Category: Resident Advice

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When Should I Change My Search Pattern?

search pattern

Heraclitus, a Greek philosopher, has been quoted as saying, “change is the only constant in life.” And that concept also extends to how radiologists should commit to a search pattern. Yes, I have stated that you should affix your search patterns so that you make sure to remember to go through all parts of a study. Of course, we don’t want to forget about the images and organs that we need to report. However, every once in awhile the tide changes and we do need to modify our search strategies to incorporate new information.

Sometimes, protocols change. And other times, how you report disease can vary. Now, that does not mean that you should entirely forego your old search pattern. Instead, you can consider adding the new concept to your old one. Based on this thought process, let’s give you some examples of how and when I have accommodated a new change in my search patterns over my career lifetime. Hopefully, these modifications will provide a better idea of when you should make the change as well.

Coronal/Sagittal imaging

Believe it or not, CT scans at one time were only imaged and reconstructed in the axial plane. In fact, there was a big uproar when we decided to add these images to our studies. The techs, administration, and radiologists said there would be too many images to look at and store. But, it turned out that these reconstructions are critical for the interpretation of CT studies. Often, the appendix only shows up well on the coronal images. And, you can have a challenging time catching many sorts of vertebral body fractures on the axial view. Additionally, I’ve seen a few renal and colon masses that you could only pick up on the coronal view. Scary stuff if you decide to neglect these reconstructions.

So, like most radiologists, I had to add these recons to my search pattern to improve my sensitivity for picking up disease. And, this also goes for other sorts of studies. Remember, different planes can be helpful on MRI to catch glenoid labral tears. So, I no longer neglect the reconstructed images and have added them to my search pattern!

TI-RADS

I figured I would also add an example of a required reporting change that had changed my search patterns for a thyroid ultrasound. Previously, I would only make a brief description of a thyroid nodule’s size and cystic/solid consistency. Now, knowing more characteristics that make thyroid nodules more suspicious for thyroid cancer, I incorporate these findings into my reports. In my mind, I run through all the attributes of each nodule using TI-RADS criterion so that I don’t miss critical descriptors.  Unfortunately, in the interest of time, I can’t always put a TI-RADS rating for each nodule. But, all the nodules have the description needed for the clinician to make that assessment. New reporting systems will often change how you look at and report the images.

“New” Techniques- Diffusion-Weighted Sequences

And, finally, as an example, new techniques and sequences can also alter your search patterns. They force you to look at new images that you had not seen before. In that regard, the diffusion-weighted technique was a game-changer for acute infarct imaging. Naturally, I always look at them first before any other to make sure patients have no acute infarct. Before the advent of this sequence, our sensitivity for detection of acute ischemia was much lower. Anytime a new technique helps with improving patient care; you need to incorporate it into your search pattern.

“Change Is The Only Constant In Life”: An Application To The Search Pattern

Like this great quote implies, we, as radiologists, cannot rest on our laurels. We need to go with the flow to improve patient care. So, when you have new ways of looking at imaging studies that help with diagnosing or treating patients, make sure to add it to your search pattern. Whether it be, different reconstructions, changing reporting systems, or entirely new techniques, our patients will be better for it!

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Techniques To Mitigate The Effects Of Sleep Deprivation

As physicians, and more specifically as radiologists, we all face the issue of sleep deprivation at one time or another. And, lack of sleep is unavoidable. Between late shifts, family issues, studying, and a late-night out with friends during the week, how does any of us get enough of it?

Moreover, we know that sleep has some potent effects on cognition and judgment. Just take a look at this link to an AJR article from 2008 about the liability of sleep deprivation. So, since we know lack of sleep is unavoidable and has potent effects, what techniques can you use to decrease its influence on you at nighttime? Let’s delve into some techniques I have used when I have been exhausted at work.

Know Your Stuff Cold

The more that you know search patterns reflexively, the more likely that you will not skip the findings, even when you are the most exhausted. Think of it as an insurance policy. When the eyes start to droop, the skills that you lose are those that are not second nature. So, take the time to learn radiology as you would understand the multiplication tables in elementary school. You should be able to spit out your search pattern as you look at the anatomy ad nauseum.

Also, make sure that you know all the most critical and common diseases that affect the population that your imaging cold. You are not going to have the wherewithal to look up everything when you are so tired that you barely keep your eyes open.

Concentrate Harder On The Key Elements

Pneumothorax, pneumothorax, pneumothorax. These words should be part of a mantra when you look at a chest film. And, that’s just one example. When you are sleepy, you want to concentrate very carefully on those entities that will make the most clinical difference for patient care. And, pneumothorax is one. But keep other critical diagnoses in mind when you are searching for findings on any new sort of study that you are reading.

Bounce Ideas Off Your Clinical Colleagues

If your mind is in a foggy rut from lack of sleep, sometimes it is helpful to talk to your clinical colleagues. That goes for both radiologists and non-radiologists alike to make sure you are keeping on the right track. Let me give you an example. Say you are staring at one site on a femur x-ray. And, you are not sure it might be either a fracture or a hallucinatory sleep-induced line. Well, give your ED doctors a call to find out if what you are looking at is even relevant to the case. Occasionally, another opinion can make the difference between a good and a bad call.

Take A Brisk Walk For A Few Minutes

When you are already sleepy, sometimes stagnation in a chair can lead to even more exhaustion. If so, think about getting up out of your seat and taking a brief walk for a few minutes. Sometimes, a brief interlude is all you need to rejuvenate your mind once again and get the adrenaline going.

Coffee (For Those That Can Handle It)

I am not saying that you should become a coffee fiend, relying on it until you get the jitters. Or, if you tend to go into cardiac arrhythmias, you should stay away. But, a dose or two at your most fatigued point, can help you to stay awake when you can’t seem to read the films. Plus, research has shown that coffee gives you some health benefits. Just take a gander at this article in Inc.!

Take A Five Minute Nap

Now, I am not suggesting that you should shirk your duties. That would be a disaster. Instead, if you get a moment, sometimes a five-minute nap can rejuvenate your mind to get back to a place where you can concentrate again on the work. Hell, it may save you time during the remainder of the night if it helps you to stay awake.

Sleep Deprivation Is Not Optimal, But We Need To Get Through It!

We live in an imperfect world. And, we participate in an error-prone specialty. Adding to the issues, we are forced to work when we are most exhausted. So, just don’t let the sleepiness take over. Fight back. Try some of these techniques to get you through the night. It may make the difference between a decent and hellish night!

 

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Don’t Skip Around! A Radiologist’s Mantra

skip around

Round, round, get around, don’t skip around. Reminds me a bit of the Beach Boys tune I Get Around. Regardless of the weak attention-grabbing first sentence, I think this advice is vital for the radiologist.  And it applies to us in many ways. First and foremost, it helps to ensure that you are covering all the findings. But, it is far more than this. Keeping reads in order without skipping around also will enable you to triage appropriately, allows you not to piss off your colleagues, and most critically, ensures that you don’t forget the reason for reading a study. So, let’s delve a little bit more behind each of the reasons behind the nitty-gritty of this philosophy.

Covering All The Findings

What is the best way to make your dictations less accurate? Well, have as many interruptions as possible! And what is it about these interruptions that cause missed findings? Typically, most radiologists will forget what they were doing before.

Since it is impossible to prevent all interruptions (although you can mitigate them), you can avoid loss of sensitivity by sticking to a routine without skipping around. So, the next time the surgeon barges into the room with a question while you are dictating, you will know exactly where to return your focus when the interruption ends. If you repeat a similar routine without skipping around, you will rarely lose your place for long!

Triage

What is it about skipping around through a list of patients that can cause triage issues? Well, it’s not fair to read a study first on a patient with similar urgency to others when he was the most recent one completed, right? How would you like it if someone cut in front of you in line at a supermarket? It’s the same philosophy.

But more critically, you should be reading the tech flagged positive findings first, the “STATS” second, the expedites third, and the routines last. Subverting this order can cause clinical disasters, potentially delaying reads on patients with positive results. Why would you want to read a routine oncology workup before a possible intracranial bleed after trauma? Finding a lung nodule is not equivalent to discovering an epidural hemorrhage. Triage in order and don’t skip around!

Order Among The Rank And File

When all members of a practice are working hard, they don’t want to worry about radiologists that are cherry-picking the most straightforward cases to spruce up their RVU numbers. How can a practice avoid such an issue? Well, have the readers read studies in order of when they were performed. Practices often perceive those members that skip around to be skirting the rules.  So, sticking to the list order can help morale!

Circling Back To The Impression

And then finally, to come up with an appropriate impression in any case you read, you should never jump to it without analyzing all the findings first. Skipping around and getting to the conclusion right away is a formula for disaster. Think of it like watching the end of a movie or novel without watching the beginning. How can you figure out the real answers to the clinician questions without going through an entire case? I know that just the mere description of the findings helps me to come up with an appropriate conclusion. Without that process, my impressions are more likely to be off-the-mark. Don’t’ skip this routine!

Following A Radiologist’s Mantra: Don’t Skip Around!

Order matters. Whether you are skipping around instead of using routine search patterns, reading cases in an illogical order, or creating an impression before looking at and analyzing all the findings, you can negatively affect both your partners and patients. We want to do the best for our patients and work partners. So, the next time you decide to accomplish a professional task out of order, think twice. It may not be the best for patient care!

 

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Read Like A Speed Demon: Goals To Read Cases Faster!

read cases faster

You are just beginning your residency, and your faculty expects you to dictate all the cases on the CT list, more than twenty. But, you are as slow as molasses, having just recently picked up a dictaphone. Unfortunately, this phenomenon is not uncommon. Faculty often forget what it is like to have recently started. Having the tools to read cases faster at the beginning is just not possible.

However, take heart. You have to begin somewhere. Most of us are not speed demons from day one. So, instead of worrying about this particular situation, it is much more critical to know how to set goals so that you can continually improve your speed. Each successive time you dictate, you need to feel more comfortable reading each case. And, eventually, you can run more adeptly through increasing numbers of cases in a shorter time.

In the past, I have written an article to help you out with increasing your knowledge to pick up speed called: How To Pick Up Speed In Radiology. Check it out to get some essential advice. But today, I am going to give you some guidelines for setting up specific goals to increase your speed. First, I will talk about what to avoid. Then, I will discuss what you should watch for from your experienced faculty. And, finally, I will go through the specifics of creating goals for increasing speed.

Do Not Deviate From The Search Pattern!

What is the worst way you can read cases faster in radiology? Cutting corners. But, I see it in residents all the time. They feel rushed, and what is the first rule that goes? Well, either they no longer search through all the fields of the film, or they skip looking at an organ system. Either way, these residents are destined to miss many critical findings as they begin to pick up speed, but in an unhealthy way. Training yourself to deviate from a search pattern is a recipe for disaster. If you cut corners as a resident, you will continue the same patterns even after you graduate. Learn the right way early on!

Learn The Tricks Of The Pros

Who should you learn from to read cases faster? Medical students rotating through radiology or attendings in other specialties? Of course not! The answer is simple, the radiology pros, of course! Learn from the best, your faculty.

So, you want to make sure to watch the people that already read cases quickly and accurately,  the seasoned radiology veterans. If you are reading CTs, for instance, sit down with the body imagers. You are bound to learn ways to cover organ systems with more accuracy in a shorter amount of time. One example would be to check out how they scroll through the cases. You may discover that running through the bowel is easier if you look at the contiguous intestine on each successive slice rather than randomly looking at the small and large bowel within the abdomen. By watching what the experienced professionals do, you can pick up additional tips such as this one to speed to your reads and search patterns.

Pick A Number And Increase Each Day

For those of you want to be weightlifters, you cannot start by bench pressing 350 lbs. That is a dangerous recipe for hurting yourself. Instead, most weightlifters set a long term goal to lift 350 pounds eventually, but increase little by little, setting daily and weekly goals. Just like that weightlifter, you need to set a long-term goal and then set shorter-term goals to slowly increase the number of cases in a day. Don’t overdo it at the beginning and strain yourself!

Let’s say that you are starting to read mammography. How many studies should you read? Well, try to pick a long term goal of reading the same number of cases that your attendings read in a day. So, say your breast faculty read around 100 mammograms each in a day. But, when you are starting, you can only read ten mammograms reasonably accurately and quickly. Then, each day, aim to complete a few more than the last.  You may not realize it ay first, but you are building mental connections and eye tracing patterns each time you look at a case. And, the more studies that you look at the stronger the connections. Eventually, it will seem effortless as you scroll through the images. However, it takes time to build this skill.

To Read Cases Faster, It’s Not A Sprint. It’s A Marathon!

Given the pressures of daily work in radiology, you need to run through lots of cases in a rapid amount of time. However, it’s not possible to begin to read accurately and quickly without starting slowly and deliberately. And, usually, it involves starting at a crawl, graduating to a walk, moving to a jog, and only then competing in a marathon.

Remember. As a resident, you have time to build up speed. So, don’t rush it. Habits that form today can last a career. Don’t let them be the wrong ones!

 

 

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What Kind Of Technology Background Is Critical For The Radiology Resident?

technology background

Ever been frustrated watching your nuclear medicine attendings use their proprietary software adeptly, while you do not understand how they manipulate the images? Or, do you notice that some of your faculty can look at a whole series with a slice by slice comparison by setting them with a point, but you can’t? Although hospital and corporate information technology should create systems easy and intuitive for every radiologist to use, in the real world, it is not the case. And, even though you may know your radiology and anatomy cold, there are serious ramifications if you do not know what I like to call technology background or “buttonology” knowledge to operate the systems.

So, first, I am going to elucidate why “buttonology” and some radiology technology background can become so critical to your skills and practices. And, then I will tell you what computer features you should expect to learn during your residency and why.

Reasons For Learning “Buttonology” And Getting A Technology Background

Helps Us With Our Job

In general, most of the technology that we use make our lives easier. It may not seem so at the beginning. But, when you do get to know how to manipulate images and information the right way, it can increase efficiency. Heck, what was life like before Picture Archiving And Communication Systems (PACs)? We read half the amount of films in double the time!

Can’t Function Without It!

I cannot even imagine how I would function without knowing how to make measurements or to get to the next case on the queue. So, it requires us to make time for learning at least the bare minimum of what we need to know to get us through the day whether we like it or not!

May Use It After You Leave Residency!

Believe it or not, yes, life exists after residency. And, many of the same hated technologies that you use during your residency, you will likely need to know later as well. I can still remember learning Penrad (a mammo text-based dictation system) that I could not stand during my residency. It took hours to learn how to use it properly. And, I thought it was a waste of time. But, you know what? It has become a regular part of my day as an attending who reads some mammography. You never know what you will need to grasp after you finish.

Clinicians May Ask For It

In our practice, clinicians ask for the use of specific technologies and documentation in our reports. So, it behooves us to learn them to stay in business. Yes, it took some time to learn how to use the DATquant software to determine the likelihood of Parkinson’s disease in patients. But, now we have cornered the market. It was well worth the effort!

Technological Features You Need To Know

OK. We need to learn these technologies even though it is a time sink and may seem distasteful. So, what are the tools that we need to look out for and take time to learn? We will go through some of the basics here.

Tools To Function Daily

This first category would be the most obvious. It would be the technology background that you need to get through the day as a radiology resident. So, which are the essential tools that residents should take time to learn? You should acquire mastery of measurement tools (distance, Hounsfield units, angles, etc.) Each resident should also be able to scroll, pan, window, link cases, and perform necessary reconstructions in a pinch.

You also need to operate any computer system that you will need to make it through a night of call. These include the general nuclear medicine imaging readers, CT perfusion technologies, and so on.

And then finally, you need to know some of the other functions that if you do not remember, you cannot read the cases. These technologies would include the dictation software and sending images to the correct workstation or software.

Tools You May Need After Residency

In your hospital and departments, you will most likely not need to know all of the technologies available. However, you may find some of them will pay off in spades later on when you begin your first job. You never know. RIS systems, complex nuclear medicine applications, mammography software, etc. are only some of the technologies that you may encounter. You may not “need” them now, but it may be worth it to put the time in upfront to learn them if you think there is a chance you may use them. If possible, you do not want to learn them at your first job where you will waste a lot more time. And, more importantly, you will seem a lot less efficient when you begin as an attending.

“Buttonology” And Your Technology Background Can Make Or Break You

Knowing the “buttonology” of radiology systems can be critical for your professional development and future career. Without the tools that you will need, at best, you may make yourself inefficient. And, at worst, you may not last at your first or second job. So, during residency, take the time to learn the basics of PACs functionality and hospital systems. Think of it as an investment in your future. I promise that it will pay off big time!

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How Do I Know Which Cases To Discuss With My Attending In The Morning?

You’ve made it through a typical night of call and the attending for the day is about to arrive. Your mind begins to meltdown from the exhaustion of it all. And, there are too many cases to discuss with your morning radiologist. It’s just going to take too long.

Moreover, you don’t want to waste your attending’s time with the obvious. On the other hand, you are not sure about what you are going to have missed during your shift. And, you want to make sure that you address all the critical issues. So, how do you go about deciding which cases to discuss with your morning attending? And what can you ignore? To increase your efficiency, let’s go over some of the basic guidelines.

All Cases That Can Significantly Change Patient Medical Management

Remember, in the end, every case that you sign off at nighttime, also will have your attending’s name on it too. By default, therefore, you should show every situation to your attending that will significantly change medical management. Now, what exactly does that mean? If your patient has gone to surgery based on your findings for any reason, that would certainly qualify. Or, if the patient needs to stay overnight because of your call, that would be eligible too.

In essence, I would have a low threshold for what constitutes a change in patient management. And, if it meets that criteria, well then, you must show it!

Equivocal Findings

It’s those cases that you hem and haw over. These are the best learning tools. So, make the most of them. Even it’s not the most clinically significant case; I would highly recommend that you try to discuss it with your morning attending. It’s one way that you may never discover that finding to be equivocal again. Think about all that time over your career that you will waste that you could have figured out immediately by just asking your attendings in the morning. Why wouldn’t you bother to do that?

Discrepant Reports With The Nighthawk

If you want to get burned, the best way to do it: Don’t go over discrepant nighthawk reports with your attending. I have been on the receiving end of one or two of these unmitigated disasters. And, the resident could have avoided it by simply telling me about it.

Moreover, even if the resident gets it right, and the nighthawk misses the case, it can still become a problem. Medically, the emergency physician can administer the wrong medication based on the nighthawk read. Or even potentially worse, she may not administer treatment based on his final report. Therefore, please let your attending know about these cases, especially if you made the critical finding, and the nighthawk reader missed the obvious!

Discrepant Reports With The Emergency Physician

Just as often as nighthawk discrepancies, if you forget to go over those cases where your opinion differs from the ED physician, you are potentially asking for trouble. Immediately, these cases should be some of the first that you must discuss in the morning. In addition to increasing the work burden on your morning reader, your attending will likely have to make a whole bunch of unnecessary phone calls if he doesn’t know that there was a discrepancy.  Your goal should be to reduce the amount of work your attending needs to complete, not increase it!

Any Other Cases With Questions

Sometimes, cases bring up fascinating points or other medical management questions. And, what better time to ask questions to reinforce what you have learned at nighttime? After residency, you will not have these opportune moments again. So, take advantage of making inquiries with experts while you can!

Whew, That’s A Lot Of Cases To Discuss!

Well, not necessarily. It sounds like a lot more than it is.  Often, these cases are the minority of what you will experience at nighttime. And, fortunately, most nights, you will encounter many normals and garden variety cases that don’t need to take up a lot of your time in the morning. However, regardless of the number of cases, it always pays to go over those cases that need extra attention and care, whether it’s for medical management issues, equivocal findings, discrepancies, or simple questions. It’s a fantastic tool for learning, and more critically, a moral duty for excellent patient care!

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Should I Waste Time Looking For Tiny Lung Nodules At Nighttime?

lung nodules

One of my former residency mentors said the following as he proudly scrolled through the electric film panel reader without stopping as he dictated, “You can miss em’ fast, or you can miss em’ slow!”

And, the life of a resident works non-stop, just like this former radiologist, especially on a busy night of call during residency. At least at our institution, we can easily have a night of 40-50 CT scans, 10 MRIs, 20 ultrasounds, multiple plain films, and fluoroscopy consults. Even though it’s tough, we expect our residents to churn through all these images and more! Then finally, in addition to all of this, we require them to dictate the cases that they’ve previewed.

So, with all this work that the typical resident needs to complete on an average night, does it make sense to worry about every little detail? I mean, how bad can it be to miss a 2 mm lung nodule or a 3 mm hepatic cyst or hemangioma? Well, I don’t like to be dogmatic about what’s right before I review the evidence. So, let’s consider the pros and cons of what it means to skip the imaging details.

Pros Of Missing The Tiny Lung Nodules

So, let’s start with talking about why we can forgive our residents for missing a few lung nodules here and there. Well, who cares if the resident flies past a few nodules at nighttime, as long as she has picked up the big stuff, yes? If you pick up a pseudoaneurysm of the common femoral artery and you miss a renal cyst, you’ve done your job. You’ve prevented severe harm and injury to the patient. What more could a residency director ask?

Moreover, the attending usually picks up the other findings in the morning that the resident misses. Regardless of whatever the covering radiologist does, she can always count on the backup of another set of eyes.

Also, if you are so busy at nighttime searching for nodules and cysts, how will you have time to look through all the other cases as well. Indeed, it is not critical to find that next nodule, when you need to get to that next case that can potentially have free air and pneumatosis.

And lastly, what is the harm to the patient of missing the incidental small lung nodule? Well, that is also close to zero, right?

Cons About Skipping The Small Stuff

But wait, is that all? Can we miss these nodules with impunity? Stop there.

Do you want to become a fully-trained radiologist? A well-heeled radiologist will never skip looking for any of the potentially relevant findings. They will always look for all the nodules and cysts on a CT scan. By practicing forgetting to search for these nodules, you are encouraging yourself to miss the same findings when you complete your residency. If you want to become a great radiologist, you need to act one early on.

Additionally, not all small stuff is harmless. Occasionally, those 3 mm nodules turn into that 4 cm mass which happens to be lung cancer. I’ve seen that happen with my own two eyes frequently, having interpreted multiple rare cases for a contract research organization that had us read cases for numerous drug trials. The risks are real, albeit small.

And, finally, not all the nodules and cysts are picked up by the morning radiologist. Just like anyone else in any profession, we cannot be perfect. If you did not make these findings at nighttime, how do you know that the morning radiologist has also picked it up as well?

For And Against- Where Should You Lie?

Both camps have some excellent points to make. And, stepping back from the fray, they can both make some sense. However, I would argue that you need to make your judgments about what to do.

Of course, if you are having an insane night with busloads of patients getting scanned, you need to triage your reads. Getting through all the cases trumps the potential for missing a lung nodule.

On the other hand, on a reasonable night, why not look for all the findings? You are doing an extra service to the patient and the morning’s radiologist. And, just as critically, you are augmenting your radiological skills.

Nodules or no nodules, one of the essential skills a resident should pick up from their residency is learning the art of sound judgment. We should leave this task to you to help you grow as a radiologist. Every time we allow, you, the resident, to make up your mind, and see the consequences, you learn a bit more. And, that’s the point of nighttime call for a radiology resident, to decide to look for tiny nodules or not.  Let’s not forget that!

 

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Don’t Forget About The CT Reconstructions!

CT reconstructions

Due to improving CT scanner and software technology, the resolution and detail of reconstructions have dramatically improved over the past ten years. Nowadays, most institutions include these CT reconstructions in their protocols without even an afterthought. However, it wasn’t always like that.  And, like most other images from a CT exam that we add onto PACs, these images exist for a good reason.

But, with the increasing numbers of slices, it has become more common to forget about them. And, that’s understandable. It takes extra time to look at so many additional images. So, let’s go through why it’s worth our time to give them a well-deserved second look and why you should not interpret a case without them.

Some Structures You Can Only See In Another Plane

Ever go through a CT scan and search for the appendix? Especially in folks with a lot of intra-abdominal fat, they pop up in seconds. But, in the typical thin child with lots of contrast filled bowel and not much fat, the abdominal axial images do not help all that much. It is the magic of the coronal plane that often lets you see the appendix in all of its glory.

And, it is not just the appendix. I have seen renal tumors with barely a contour defect at all on the axial images. But, when you look at the coronals, they become readily apparent.

What else? Well, compression fracture deformities magically appear on the sagittal images, sometimes without a hint of abnormality on the axials. So, make sure to use these reconstructions wisely!

Increased Conspicuity

And, it’s not just that you can only see some structures on individual planes. Other times, it just becomes a whole heck of a lot easier to make the findings. Take the bowel, for instance. If you go back to one of my cases from May 25, 2019, you can find a colon cancer that was exceedingly hard to pick up on the original axial images. However, on the coronal images, it becomes a bit more reasonable to find. And, this holds for many other organs as well. Liver lesions, lung nodules, and fractures are other examples of findings that can sometimes be much easier to detect in different planes.

You May Miss The True Consequence Of The Finding

On the axial images alone, you can interpret the findings in the wrong way. Take a look at a typical CT scan. Many times diffuse ground-glass opacities on axial images can look entirely linear on a coronal or sagittal. And, that makes an enormous difference in the final interpretation. Linear opacities on a chest CT are not clinically relevant.  On the other hand, diffuse ground-glass opacities may mean pneumonia, invoking antibiotics and a call to the doctor to return.

Or, you can easily misinterpret disc disease if you look at it in the wrong plane. I can’t tell you how many times I have seen neural foraminal stenosis that disappears once you look at the right sagittal or reconstructed axial planes.  It pays to take another gander at these recons!

CT Reconstructions- Not Just Another Useless Set Of Images!

Unfortunately, reading additional images adds more time to the radiologist’s workday. But, the rewards for reading CT reconstruction series and penalties for missing findings without using them are enormous. So, the next time you see another sequence of reconstructions, do not brush them off as just another set of useless images. Instead, make these reconstructions a regular part of your search pattern for any CT scan study that you read. First of all, you will know to ask for them when they are missing. And finally, you will be glad that you did!

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The Fellowship Personal Statement- What’s The Deal?

fellowship personal statement

After the popularity of my initial article called How To Write A Killer Radiology Personal Statement, I’ve had multiple requests to write a post on How To Create A Fellowship Personal Statement. Now, I have to admit that there are lots of similarities between the two. And, many of the same writing techniques still hold. So, I would recommend that you click on the link above to remind you of some of the basics. However, you will find a few unique differences that I will share. Let’s have at it!

The Fellowship Personal Statement- Does It Matter?

Well, to start with, even though personal statements tend to be one of the least critical parts of the application, they are a bit more important in fellowship. Why? First and foremost, fellowship directors have fewer data points than residency directors. For instance, applicants may have a Deans letter and USMLE scores, but they are out of date. And, extracurriculars do not play as significant a role in the fellowship application since residents do not have as much time. Moreover, core examination results do not change the equation at all because they come back too late.

So, what’s left? The application, recommendations, interviews, and then, finally, the personal statement. So, by the sheer decreased numbers of relevant items to peruse, you will notice that the personal statement must play a more substantial role in the decision for fellowship.

To balance that out, however, most radiology fellowships, currently, are less competitive than the same application to residencies. Of course, that statement probably does not include some select programs such as the independent interventional radiology fellowships. But for most applications, if you take the higher weighting and the less competitive nature of fellowships, both factors probably cancel themselves out.

Finally, it’s not just my words. Instead, it comes directly from the mouth of several fellowship directors that I know. Most do not put too much stake in the personal statement. (Similar to residency directors!)

So, what’s the take-home point of all this? Well, even though marginally more influential, the personal statement still has little sway on most fellowship applications.

OK. How Should The Fellowship Personal Statement Differ From Residency?

Now that we got that brief introduction out of the way, here is the million-dollar answer to the question. And, it is rather simplistic. In addition to all the general recommendations for a residency personal statement, you need to add why you are specifically interested in this particular fellowship. And, you should also incorporate the reasons and motivations for you to select a fellowship in this area.

Unlike the residency personal statement, you want to rely less on extracurriculars and more upon your experiences in residency, not medical school. And, unless they pertain directly to the fellowship, your statement should not emphasize the motivations that initially led you to go to medical school or residency. Of course, however, if you continued to pursue an impressive extracurricular or motivation that began before residency and is relevant to your fellowship, you can add it.

What should you add to show your interest in your fellowship? It could be a radiofrequency ablation device if you want that fellowship. Maybe, you secretly desire to interview patients and miss close patient contact as a mammographer. Or, it could be your love for untangling wires and hoses as former electrician or plumber (notice the touch of lousy humor- that can be a useful tool!) Whatever you choose, you need to make it specifically known why you have decided upon this career path. And, show not tell why you have made that decision.

Where Does This Information Belong?

If you click on the following template link (Fellowship Personal Statement Template), notice that in the first section, you have the “hook” to reel that program director into your application. (That still counts!) Well, you need to apply the reasons you are interested in radiology to this first paragraph. Makes sense, right? Get to the point!

The Fellowship Personal Statement- Not So Hard Right?

To make a great fellowship personal statement, all it takes is a few steps. First, take a look at my Fellowship Personal Statement Template and the link to How To Write A Killer Radiology Residency Personal Statement. It’s an excellent summary if I say so myself!  Then, make sure to add your specific motivations for fellowship in your first paragraph. And, finally, explain any other extracurriculars or specifics during your residency that may be relevant to your fellowship. There you have it. Now, you have the system that you will need to make that exceleent fellowship personal statement!

 

 

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What Diagnoses You Shouldn’t Miss As A Radiology Resident And Why!

diagnoses

For some of my readers, you will be beginning or are currently participating in a journey into the heart of radiology learning, the world of overnight call. And, I can think of no better way to master all the diagnoses you need to become a true radiologist. With all privileges comes significant responsibilities. And, overnights are no different.

So, how do you prepare for such a critical episode in your career so that you do not miss the basics? Well, I have just the solution for you. In addition to reading lots of cases on PACs, taking precall quizzes, and, reading books in general, you also need to triage your time appropriately to learn those topics that will become most critical to know at nighttime.

Therefore, today, I will give you a simplified series of lists of what diagnoses you should not miss and why by dividing the most important types of cases into three main categories: those diagnoses that will kill the patient, common diseases, and entities that will make you look silly if you make/miss them. If only I had a few lists like these when I started — just something to simplify what you need to know for your first forays on call. Well, now, you do. Try to review them before you start. So, let’s begin!

Killer Diagnoses/Findings

Vascular

Aortic Rupture
Aortic Dissection (Type A)
Active Extravasation From Vascular Organ Issue (Arterial Blush)
Portal/Splenic/Renal Venous Thrombosis/Thrombotic Arteries

Abdominal

Pneumatosis/Free Air/Portal Venous Gas/Extraluminal Contrast/Perforation
Shock Bowel
Bowel Obstructions/Volvulus/Bowel Ischemia
Peritonitis

Thoracic

Pulmonary Embolus (V/Q scans and CT scans)
Pneumothorax/Pneumomediastinum (Esophageal injury)

Brain

Large Bleeds Of All Kinds (Subarachnoid, Epidural, Subdural)
Anoxic Brain Injury
Large Acute Brain Infarcts

Gynecology

Ectopic Pregnancy Rupture

 

Common Important Diagnoses

Gastrointestinal

Appendicitis
Diverticulitis
Infectious/Inflammatory Colitis
GI Bleeds
Abscesses
Pancreatitis
Organ Lacerations
Intussception
Pyloric Stenosis
Cholecystitis/Gallstones
Biliary Leaks/Bilomas
Seromas/Lymphangiomas/Hematomas
Organ Trauma/Lacerations (Depends on whether you work at a level one institution)
Free Fluid

Genitourinary

Urinary Tract Stones Of All Ilks (Obstructive/Nonobstructive)
Hydronephrosis
Pyelonephritis/Renal Abscesses
Cystitis
Prostatitis
Ovarian Cysts/Dermoids/Tubo-ovarian Abscess
Ectopic Pregnancy
Early Pregnancy
Fetal Demise
Retained Fetal Products/Endometritis

Neuro

Masses
Encephalitis
Berry Aneurysms
Small Bleeds/Infarcts
Meningitis
Multiple Sclerosis/Demyelinating Disease/Optic Neuritis

Thoracic

Pneumonia
Pericardial effusions
Pleural Effusions
Empyema/hemothorax
Pulmonary Nodules

MSK

Fractures Of All SortsOsseous Avascular Necrosis
Osteomyelitis
Soft Tissue Injuries Of The Knee And Shoulder (ACL, rotator cuff tendon, etc.)
Cord Compressions/Disk Herniations

Oncology

Cancers/Metastases/Adenopathy

Head/Neck

Tonsillar abscesses
Acute Sinus Disease
Parotitis
Sialoliths

Miscellaneous

Foreign Bodies From All Ends (Esophageal, Rectal, Soft Tissue, Etc.)

 

 

Silly Entities Not To Make/Miss

Prostates in Females (Post Hysterectomy Changes Can Sometimes Look Like Prostate Glands)
Uteri in Males (Big Prostates Can Look Like Globular Uteri)
Penile Prosthetic Devices (Reserves Can Look Like A Urinoma)
Normal Studies (The Majority of Cases!)

 

By the way, if you are interested in going through call cases like these and more, take a look at the three quizzes (10 cases each) that I have given to previous residents before starting the overnight call.  See if you are ready!

Click here to get access to the precall quizzes for $9.99!!!