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What Makes The Ultimate Radiology Job?

Recently, I received a question from one of my readers about the ultimate radiology job. What kind of job would it be? I was about to spit out the dull answer: there is no perfect job for everyone, which is true. However, I thought about this question more deeply. I figured I could get a little more down and dirty because there might be a perfect job for a specific person. So, I will do just that. 

Let’s talk about the ideal job for three different particular kinds of radiology personalities. The first would be the perfect job for the lifestyle radiologist. The second would be for the academic radiologist. Finally, the third would be the money-loving radiologist who wants to pay off all their debts as quickly as possible. At the end of each description, I will give you what I think would be a reasonable but high-end salary for the job I describe. You can’t have all the lifestyle features with all the money. And, you can’t be hardcore academic and always have the best lifestyle. But you can find a radiology job with at least one of these features!

Lifestyle Radiologist’s Ultimate Radiology Job

Optimal Working Time

Picture this. You get up late at 10 am without a furrow in your brow after taking a stroll with your dog down the street. Afterward, you return home and start working at 11 am at your own pace. You encounter nary an interruption. After a few hours of work, you have had enough for today. So, you take a shower and plan your next vacation to Thailand. Of course, you have 16 weeks of vacation per year, so finding time for this next adventure is not too difficult. You spend a leisurely dinner with the family, and the day ends smoothly.

The next day, you get up a bit earlier because you had gotten more than enough sleep the day before. Today is your day to come to work. Out of every three days of work per week, you stay at home one day, the other one you come in for, and the third is a miscellaneous day to catch up on the practice’s studies in no particular place and without hurry.

Friendly Practice Situation

As you arrive, all the techs and nurses greet you excitedly and are happy to see you. You are well-liked in the imaging center. Because of the complexity, you start reading through interesting films in your subspecialty that no one else can read. Of course, there is a smattering of normal cases every once in a while in between. Lunchtime finally arrives around noon. You meet with your colleagues for about an hour and go to a fancy restaurant to chat and enjoy the lunch break like you do when you go to work. You return to work unrushed and unfettered, in no rush to complete the rest of the day because you could always finish the rest some other time. 

The following day, the last one of the week, you help the practice catch up on occasional studies. You log on from home and leisurely read your cases. You make a few phone calls and complete your day’s work in a few hours. Of course, you may not get paid like other radiologists who do more. But the time off is worth it!

Radiologist Pay:350,000 dollars

Academic Radiologist’s Ultimate Radiology Job

Out of every five days of work, you have three full days to work on your academic research. Of course, that does not include the eight weeks out of every year that you receive paid speaking engagements or have time for continuing medical education (CME). Moreover, you have the support staff that most others can only dream about. These include two statisticians, a research coordinator, and your secretary. And you have the software and backup to quickly garner the resources to create well-sourced papers at the drop of a hat. Additionally, you have the administration’s help to obtain grants from private and public sources. This help includes multiple connections that overcome many hurdles other academics may encounter. 

Then, you have several days every week to resume clinical work. But, you have the help of your resident, fellow, and junior attending. They do most of the dictation; you get to edit and sign off on their reports. Your residents, fellows, and observers also do much of the work to help you create your following research paper. 

Also, you have easy access and collaboration with multiple specialties throughout the institution. No one is at each other throats. Everyone is willing and able to help each other to come up with great ideas for projects. It’s an environment that fosters learning and research.

Finally, you have already accumulated tenure at your institution. There is almost no way that you can be “canned.” You have put in the time, and the work has paid you back. 

Radiologist Pay: 550,000 dollars

Money Loving Radiologist Ultimate Radiology Job

This radiologist is willing to work as hard as it takes to repay all their student loans as quickly as possible and accumulate enough income to retire as soon as possible. That is the prime goal of this radiologist. And they have found the job they need to meet this goal. 

First, they found a job where the practice pays them precisely what she is worth for each case, plus a stipend from the hospital because she is in a somewhat underserved location. Her days are busy, but they go by fast. They read 200 cases daily, and the caseload is light on findings but large in number. Fortunately, she also works in an area where the case complexity is relatively low and the payer mix is quite high. Of course, they don’t take much of a break during the day, but they work hard all day and reap the rewards.

They also have the backup they need to increase speed regarding radiologist support. These include radiology assistants, a fabulous computer IT department, and an excellent dictation system. They work five days a week, and she gets paid a lot of extra money when they work on the weekends. But most critically, they can do that when they want. Finally, they get lots of vacation, but only take a few weeks out of the year to go away because they don’t want to do this job for the rest of their lives. She would rather have the cash instead. 

Radiologist Pay: 800,000 dollars

The Ultimate Radiology Job- What Do You Think?

You may or may not think that any of these jobs sound great. And that is OK. However, these scenarios are perfectly reasonable for these individuals and can present an ideal situation for these individualized career paths. Let me know if you have an idea for the perfect job, and I can devise another scenario for you!

 

 

 

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How To Keep Up The Momentum For Residency?

momentum

 

Question About Maintaining Momentum For Residency

Hi Dr. Julius,

I’m a first-year DO, and I am just finishing up the final exams for the first term. I’ve done very well so far and am on track to be near the top of the class, if not first (Though it is just the first term, much can change). I’ve had a strong interest in radiology before medical school, much of it due to my physics background as an undergrad.

I wanted to ask, how can I keep the ball rolling to make for a successful radiology application? I’ve heard conflicting answers about research. Some say that research isn’t as important in the eyes of PDs, but most of that advice I hear is towards MD candidates and may not necessarily apply to me.

I have two publications from undergraduate in my specialty field of physics. Still, I am a little lost on finding opportunities in radiology research, given that my school does not have a radiology department. Is it unprofessional to reach out to nearby departments to see if residents have any ongoing projects?

The Momentum Chaser

Answer About Maintaining The Momentum:

Hi Momentum Chaser,

I’m glad to hear that you are starting your medical school on the right foot. However, remember that the first couple of years are very different from your school’s clinical portion. Many students who do well during the first two years do not repeat the same grades when they make it to the clinical years when the medical school evaluates you on some of your softer skills. (Although some do) So, try to play nice in the sandbox to keep the momentum when you get to your clinical years!

Importance Of Research For Residency

Regarding research, the importance of it to residency programs differs widely depending on where you apply. And, I don’t believe it changes anything if you are DO or an MD. Some highly academic programs rely on their residents performing research during the four-year residency program. So, a Mass General type of program is going to want to see lots of research. On the other hand, a community program will not care to the same extent about the research you have conducted already. They will worry a lot more about having a good quality clinical resident. Specifically, they want one that can handle the overnight call and the residency workload. So, the answer to your question about the importance of research is it depends.

What To Do If Your School Doesn’t Have Radiology Research Opportunities

To answer your last question, it is certainly appropriate to ask other departments within your school or other sites for ongoing research opportunities. You may also want to consider finding a project within your school that may overlap with radiology, although not radiology specific. For example, there may be an internal medicine project that requires some imaging. I mention this because it can be more challenging to find projects outside your institution (although possible). To also answer your question, it is also professional and appropriate to ask about projects in nearby departments. It may be helpful to continue the momentum for your application and career!

I hope that helps a bit,

Barry Julius, MD

 

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Is There A Link Between Jigsaw Puzzles And Being A Good Radiologist?

jigsaw puzzles

Putting together jigsaw puzzles is one of those hobbies that residents love to add to their ERAS resume, especially during Covid. What better way to spend your time when you have been quarantined in your apartment, right? To give you an idea of how popular jigsaw puzzles have become, out of every five or ten applications that I review, I see one that briefly mentions this pastime. Presumably, therefore, residents must think that jigsaw puzzles must have something to do with the practice of radiology.

To help me find the connections between radiology and jigsaw puzzles, I did a brief internet literature search to see what I could find on this topic. But I couldn’t find much. Let’s sort out for ourselves how strong the correlation is between the love for jigsaw puzzles and the ability to practice radiology. The connections, or lack thereof, might not be as apparent as you think!

Where Jigsaw Puzzles Overlap With Radiology

Understanding Geometry

You must have some knowledge of geometry when you have a three-thousand-piece puzzle. Why? It is almost only possible to complete the puzzle by recognizing the pieces’ asymmetry and how they fit together. It is a fundamental skill that radiologists also need. In what form? Well, our eyes always look for symmetry. Whether you look at a head CT or a chest film, many modalities require the reader to check for symmetry of density or contours. Therefore, there is some overlap with the jigsaw puzzle.

Methodicalness

To complete a jigsaw puzzle successfully, you need some strategy to get there. Most puzzle aficionados will begin with the corners and work their way to the edges. They could sort the pieces by colors or design to find the most likely candidates to fit together. Regardless, it is only possible with some organization to get to the end goal of completing a three thousand-piece puzzle or more. Likewise, all radiologists need some search pattern on any image to glean all the critical information from a film. If they forget to look at the spleen on a CT scan, you may miss a critical finding, such as an infarct, that could have helped you make the final diagnosis. This characteristic of jigsaw puzzles is also vital for the radiologist.

Doggedness

Finally, it would help if you had some tenaciousness and grit to get through that puzzle of thousands of pieces. It is just impossible to complete a jigsaw puzzle without that personality characteristic. It means sitting down for hours staring at the construction site, trying to mix and match multiple pieces. You can only achieve your final goal of a completed puzzle after putting the time in. Radiologists must also realize that they must read for hours and go through thousands of films to become a master or a radiology expert. Without putting in all this time, effectively practicing radiology is next to impossible.

What Being Good At Jigsaw Puzzles Doesn’t Mean

It Doesn’t Mean You Can Make The Findings.

Sure, you can put together that picture of a grassy knoll or a freeze-frame photograph of your favorite show with 4000 puzzle pieces. But, it doesn’t mean that you will necessarily make that finding of the mouse sitting in the corner of the grass or the misspelled t-shirt on your favorite character. All it means is that you can combine a picture from many fragments because the colors, patterns, and shapes fit together. Finding the little details within the image is a whole other skill!

Baseline Knowledge

Being good at jigsaw puzzles does not mean you necessarily understand the topic or theme of the puzzle you are putting together. You liked putting that jigsaw puzzle showing a nebula of stars because it looked so dazzling. But do you know anything about nebulae? Perhaps not; you don’t need to know that information to complete a puzzle. It helps to have a good baseline of knowledge to understand the images in radiology. Wisdom only comes with reading and an interest in learning.

Good Communication Skills

Does completing a jigsaw puzzle have anything to do with communicating the picturesque scene you just put together? Not! Jigsaw puzzles have little to do with sharing what you know with others!

Interpretation Skills

Finally, putting together a puzzle and identifying the picture doesn’t translate to understanding the more profound meanings of the jigsaw puzzle themes. You can complete a beautiful jigsaw puzzle without knowing why the water appears blue or why that character is smiling. Understanding what is happening when you assemble that final puzzle piece is another leap! We can indeed say the same about a radiologist who can identify the findings but can’t make a proper differential diagnosis!

Jigsaw Puzzles: What Do They Say About The Applicant?

Sure, there are some links between a radiology candidate’s quality and the ability to complete a jigsaw puzzle. However, there is undoubtedly a lot more that we need to assess before concluding whether an interviewee has all the qualifications to make a final decision. Geometric understanding and methodicalness/doggedness will take you further in our field. However, it is undoubtedly not enough without all the other components that go into becoming a great radiologist. The bottom line is to put your love for jigsaw puzzles on the application, but be aware that you must show us a lot more when you get to your interview!

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How Critical Are Connections To Getting Into Radiology Residency?

connections

Let’s face it. In any job, position, or institution, connections can make all the difference between getting an opportunity or falling short. Even in medicine and radiology, nepotism is alive and well. Sometimes, a lesser qualified applicant can get an interview because the father is a large donor to the institution. Maybe, a cousin of the applicant is a physician on staff and asks the coordinator to give her nephew an interview.

So if you ask the question, does influence sometimes trump qualifications on an application? The answer is still yes. Unless egregious, it is easy to disguise. Why? Because the evaluation of applicants for an interview is so subjective.

All this said, I believe most programs and program directors strive to take the best applicants possible to make sure that the most qualified applicants get the position. And I think that the radiology field is more equanimous than most!

So, How Critical Are Connections In Radiology Residency?

Well, all this discussion leads us to the theme. For the average applicant to radiology residency, how critical are these connections? And, my brief answer to that is not so much. Of course, this statement comes from someone who has vested interests not to expose the radiology program to undue scrutiny. However, in all sincerity, we strive to be as fair as is humanly possible. And, I believe for most program directors, the answer is the same.

It is exceedingly rare that a connection will have more influence than allowing a candidate to receive an interview that otherwise wouldn’t. But even if the candidate with a relationship gets an interview, most program directors and chairmen are unwilling to take candidates that cannot get through the rigorous requirements of a radiology residency no matter how “powerful” the connection. A resident who can’t make it through a four-year residency is far more damaging to the program’s reputation than the opportunity cost of an “upset connection.” The amount of time and effort wasted to support an unqualified candidate is enormous. And, the pain and suffering of having to terminate an incompetent resident is worse. Even more so, when the resident who we admitted is a relationship to a “connection.”

Should You Use A Connection If You Have One?

Given all this questionable power of the “connection” and how it affects the application process, you may ask, is it even worth it to use one. Well, as always, the answer is it depends. If you are a borderline candidate who may not score an interview, a kind word from a known connection can push your application into the interview pile. On the other hand, if you have excellent qualifications that speak for themselves, too much name dropping can irk the interviewers. Yet, a well-placed phone call from a trusted source can confirm the quality of the candidate.

So, you can see using a connection appropriately can be a bit tricky. You need to thread the needle, so to say. And make sure to do it diplomatically.

Using Connections To Get Into Radiology Residency- A Mixed Bag

So, there you have it. Connections can help, to some extent. But, more importantly, you need the appropriate qualifications to get the spot. No matter how good the link, make sure that the program is the right fit for you. And use the relationship discreetly so as not to overpower the admissions committee. A connection should confirm the candidate’s quality, particularly when the admissions committee may otherwise skip over the application before the interview ever happens. If used as a battering ram to push an unqualified candidate into an open residency slot, it doesn’t work. (At least at our program!)

 

 

 

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What Is The Difference Between Categorical And Advanced Radiology Positions?

categorical and advanced radiology positions

Question About Categorical And Advanced Radiology Positions:

Dear Dr. Julius,

I wasn’t sure of the difference between categorical and advanced radiology positions. What should I tell the applicants this year? Could you let me know the differences?

A Confused Program Coordinator

 

Answer:

For some reason, I have been receiving this question about categorical and advanced radiology positions a lot this year. Perhaps, it has something to do with how ERAS lists our residency program on its website. In any case, I had to look it up to make sure to give you the correct answer!

Definitions

First of all, some of you know that an Advanced residency, according to ERAS, is any residency that begins after the postgraduate one year. On the other hand, a categorical residency is any residency that begins at PGY-1 year. This categorical spot must continue for subsequent years until the end of the training. 

In this situation, how is it possible for some radiology programs to have a categorical spot when radiology training begins during the PGY-2 year? Well, some radiology programs have an affiliated prelim year at the same institution. And, usually, there is some form of agreement between the two programs. This combined prelim year could be any of the approved PGY-1 slots for radiology, including Prelim surgery, Prelim medicine, transitional year, etc. Therefore, if you are not applying to the prelim spot at the same institution, you should not apply for a categorical slot in radiology.

If Interested In A Prelim Spot At The Same Place As Radiology Residency, Ask!

Also, if you are interested in completing the PGY-1 year at the same institution as the radiology residency, make sure to ask the radiology program director if they have a categorical connection with the same institution’s prelim year. Some do, and others don’t. If they do, sometimes the radiology residency can make a phone call to the prelim program. In this case, this connection can give you a better shot of getting the prelim year slot at the same institution. Why? Because programs want to make sure that you will have an ACGME accredited prelim year before starting residency. Likewise, it’s harder to ensure that outside the institution.

However, if you apply to prelim and radiology spots at the same institution, you may or not be applying to a categorical position! It all depends on the residencies and agreement among the programs. Bottom line, make sure to check with the program director or the graduate medical education office.

Hopefully, you now know what you need to know about categorical and advanced positions!

 

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Live Second Look Interviews Post Covid: A Permanent Paradigm Shift?

live second look interviews

Nowadays, all radiology programs have migrated to a completely remote online interview model. And I get it. With Covid around, it needs to be that way. Regardless of the reasons, there are a few advantages to Zoom interviews. Especially now, applicants don’t have to waste time and money traveling from program to program. But it’s not all a bed of roses. The remote interview system leaves some significant issues. How do you get a good feel for the program when you are not present? And how do you know about the area around the residency? Here lies the new role for live second look interviews!

Rank Lists Will Be Different With Online Interviews!

I harken back to my interview experience back in the days of the dinosaur! If I couldn’t join the residents at my Brown University residency dinner the night before, I am not sure that I ever would have ranked them. By meeting the program’s capable and happy residents the night before (maybe it was something in the fruit punch!), I changed my opinion entirely. I don’t think I would have gotten that sense if I wasn’t there. My entire rank list would have looked wholly different, and not for the better. All these issues lead me to believe that we may have a significant problem. We have an application pool of residents this year who are applying to programs they might not want to go to but don’t quite know it yet.

So, how can we keep the low cost/time solution of Zoom interviews and allow residents to know the programs they are applying for? I am even thinking about the world post–Covid (yes, I believe that it is coming soon!). Well, the answer is straightforward. The second look will play a critical role as a new paradigm for interview seasons going forward.

The Rejuvenated Live Second Look Interviews

Second look interviews used to be the domain only of borderline or unsure candidates. Please take a look at my previous blog on this topic from 2017 about second looks. I mean, who else would want to return to a place they have already been for interviews? It’s expensive and time-consuming to do it again. Right? 

But, I have a feeling that this paradigm is about to shift in the long run. In the post-covid future, the second look interview will become the shortlist domain, those programs that residents are most interested in ranking highly. At the same time, I believe that residencies will also use this second look to reevaluate the candidate live to make sure that it is the right fit.

Think about it. Instead of going to ten to fifteen interviews or more, now you can go to your top two or three choices. And, you can get to know these programs well. Simultaneously, other programs that applicants are not interested in will not have the pleasure of meeting the resident. It makes a lot of sense because most applicants get one of their top three choices anyway. And now, applicants no longer have to waste as much time and money on interviews as they did before Covid.

Live Second Look Interviews Will No Longer Be Optional

So there you have it. The second look interview, I predict, will no longer be the domain of the few. It will become the tool for most residents to make sure they make the right choice for four years. Choosing a residency can be difficult. There is no reason you should make that decision without getting all the information you can. Think about taking a shot at a second look!

 

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How To Be Successful In MSK Imaging

successful in msk imaging

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

MSK Reading

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

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

First Year

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

First Or Second Year

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

Second Or Third Year

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

Final Year

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

All Years

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

Other Thoughts About MSK Imaging

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

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

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

How To Be Successful In MSK Imaging

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

 

 

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Failed Course And Switched Schools: Is It Possible To Get Into Radiology Residency ?

course failure

Question About Failed Course And Acceptance To Radiology Residency:

 

Hello Dr. Julius,
I am an applicant for this year’s DR residency cycle. I’m in a unique position and would value your opinion. I began medical school at a DO program but am now graduating from a foreign MD program. In essence, I was not able to satisfactorily perform osteopathic manipulations. And, I couldn’t pass the final lab at the end of year 2. Instead of repeating the year, I transferred to an offshore school with US-based rotations on my original four-year timeline for graduating.

Nonetheless, I have otherwise satisfactory pre-clinical grades, clerkship scores, and decent board exams, without any other failures or professionalism concerns. My failure of the class and switching school is a large red flag in my profile. I’m very candid about all of this in my application but would like to know your initial impression as a program director if this scenario came across your desk.

Thanks for your time!

 

Answer:

Unfortunately, I have to say that you will have an uphill battle after your failed course, not to say that getting into residency is impossible. One of the red flags that most radiology residencies look for is why you have changed schools. And, if you couldn’t pass a particular class, most residencies will want to know why.

In radiology residency, you will need to perform procedures in interventional radiology and body imaging. You will need to develop a reasonable explanation of why you can perform these technical procedures competently even though you had a failed course of osteopathic manipulation. Maybe, you can demonstrate that you performed well in another technically based rotation and get recommendations in that area. That would certainly help your case. Nevertheless, your goal should be to explain to residencies why you can safely complete procedures, especially since that seems to be the reason why you were unable to complete your DO degree.

Hope that helps a bit,
Barry Julius, MD

 

 

 

 

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How To Be Successful In Breast Imaging

successful in breast imaging

In the second part of the “how to be successful” series, we will walk you through the ins and outs of the breast imaging rotation. Breast imaging, in general, is much different than almost any other area in radiology. (except for some interventional radiology) Why? Because the whole subspecialty hinges on management instead of differential diagnosis. Differentials are usually relatively limited and easy to remember. The challenging part of becoming successful in breast imaging is deciding what to do next. (As long as you don’t miss the finding!)

Also, there are multiple shades of gray in this area of radiology about how to manage patients appropriately. And, it takes a whole heck of a lot of experience to get good at it.

In any event, just like last week, let’s run through what you should read, what and when you should study the appropriate topics, and then finally how you should tackle learning for each year that you are on the breast imaging rotation.

Reading

First of all, I would highly recommend that you check out the free material from the ACR BIRADS atlas on the web. Here, you will get the most up-to-date resource to understand how we dictate breast imaging cases. Additionally, you will learn the appropriate semantics for all sorts of calcifications, masses, etc. I would also advise you to look for a copy of the paid atlas to see each of the different descriptors and associated findings. (see if you can find one lying around in your residency program because they cost 250 dollars!) These sources are the best way to understand the mechanics of reporting breast imaging modalities.

Furthermore, you should also have a supplemental reading to understand the rest of the gritty details about breast imaging. My residents have recommended Breast Imaging, the Requisites (I am an affiliate of Amazon for purchases when you click on the link) to do just that. Although reading during this rotation is required, it is a little less critical to function as well than some of the other radiology areas because it is so “experience-based.”

When To Study Topics In Breast Imaging

First-year

During the first year of breast imaging, I would recommend that you stick to reading out mostly screening and diagnostic breast imaging cases while reading the above resources. Why? It would help if you got acquainted with the basics of breast imaging. The basics include positioning/views, artifacts, searching for findings, and breast imaging’s basic mechanics. Try to hold off on doing too much interventional breast procedures until you are well acquainted with the imaging. You can check out a few to get your feet wet. However, the interventions may not make as much sense because most radiologists make the initial screening and diagnostic imaging findings to get to the intervention point. And, you need to understand these modalities first. You will benefit a lot more from understanding all the interventions better later on.

Second-year

Toward the end of your first rotation or beginning of your second rotation, try to be the initial reader on diagnostic mammography cases. Be in the position of deciding on the additional views and then run it by your attending. In mammography, the only way to learn is to handle parts of the cases yourself. If you don’t take charge, you will miss a good portion of the key to breast imaging- management. Also, be sure to enter the ultrasound room for all the breast ultrasound cases possible. Scanning patients will help you learn how to find lesions and what to look for when you find a mammography lesion.

Final residency years

For your subsequent months of mammography, you should make sure to learn how to perform stereotactic breast biopsies, needle localizations, and ultrasound guide breast biopsies. Also, this is the appropriate time to learn the basics of breast MRI. Breast MRI has become an integral part of imaging in the breast imagers arsenal. You need to understand its place and the basics of how to read them. Again, check out the ACR-BIRADS book for the reporting of MRI findings.

Finally, during your last year of mammography, learn all the new “fancy-schmancy delancy” add-ons. Learn about breast MRI biopsies, PEM imaging, or other modalities that may be unique to your institution. At this point, you want to fill in the blanks. Also, make sure that you have a mammography rotation during your fourth year of residency because the mammograms you read count toward MQSA requirements when you start reading mammograms after a one-year fellowship.

How You Should Learn Breast Imaging As A First Through Fourth Year Resident

More so than other specialties, breast imaging is not a “spectator sport” (a quote from my former chairman during my residency!). It involves being proactive in getting the experience that you need. Moreover, there have been a host of studies, specifically for mammography, that show you need to read tons of images to become an expert in breast imaging. So, you will have to be aggressive to get the numbers that you need to be successful in breast imaging. Not all residencies provide the same training in mammography, and some have significantly fewer cases than others. Therefore, this is a critical piece of the pie that you will need to become a consummate breast imager.

The Basics Of Being Successful In Breast Imaging 

To summarize, what are the critical factors in learning how to become an excellent breast imaging resident and future attending? Ensure that you read the BIRADS atlas and a supplemental book such as Breast imaging, the Requisites. Start with reading screenings, ultrasounds, and diagnostic mammography. Then, when you are ready, take charge of your cases independently. Perform and learn about interventional procedures a little later. Then finally, fill in the blanks during the final years. 

Also, I cannot repeat enough how important experience is for the breast imager. Writing down that you have seen “x” number of cases is not enough in the world of mammography. Make sure that you are looking carefully at each breast image. It is only with experience that you will feel competent enough to become a breast imager when you complete your residency. And, the best breast imagers have seen tens of thousands of cases!