Category: Resident Advice

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So, You Want To Become A Radiology Chair?

radiology chair

Maybe, you are ambitious and want to head a department. Or perhaps, your parents have high hopes for you and want you to become the boss. Although you think you may know, you probably have no idea about what goes into the radiology chair role. I know I didn’t until I started to practice. And, it can be challenging to find the truth about the job description (because they have too much bias!). So, what better venue than this blog to give you an accurate depiction of the position?

Of course, how much work you want to put into becoming a Radiology Chair is up to you. But, what does it entail to play the role of the Chair and do it well? And, is it worth the extra effort? First, I will discuss some of the personality traits that may be beneficial for the job. Then, let’s talk about the work, struggles, and benefits that you will need to think about before you start the process of working toward this goal. If you dare, go into this job pathway with your eyes wide open!

Personality Requirements For The Radiology Chair

Politically Savvy

Why is it critical to have a knack for politics? Well, invariably, there will be political factions that will push you towards different ends. And, you need to be strong enough to move the ship in a direction that is just and right for the practice. Therefore, you will need to deal with all sorts of personalities and points of view well.

Not Take All Criticisms To Heart

As a Chair, you will hear and field mostly complaints from colleagues, staff, and hospital administration. Very rarely, do folks get a compliment on a job well done. (Even if you are doing so!) So, you will need to let the upsetting criticisms slide off your back. Do not take it to heart. Or else, you will become a depressed and bitter radiologist!

Good Communicator

You need to let all parties know what you are doing with an open hand. One ingredient that gets employees more upset than anything else: finding out changes after the Chair has implemented them. Or, not letting anyone know about your intentions. Poor communication is a recipe for disaster in practice.

Strong Decision Maker

And, finally, this position entails making some hard choices that you will have to live with for the rest of your life. You will need to hire, fire, budget, and strategize. I would recommend that you have a strong stomach to make these decisions. Rarely, can you make everyone happy with all the decisions you make.

Job Requirements

Hiring and Firing

First of all, you will have the honor and privilege of hiring new employees. Not so bad, huh? But, that also comes with the painful task of firing ones that are not working out. If you have never experienced such a job, let me tell you, from my experience as a partner, that is certainly not fun. And, the Chair tends to be the leading player in this activity.

Fielding All Complaints- Radiologists And Other

Any practice of substantial size will receive complaints. And, if you are not getting them, you are probably not reading enough films to sustain a business. But with the territory of Radiology Chair comes fielding those complaints. And these can be from your practice, staff, hospital administration, or other clinicians. You will soon discover that many folks are not happy. And you have to deal with it all!

Attending Tons Of Meetings

If you like meetings, the chairman position is the job for you. Between partnership meetings, hospital staff meetings, galas, and more, you will soon become all too familiar with gatherings. You better have some tolerance for this activity!

Paperwork and Budgetary

As the head of a department, your signature needs to go onto lots of documents. It’s not official unless your name is on it. Moreover, you need to read those papers. Indeed, you don’t want your name going out on something you or your practice does not want.

Future Planning/Strategic Management- Mergers, Acquisitions, Contracts, Etc.

OK. I think that this part of the job is not so bad. Who doesn’t like planning the direction of your business? I believe it is the responsibility of all partners. But, the Chair should take a particular interest in these activities. They need to lead the business to better places!

Political Representation For Department- Parties, Etc.

The Radiology Chair is the figurehead of the practice. Think of the position as the President of the United States. If you don’t go to the hospital gala, who else will? And if you don’t show up on time for your work, everyone else will arrive late as well. Whatever you do makes a statement for better or worse.

Negotiations- Insurance and Other

Every hospital and private practice has times when you need to arbitrate to accomplish the goals of your department. Perhaps, you need to negotiate a salary or an insurance rate. Or, you need to get that great new CT scanner for the department. Regardless, you will be in charge of this process. Learn how to bargain with your peers!

Legal

Finally, your name will appear on lawsuits that strike the partners and employees. Since you are representative of the practice, there is a better chance that you will have to show up in court to defend the group’s position. Be prepared for this eventuality.

Advantages To The Role Of Radiology Chair

More Admin Time

Well, now you finally have what you want. You’ve got some more administrative time. Unfortunately, you will dedicate that time for all of those new responsibilities listed above (and probably a few more!). But, you may have a little bit more flexibility with your schedule. (If you are lucky!)

? Increased Pay

In some departments, the Chair makes a substantial amount more than her colleagues (especially in academics or massive private practices). For others, it does not move the needle that much. Regardless, there is usually some monetary bonus to being a chairman

? Respect

If you do an excellent job as a Radiology Chair, your colleagues and work alliances will respect you more. You will become a highly trusted member of the hospital and physician community. On the other hand, beware of becoming a poorly performing chair. You will have the active hostility of all!

Disadvantages

Time Away From Family

All these additional roles do not come without a price. You will most likely need to spend more time with your colleagues than with your family. It’s just the nature of the job.

Meeting After Meeting

The chairman’s role necessitates numerous meetings. To maintain communication with all parts of the practice, it becomes a necessary evil. The worst of the meetings are about when to decide the next meeting!

Less Clinical Time

The more you spend on administration, the less you spend on clinical work, That is just the nature of the beast. For some folks, this may seem enticing. And for others, not so much. In either case, know what you are getting into before you take this path!

Radiology Chair- Is It A Job Or A Lifestyle?

So there you have it. As you can see, becoming a chairman is not a road to a passive job with passive income. Instead, you most likely will work harder than you ever did before (unless you don’t care and want to do a bad job!) But, at the same time, it can come with a few rewards and prestige if approached in the right way. Just think about all the possibilities if you take this path. And, as I said at the beginning, go into this role with your eyes wide open!

 

 

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Are You Getting the Outpatient Experience You Need In Your Residency Program?

outpatient experience

Some radiology residency programs throughout the country often claim a great outpatient experience. And others, if you ask, they won’t mention it at all. As an interviewee, you may not think about this segment of radiology. But, as a practicing radiologist, this is where you will spend a good chunk of your time.

So, what are the different sorts of outpatient experiences? And, is this outpatient experience even critical to your training? Or, is it something that you can forego because the hospital covers it? The bottom line, are you getting the outpatient time that you need?

Let’s investigate the world of outpatient radiology and what it all means for the typical radiology resident. To do so, I am going to discuss why it is critical to your training. Then, I will split the categories out outpatient imaging into those that you might encounter. And finally, I will talk about what you genuinely need in radiology residency to make your outpatient experience complete.

Why Is Outpatient Imaging So Important?

They say that about 90 percent of radiologists go into private practice (me included!), and the other 10 percent become hospital academics. And, a large swath of those 90 percent practices some form of outpatient imaging. Moreover, the imaging mix differs in outpatient imaging compared to the standard hospital menu of cases. So, if you want to simulate the real practice of radiology, you need some form of outpatient experience.

Three Different Types Of Outpatient Environments

Hospital Outpatient

Almost all hospitals have nonemergent patients that will show up to receive their imaging. The extent can vary from hospital to hospital depending on the location, patient mix, etc. However, the sort of patient that shows up for nonemergent imaging at a hospital tends to differ from the standard clinic patient that wants imaging. These studies often are more complex. And, they show up to the hospital either because they have some complicating issue that prevents them from getting outpatient center imaging (asthma, contrast reaction, etc.) Or, they may have an appointment at the hospital and may as well get their studies. Finally, less likely, a patient will show up here because he wants to go to a hospital rather than an imaging center.

Regardless, these outpatients will less likely have complaints like osteoarthritis or a superficial lump on the back. Instead, the patients will overall have more complex and involved issues. So, your mix of patients will not be the same.

Hospital Owned Outpatient Center

This experience is a hybrid between private practice imaging and the outpatient hospital experience. Here, you will get complex referrals from a hospital center. But, you will also receive the more typical outpatient type of studies. When you sit down and read, you will find a mix of patients with widely varying difficulty levels of cases.

Private Practice Outpatient

And most likely, private practice is what you think of as the “pure” outpatient experience. Here you get referrals almost exclusively from local doctors. Or, you will get patients who come in independently to receive screening tests like mammograms. Cases tend to be more one complaint sort of issues with more “normals.”

How You Might Experience Outpatient Radiology

Sampling

Depending on how the residency arranges your outpatient experience, you may be an occasional observer. Perhaps, the attendings dictate the outpatient cases because they get paid for them. And, you get to watch them interpret the studies. Or, it may be a random sampling as you are reading hospital outpatients. In either case, this is not the immersive type of outpatient experience.

Immersive

Here, you will be primarily interpreting outpatient cases and having your attendings sign off on them. It is much more similar to the daily workflow you might encounter in any given private practice. You will have a more similar experience as an outpatient private practice radiologist.

What Is The Best Outpatient Experience?

Well, as usual, the answer depends. Though, the key to becoming an excellent radiologist, in general, is to have varied experiences across the board. It is possible to have too much outpatient radiology at the expense of inpatient imaging, especially if you want to become a hardcore academic. So, you need to ask yourself, am I getting a broad enough experience concerning all the other segments of radiology training for my interests?

Nevertheless, I would recommend searching for a program that gives you the capability of reading and interpreting all sorts of “simple” and complex outpatient cases. And, I also believe that immersive experience is better. Why? Well, it allows you to get a feel for private outpatient practice. And, it will enable you to make a more informed choice of practice situations when you ultimately decide to settle on a final path.

Are You Getting What You Need To Become An Excellent Radiologist?

Having all the ingredients available for you to get the training you need to become a radiologist, well, that is the main point of residency. So, if you are in a situation that does not give you the right mix outpatients, look into ways that you can get the appropriate outpatient experience. Take some time and effort on your part to create a custom rotation. Or, push your faculty to allow you to get the proper exposure. In any case, make sure not to skip out on this subsegment of radiology. Without this experience, you will not be the consummate well-trained radiologist you want to be!

 

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What Do Radiology Program Directors Really Want From Their Residents? The Perfect Resident Triad!

perfect resident triad

This year, applicants have asked the following question more than ever before, “What do I look for in a radiology resident?” And I will answer this question with what I like to call “the perfect resident triad.” But first, I thought it would be interesting to discuss why I believe this question has become more common coming from medical students.

The Psychology Behind The Question, “What Do Radiology Program Directors Really Want From Their Residents?”

On the surface, some folks may say I am putting too much thought into why applicants may be asking this question. But, I believe this question says something about medical students applying to radiology. There is more to it than meets the eye.

First, I believe this question reflects current medical student cultural differences. Distinct from generations past, this question requires applicants to worry more about goals and expectations than any class before. And I think this difference is a function of what today’s educational system has demanded of all these students.

Moreover, I believe that schools have gone “ga-ga” with grading. From my own experience with kids, students today are continually bombarded with grades and tests, more so than I had ever experienced. In essence, the increased frequency of this question with the implied inherent message of “how do you evaluate me?” makes a lot of sense given today’s student culture environment.

Regardless of all the hidden meanings behind the question (that could be a whole psychological blog in itself!), I figured this would be a great forum to provide you an associate program director’s perspective and answer to this common question. And, maybe it will help you to figure out how to become a better radiology applicant and resident. So, here’s a summary of the perfect resident triad, the three characteristics that I want from incoming residents!

The Perfect Resident Triad

Academic Abilities

First and foremost, we need to know that a resident can make it through the radiology residency program. And, nowadays, unfortunately, the best piece of evidence that allows us to assess if a resident can pass the boards is the USMLE Step I. Studies have correlated excellent performance on this examination with the core examination, So, we need to take this data point seriously. To do so, we have made a cutoff score that will lessen the chance of having residents fail the exam.

Second, we need to see that you have done well in medical school. Our best assessment of this comes from the Dean’s letter. This document tends to be the only one that will say anything negative about the applicant. Therefore, we need to use it as a means of distinguishing resident academic qualifications. Also, from our experience, this measure correlates well with how much a resident will study during residency. And, radiology residents need to read a lot!

Personality

Although you might not think personality should matter much in a radiology resident, nothing could be further from the truth. Faculty members can sit with a radiology resident for hours at a time. The ultimate burden that a faculty member needs would be to dread that a particular resident is going to be there on any given day. Additionally, program directors do not want a “rabble-rouser” that will create problems every other day for her fellow residents.

The bottom line is, personality counts. And, to assess personality, there are only a few bits of information that we can use, interviews, and the Dean’s Letter. We rely on our interviews to make sure that the applicant responds reasonably to a conversation with questions. And, we utilize the Dean’s Letter to look for patterns of behavior that may cause our lives to be miserable!

Independence

Finally, we do not want to have to tell our residents what to do at every given moment. Sometimes, you have to take the bull by the horns. So, we expect not to have to tell them to get involved with as many procedures and cases as possible. And, we don’t want to be on top of them all the time to make sure that they find a research project. And so on. Residents are adults, and we expect them to act like mature learners that can take charge of their education.

We assess this characteristic based on the interview, previous research, and academic performance. Although not perfect assessment tools for this trait, they do provide us with some quality information.

What Do Program Directors Want?

So, that’s what I want from my residents and what I believe most program directors would wish: the “perfect resident triad”: To summarize, we want the following: 1. A team member that does well academically. 2. A resident with a personality with which we can work. 3. And, someone who maintains a bit of an independent streak. If you are that sort of medical student or resident now, you will be an invaluable member of any radiology residency team. Come aboard!

 

 

 

 

 

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There’s No Substitute For Learning Diagnostic Breast Imaging!

diagnostic breast imaging

Diagnostic breast imaging is the nexus between screening mammography and procedures. It is that step where a breast imager has already made the screening finding but needs to figure out what to do next before an invasive procedure. So, why do I bring up this point?

At our residency program, we are currently restructuring rotations in the expectation of a newly merged program. And, more specifically, we recently started discussing the breast imaging rotation. So, we are communicating with our residents about the best ways to do so. (Their input is critical!) Recently, I took the chief resident aside to discuss the best way to accomplish this task.  In the midst of it all, he stated, “we can just have our residents do screening mammograms and procedures, right?”

I paused for a moment and reflected. Then, I exclaimed, “Uh, no!” Why? Well, herein, let me show you why reading diagnostic breast imaging is, perhaps, the most critical element of breast imaging training. Screenings and procedures alone are not enough!

Mammo’s All About The Management

Unlike other specialties in the field of radiology, the main decisions that we make in mammography are not diagnostic dilemmas. And, the diagnostic mammogram is where the rubber meets the road. Here, our big choice is what to do next.  For instance, in a case with a complex cyst, you need to decide between biopsy, six-month follow-up, or MRI. The answer can depend on the context of the breast imaging findings and the patient’s personality. How do you know how to make those decisions? You need to have the experience of what to do next. That’s how!

Off The Cuff Decision Making

With diagnostic mammography, mammographers need to make decisions in a short time frame. You have a patient waiting for your answer as they lie on a table waiting for you to hand down your final decision. With screening mammography, you have lots of time to mull everything over. But diagnostic mammography is very different. It’s real-time. And real-time decision making can be hard. Especially when you have had little practice. Patients can get angry fast if you don’t make responsible and reasonable decisions. It shows!

Management For Mammo Is Very Flexible- Can’t Learn In It A Book

In many specialties, the protocols do not vary at all. Diagnostic mammography is very different. For the claustrophobic patient, you may need to avoid the use of MRI. On the other hand, you may have a nervous patient that would benefit the most from an aspiration because she can’t handle the wait. The only way to discover the appropriate individualized management for each patient is to make those decisions. And, I have never found any book that can adequately describe the techniques to make these decisions. It’s one of those specialties that you have to live to practice!

Need To Learn Appropriate Interactions With Patients

Finally, diagnostic breast imaging is one of those skills that hinges upon appropriate interactions. A patient encounter can go sour very fast if you do not appear competent. How do you address recommending a biopsy with a crying patient? Or, how do you scan a patient with a mass when you don’t know what it is? You learn these patient interactions only when you are practicing the art of diagnostic breast imaging. Skipping this step will surely make life difficult if you practice breast imaging when you begin a new job.

Diagnostic Breast Imaging Training: More Than Just Optional!

To become a breast imager in practice, you can’t get away with reading only screening studies. That will only get you a part of the way to understanding the role of breast imaging for patient care. Additionally, learning technical procedures, although crucial for full-time breast imagers, may or may not need to be part of your repertoire. However, every breast imager must be able to make competent decisions on how to manage patients. And, the only way to learn management is to have practiced diagnostic breast imaging. If you have the choice, don’t skip this step!

 

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Diagnostic Certainty: Can We Ever Get It Just Right?

certainty

How confusing is this? You speak to one attending who tells you that you should come down hard on a diagnosis in your impression. No differential, please. (usually a more senior attending) And, then, the next one tells you to make sure to put all the diagnostic possibilities in your dictation with impunity. (most likely the attending that has been sued several times!) Well, if you are a resident, this situation most likely applies to you. Why? Because every attending sets their threshold for certainty. And, each does it based on their experience and insight. So, where do you set your limits for diagnostic confidence as a radiology resident?

How I Developed My Level Of Certainty (A Bit Of Back And Forth)

In my residency program, the faculty and program director emphasized saying what you mean and meaning what you say. If a study appeared normal, call it normal. Or, if you had a patient with all the findings of an adrenal adenoma, call it such. End of story.

But, as I went along in my training, I began to realize that most normals are not exactly “normal.” And, even the most “certain” diagnoses are not indeed “certain.” Now, in these situations, you will be right 99.9% of the time. However, in that 0.1%, you will discover something different. In essence, by following the philosophy of my residency program, I resigned myself to automatically missing some of those rare zebras. These two discrepant themes played itself over and over, conflicting with my initial training.

So, how did I resolve this conflict? First, I recognized that I would have to be wrong a tiny but real percentage of the time to make the right recommendation for the referring physician. Moreover, I realized if I left some of those rare birds in the dictation, I would lead my referrers astray in most situations. In essence, I would increase costs to the patients and the health care system as a whole. So, calling something normal when you think it is normal did begin to make some sense again. I began to approach my dications from that angle.

But wait, what happened if that Haversian canal was that fracture that you thought unlikely since there was no adjacent soft tissue swelling? Or, what transpired when that stoolball stuck in the middle of the colon turned out to be a massive polyp? Was I setting myself up for massive lawsuits? Herein lies the rub. Over time, I realized I could not be too sure in any report.

How I Resolved (Some) Of The Certainty Conflict

I’d love to say that you can conquer this fight between certainty and uncertainty in one fell swoop. But, to say so would be naive and even worse, outright dangerous. All I could do is to mitigate the potential pitfalls. It has been a slow process to figure it all out.

So, how did I begin to tamp down this conflict to a much lower level? Well, it’s all about probability. I made sure to give a measured response in my dictations about the likelihood of my primary diagnosis versus the most reasonable zebras. That worked 99 percent of the time. It reduced the probability of zebra misses. Likewise, most physicians will use your primary diagnosis and follow the recommendations.

Why Giving Probablilities Does Not Always Work

Here’s the real issue, however. Your audience could be a physician assistant, a nurse practitioner, or a physician. Some may have more or less experience. And, this provider may practice patient care based on your unlikely diagnosis of a zebra instead of the more probable outcome. So, no matter how hard I try to steer the referrer in my preferred direction, that clinician may not use the probabilities in any report as I have intended. We must accept this fact. And, that is a tough pill to swallow.

Feeling Comfortable With Your Level Of Certainty

But, knowing that we cannot control for rogue clinicians, we can only do our best to relay our probabilistic approach without making the misses that can endanger our livelihood. It’s a sacrifice we must make to practice our specialty.  And, we should do it in a manner that will lead the majority of clinicians to the most appropriate patient care as well as mitigate the potential for lawsuits. Remember. We are not here to control the flow of patient care in every patient, but rather to guide it. I can take some comfort in that notion!

 

 

 

 

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Are Two Fellowships Too Many? Probably Most Of The Time!

two fellowships

Since most job seekers look for new jobs for only a few years and the majority of those job seekers are fellows, the collective consciousness of the radiology job market at any given time rapidly fades away. And, when the job market changes, we often forget about what new radiology residents had to deal with only a few years ago. But, talk to radiologists that graduated around 5 or 6 years ago. You will find that many of these folks had experienced a 180 degree opposite job market of today’s when they started to look. Moreover, if you ask them which fellowships they have completed, you shouldn’t be shocked to hear that they finished two of them. In all likelihood, that may have been the norm!

So, the question I pose for today, is there still a role for completing two fellowships? Are there any economic advantages to finishing two advanced subspecialty programs? And, what circumstances should lead a new resident to achieve more than one? You should find this discussion enlightening!

Why Should Anyone Complete Two Fellowships?

OK. From a monetary standpoint, it no longer makes much sense. Most folks can receive the same pay regardless of whether they have completed one or two, let alone none! And, indeed, the job prospects don’t change all that much nowadays if you have finished one or two. So, let’s scratch that reason off the list.

What about future job security? Well, again, I believe that folks that fellows that have completed two fellowships are just as likely to get canned as those have finished one. If you are an excellent radiologist, it should not matter much. And, you can be a lousy radiologist regardless of if you have one or two fellowships. Additionally, I can make the argument that some less competent radiologists have completed two advanced programs because they did not feel comfortable initially starting in the job market with just one. So. let’s nix that reason as well.

How about allowing you to do what you want in practice? No, most jobs have a niche that they need to fill. And, they will meet the demand regardless of the number of fellowships you complete. Sure, you may find a job that advertises for someone that could perform two specialties competently. But, by no means in most cases, do you need to complete two fellowships to fill the position. Those positions tend to be more general. And, it probably does not matter if you have graduated from two subspecialty programs.

So, When May Two Fellowships Come In Handy?

Honestly, I could come up with three main reasons for completing two different fellowships in the market in general. And, one reason specifically for economic reasons.

So, let’s start with the economic reason. (Does not apply for the current market!) When the job market is terrible, you may need two fellowships to stand out from the crowd. And, precisely, that situation happened five or six years ago. It was not uncommon to find these applicants at that time.

Next, some folks choose the wrong fellowship from the get-go. I know of one interventionalist that never really liked it much. And, this person practiced for years and years with the hope that one day she would grow into it. It never happened. So, she chose to start from scratch at a different fellowship. That could make some sense in certain situations.

What else? Say you want to bolster your academic credentials. Well, in the game of academics, numbers of papers, lectures, abstracts, and even degrees matter. And, yes, having an additional fellowship is like having an extra degree. It has the potential to boost your academic prospects in that sort of venue. (A bit different from my world!)

Is More Than One Fellowship Too Many?

Based on our short discussion, the answer is sometimes. And, for most people today, that want to set out into the world of radiology, two fellowships is most likely overkill. But, there is a time and a place for the second fellowship. The question is: is it yours?

 

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Why Breast Ultrasound Should Only Be Performed In The Breast Imaging Department!

breast ultrasound

How often have you heard the following from an outside clinician, “My patient has a breast lump? Maybe, while they are in the emergency department for abdominal pain, she can go ahead and get a breast ultrasound to take a look.” And, as a new radiologist yourself, you may wonder why, out of convenience, you should not say yes. I mean, what’s the big deal, right? How hard can it be to do an ultrasound of the breast while the ED docs are taking care of the patient for something else? It’s a two-minute procedure!

Well, there is a lot more to that simple breast ultrasound than you might think at first glance. And, believe it or not, you may be doing a lot more patient harm than you think if you are using an ultrasound machine in the emergency department.  So, let’s talk about some of the factors, more specifically, that you should consider before making that decision to allow breast imaging outside of the breast department!

Wasted Health Care Dollars

If you scan a patient for a lump in the emergency department, what are the chances you are going to need to do it again? Close to 100%! Why? Breast ultrasound techs have a particular skill set that is unique to their specialty. Plus, the Sonosite is not the same as the hardcore breast ultrasounds used for breast imaging. Who wants to pay for both a wholly inadequate test and an additional appropriate exam in the breast department the following day?

Inferior Equipment

Now, for the next point. Most Emergency Departments don’t stock themselves with the latest and greatest equipment for imaging of the breast. How many times do inferior machines create masses when there are none? A lot! And how many lesions are missed due to poor penetration of the tissue or lower resolution? A ton! It pays to wait.

Technologist Performing Cases Without Experience

Most technologists in the breast department have been performing breast ultrasound for years. It’s not quite the same when you ask a technologist without this experience (which you might have at nighttime!) to complete the case. It is very easy to under call  and overcall a breast ultrasound without the appropriate qualifications.

Radiologists Interpreting Cases Without Breast Experience

What are the chances that you will get a radiologist with a ton of breast experience on call? Maybe 50-50 at best? In truth, most of the die-hard mammographers don’t even take emergency calls. And, now you are asking a second rate breast radiologist to do your exam. It makes no sense!

Additional Procedures With Untoward Harm

Inferior equipment and inexperienced ultrasound users lead to further tests that the radiologist or imager will recommend. More importantly, however, inferior exams are not harmless. Quickly, an inadequate breast ultrasound can lead to an unnecessary biopsy or aspiration with potential complications such as bleeding and infection. Or even worse, a pneumothorax (I’ve seen it before!)

No Knowledge of BI-RADS/Patient Letters

Nowadays, the government heavily legislates breast imaging, and they regulate the process down to the result letters that you send. What are the chances that the radiologist uses the appropriate lexicon for the exam? And, is the ED radiologist prepared to create the proper letter to the patient when he completes the test? Probably not! You may not be following the letter of the law!

Are There Any Exceptions?

OK. For every rule, there is an exception. And, I can think of one condition off-hand that may “qualify” as a “breast emergency.” That diagnosis would be a breast abscess. But, even this exception is debatable. Some radiologists would say you can sometimes drain it the next day in the breast imaging center as an outpatient.

Breast Ultrasound Is Generally Not An Emergency Procedure- Don’t Perform It Outside The Breast Department!

For the most part, however, there are many ramifications to performing breast ultrasound outside the breast center. And, you don’t want to contribute to poor patient care. So, please, I implore you. If you are ever pushed to complete a breast ultrasound outside the breast imaging department for a lump, tell your colleagues why it doesn’t make sense!

 

 

 

 

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Can Trauma Radiology Help You In Your Career?

trauma radiology

I have to admit. When I was a radiology resident, I used to dread the “traumaramas” that would arrive at our level one trauma center in Rhode Island. Because of our unique location, we would receive tons of vehicle accidents. And motorcycle accidents were the worst. Limbs would hang on by a thread. Road burns, covering more than half the body, shearing off half of the patient’s skin. And, horrible head injuries would be part of the norm (especially in those riders without a helmet!). Subsequently, we would image almost every body part imaginable! Squadrons of surgeons and surgical residents would stop by to check the films. Trauma radiology was an enormous time drain.

In the past, I did talk about trauma radiology a bit (check out How Important Is Level One Trauma To My Radiology Training?).  But, recently, with our residency merger marching onward and new potential opportunities for our residents to rotate through trauma at other sites, I began thinking again about the highlights and pitfalls of a trauma rotation again from a new perspective. Did all this extreme level I trauma help me to become a better radiologist? What about it do I still utilize today? And, most importantly, the question that you would be afraid to ask… what about the experience may not add anything at all to your radiology training experiences? These are some of the issues that I will tackle (like a 400-pound linebacker!)

The Good

Organizational Skills

First and foremost, since you have these trauma patients that come in with a gazillion injuries and bazillion imaging studies, you have to keep your wits about you. You cannot afford to forget about any of the search patterns you have learned and miss any of the studies that the ED performs. Of course, if you do, Murphy’s law says that it will be the one with the critical findings!

Having a trauma rotation forces you to keep your priorities straight and organize your work. And, it’s critical for getting through the night. But, these same skills will aid you immensely when you start your first radiology job.

Working Under Pressure

Pressure creates diamonds. Sometimes we all new need a bit of pressure to be at our best. Unfortunately, our work is not all beds of roses and teddy bears. We need to think on our feet and give appropriate advice. And, that also applies to the real world. Doctors expect their reports on time without mistakes. And patients want excellent patient care. Working in an active trauma rotation allows you to build these critical skills that will find you in good stead later on.

Trauma Findings

And then, of course, you will not look at studies the same way after completing a trauma rotation. Instead, you will read every image with an eye toward trauma. Liver lacerations, bowel injury, renal pedicle avulsions, and more will become part of your search pattern for all-time. In the real world, sometimes, but not often, we still see the same trauma that you will learn about during your residency.

Just as critically, it can help to prepare you for the boards. If you have seen a bit of trauma, it that much less you need to study. You have lived it!

The Not So Good

Trauma- Can Be Overly Repetitive

I’ve mentioned it before in my other blog on the topic, but I will re-emphasize again. Trauma radiology is a bit more repetitive than other areas in radiology. The patterns remain the same with a more limited repertoire of findings. There is only so much that we need to enhance our skills.

Learning Checklist Radiology- Not So Great!

I hate cookbook medicine. And, unfortunately, trauma radiology can be the epitome of the proverbial cookbook. Emergency doctors and surgeons expect particular views and types of studies for every given trauma patient and situation. And, we need to oblige as their radiologist. They will assume that we do things their way, whether required or not. It is just part of the trauma formula. I like a bit more flexibility!

The Hours

For multiple reasons, traumas tend to roll in late at night when you are at your peak of exhaustion. Additionally, they tend to occur all at once. It’s just a fact. So, you will have to power through the tough nights when you will not get an ounce of shuteye (Not that you were getting any on other call rotations anyway!)

Trauma Radiology- The Final Verdict

Learning trauma radiology is critical for the boards. And though it may or may not be central to your practice of radiology, and can drain you at times, it can reinforce some good habits that you need to become an excellent radiologist. Whether it is organizational skills, working in tough situations, or knowing the critical elements of trauma, these are some of the skills that you will need later on in your career. So, take it all in stride!

 

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How To Be Happy In Your Radiology Career: Internalize Rewards!

internalize rewards

If you were to ask me about the most critical part of my radiology residency and practice experience, my answer would not be what you might think. Yes, the medical knowledge that I learned was important. And, the communication skills I obtained were invaluable as well. But, those experiences are not to which I am referring. Even perhaps more significant than anything else, I learned the ability to internalize rewards from the practice of radiology.

What do I mean by this? For me, the most significant rewards of practice don’t come from the administration or my colleagues’ lathering praise onto my work. And, it does not come from a massive monetary bonus. (although it can’t hurt!) Instead, I do what I do because I take an interest in the science, art, and practice of radiology. And I derive joy from giving patients quality care.

For new folks coming out, this may not make much sense. Programs have given them evaluations and recommendations, giving them tons of external feedback. And, they continue to thrive on words from others. Additionally, they hear about more significant attending radiology salaries and look forward to getting their own. But that is all fluff. Only when you can internalize the rewards of practice, you will find happiness in your career.

Why Do I Mention All This?

Many new graduates (but not all) expect the applause of others to continue in their job, whether it be your bosses, colleagues, or patients. And then, one day, a clinician criticizes your work, or your colleagues say you are missing findings. Or, maybe at the beginning, you didn’t quite receive the salary you may have initially expected. Then, at the drop of a hat, you want to pack it all in and then quit. Why is that? Well, I believe part of it has to do with the inability to internalize rewards, expecting all the rewards to come from others. And, I have a few theories for this issue! Let’s call them the Millenial Mentality, too much feedback, and lack of experience/grit. I will go into each of them individually.

Causes For Inability To Internalize Rewards

Millennial Mentality

I am sure I will get blowback from this one. But, I think there are unique parenting differences between the millennial generation and the ones before. Of course, these differences don’t apply to all of the parents of the Millenials.

One of the most significant differences is the overemphasis on the reward rather than the process. You can see that represented by all the trophies that children receive for just participating in an activity. Nowadays everybody gets a prize. It never used to be like that. Only the best or the winner would receive the reward. So, if you came in fourth place, you wouldn’t get a badge of honor. And, you had to learn to deal with losing. Learning sometimes to lose enables kids to learn to love to emphasize the competition (or the process) and not the reward (the trophy).

Let’s now fast forward years ahead to your first job. No longer are you receiving the reward, the adulation of your faculty colleagues or the feedback you were expecting? It’s not what you are accustomed to. And, it becomes much harder to appreciate the work that you do.

Too Much External Feedback

Residencies nowadays are on feedback overload. Between milestones and monthly evaluations from attendings and colleagues, semi-annual assessments by the program director, and daily feedback from your faculty, it doesn’t end. And, this was just the tip of the iceberg. Formerly you would receive tons of forced feedback in medical school and college as well in the form of tests and evaluations. And, this is what graduates continue to expect.

However, this is not the way most practices and businesses work. You cannot expect to receive constant attention from your bosses. They may be very busy and have to attend to lots of other issues. Now, this is not to say that you can’t expect some feedback. However, it can make a new radiologist very uncomfortable when all this feedback suddenly stops at her first job.

Lack Of Experience/Grit

And, then finally, many new radiologists have never held a regular job before going to medical school. In truth, being a radiologist may be their first leap into the real world.  Yet, many times, it is only by experiencing the realities of an average job that many folks learn to appreciate the ups and downs of your career and let some of it roll off your back.

It’s those times that a customer yells at you for not getting their drinks on time. Or, the occasion that you had to deal with a fight between you and your manager. You learn to deal with these untidy situations. And, you apply them to your career. It allows you to brush off the criticism you may take and move on. You learn not to take everything to heart.

Internalizing Rewards: A Key To Success?

With all this baggage upon many new radiologists, it is possible to shed the luggage one by one. Be mindful of some of these learned behaviors and the historical context through which you have lived. And, don’t expect your colleagues, superiors, and employees to kowtow to your greatness. Learn to love what you do and not just the external trappings of success. You will be much more happy in your career!

 

 

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Should Radiology Residents Be Chronic Overcallers?

overcallers

In an ideal world, radiologists, in particular, would like to get all the cases right all the time. But, in reality, we know that can never happen since radiologists are people. And, we deal with imperfect technologies. Some findings will go undetected, and others misinterpreted. But that is the way of the world.

So what can we control? Well, we can adjust our sensitivities. Increasing our sensitivity allows us to make more findings at the expense of causing all our patients to receive too many additional tests. Subsequently, they would receive elevated doses of radiation and too many biopsies.

Decreasing our sensitivity sets us up for missing findings. These same misses can lead radiologists down the path of patient care issues and lawsuits. So, we continually set our internal thermometers to call cases toward either overcalling or under calling to get to that perfect mean. And, radiology residents must learn to do the same.

How Do We Adjust Our Internal Thresholds?

So, what causes us to change our sensitivities and become overcallers? Well, have you had a recent lawsuit or a bad mistake? You probably will overcall a bit for fear of missing findings. Do you have a large population with healthy hearts and read cardiac nucs. You probably are under calling a patient’s cardiac disease, knowing that most patients have none.

Additionally, we are continually tweaking our internal standards all the time. Should we call that skin fold over the chest as a pneumothorax? Or, is there a trace subarachnoid hemorrhage near the calvarial fracture site? These are the questions that we face daily. And how we choose to answer them affects the patient care we deliver.

What About Radiology Residents Versus Attendings?

Moreover, radiologists and radiology residents practice in two alternative universes. And, their pitfalls differ substantially. To that point, what can dramatically affect an attending’s care can barely impact a resident and vice versa. For instance, chronically overcalling lung nodules on chest films as an attending can anger your referrers. In a worst-case scenario, a practice may even decide to fire overcallers over the issue.

On the other hand, it may be desirable to overcall those same nodules as a resident. Your attending may want you to call the finding to alert them to whether it should make a clinical difference. She can always discard it in the final report if it does not change management.

So, Where Should Residents Lie Within The Spectrum During Residency?

In general, under calling as a resident, can be particularly dangerous for many reasons. First and foremost, residents have a lack of experience upon which to rely. After your 10,000th case of pneumonia, you will have probably have seen enough to almost instinctually know what most types of pneumonia look like on a chest film. Residents don’t have that background on which to make a judgment. So, when you don’t call pneumonia, you are more likely going to miss the signs of one.

Second, the hazards of under calling far outweigh the benefits of overcalling. If you are on an overnight shift and you are not sure whether your patient has a bleed, you can cause much more damage by sending the patient home with a bleed. The consequences of keeping the patient in the hospital with that more sensitive call are much less devastating. This philosophy goes for most serious disease entities.

And then finally, you make your attendings happier when you overcall rather than under call. I would much rather see a resident make all the findings of equivocal tiny nodules and questionable hepatic cysts. Although part of the spectrum as overcallers, these residents make findings that can help me to pick up lesions I may miss as a radiology attending. A pair of second overly sensitive eyes can be an excellent accessory screening tool to ensure that the radiologist does not miss the findings as well.

Chronic Overcalling Can Lead To A Difficult Attending Transition

But, this chronic overcalling can lead to a problem at your first attending gig. You have accustomed yourself to overcalling findings as a resident. Now, as radiology faculty, that same sensitivity point may not work well to allow you to flourish in your career. But, you have worked at this threshold level for a while. Not so easy. Habits die hard. We see this issue all the time with new radiologists.

What’s The Point Of This Conversation About Overcallers?

Well, residents need to be aware of their thresholds for making findings. Yes, it is worth it to start as overcallers based on less experience and the consequences of missing critical diagnoses. But, be wary about maintaining the same thresholds as you move along in your career. Be mindful of slowly trying to increase your limits for detection over time using your increasing experience and knowledge. The goal is to get you closer to the perfect sensitivity in an endless asymptotic curve. So, be ready to adjust your approach as an attending. It may save your career!