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Posted on March 1, 2020March 1, 2020 by Barry Julius

So, You Want To Become A 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!

Posted on February 23, 2020February 23, 2020 by Barry Julius

USMLE Step 1 New Pass/Fail Grading-Winners and Losers From A Program Director’s Perspective!

Every year, program directors spend large amounts of time and effort in the application process to select qualified radiology residents. Currently, we rely upon sparse information to ensure we get capable residents. And, one of those pieces of data includes one of a few items that discriminate all applicants equally regardless of institution, nationality, or sort of medical school degree: the USMLE Step 1 examination. But, that stream of information will become even more meager. As some of you may have heard, as of 2022, this USMLE Step 1 examination will become a pass/fail examination. As a result, we lose out on a discriminator that can assess a resident’s ability to pass exams and correlates to passing our radiology core examination. Unfortunately, these changes render the test useless for our purposes.

So, we will need to rely upon other methods to select residents that can pass a radiology board examination. In this case, let’s take this issue on step further. How is the new grading system going to affect applicants? And, who will be the winners and losers? Let me guide you through what I predict will happen once the new grading system for this exam begins.

Winners

Ivy League Medical Graduates/Medical Schools

Since we are losing out on one of the few means of equalizing all applicants, we will have to rely more upon the “name” of the school rather than the individual data points. Therefore, known medical schools will take on higher importance in the application process. Regardless of quality, the system is forcing us to use the institution’s reputation over the quality of the individual’s data.

Poor Test Takers

For those folks with problems passing an examination, this change will help somewhat. You will have one less exam to obsess about your score, now that you only have to pass the test. Of course, you will now need to do well on the Step II examination. And, this test will probably replace the Step I exam as a screening tool for the ERAS application to our specialty. But, it is one less hoop for the average poor exam taker to jump through.

Step II USMLE Examination Review Courses

Now that acing the Step I examination no longer becomes significant, program directors will need to rely on another indicator for test-taking abilities. And, the only one left during the residency will be the Step II examination. So, this will force applicants to take this examination m0re seriously. So, you will probably see more Step II courses sprouting up to help applicants score well on this test.

Losers

Foreign Applicants

As program directors, we like to compare apples to apples when assessing resident applications. And, many times, it is harder to determine the quality of a medical school when it does not adopt the standards of the ACGME. So, we need to rely on other means to assess the residents. Now, we lose out on another data point to do so. Therefore, foreign residents will be the first to lose out in the selection process at the expense of other standardized medical institutions.

Radiology Program Directors

For several reasons, this will hamper our radiology residency selection process. First of all, we are losing out on one of the only examinations that correlate with passing the core exam. Therefore, theoretically, we will be accepting more residents that will not be able to pass a standardized test, the core examination. Second, we will have a smaller pool of applicants from which to choose, now that many of us will require applicants to take the USMLE Step II as our “test-ability discriminator.” Third, we will be more delayed in waiting for Step II exams to come in for the ERAS application. And, finally, we will have one less data point to use in our assessment arsenal.

Step I Pass-Fail Grading: Changing The Playing Field!

Tweaking the testing process always changes the outcomes for those applicants that take them. And, the new grading system for the USMLE Step I is no exception. In the radiology application process, there will be clear winners and losers. Foreign applicants and radiology program directors will get the short end of the stick. Meanwhile, Ivy League applicants and poor test-takers will benefit a bit more. And, to assess applicants, we will become more reliant on Step II USMLE examination. So, these are the main changes that lurk over the horizon. Get ready to change accordingly!

Posted on February 15, 2020February 15, 2020 by Barry Julius

Things To Not To Do When Ranking A Program Number One

For those of you involved in an NRMP matching process (radiology residency or fellowship), you only have a few more weeks to finalize the rank list. But, the most significant decision is to rank number one. Why? Well, you have around a fifty-fifty chance of getting that spot if you are thinking about putting it down on your rank list, better than any other place. So, how do you make sure that you are clicking the right program when you finalize it all? Well, to sure ensure your sanity and make sure you have the best likelihood of getting this spot, here are some things that you should not do with your number one ranked program.

Don’t Play Mind Games

It’s not worth thinking about whether or not the program wants you badly. That should play no part in the assessment to rank a position as number one. Only, and I mean only, should you list a program first if you want to go there. It would be best if you only took your assessment of the program into the equation. If the program selected you and you didn’t want the program, where does that leave you? In a matching spot that you don’t like, of course!

Don’t Lie

It is unethical to let a program know that you are going to be ranking a program first unless you mean it. Some programs will use this information to rank you higher if they liked you in the first place. (a residency will not change their rankings if they don’t!) Regardless, if for whatever reason, you decide on a different program than the program that you said was your first choice, and then match with another site, forever hold your peace! Radiology is a small world. And, the ramifications of doing this are myriad. Not to say the least, unbeknownst to you, programs may blackball you in the future if you decide you want a job with one of their faculty. You never know!

Don’t Get Too Invested In Your Number One Choice Before You Match There

There is one guarantee in life: that there is no guarantee! Just because you are confident that a program is going to choose you, don’t buy a condo next door. Until it is official, you never know. I know of several students that had bought all the T-shirts of the presumed institution that they will attend, only to find out that they had not matched at the program. Please. Wait until you have the residency has accepted you before telling your colleagues. You don’t want to look like a fool!

Don’t Psyche Yourself Out Of Your Number One Rank

Your number one choice selected you for an interview for a reason. Regardless of how you may feel now, you do have a chance of getting a spot at your first choice. That chance is probably better than you think!

Don’t Forget To Double Check You Number One Choice

Computers and people’s hands are finicky. You can easily click the wrong button and not realize what you have selected. Or, maybe you changed your mind about your first choice and forgot to choose the program on the match list. In either case, check and recheck that list multiple times before you click submit!

Ranking A Program Number One- Don’t Take It Lightly

The matching process is a headache. But, you’ve already made it through seven-eighths of the ordeal. Don’t screw it all up at the last minute. Make sure to dot your i’s and cross your t’s. Ranking your first choice is a big deal. So be careful and remember: many applicants get their first pick!

Posted on February 9, 2020February 9, 2020 by Barry Julius

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

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!

Posted on February 2, 2020 by Barry Julius

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

Posted on January 26, 2020January 26, 2020 by Barry Julius

Radiology Should No Longer Be Just An Elective: Get With The Times, Medical Schools!

As the 2020 interview season begins to wane, I have noticed a continued pattern among many medical schools. They still consider radiology to be just an “elective.” So, why do medical schools not take the specialty of radiology seriously enough to make it a requirement? Well, I have a few theories. Maybe, they want to limit exposure to medical students to shunt them toward the primary care track. (Yes, they do get government and private funds for doing so!) Perhaps, it’s a bit of inertia that schools don’t like to change. Or, it may take the place of education in other specialties since there is only so much time.

Regardless, they are making a big mistake for several reasons. First, of course, radiology insinuates itself into almost every medical specialty. And then, let’s face it, all students should learn a bit of radiology to be a well-rounded clinician. But, most importantly for society, however, radiology is one of the most expensive cost centers in health care for patients. So, let me give you a few good reasons for why medical schools should make radiology into a requirement instead of an elective and how it increases the cost of patient care.

Incorrect Orders

As a radiologist, if you haven’t noticed all the incorrect orders that flow through the system, you are probably living under a rock! Daily in breast imaging alone, I see at least a few ordering mistakes come through the department. For instance, the doctor orders a bilateral breast ultrasound when the patient only needs a unilateral breast ultrasound. Or, a clinician requests an ultrasound of the breast when a mammogram is in order. Sometimes, I can catch these mistakes before the imaging ensues. But other times, the study is completed before I even had time to decide on appropriateness. And, yes, doctors sometimes order these studies incorrectly because they have not had experienced a radiology rotation! Imagine the decreased costs of getting these orders correct?

Repeat Tests

Along with the theme of incorrect orders, clinicians wind up reduplicating their efforts because some don’t know what they are ordering. Let me go back to the example of breast imaging. Typically, we do a mammogram first in older patients when they say they feel a lump. If you do the ultrasound first before a mammogram, you are more likely to have to do two ultrasound exams instead of one. Why? Because you are more likely to find other findings on the mammogram that you will need to image with ultrasound. If the ordering clinician knew this, he would have been much more likely to save the extra test. And, this is just one example among many!

Wrong Disease Pathways

Then, of course, ordering the incorrect test leads to working up incidental findings. You gotta love those incidental findings! Noninvasive imaging is not benign. Why? Because it can lead to invasive procedures. How about that thyroid nodule that you incidentally detect on an unindicated MRI of the cervical spine? Or, you find a benign lung nodule on a CT chest that the doctor should have ordered as a regular chest film. You now need to work it up! All these incidental findings add undue costs to the system!

Lack Of Understanding of Reports

And finally, without adequate training in radiology, you can blow the significance of findings out of proportion or shove them under the rug. For instance, I have reported on a Schmorl’s node in the lumbar spine (intravertebral disc herniation) with little clinical significance. And I have received phone calls asking what to do for the patient with this diagnosis, biopsy, or not! (Absolutely nothing, of course!) Likewise, I have seen patients with new cortically active bone lesions that a clinician may ignore due to a lack of understanding of its significance. Nevertheless, in both situations, the costs of acting or being inactive incorrectly can rapidly add up for the patient and the system!

For The Sake Of Society- Make Radiology A Requirement, Not An Elective!

Unfortunately, these examples are just the tip of the iceberg. Inadequate radiology education as only an elective allows physicians to skip out on radiology in medical school. And, since radiologists do not control the flow of imaging exams, incorrect orders from poorly trained physicians will continually slip under the radar. So, the solution is simple yet bold. Make sure that all medical students receive a basic education about radiology and ordering radiological tests. We will markedly decrease the cost to the health care system and improve patient care. You got that, medical school administrators!

Posted on January 19, 2020January 19, 2020 by Barry Julius

Radiology Resident Myths Versus Reality

One of my mission statements is to be an excellent forum to dispel the myths and false expectations about radiology and radiology residency. So, I’ve done a post on the top myths about personal statements (Radiology Personal Statement Mythbusters: Five Common Misconceptions About Radiologists). And, I’ve written about the unexpected traits of great radiologists (Top Traits Of Great Radiologists (They Might Not Be What You Expect) ). But, I have not yet written about what is real versus myth for radiologist residents. And, yes, there are lots of false information out there!

So, one by one, I will take each bit of rumor and conjecture you might have heard bandied about the internet below. Then, I will dismiss the fake truth about radiology residency that you may listen to from your classmates and colleagues. Beware the false information that you may see posted on forums, social media, and other websites. Here are some of the more common statements you may hear from your fellow students, and medical colleagues about radiology residency that are not the truth!

You Don’t Need Good Communication Skills To Become A Radiology Resident!

Have you ever heard of a successful radiology resident that cannot communicate with her colleagues? Among all the reports, conferences, and all physician interactions, the only successful residents are those that can speak and write in a manner that others can understand. Moreover, I have never seen a halfway decent radiology resident that can’t give an interdisciplinary conference or handle a team of ornery surgeons at nighttime. You cannot just pump out ill-conceived reports in the dark sitting at a computer. It just doesn’t work that way!

It’s A Cush Residency Compared To Others

Talk to most any resident at nighttime. And, she will tell you the hardest working resident in the hospital is the radiology resident. Regularly, they are bombarded with orders, phone calls, demands for reports, and diagnoses at any moment without a refrain. Do they get a wink of sleep? You have a much better shot at some rest as a surgeon or internal medicine resident between cases!

You Can Get Away With Reading Like You Did In Your Subinternship And Internship

Total BS! I don’t care what they might say about on that radiology forum that you have read. Never, and I mean NEVER, have I seen a resident that can perform well without putting in the time to read. It’s just not possible. We are covering almost every single specialty of radiology. And, yes, that even includes psychiatry and dermatology (on occasion)!

All The Residents Will Be Nerd Techies

Radiology attracts all types. I’ve seen men and women come through who have been “fashionistas.” I have also seen the more techie/nerdish sorts. And I have seen all kinds in between. A stereotype like this does not do justice to the wide variety of personalities that enter our fold. Just stop by most any residency program and see for yourself!

We Hedge More Than Everyone Else

Medicine is not physics. There are so many variables in medicine that no one in any particular specialty can be one hundred percent sure of the future. Radiologists, like any other specialist, operate in this same environment. And, if you talk to almost any excellent physician in any specialty, they are aware of this fact. And, they hedge just as much. Check it out for yourself. Go into the medical records and charts, and look at all the notes from all sorts of specialists. You will see the same!

It’s The Best Way To Get Away From People

Well, it depends on which people!. Indeed, you will have less patient contact if you are working on some outpatient imaging rotations. But, you will not get away without speaking to other nurses, technologists, and other physicians. That is part of our job description! We talk to these folks every day.

It’s Impossible To Get In If You Are A Foreign Resident

Yes, it is a bit more challenging to get into radiology if you are coming from outside the United States. But, certainly not impossible. About a little less than a third of radiology residents graduate from outside the country. (From the NRMP) That’s a decent number of residents!

Radiology Resident Myths Versus Reality

We exist in an environment where it is effortless to propagate untruths and fake data. In a world of inaccurate information, I aim to provide you a bit of the truth in the world of radiology residency from a reliable inside source. So, don’t just take the information about radiology residents at face value. At radsresident.com, you can discover facts about radiology residency like these, which is the reality rather than myths!

Posted on January 12, 2020January 12, 2020 by Barry Julius

Is The Adult Abdominal Series Like Reading Tea Leaves?

At some point, most of you have probably come across the adult abdominal series, most often used for abdominal pain. You will see these exams performed in most Emergency Departments throughout the country. Typically, it includes a supine and upright or decubitus view of the abdomen. At some institutions (like ours), it also consists of an upright chest x-ray. So, why do I want to bother discussing this imaging examination? It must have some issues, right? Well, of course!

So, what’s my beef with this exam? Well, I will go through all my issues with the study one by one. First of all, we will mull over the purpose of the imaging examination and its redundancies within the system. Then, we will discuss precisely who may be ordering the study and why that has repercussions for the expense and overutilization of patient care. And finally, I will go into detail on how the ordering clinician uses the information (if they do at all!). All these points will show why I have negative feelings about the abdominal x-ray series. And, by the time you are done reading this, I believe you will too (assuming you don’t already!)

The Lowly Abdominal Series: Is It Being Used As It Should?

It may seem that every time a patient walks through the door with the complaint of abdominal pain, he gets an abdominal/pelvic CT scan and an abdominal series. But, what is the point of getting an abdominal series if you already know that the patient is going to receive an abdominal CT scan for the same complaint? Can’t you get more information from a CT scan than an abdominal series? Well, the answer to that is clearly yes. That abdominal series becomes nothing more than redundant when you have already have a CT scan on the same patient.

Moreover, some clinicians say that they need it for triage. Well, in my experience, that is debatable as well. I can’t tell you how many times clinicians report that they will utilize the test to help them to determine if the patient needs a CT scan. But, if you think about that usage, it does not make sense as well. Why? Because the abdominal series is a notoriously insensitive and nonspecific test. I can think of gazillion times that I have seen a negative abdominal series in the setting of a rip-roaring positive abdominal/pelvic CT scan. Likewise, I see lots of positive tests that turned out to be nothing on the CT scan.

And, I have the data to back me up. Check this out. Here is a paper from the Radiology journal that gives the sensitivity of an abdominal series compared to a CT scan of 30%. Now, that statistic alone is pretty horrible. Translating that number into everyday English, it means that you will miss a positive abdominal diagnosis of about 70% of the time. Moreover, the specificity of a plain is around 56.5 percent. Or, that means that only just over about half the amount of time will the study give you the correct diagnosis. Not much of an improvement, huh? All this information begs the question, should we use this examination at all for triage for the complaint of general abdominal pain? Probably not!

Who Is Ordering This Study And Why It May Be A Problem

I don’t know about your ED, but at ours, ordering this study has almost become reflexive. As soon as the patient walks through the door, a “midlevel” orders the study. Very rarely is the abdominal series used as initially intended, as a triage tool. And, using the abdominal films for triage is also likely not of much value, with such low sensitivity and specificity. It will misguide as often as it will send you in the correct direction.

So, why do clinicians utilize the study? I have a theory that it is no more than a crutch of tradition. It’s something that some clinicians hang onto because it was the test of choice in the past. And, the less you know, the more you cling onto things. Unfortunately, that leaves the less informed and educated staff to continue ordering the study.

And it is not a “benign test.” There is a significant radiation dose that accompanies it. Check out the list of radiation doses on this RSNA sponsored informational site. Each clinician needs to think about every test they order before they do so. I have a feeling that is not happening!

Does It Help Managing Patient Care?

And, then finally, what happens when the clinicians receive the report from the lowly abdominal series? Is that information used? Well, I hope not! If you buy the previous studies, you will miss most diagnoses if you use it without a CT scan. Given the sensitivity and specificity, I believe the exam more likely increases the expense of healthcare because of false negatives and positives. The abdominal series is a prime example of a test that may cause the caring physician to order more tests than otherwise needed.

Abdominal Series For Abdominal Pain: Is It Like Reading Tea Leaves?

Based on the preponderance of evidence here, I believe it is probably not the best usage of our health care dollars. Sure, it is a quick and easy test. But, quick and easy does not imply cost-effective and useful for patient care. We need to reconsider the use of this unhelpful exam, especially for the general complaint of abdominal pain. It does no more than lead our clinicians astray and increase the costs of health care for you and me.

Posted on January 5, 2020 by Barry Julius

There’s No Substitute For Learning 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!

Posted on January 2, 2020 by Barry Julius

2019: Best Of Radsresident.com

It’s now the new year, so it’s time to look back at what happened in 2019. And, last year there was no shortage of events that affect radiology training and residents. Therefore, I figured what better time than now to look at the most popular articles from 2019. Moreover, there’s lots of great information to help radiology applicants, residents, fellows, and early attendings alike. And, I don’t want you missing out. So, here is a list of links for the most popular articles written in 2019 and another list with links to the most popular articles of all time in the year 2019! Read through what you didn’t have time to read the last time! Enjoy!!!