Category: Uncategorized

Posted on by

Reading Imaging Studies On Our Clinical Colleagues

colleague

The Scenario

A clinical colleague walks up to you, and the following conversation ensues.

Clinician: Can you take a look at my chest film? I have had a cough for several weeks that won’t go away.

Radiologist: Sure. Let me take a look at the image.

The name of the clinician is on the computer, and the scan pops up on the screen

Clinician: Well, what do you think?

The radiologist stares intensely at the screen. Beads of sweat begin to form on his forehead as he sees a spiculated 6 cm left perihilar mass with adjacent interstitial changes and pulmonary nodules in the opposite lung. The clinician stares at the radiologist in front of the desk.

Radiologist: Well… Ummm…

Clinician: Well, what do you see?

By far, reading your fellow clinical colleague’s imaging studies has the potential to be one of the most stressful clinical situations as a radiologist. (as witnessed above) Even worse, the physician-patient may stand directly in front of you while looking at the films for the first time. God forbid we find something potentially lethal or unexpectedly harmful.

Over the years, similar scenarios have played themselves out several times. And, it’s not just me. It happens to most radiologists at some point in their careers, probably you as well. So, what do we do in these situations? Well, you guessed it. That is the theme for today’s post. Let me try to give you a few pieces of sage advice.

Take Time To Read The Study And Call The Clinical Colleague Later

Like I previously advised in prior posts such as Radiology Call- A Rite Of Passage, you are better off taking your time and going through your search pattern rather than being interrupted and making the wrong diagnosis. When a physician-patient stands right in front of you and stares at the screen, you direct your attention toward your emotions, leading to poor discrimination and interpretations. You are not doing justice to good clinical care.

I know. It is challenging to say to the physician-patient, “I can’t look at your images while in the room.” Instead, just say, ” I will look at your images later when I can make my best interpretation.” Most of the time, your clinical colleague will comply (But not always!). It indeed allows you, the interpreting physician, to have time to think about the films and diagnosis appropriately.

Don’t Beat Around The Bush

Your colleagues are physicians and generally know a bit about imaging/radiology. They will see if you are holding back a finding. So, regardless of whether you are on the phone or in person, you just need to tell them what you see. In radiology, however, most findings and impressions (even malignant-looking ones) can have numerous outcomes. In this situation, it is reasonable to say I think it may be x (a malignant diagnosis), but I have seen when it turns out to be y (a benign diagnosis). Of course, you don’t want to give false hope. But we, as radiologists, are rarely 100 percent correct! That gives you a little bit of an out.

Never Farm-Out This Responsibility To Another Radiologist!

Generally, there is a reason why this physician-patient comes to you to read their study. Maybe, they like your skills as a radiologist. Or perhaps, she sees you as a confidant and friend. But for whatever reason, this person came to trust you to read his film. It is never appropriate to shirk your responsibility to talk to the physician-patient by doling the obligation to another physician. It is part of your responsibility as a colleague and physician. Not to say, you cannot get help with the interpretation if complicated. But, you need to be the one that directly speaks to the physician-patient.

Be There As A Friend/Colleague

Finally, as radiologists and physicians, we are all interconnected to our fellow clinicians through the shared medical experience. It is essential to remain present as a friend and colleague to the physician-patient you diagnosed. Give the physician-patient your number to call if they have any additional questions. Commiserate over the diagnosis. Treat this person as you would any friend.

Treat A Colleague As We Would Want To Be Treated!

Our most demanding jobs as radiologists and clinicians are not the day-to-day interpretations of films and coming up with differential diagnoses. But instead, they are the problematic interactions that we may need to have at some point with our colleagues and friends. We need to relay the information to them about their images in an appropriate, correct, and thoughtful way. Even though there is no perfect way to do so, we must treat our colleagues as we want to be treated ourselves.

 

Posted on by

Halloween Tales From The Radiology Residency Crypt

crypt

 

In honor of the up and coming Halloween holiday, here is a collection of two of my own homemade nightmarish radiology residency stories. (written expressly for your amusement!!!) Beware of ghouls, ghosts, and program directors!

Story 1 – End Of Days

The noise of the resident’s footsteps battles the endless quiet of the hospital corridor but to no avail. A faint silent breeze blows through the hallway with a subtle smell of disinfectants, used to mask the horrid smells of sick patients that have rolled through the hallway. Doorways to physician offices and patient rooms are already locked and closed as the resident’s digital watch approaches 5 o’clock on Halloween, the hospital witching hour when everyone seems to leave. But, there is one door 30 feet down the hallway that is slightly ajar with light peeking through. It is his final destination.

He thinks about how it was only just an hour ago when the hospital was active and buzzing. The program director took him aside to tell him to meet at 5 o’clock, speaking curtly. Yet, it almost felt like an eternity. No sign of anything he could have wanted. But the time has now almost arrived. He is almost here.

Turning his attention back to the slightly ajar door, his stomach begins to knot up. Heart paces more quickly. Thump, thump, thump… he can hear and feel his chest almost explode. Barely can he muster the energy to knock on the door. But, he does. And, he hears the faint serious tone of the program director’s deep voice, “Come in…”

As he peers into the office, ancient films line the edges of the walls with glowing light panels underneath them. Diseased skull images, x-rays of horribly broken bones, and bizarre abdominal series with a variety of different foreign bodies all sit tucked into their appropriate places on these walls. Perhaps, the program director found them amusing. Nonetheless, they are entirely inappropriate and bone-chilling. And there, behind a large messy wooden desk sits the program director watching and waiting for him to sit down…

Resident: Gulp… “Uh, sir, why I am here?”

Program Director: “Well… I spoke to the technologists and they said great things about you. I wanted to relay the information that you had done a great job with your patients in interventional radiology.”

Resident: “That’s good news, right? Well then, I will get out of your hair”

Rapidly, the resident gets up out of the hard seat and makes a beeline for the cold door. But, he stops short just before arriving there.

Program Director: “Well, there is one more thing I need to tell you.” He clears his throat with a loud, “Ahem…”

Turning back toward the director, he notices his eyes become a bit glossy and sees a lump form at the back of his throat. He endlessly waits for another word to leave from his mouth, but it doesn’t seem to come.

Resident: “OK… What is it?”

His eyes point to a box across from his door that he must have missed when he entered the room, so nervous for this encounter. The resident looks closely at the side of the box and notices his own name. Pictures line the edges of the box. They look familiar. He notices they are pictures of him and his family. Wait a second… They were just on his desk in the resident room yesterday. At the base of his box lies a thick binder. His learning portfolio.

Resident: “Uh sir. What does this mean? Why is all my stuff from my desk in this box?”

Progam Director: “Well, I guess I didn’t tell you. I thought you knew. The hospital ran out of money for your residency spot. You were chosen out of a hat. We have to let you go. You have to find a residency slot somewhere else.”

Resident: “Noooooo!!!!”

Moohaahaahaa!!!!

—————————

Story 2: The Halloween Reading Room Of Hell

It’s 5:00 PM on Halloween evening and the resident begins his shift. He remembers hearing how the other residents say they were “killed” by the number of cases on call on Halloween night. Even so, like many other nights, he enters the reading room.

Although the room only contains a few PACS monitors, a cramped desk, and a hard wooden chair, his reading room is so small that there is barely any space to move about and there is no wired phone. The walls and door are thick and lead lined. All these factors together, make physicians that enter the room feel like the walls are about to cave in. The walls rapidly muffle the voices from within. Noise from outside the door does not penetrate through the heavy doors and walls to allow the radiologist to dictate cases uninterrupted.

The room begins to bustle with activity as clinical attendings and residents walk in and out viewing CT scans of a group of Halloween pranksters caught by the police with altered mental status after their pursuers beat them silly. And, others were interested to see the scans of some kids with stomach aches from eating too much treats/candy, of course, to rule out appendicitis.

The workload is nonstop. His cell phone rings off the hook. And, clinicians stop into the cramped room by the dozens. Hours go by.

It’s now about 10 pm during the heart of Halloween eve. Clinicians continue to bombard the poor resident throughout the evening. A final large bolus of clinicians stops by to see another imaging study. They finally leave. After all this activity, the resident didn’t have a moment to himself to dictate any of the cases on the PACS system.

Now that everyone left the room, he thinks he has the time he needs to get all the dictations out for the morning’s attending. He can’t take another interruption. Suddenly, with frustration peaking, he slams the door and yells, “I can’t take it anymore!” There are a loud bang and a click. The room falls silent.

Rushing through the next ten CT scans in the cramped room, he notices something unusual. No one comes in or out the door. He dismisses the issue and continues to run through the next ten CT scans. Still not a peep. It’s just his voice and the computer dictaphone.

Exhausted from dictating so many CT scans, he rises from his chair to stretch his legs. He realizes that he wants a breath of fresh air. Slowly, he attempts to turn the doorknob and pull the door. Nothing happens. He tries again. No movement.

No big deal. He decides to get out his cell phone to call security to get him out of the reading room. As he attempts to turn the iPhone on with his fingerprint, nothing happens. The battery must have run out after being in his pocket for all these hours in a lead-lined room and all the phone calls he had to make.

Now he begins to furiously bang on the door. No response. Nothing. How can anyone hear him in this lead-lined tiny room?

He begins to feel hot as the air is stagnant. There is no temperature control. Now sweating like a banshee, beads drip onto the floor from his forehead. Claustrophobia sets in. Feels like a coffin. He can’t breathe. Eyes roll to the back of his head as he slumps down in the seat. Everything appears blurry. The room is moving back and forth. He finally settles down, now unconscious.

Floating upward, he is looking at his body slumped in his seat not breathing. The rest of the night’s CT scans not dictated. Clock on the wall says 8 AM. The door is finally jiggling. A security guard opens the door, not even taken aback by the ghastly sight of the dead resident. He begins to wrap up the body in a plastic bag and thinks  Another resident killed by Halloween call. No one will know the difference. Just like the other residents always say- residents are “killed” on call. It happens every year!

Moohaahaahaa!!!

 

 

 

 

 

Posted on by

Should Artificial Intelligence Be Feared Or Welcomed?

artificial intelligence

Question:

Hello!

My name is Yasmin Amer, and I’m a producer for WBUR in Boston. I’m working on a segment about machine learning and medicine, and, of course, radiology is part of that discussion. I spoke to a local doctor and machine learning specialist who says artificial intelligence will make the field more exciting. Is this the attitude of many med students and residents interested in radiology? Are they primarily excited about tech in radiology, or is there any nervousness there? I’m happy I came across this blog – I would love your input.

thank you,

Yasmin Ameren

—————————————————————————

Answer To The Artificial Intelligence Question:

Yasmin,

Speaking to my residents about the topic, several of them fear the onset of artificial intelligence and its effect on radiology. Therefore, some residents have decided to go into “hands-on” fields like interventional radiology and breast imaging.

However, most others have responded they don’t see how a machine can synthesize the context of a case, the images, and all the patient-related factors to arrive at a final impression that tailors itself directly to a patient. Let me give you an example in the next paragraph.

Sometimes, two similar ultrasound findings can lead to entirely different management scenarios on breast ultrasound. An MRI may be the most appropriate for a noncompliant patient with multiple slightly complex cysts instead of serial follow-up ultrasounds. On the other hand, in a low-risk patient with the same cysts, the most appropriate conclusion may be to follow them every six months. These are slightly different patients with the same images. How would the artificial intelligence judge who is noncompliant? So, it takes more than just pattern recognition to process the information and arrive at a viable conclusion for an individual patient. I don’t think we are quite there yet.

Then, legal barriers prevent easy entry into the independent practice of radiology. Are large companies going to take responsibility if the machines make mistakes? Billions of dollars of losses are potentially at stake.

It is also interesting that applications to the radiology field have dramatically increased over the past few years. Improvement of the job market right now likely contributes to the increasing desirability of radiology. But that cannot be all. If applicants thought artificial intelligence would rob residents of their future 25-30-year radiology careers, we would not receive so many applications for radiological residency programs.

Long story short. Some fears of the unknown consequences of artificial intelligence exist. Overwhelmingly, however, I believe most resident concerns of artificial intelligence encroaching upon the radiologist’s work are less than the expected barriers to independent widespread implementation without supervision by a radiologist.

I hope that helps,

Barry Julius, MD

Posted on by

How To Avoid The Second-Guesser Syndrome

second-guesser

Most of us know other radiologists that fit into the category of second-guesser. Perhaps, you trained or are training under someone like this. Consistently, they debate whether to call a pulmonary nodule or vessel on every other chest x-ray. Or perhaps, when a nurse asks a question about intravenous contrast amounts, they equivocate for what seems like hours. Clinicians don’t know how to proceed. The staff becomes upset. Worst of all, even though these radiologists tend to be very smart, they are targets to lose their job because no one is comfortable with their decisions. You know the type. In today’s post, I will give you some tips to avoid becoming a second-guesser.

Think In Terms Of Highest To Lowest Probabilities

Second-guessers often think about differentials that could be this or that with no differentiation between “this” or “that.” What do I mean? All the different options have the same probability as one another. It is rare for all the differentials to be just as likely as one another in the real world. In less than one out of a hundred cases, there are multiple diagnoses with equal probability of an outcome. So, if it makes sense, stick your neck out a little bit in your conclusion and make your impression the most likely diagnosis. Mention the differential in the comments sections with a description of what is most likely, less likely, and outright unusual. Typically, you will find that you are hemming and hawing much less.

Little Decisions Deserve Little Time; Big Decisions Deserve Big Time

When a nurse walks into the room to ask you how much contrast you should give to a patient with a GFR of 59, you need to decide quickly. Sure, it is somewhat important. We do not want to cause a patient renal failure. But, the difference between giving a patient 100 ccs versus 75 ccs of contrast is unlikely to make much of a difference. This decision is worth no more than 10 seconds of my time in my book.

On the other hand, let’s say you need to decide whether you should biopsy a lesion in the liver. Now, this decision has significant consequences. Biopsies can cause bleeds, infections, and more problems. You really may need to spend some time making this decision. If you have to think through the problem for a while, it makes some sense.

Don’t confuse the little decisions with the big decisions. It goes a long way to preventing you from transforming into a second-guesser.

You Can Miss Em’ Fast Or You Can Miss Em’ Slow

A great radiologist from my residency quoted me the following as he scrolled through a panel of plain films very rapidly, “You can miss em’ fast, or you can miss em’ slow.” I take this statement to heart. Sometimes, when reading cases, there comes the point that looking at a film for a while longer makes no difference in terms of perception. Your first look can be your best look. During the first few milliseconds of looking at a film, your brain unconsciously analyzes the film and can tell if something is off better than staring at an image for hours. Use your gut. Don’t perseverate too long!

Not Every Pixel Is The Same

What do I mean by this? Certain parts of a study are high yield, and others are low yield. For instance, in a patient with breast cancer, metastatic disease likes to go to the bone and liver. So, spend more time looking at these organs. On the other hand, metastatic breast disease does not tend to spread to the spleen. So, use your time accordingly. Spend the appropriate amount of time on each pixel. Pixel selectivity is a tool to prevent you from second-guessing yourself.

If All Else Fails, Make A Decision

Finally, sometimes there are no right or wrong answers. Although not perfect, both directions will allow the clinician to proceed appropriately with a workup instead of perseverating. Sometimes, clinicians need that push to do the right next step for the patient. In this situation, go ahead and make a final decision. You’ll be glad you did!

Avoiding The Second-Guesser Syndrome

Sound advice for avoiding second-guesser syndrome is not emphasized in the radiology curriculum. That’s why I’m here! So, avoid the pitfalls of the second-guesser. Go ahead and create a differential with your most likely diagnosis; utilize the appropriate amount of time for the decision, go with your gut, and spend the right time on each part of the images. You, too, can avoid the second-guesser syndrome and become a decisive radiologist!

Posted on by

Loss Of A Pet- A Lesson All Residents Can Learn About Quality Of Life

Today’s post is not for everyone. For those of you that have never owned a pet or do not understand why anyone would decide to keep a pet, especially during residency, you can stop reading here. But for those of you that take a keen interest in living with a pet of some sort, I think you will find this post very enlightening.

Most posts I write are not personal. Today’s post is very different. It serves several purposes. First, I aim to show my readers how we dealt with a sick beloved pet during the past few weeks in order to give examples of tough decisions that need to be made. Next, I am going to translate this episode into a life lesson about maintaining a good quality of life, translating it to residency. And finally, more importantly for me, I am going to be a bit selfish and eulogize the recent loss of my best friend and dog, Otis. The past few days have been some of the most difficult days of my life. I already miss him dearly.

The Ultimate Responsibility of Pet Ownership- Our Story

When we decided to commit to getting a dog, we committed ourselves to its entire life. We are ultimately not only responsible for feeding, comforting, bathing, and taking our pets outside but also the decisions we need to make when facing an inevitable loss. The difficulty is only compounded when you are training during the incredibly busy time of residency.

In our case, our incredible dog, Otis, had an episode of spontaneous agonal breathing. Like a madman, I rushed him off to our car and drove him to the animal hospital nearly 70 miles per hour through side streets. I passed him off to the technologist like a football so that the emergency veterinarians could instantly treat him. And, they treated him rapidly and professionally with a pericardiocentesis to drain off fluid during an episode of pericardial tamponade. While performing the ultrasound, the sonographer discovered a right atrial mass. Then, in the morning, the veterinarian radiologist scanned his abdomen, only to diagnose him with splenic nodules as well. They declared that he had untreatable metastatic hemangiosarcoma, a terminal cancer of dogs. It would consume him possibly in days or weeks, and if we were lucky, months.

We faced the ultimate decision after the veterinarians stabilized him. What do we do next? Do we bring him home now? Should he be euthanized? I couldn’t bear to say goodbye at this point because he seemed like he returned to his normal self for the time being. We decided to bring him home, hoping he would have a few more good weeks, maybe months.

The next week was one of the best weeks I ever had with my dog. We walked, let him roll in the grass (his favorite activity!), and allowed him to sniff just about everything. It was great. But, the day of reckoning finally arrived too soon. This time, the whole family came with him to the hospital after we noticed some subtle discomfort and worried that he was to become unstable.

The Big Decision- Quality of Life Issues

We knew at this point we had the big decision to make. Do we treat him with serial pericardiocenteses aware that the fluid accumulation and new episodes of pericardial tamponade would become more and more rapid? Or, was it time to say goodbye? We based our final decision on his quality of life. We had to say goodbye.

It was one of the most gut-wrenching decisions, I ever had to make. He was my best friend on earth.  We slept on the same bed, traveled together, and ate meals with each other. He was always there for me over the past 10.5 years. It was his helplessness and innocence that pulled at my heartstrings. And now, I had to put him down. It was for the best. But, it made the decision no easier.

Life Lesson

What is more important than the quality of life? Whether it is a person or a pet, it does not matter. We need to do for our loved ones what is right for them and not for ourselves in the moment.

Translated into the residency experience, we should always think about the quality of not just our own lives but also the quality of life for our spouses, relatives, friends, family, and beloved pets. It’s not always about reading the most cases, staying late every day, only to miss out on our loved ones as time passes by. Bottom line. We need to sniff and smell the roses, just like Otis always did.

Ode to the Memories of Otis

You were the size of a toy truck when I picked you up in Charlotte, North Carolina over 10 years ago. You lovingly sniffed me and graciously accepted me into your life. I thank you for that.

Driving home from the airport, you slowly pushed open the Sherpa bag with your nose as I drove you to our house to see what was happening. Your curiosity was always without boundaries. I thank you for that.

Rolling in the grass was your heaven. You could always spontaneously enjoy the moment. I thank you for that.

When other puppies would bite the hands of their owner to get a treat, you would make sure to take the treat carefully always making sure that we were OK. You were always like that in your life. I thank you for that.

Sitting crosswise, you were always there to protect the kids. I thank you for that.

Good-natured and non-aggressive, you were beloved by all the people and canines you have ever met. I thank you for that.

For all the wonderful memories we had together over the past ten years, I wish we had more. Your life was too short. And, we will miss you dearly. The great memories of you will last our lifetime and beyond. I thank you for that…

From Your Beloved Family- we give thanks for every moment we shared together. Rest in peace…

 

 

 

Posted on by

How-To Procedure Manual For The Klutzy Radiologist

procedure manual

Some of us are not born to be athletic and coordinated like Michael Jordan or Pele. It’s just not in the cards. As a part of this group, I can remember many simple radiology procedural activities challenging me that would make the average resident wonder! Simple things like putting on sterile gloves and coiling interventional wires seemed like rocket science. However, hope springs eternal. And, believe it or not, many strategies exist to allow the klutzy radiology resident to become an expert at performing a procedure. We will discuss these today in this mini procedure manual.

Read Everything You Can About The Procedure

Procedural work is not just about performing manual tasks. It involves significant preparation and planning, both from a hands-on and an intellectual standpoint. Therefore, your role is to know all you can before performing the procedure. Some of the questions you need to be able to answer before any procedure include: What is the reason for the technique? Is it appropriate for the patient? What are all the tools and equipment needed to complete it? How can you avoid complications? And, if a difficulty arises during the test, do you know what you have to do next? And, of course, what are the appropriate ways to manage the patient after you have completed the procedure?

In addition, nowadays, most procedures have an associated “how-to” article or procedure manual in the literature that can help you understand step-by-step how to perform a technique. Not only do you want to read each of these articles, but you also want to live and breathe all the information in it. What do I mean by that? If you can, mentally picture yourself performing the procedure steps before stepping into the interventional suite.

Gather All The Relevant Patient Information

Patient research beforehand can be just as important as the procedure itself. You need to be able to complete the appropriate test for your patient. If not, you can cause additional radiation exposure and potentially irreparable harm.

Therefore, gathering relevant patient information is essential before performing any procedure. What do I mean by that? Here are some of the pertinent questions you want to answer. Does the reason for the technique match the history of the patient? Is the patient able to consent? Are all the appropriate blood tests completed before starting it? Do you know of anything about the patient’s history that would increase the likelihood of complications? And so forth. Ensure that if your attending asks you something about the patient before its performance, you know the answer. It will come back to bite you if you don’t.

Practice Outside The Interventional Suite

As Malcolm Gladwell states in his book Outliers, you need to do something 10,000 hours to become an expert. Therefore, your work mustn’t end after the initial steps. If you have problems coiling a wire, practice the maneuver at off-times at work or home. When you have difficulty putting on sterile gloves the right way, take a pair and practice. If you have problems with suturing, learn needlework. Especially if you are not a member of the athletic/coordinated club, you will need to practice, practice, practice until you get it right!

Volunteer Ad Nauseum

Lastly, you need to develop the qualities of grit and perseverance. When a procedure is available, take the opportunity to participate. Don’t be a wallflower. One of my program directors during my residency repeatedly stated, “Radiology is not a spectator sport!” He was right. Procedural comfort is directly related to the number of times you have completed a procedure. So, go forth and participate as much as possible!

Read This Procedure Manual Again If You Have Doubts!

Everyone has some deficiencies, and we are not born perfect. We need to proceed with hard work and determination to overcome these weaknesses. Procedural skills for the klutzy resident are no different. So go forth and read avidly about procedures, gather the appropriate patient information, practice outside the interventional suite, and volunteer repeatedly. No matter if you are a bit klutzy. You, too, will have the power to master any procedure if you follow these basic guidelines!

 

Posted on by

Radiology Swap- University Radiologist Goes To Private Practice (Part 2)

radiology swap

Today we return to Part 2 of our Radiology Swap blog. Click on Radiology Swap- Radiology Private Practitioner Goes To University (Part 1) to catch up if you missed the first part of Radiology Swap!

University Radiologist Goes To Private Practice

Day 1 Radiology Swap:

Unaccustomed to working in a private office, the University radiologist is surprised by the relatively small size of the office. The parking lot is not too full, and he can walk rapidly from his car to the office, very different from usually having to walk from the back of the parking lot—a nice perk.

Finally, entering the building, he locates his workstation and seat. As soon as he sits down at the desk with the PACS monitor, a technologist dumps a stack of papers with today’s work next to the monitors. It must be about 150 cases. Where are my resident and fellow? I need them to help me with the dictations! Oh, my God!!!! I just realized that I forgot how to use a dictaphone.

After struggling with dictations and having read maybe 10 of them, 11 AM rolls by as he teaches the technologists about the ultrasounds they show him. But, the technologists roll their eyes as they just want to get through the cases so they can go home. They sense him droning on and on! He looks at the stack of papers given in the morning. It still looks the same!

Noon: He begins to receive phone calls, not happy ones. Clinicians are asking him about the results of chest x-rays, ultrasounds, and MRIs. Unsuccessfully, he tries to soothe them and let them know he has not looked at them yet, but he will get to them! No lunch for me.

Eyes reddened, head bleary, and voice cracking, the University radiologist now realizes it is almost 5 PM. He has only finished maybe half of the stack of orders. Lots more to go. No one to talk to. I can’t leave yet to get to the family.

10 PM arrives, and he is finally finishing his last dictation of the “day.” How does the private practice radiologist do it?

Day 15 Radiology Swap:

He arrives wearily into the office, looking haggard and worn with a 15 lbs weight loss since he started the job (1 pound per day!). His temper flares every once in a while, taking out his frustrations on the constant bombardment by the technologists by making snide remarks and yelling at the staff’s mistakes. For the past 15 days, he has left the office in the dark, no earlier than 8 PM. No direct contact with interested learners or other clinical physicians. All interactions on the phone. So, this is physician burnout!

Day 30 Radiology Swap:

Assessment day for Radiology Swap!!!

Practice President: So, you have worked in our practice for the past 30 days? Let’s start with the good part: I’m glad to see that you have made it through the encounter.

Academic Radiologist: Yeah, barely. How do you guys do it?

President: We do it efficiently to make money. The more we read, the more we earn. It keeps us going. In any case, let’s continue with your review. We received many complaints from our staff that you were curt and inappropriate at times. It was like pulling teeth to get you to do fluoro cases on our patients. You kept on grumbling- “Where’s my resident?”

Academic Radiologist: I thought you would at least provide me with a physician assistant to help with daily work. I don’t usually touch patients. My residents do it for me.

President: We also received numerous complaints from our referrers that they did not receive their reports in a timely fashion. We lost some serious business this week.

Academic Radiologist: When you get 150 new studies per day, everyone has to wait!!!

President: I don’t think we would be able to keep you here because we need radiologists to keep up with the work. We don’t get paid if we don’t read the minimum volumes!

Academic Radiologist: The best part of this job was the 15 lbs weight loss! I can finally get some sleep again. His eyes begin to close, dreaming about returning to his academic position.

 

The Radiology Swap Meetup

So, the academic and private practice radiologists now seat themselves in the same room to share their experiences after having returned to their respective jobs.

Private Radiologist: How do you do your job on a daily basis without getting totally bored?

Academic Radiologist: How do you do your job without getting totally burnt out?

Private Radiologist: Let’s agree that we are not right for each other’s jobs. It would never work out for us.

Academic Radiologist: At least I can understand what you go through on a daily basis. We used to make fun of private practice radiologists. Don’t think that I will do that anymore.

Private Radiologist: Doesn’t mean that we can’t be friends. Let’s go out for drinks! I think we both earned it…

Academic: True. We both earned some stiff ones.

The radiologists leave the room and head down the street, never to look back on their former residency swap experiences again and happy to go out for some drinks…

THE END

(until next time!)

 

 

Posted on by — 3 Comments

Want To Be A Successful Radiology Resident? Learn To Triage!

triage

When program directors hear complaints about their residents, we find most do not stem from resident incompetence. Nor do the complaints relate to professionalism issues. Instead, a good majority arises from a lack of a timely response to reading cases. And these delayed reports result from a lack of appropriate triage. So, I think you know what we will talk about today. You guessed it! The topic is tadaaaa… how to triage your cases.

A Common Scenario

It’s 2 AM, and a bleary-eyed resident starts to pick off STAT CT scans from the worklist to catch up on his reading from the nighttime. A house physician rushes down from the floors to speak with the resident in a huff. She explains that she needs to discuss a case from a week ago that she must present for the tumor board the following day. The resident obliges. Thirty minutes pass, and the house physician leaves.

Next, a few minutes later, an ultrasound technologist stops by the reading room because she questions whether a renal cyst is simple or complex. Like a robot, the resident scans the patient in the ultrasound room to make the determination. Another 30 minutes go by.

While scanning the patient, the resident gets two beeps which he needs to call back. He gets to both those phone calls. One of the phone calls comes from a patient’s father, who asks a question about his son’s chest film from the previous day. The conversation drones on for 15 minutes, and the resident can barely get off the phone. But he does eventually. Right afterward, he quickly responds to the other phone call and promptly answers the nurse’s question on the other end.

The resident starts to reread the CT list, and a technologist interrupts his train of thought as he walks into the room. Solemnly, the technologist asks, “How much contrast should we give this patient with a slightly low GFR?”. Immediately, the resident attends to the technologist. However, the resident is unsure and looks through the literature to find the appropriate answer. After 10-15 minutes, he finds a piece of paper and says, “75 ccs of Visipaque.”

Finally, an angry emergency department attending calls to the radiology reading room, “Where the hell are the results from the nighttime CT scans? We have been waiting 4 hours. Sorry, but we are going to have to write this up as an incident in the morning!” Where did the time go by?

Ways To Triage In The Above Scenario

So, what could this poor weary resident have done differently to prevent himself from getting written up by the ER doc? Well, lots of things. For one, did he have to review the tumor board case with the house physician? No. Should he have spent 30 minutes determining whether the renal cyst was simple? Probably not. The resident could have delayed until the morning. Did the resident need to speak to the patient’s father for so long? I don’t think so.

To summarize some of the problems the resident experienced with triaging in the scenario above, I have divided some of the main concepts about radiology triage into the following paragraphs. Here are some general recommendations for triaging cases to avoid situations like this.

Keep Your Eye On The Prize

Remember… When you are on call, the first goal is not to kill anyone, and the second is not to injure anyone. By ignoring the STAT list and tending to other people’s “problems,” you are increasing your chances that something terrible will occur. Perhaps, the CT Abdomen/Pelvis for appendicitis with a positive study will get delayed. Or, you will miss that opportunity to catch that hemorrhagic stroke before it is too late. Delaying STAT reads can theoretically cause irreparable morbidity to your patients. Therefore… Keep your eye on the prize. Complete those studies that are urgent first!

Also, if the activity is not critical, you can delay it until the following morning. In the case of the ultrasound technologist questioning a cyst above, sure, it is an important question to answer. But not so much when you have a list of 5 or 10 STAT CT scans you need to look at. You always have the option of delaying such study until the AM.

It’s OK To Say No

At nighttime, you are going to get all sorts of requests. Some are important, and others are nonsense. Do not let your colleagues bully you into concentrating on peripheral activities that do not directly affect patient care. If you don’t have time to look at that tumor board case, simply say so. Sometimes saying no is just the right thing to do.

Attend To Your Study First, Then Your Colleagues

According to my previous blog, Should Radiologists Ignore The Phone?, residents pay a significant penalty when discontinuing their thoughts midstream. Error rates increase dramatically. More relevant to this post, however, the time to complete a study increases significantly, increasing your chance of causing an angry ER physician. Therefore, it is imperative that you briefly let your colleagues know that you need to complete the study first and will answer their questions as soon as you finish.

Triage And You

One of the most essential facets of the nighttime experience is learning to triage. Believe it or not, you will use these skills for the rest of your career regardless if you take call or not as an attending. What studies do you need to complete first? Who should you attend to? These are all triaging skills you need to learn to succeed. Using some basic triage concepts above, ensure your nights are shorter and safer!

 

 

 

Posted on by

Radiology Swap- Radiology Private Practitioner Goes To University (Part 1)

swap

Ever watched the show called Wife Swap? Essentially, women of two households “swap” roles and responsibilities for different families and share their experiences with the TV audience. It’s a lot of fun to watch! Like this exercise, I thought it would be fun to speculate on what would happen if you swapped a private practice and academic radiologist for a month. How would each experience the other’s world? What would be the trials and tribulations? Let’s see!!!

Radiology Swap- Private Practitioner Goes To University

Radiology Swap Day 1:

The private practice radiologist walks into his university radiology reading room for the first time. Looking around, he encounters a group of 2 medical students, one resident, and one fellow waiting for him to read out the films from yesterday evening and the morning. He thinks: Why are all these people here? Do I need four additional trainees to look at the ten cases left over? This excess is sort of ridiculous!!!

He begins to sort through the pre-dictations of the radiology resident and fellow. As the cadre of 4 trainees looks over his shoulder, he looks at the first dictation and decides to erase everything. Although he feels a little bit self-conscious from all the stares over his shoulder, he starts all over from scratch. He doesn’t like the way the resident words the dictation. It’s too freakin’ long. Rapidly, he runs through each resident and fellow’s cases, erases each, and re-dictates everything.

Only a few additional cases come through the department, and the resident/fellow handles each before looking at the images. They are tertiary referrals from another facility and are very complex, but he does not perseverate and completes the cases in 30 minutes. Staring at the clock, he begins to walk around. Well, not much going on. I’m going to grab some breakfast!!!

After grabbing breakfast for 15 minutes, he arrives back at the reading room. Two more cases show up. The residents, fellow, and student seem to wait for the radiologist expectantly. Again, he promptly erases the resident and fellow dictations and quietly reads the two cases very slowly with the team, trying to pass the time. This day is Chinese water torture! Learning to run intermittently once every few hours from his office to the reading room, the day continues, as is, until work ends at 5 PM.

Radiology Swap Day 15:

It’s the weekly admin slot. On the schedule today, the radiologist attends a tumor board with bleary eyes at 7:00 AM. Not accustomed to the so much time spent on each case, it is hard for him to stay awake. But he manages. Next, at 8 AM, he attends a meeting to discuss performance reviews for the technologist staff. For half of the conference, the attendees discuss when the next meeting will occur. Ugh!!! What a waste of time! 

He quickly dots off to read a few films to help out his colleagues instead of perching himself at his desk to write a grant. He has writer’s block. What the hell should I be writing now? I haven’t written anything but a dictation for 20 years!!! He sits and sits and finally falls asleep at his desk.

Noon arrives. Thank God it’s lunchtime. Something to do!!! He happily runs down to the cafeteria to eat. He stretches out his lunchtime meal for one hour when the next meeting starts. Quality improvement initiative is the theme of the next conference. Could they think of a more boring topic to meet about?

It’s now 3 PM. He begins to meet with the backup staff in the department to discuss increasing resident and attending research output. This group includes the research coordinator, the head of research, the research financier, and the student research liaison. A recurrent thought flashes through his mind during the entire meeting. Who pays for all these extraneous people and why? I would cut the fat here immediately if I could!!!

Radiology Swap Day 30:

Assessment day! The department chairman sits the private practitioner down to summarize the events that ensued over the past month. The conversation goes something like this:

Chairman: I am impressed that you got all the work done quickly. They can be challenging cases. Our other academic radiologist never seems to get to read all the films.

Private Radiologist: Really? He only read 20 films per day!

Chairman: However, you did not apply for one grant; you did not even start on one paper. And, the physicist caught you sleeping at several meetings. Publish or perish!

Private Radiologist: Well, it’s challenging to write anything when you haven’t written a paper for over 20 years! How do you not sleep when half your meetings are about when the next meeting will be?

Chairman: And, your student, residents, and fellow claim that you rewrite all their dictations. You then grumble how they don’t know how to dictate and forget that they are there. Teaching is an integral part of academic radiology.

Private Radiologist: I don’t understand why they have to be there. They don’t do anything but stare over my shoulder!

Chairman: Although you can make it through all the films, your academic prowess is very poor. Academic radiology is not for you.

Private Radiologist: Thank God I can return to my private practice tomorrow!

See you next week for part 2!!!

Posted on by — 1 Comment

Ten Things Radiologists Cannot Tell The Ordering Clinician (We Wish We Could!)

ordering clinician

As residents and radiologists, we have all experienced frustrations that we cannot verbalize to an ordering clinician for fear of retribution. Perhaps, the ordering clinician may stop referring patients to us. Or, just maybe we will get written up in the middle of the night for performing unprofessionally. That would end badly! Regardless, I have created a list of ten things that all radiologists and radiology residents wish we could tell you, the ordering clinician, but cannot quite get up the nerve to do so. So, here we go.

Examine The Patient First

How frustrating is it that patients get a hepatobiliary scan to rule out cholecystitis, only for us to discover afterward that the patient had a cholecystectomy? Or, we receive a CT scan to rule out appendicitis, only to find out there is no appendix! Come on, guys, do your due diligence, PLEASE!!!

Throw Me A Bone- Give Me Some More History

You ever heard that saying called GIGO- garbage in, garbage out? Well, that certainly applies to us! Please, no more clinical histories with abnormal clinical findings or rule out? What does that exactly mean? If you want your reports to be somewhat valuable, throw us a bone!!!

I Cannot Read Your Handwriting- Write Something Legible Next Time.

Ever consider the amount of time we waste trying to mull over what you wrote on the prescription? Precious time that we could have used to get home earlier lost! Did you write CT w/ for contrast, or does CT w/o mean without contrast? This stuff matters!!!

Get An Answering Service, Bub!

Yes, there are times that we need to contact you. One of the most frustrating things in the world is to make that phone call that your patient has a pneumothorax only to find you, the ordering clinician, are out to lunch without anyone to contact. Please, please, please. If you are not around, find us someone who is covering!!!

Don’t Kill The Messenger

Hey, guys… We are only trying. Don’t get angry with us when we are doing you a service by letting you know that patient has an unforeseen pulmonary mass. Or, maybe we want to tell you that your patient has acute appendicitis. I don’t care if you are on vacation when we get you on the phone. Please show us a little bit of respect!

Just Provide The Relevant Facts, Man, We Don’t Have All Day!!!

We, too, have studies to read and patients to see. Could you not keep us on the phone? We have to hear about all the patient’s irrelevant labs, history, and physical examination. Keep it short and sweet, folks. We have lives that we would like to lead!

Don’t Send Us Your Patients At 4:55 PM!

Why do you like to send us your patients right before we are about to leave? Well, maybe, that patient with a GI bleed that you don’t want to work up because you want to go for the day. So, you send that patient for a GI bleeding scan instead of an endoscopy that you would typically do. The patient gets extra radiation, and then you delay the final diagnosis. Is that good patient care? NO!!!

We Are Not The Hospital Dumping Ground- Take Care Of Your Patients

So, your patient is giving you anxiety because he is combative on the floor. Therefore, you send the patient out to get a test so you can get a breather. Well, if you can’t handle your patients, we certainly can’t control your patient when they need to stay still. We are not the hospital dumping ground. At the very least, give your patient a valium if you send them down to our department!

If You See Us Dictating- Don’t Interrupt Us Until We Are Done!

You wouldn’t stop a surgeon in the middle of surgery. So why the heck would you want to interrupt us in the middle of our dictation? We provide essential information to our clinicians, and studies (1) show that interruption prevents radiologists from making all of the findings. Please… Appreciate what we do!

Give Us A Chance To Look At The Films Before Coming Up With A Final Opinion

So, you came down to our department to talk to us about the study you just ordered. Maybe, it is a CT scan of the abdomen and pelvis. Or perhaps, an MRI of the knee. If you know the nuances of reading these studies and you are telling us all the findings, then why did you come down in the first place? Did you do a 4-year radiology residency already? I think not. Give us a chance to make the correct diagnosis, not the one you want to tell us!

Final Words To The Ordering Clinician

We are clinicians, too, so we appreciate some professional courtesy. Do onto others as they would do to you!

 

  1. http://www.academicradiology.org/article/S1076-6332(14)00307-9/fulltext?cc=y=