these ancient cases? And, at what point, do we need to bite the bullet and dictate the darn thing?

Believe it or not, this deadline for radiology case interpretation is a complex issue. It is not quite like the “best by” date on a package of bread. (although that date can be a little confusing as well!) And, like most complex issues in this world, the answer to how long you can sit on a case depends. Furthermore, I would go as far as to say that each case has several different shelf lives depending on the eye of the beholder. Each time is more relevant to a specific entity within the health care system. Let’s categorize them into the standard institutional time limit for the institution, the deadline for excellent patient care by the radiologist, the legal time limit for the attorneys, and the expiration time for reimbursement by the billers. So, let’s go into through what each of these means.

Hospital Statistical Deadline

Many of you have probably heard of the time to transcription. Well, that is an example of a statistic that many hospitals, practices, and institutions monitor closely. In some centers, if there is a case that goes past that typical time, the institution may flag it or call the doctor to let them know. Each institution has its numbers based on the type and the place performed.  For instance, an ER x-ray may have a mean time to transcription of a few hours. And, a non-emergent MRI may have a typical time to transcription of 24 hours. We can consider those cases that significantly surpass these time limits to exceed the standards of the hospital or the credentialing societies. And, sometimes, this may be at a detriment to patient care. Other times, not as much. (depending on the case!) All this brings us to the next limit.

Quality Patient Care Deadline

OK. So, you’ve run past the “hospital statistical deadline.” But all is not lost. Depending on the situation, you may be well within the expiration date for quality patient care. Sometimes, it pays to wait past the hospital’s statistical expiration time. Let’s take, for example, an oncological CT scan that sits waiting for comparison. If you were to dictate it right off the bat, you would have a meaningless report. Why? The oncologist most likely wants to know if the lung cancer metastatic disease is better, worse, or unchanged. In this situation, you cannot provide that answer with only a single time point. So, the hospital statistical expiration time often does not necessarily match up with the time it takes for quality patient care.

Legal Deadline

Simply put, this time is when the radiologist or institution becomes legally responsible for any findings missed because of a lack of interpretation. This time frame is a little bit more shadowy and vague. To understand this expiration time, think about the nighttime floor film that has a pneumothorax. If you do not read this case in a reasonable amount of time, and the findings go unnoticed, you and your group can be in for some trouble. But, this legal time limit can vary depending on the situation. Indeed, if the clinician notifies a radiologist to read the film immediately, and the radiologist does not, that could be a cause for immediate liability. On the other hand, if the clinician ordered a study without any priority notification, the timing for radiologist liability can become a lot longer. Additionally, in any given case, the time of delay in interpretation that can cause radiologist liability can vary widely depending on the situation, location, and jury (if the case goes to trial!)

Reimbursement Deadline

And then finally, we have the reimbursement expiration time. Believe it or not, this was difficult information to find on the web. In my opinion, it is because insurers do not want to advertise these dates. But, Scott Raley, the client service manager from Zotec Partners, gave me a few benchmark dates to remember. He stated that the reimbursement expiration time for Medicare cases is one year, and Medicaid is 180 days. For private insurers, this time can vary depending on the contract negotiated. But it typically ranges from 90-180 days. So, these times vary widely.

The Deadline For Final Radiology Interpretation- More Than Meets The Eye

Whew. So, there you have it. The shelf life of a radiology case can vary depending on the eye of the beholder. For the hospital, it’s one time. For the radiologist, it’s another. And if you are a lawyer or a biller, you will worry about other times of expiration. The bottom line is that you should be aware of all the consequences of those films that lag on the list forever. So, if you see one of these cases on the worklist, don’t just let sit. See if you can figure out why it’s there and follow it through to its conclusion. The patient, hospital, and radiologist will benefit immensely!

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Technologists Can Make Or Break You: Three Sample Cases

technologists

Here is the real world: Technologists sometimes forget to report on or miss findings. Other times, they may perform a new protocol without checking it with a radiologist. And, this is just the tip of the iceberg. All sorts of technologist mistakes and judgment errors can happen that can affect our interpretations. And since most of us rely on them so heavily, these errors can make our jobs just a bit more complicated.

Why do these errors happen? Well, technologists are human. In some cases, just like some physicians, a few technologists want to do the least amount of work possible. But, that is the minority. More commonly, they may be exhausted from a tough night. Or, perhaps, it’s just an erroneous judgment call. The bottom line is that their work can be very subjective. And any of these errant cases can ruin your day (and the patient’s too!) if you miss the opportunity to correct it. It’s why we need to check and double-check. Recently, I had some cases that reminded me of the fallibility of the technologist. So, I am discussing them to reinforce my point: don’t accept all the information provided by a technologist at face value!

A New Fibroid In a 65-year Old

For those of you that have completed an ultrasound rotation, you probably have learned about the subjective nature of finding uterine fibroids. Some technologists need to see a very well-defined mass before calling them. And, others will measure almost anything with a slightly different echotexture.  Nevertheless, standards can vary widely. (One of the reasons it is better to have the same technologist to perform case after case)

So, in my situation, I had recently reported on a small intramural uterine mass that was not there in the prior study three years earlier.  And, I could not define a lesion in the previous study based on the images provided. So, I called it a “new” intramural uterine mass, most likely a fibroid. This time around, I received a phone call from an irate physician, saying that it is impossible to have a new fibroid crop up in a post-menopausal female. (Although not true) And for this reason, she said she was ready to take out the uterus.

Meanwhile, I had to calm her down by saying that the most common cause for a new lesion in the uterus is technical subjectivity. (Unless there was other clinical information that I was not aware of) Although, of course, weird lesions like leiomyosarcomas can occur. However, they are rare. And, it would be clinically appropriate to monitor the uterus for any significant changes closely. The clinician finally backed down. Who knew that an errant fibroid could cause such a problem? Just another example of how “minor” differences in the subjectivity of ultrasound technologists can have considerable ramifications!

A New Intussception- Get The Pediatric Surgeon Down Now!

A few weeks ago,  as I was packing my bags to leave at 10:01 pm as my shift had just ended, one of my residents runs into the reading room.  He yells, “Don’t leave! We have to reduce an intussception.”

So, I looked at the initial ultrasound images, and I saw bowel loops containing echogenic material. But, there was no significant bowel wall thickening or abnormal flow. It was almost a target sign, but it did not look quite right. Moreover, the technologist did not provide any real-time images to support her claim.

Therefore, like any half-way decent radiologist, I went back and looked at the priors. So, I checked a previous abdominal series performed right before the ultrasound. In it, you can see dense inspissated oral contrast through the colon, especially filling the entire cecum and a good majority of the large bowel. Well, there was my explanation for the appearance of hyperechoic material within the intestine on an ultrasound, not an intussception. Just because a technologist makes a diagnosis, doesn’t mean it is correct. Use all the information at hand!

New MRI Sequence Withdrawn

Finally, a while back, one day, we performed a brain MRI  to follow a patient with multiple sclerosis. And, the technologist called me after the patient had left, stating that they have a new protocol for multiple sclerosis patients, handed down from the administration. No one consulted me about this until this point. So, I look at the case, and I see that the typical most sensitive sequence for detecting plaques, the FLAIR sequence, is entirely missing. Additionally, I have no means to compare this study with his priors that had this same sequence. So, how can I say if the case is better, worse, or unchanged?

I consulted with my neuroradiologist colleague to confer about this situation because it didn’t make any sense. He agreed the patient needed to return and didn’t understand why the protocol was changed. Yet, the change in protocol forced a busy patient to return for additional imaging, wasting everyone’s time. A little bit of communication upfront could have resolved the situation. As you can see, protocol tweaks without communicating the change to the reading radiologist can have negative consequences!

Check And Double-Check- Technologists Can Make Or Break You!

Now, my primary goal is not to berate technologists. Instead, these examples show you that it is mission-critical to check and double-check their work, just like they should do the same for us. One wrong technical misstep can derail our ability to interpret images or provide quality patient care. Therefore, we need to catch them as best we can. We are all on the same team. So, remember that technologists, like radiologists, are fallible. Keep your eyes wide open and your head in the game!