Radiology jargon that we use to describe our findings to our fellow clinicians and radiologists differs widely from what we have to put in our reports. If only we could use these words in the final dictation because these words are so much more picturesque and meaningful. In addition, they can replace a long-winded description with a simple phrase. Life would be so much more fun!!! Ohh, to be truly living the moment. But alas, we can’t do it for legal, moral, and ethical reasons. Perhaps, the words are too flippant. Or maybe, they are not grammatically correct. But what if we could? I’ve come up with an excellent glossary of thirteen words that should be in common usage that we do not dictate or write down for these reasons. So, here we go!
Badness/Pure Evil
Some tumors have such an aggressive configuration; these words apply. Usually, these lesions are over 99% likely to be malignant with a high probability of metastases.
Brain Teaser
When you obtain the final diagnosis, you are dying to put this your dictation by complicated, circuitous logic. However, it is just not allowed!
Cheesy Consistency
You know it when you see it. It is slightly higher density than fluid with small foci of air.
Ditzel
A tiny finding that you see of no significant consequence.
Fecally Challenged
It’s what you say when you can’t mention constipation because that is a clinical diagnosis. But yet there is tons of poop everywhere!
Glom
It is usually a proteinaceous mess within the body. The glom can be contained or free! I would love to use this one. It sounds so right…
Gumba
A gumba is an enormous finding that is of paramount importance.
Nightmare Case
It is the perfect descriptor for that case, with a billion findings on a CT scan, usually with no oral and intravenous contrast. The problem is- who wants to be called a nightmare?
Ring Magnet
A patient who has rings in almost every orifice imaginable. I am waiting for the proper case to use this one!
Screenostic
Screenostics are breast studies ordered as a diagnostic for a callback or finding and include the opposite breast for some unknown reason. Hence, the “Screen” part of the word.
Shpiel
It’s the real story, not the long-winded, boring version. It can be a word or phrase to replace the written history or impression. Direct translation from Yiddish
Sweet Pickup
It’s what you like to say when you make a subtle but significant finding. Unfortunately, there is nowhere you can say it in your dictation! You have to rely on hearing it from others.
White Cow In A Snowstorm
It’s what you see when there is so much noise that the findings are impossible to visualize. Usually, it is present on ultrasound in an obese patient, an underpenetrated film, or a study with tons of artifacts.
Unfortunately, not all practices are equal out there. Some abuse the junior employees. Others require responsibilities of their employees that the employer does not outline in the contract. And, even others promise partnership with its employees and do not deliver. So how do you know that your first job is going to work out for you? Well, it can be exceedingly difficult to tell for sure. But, I have come up with twelve red flags while employed or interviewing that will enable you to figure out if you need to move on to a new job or interview elsewhere.
No One Tells You Anything
You show up to work one day and discover that the hospital owners changed the location of your reading area within the imaging center without warning. Or, the private practice partners have a partners’ meeting and are unwilling to divulge any information, even non-sensitive information such as compliance issues for the employees. If this pattern of poor communication continues over time, it is a sure sign that the partners either have poor communication skills or do not respect the employees’ work. Be very wary!!!
Constantly Changing Work Responsibilities
You may be a neuroradiologist, but the practice expects you to all of a sudden read mammograms that you have not read for many years. And, the next week, you are responsible for all the arthrograms, even though you have not done one since your residency. If this happens once or twice, it may be related to staffing or temporary issues. On the other hand, when it is a recurring theme, it may be the first signs of an inept management structure unable to either retain its employees or, perhaps, severe practice disorganization. Think twice about staying!!!
Severe Isolation Syndrome
When you come into work, you see all the offices with radiologists with the doors locked. Just like everyone else, you shut your door too. And, you don’t even hear a peep from another radiologist for days at a time. Is this a collaborative environment? Certainly not!!! It doesn’t bode well for a fruitful, enjoyable long career!!!
No Practice Socialization Events
Most practices have some sort of get-together for the members of the group or hospital, whether it be the attendings, technologists, nurses, or other staff. And, there is a good reason for that. It is essential to get to know your colleagues so that you can feel comfortable relying on them as people. If none of these events are available, it sure seems that a lack of trust may be in the cards. Do you want to be part of a practice where you don’t even know your colleagues?
Hallway Brawls
OK. Perhaps, once in a while, a colleague does not get along well with another. However, if you find this a regular occurrence, there is a good possibility that your colleagues have significant personality disorders. Are you willing to deal with this behavior for the rest of your working career?
No Rewards For Good Employees
Sometimes your employees go above and beyond what the employer expects of them. Practices that ignore good employees also tend to overlook each other. How do you reward someone who is adding value to an imaging business? Well, you give them a bonus, extra vacation, or at the very least essential verbal recognition of their excellent work. If your practice can’t see how good you are and are working hard to better the business, consider going elsewhere!!!
Always Being Told You Are Wrong
Perhaps, you are missing a lot of findings or do not communicate well with colleagues and physicians. But, if you find that you are within the bell curve and your employees are constantly criticizing your work, did you ever think that they might just not want you there? Start looking around!!!
Running Around Like A Chicken Without A Head
Living in constant stress with tons of studies and responsibilities without end is not sustainable over the long run. Some practices run continually by having radiologists read too many cases to be safe. They are just in the business to make money for the bottom line of the partners’ pockets. Can you work in this sort of situation for the rest of your working life? Think about finding someplace where you can work over a long, sustainable period!!!
Lack Of Hospital Involvement
You notice that none of your colleagues or future employers is on committees within the hospital staff. If you want to stay relevant to your place of practice, at least someone needs to be involved. Otherwise, if there is no connection to the practice facilities, the ax may fall when you least expect it, and all of you may be out of a job!!!
No QI Committees
Believe it or not, quality is a crucial element of good practice. How do you know how you are doing? Well, there is only one way. You need to have someone that monitors the quality of the practice. Does the imaging business have morbidity and mortality conferences or peer evaluations? If your future coworkers are embarrassed to have their work checked, you may be looking at a practice that doesn’t care how they are doing. Start thinking about finding a practice that cares about the quality of their work!!!
No One Cracks A Smile
I find it a relief to crack a joke or say something nice and get a good response. However, some practices take themselves way too seriously. Do you want to be in a practice where everyone is miserable?
The Almighty Buck Always Rules The Roost
If you have not learned it yet, you will undoubtedly learn it at some point. It is not always about the money. Employers need to value ethics, practicality, and hard work over money at many points to run a genuinely great practice. If there is never a time that your future employer factors these attributes above the almighty buck, consider your alternatives!!!
So There Are Red Flags. Now What?
Not all practices are perfect, and it doesn’t necessarily mean that they are dysfunctional. However, when you catch a pattern of multiple red flags again and again without correction, it may be time to rethink your employment strategy. Keep your eyes wide open and your ear to the ground!!!
If you have not read The Lord Of The Flies, you are missing out. It is a “must-read” for all professionals and especially for residents and residency leadership. For those of you who have never read the book, the story is about human beings’ “true nature.” A plane crashes on an uninhabited island, and the survivors are children without any adult supervision. The children create a society that slowly devolves into utter chaos. The book uses this as a metaphor for civilization and culture.
Well, how does this relate to radiology residency? Some residency programs over time become “leaderless.” This situation can occur due to a change in program directors, weak, ineffectual leadership, or program leadership in-absentia. When this happens, the residents may take over the “island.” This debacle can sometimes lead to utter chaos since most residents do not have the training to understand what is essential in radiology residency and beyond. Individual programs need residency leadership.
So, what are the signs that your residency program has turned into the Lord of the Flies?
Residents Arrive Late And Leave Early
You know the residents rule the roost when the program has no accountability for the attendance of your fellow resident colleagues. Your fellow resident arrives at noon because they “need to study” and leave at 2 pm for happy hour at the local bar without some form of consequence. Members of a residency “island” cannot survive unless all the participants band together and work to make residency the best it can be!
Residents Not Showing Up On Rotations
Residents miss out on the most crucial residency experiences when they miss their rotations. These rotations are the time to learn how to be a great radiologist and understand the subtleties and context of their future profession. Instead, the radiology residents gather in the library downstairs to read books rather than active cases. It’s just like not showing up to the hunt to get food for the members of your island. How can you survive?
Infighting Amongst Colleagues
When your fellow residents have decided to divide into two factions, constantly trying to throw each other under the bus, you can’t even look at your fellow residents in the eyes without arguing or getting upset. Even giving each member of your residency a conch before speaking does not help!!!
Shirking Responsibilities
You notice that the radiology residents ignore their responsibilities. The attendings are now performing “resident procedures” like sentinel nodes and paracenteses. All members of a “residency island” need to perform their duties. In the book, the responsibilities of the society were to create shelter, forage, and hunt. In a residency program, it is performing procedures, consenting patients, and reading studies. Residents need to perform these duties to receive the training they need to meet the needs of the survivors. Perhaps, the faculty do all the work because they cannot rely on the radiology residents!
No More Evaluations
If the program director and attending staff have not evaluated you over the past year, the program leaders are likely not following up on your training. The leadership has abandoned its post! Each member of the “residency tribe” is now forced to assume that they appropriately perform their duties. Residents learn bad habits that can stick for the rest of their careers without the guidance they require. How can the individual know what to improve when the residency provides no feedback?
Educational Meetings Are Gone!
When the educational committee disappears, the individual resident has no representation in how they learn radiology during the four years of residency education. Just like the book, once the tribe members no longer have a say in the functioning of the island, the “leaders” slowly take over and create an oppressive society. Those who did not comply were tortured and killed! Education needs to be a partnership between the residents and attendings.
Residency Leadership And The Lord of the Flies
All residencies need leadership with the best intentions of the individual resident physicians in mind. Sometimes it means rules and regulations that the program needs to enforce that allow the individuals to maximize learning. Other times, it requires the participation of its constituents so that the program gives the best educational experience possible over the four years. If these institutions are not in place, you are in for a rough ride. Your residency island may not survive!!!
If you haven’t had a discrepancy with the covering morning radiologist as a resident on call, then one of you encountered one of three outcomes. You either haven’t read enough cases. Two, you are the long-lost great-great-grandson of William Roentgen; Or finally, perhaps your name is Watson, the artificial intelligence computer, and you work for IBM!!!
The truth that very few attendings seem to admit is that everyone, including themselves, will miss something every once in a while. One study reported radiologists clinically miss something important between 2-20% of the time. (1) From my experience, that number looks pretty high, but the rate is significant enough. So, when, and notice, I don’t say if you miss something and have a discrepancy at night, you are an ordinary radiology resident. I would even go as far as to say that you are fortunate, in a sense, because you didn’t miss the finding as a full-fledged attending. You have someone to back you up, and hopefully, you will never forget that finding again.
Accepting The Inevitable Discrepancy!
The first step, of course, is to prevent major misses. The cases you need to study leading up to taking calls are the cases that are common and lead to significant morbidity and mortality. You want to view hundreds of different types of appendicitis, aortic ruptures, pulmonary emboli, and so forth so that when the time comes for you to take a call, the chance of missing the critical finding is significantly lower. Unfortunately, however, we can’t prevent all the inevitable misses, and frankly, we have to admit to ourselves first and foremost that this will be the case.
So, what do you do when you have a significant miss? Maybe you sent a patient home with acute appendicitis or a patient with a ruptured ectopic pregnancy. Perhaps you missed an early retroperitoneal bleed. There are specific keys to making the discrepancy in any of these cases, not just another horrible encounter, but rather a learning experience that is valuable for the remainder of your career. We will go through a few rules that you need to follow in the rest of this chapter.
Don’t Perseverate Over The Discrepancy
The first important point is how you emotionally react to the discrepancy. It is also a life lesson. We can’t undo what you did. You need to move on… Perseverating on a miss is counterproductive at best and, even worse, can cause future misses. Remember, just because you made a significant miss does not mean you are or will be a horrible radiologist. So, you need to get over it. The same rules apply to questions on written exams, future failures, etc. One miss does not a radiologist make!
Make Sure To Follow-up The Patient In The Morning
When you find out about the bad news, it is inappropriate to leave the department sulking, not attempting to make good on the miss you made. Try to do what you can to make sure that the physicians in the emergency room know there was a discrepancy. Or, you may need to call the patient back yourself, if need be. Bottom line… You need to make an effort to clean up your mess. It is partially your responsibility.
Read All You Can About the Miss To Not Make the Mistake Again
Reading about the disease, reviewing the films, looking at other similar cases: These are all the things you should be doing soon after the miss. This miss is a real opportunity to understand and fix the incomplete knowledge you had on the subject before, and, of course, to never make the same mistake again.
Teach Others
One of the most rewarding ways of compensating for the discrepancy is to make your fellow residents and junior residents aware of the miss. Teaching your colleagues protects them from making the same mistake that you have made. And, even better, it reinforces the knowledge you have, thereby making it much less likely that you will repeat the same mistake. Just like lightning, it rarely strikes twice!!!
Learning From Midnight Discrepancies
Midnight discrepancies are part of the everyday learning ritual for a radiology resident. It is not the discrepancy itself that is a problem. That is expected and is part of the typical routine residency learning experience. But instead, the issue is how you as a radiology resident learn and grow from the experience. Make the best of a challenging situation!!!
I read your article on the struggling radiology resident, and it prompted me to contact you. I am an R1 and just finished my first week on Body CT. After this week, I feel panicked and have been attempting to study almost every chance I get, including all day during the weekend. Still, I think I cannot possibly learn all this information (just the anatomy base I need has worried me). I know it is still early, but my colleagues are way more relaxed and comfortable in their current roles than I am. I would greatly appreciate any suggestions you have for me.
Thank you so much for this article and your help,
A Concerned Resident
Answer:
Detailing The Problem
To begin, I want to stress that your colleagues who appear as if they are more relaxed and comfortable may be putting on their best face, but they may be panicking too. It can be challenging to tell how another resident or colleague feels. Regardless of how they appear, it would help if you didn’t worry about them. Instead, you must ensure you are doing your best instead of panicking.
I don’t care what anyone says. The first weeks of the first year of radiology are some of the toughest. Anyone who doesn’t think so is in for a big surprise later. It’s good to have a little bit of fear at the beginning. It can motivate a new resident to become great. Excessive fear, however, is no good. You certainly don’t want a fight or flight response!!! Or, you can burn yourself out before you’ve even started. That will make you make you sick.
Also, I think body CT can be one of the more difficult rotations to feel comfortable with, especially at the beginning. Some of the personalities can often be difficult in that field. And, there is more anatomy to know than you may have imagined. This large amount of anatomical information is more so than other subspecialties like nuclear medicine. Plus, you have to start to get to know the pathologies on top of that. So, I know you are in a tough spot.
Solving The Panicking Problem
But alas, there is a solution. I find that the best way to deal with a challenging situation, like the beginning of the first year of radiology, is to establish a reasonable plan of attack. You and I know you cannot know everything. Albeit, many of your attendings may make you feel that way. (you have to try to tune that nonsense out.) However, you can learn what you need to know to become a trusted first-year resident. The key here is to study smartly. Certain books are geared to the first-year resident. For instance, the Webb Body CT book is a great and short resource to learn the basics of body CT scans. You need to concentrate on these.
In addition, the reading style in radiology differs significantly from what you have been learning. Make sure to read the pictures first, the captions next, and then the text last. This strategy will give you the most bang for your buck when reading radiology. Once you have the basics down of a modality within the first week or two, I would also emphasize reading the case review series. Radiology is about pictures. So, why would you not want to emphasize the images? Memorizing lists is daunting and usually not very fruitful without context. Looking at a bunch of pictures makes a list more relevant and memorable. This technique will leave you less prone to panicking. Try to study in this manner.
Also, I would recommend you look at my article on taking oral cases. Handling cases with oral technique is readily transferable to your day-to-day radiology activities. If you can do that well, your colleagues and attendings will appreciate your intelligent assessments more.
In any case, let me know if there is anything else I can help you with. With a bit of change in the study method and trying not to worry about how others look compared to you during your first year (which can make you crazy), I think you can do just fine.
Thank you so much for reaching out to me with your advice. I am doing my best to stay positive and study hard. I will let you know how it goes. Thank you!!!
Best wishes,
A Concerned Resident
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It takes some time to get into the routine. Good luck with it!!!
As radiology attendings, we need to sit next to our radiology residents for hours at a time. We get to know your quirks, mannerisms, and other personality features for better or for worse. (Kind of like a marriage!) Interviews are a time to let that personality shine through. We want to make sure that you are a living, breathing person with a soul. Can you speak understandably? Can you hold a conversation? Are you funny/witty? What’s your hygiene?
A radiology residency interview can also confirm that you are the person you say you are in the application. Can this person be trusted? Is this person going to lie to his attending about a procedure or history? For these reasons, significant weight is placed on the interview even though the process is imperfect. Furthermore, it does not always weed out the bad from the good.
Even knowing the importance of the radiology residency interview process, many prospective radiology residents enter the interview unprepared and have the perceived emotional/situational IQ of a tomato. If that were you, I recommend you practice your advertising pitch numerous times before beginning the interviews. If you want that residency job, you need to be the greatest of actors/actresses during the interview process. Show us that you can handle the demands of radiology residency!!!
Throughout my interview experience, I have seen all sorts of applicant disasters during the radiology residency interview process, usually related to unprepared applicants. Most can prevent these catastrophes with attention and practice. I am going to go through 10 real interview characters that have sabotaged their application. I hope these scenarios will be instructive in the art of the radiology residency interview. DON’T LET ONE OF THESE CHARACTERS BE YOU!!!
The Liar
Our third radiology residency interview candidate of the day walks into the room and shakes my hand firmly as we sit down to talk. He seems very focused, and I enjoy talking with him. He starts talking about how he developed an organization that hires famous CEO guest speakers to come to his medical school and lecture on business in medicine. Wow, very impressive! The interview ran smoothly, so I preliminarily gave him high marks.
After the interview session, the selection committee convenes to review each of the applicants. It turns out, the application and the other interviewer had different stories. Upon review of the application, it says he was just a member of the organization’s club. The other interviewer said he would only chauffeur the CEO to the meeting. Out of concern for the applicant’s integrity, we put him in the do not rank pile.
Bottom line: Make sure to get your story straight. Your oral presentation and written information should all be aligned. The interviewers regularly reconcile everything together. You need to tell the truth and stick with the same story!!
Smelly Guy At The Radiology Residency Interview
Before the formal interview procedure, we have a social interaction period with the residents to get to know the applicants. After most of the residents leave the room, we begin to hear some grumbling from the residents. So, I walk into the room, and as I walk toward a particular applicant, a stench becomes stronger and stronger. Oh my God!! It smells pungent, and I can almost taste it in my mouth. My impulse is to run, but I have to be cordial due to the circumstances. I am dreading the one on one interview process.
Bottom line: Make sure your hygiene is appropriate before starting your interviews. Appearances and “smells” are essential!!
The Sleepy Man
My introductory lecture to our residency program starts, and the lights begin to dim. I typically look at all the applicants in the room to keep the interest level high. But after 5 minutes of lecturing, I hear a loud freight train-like noise emanating from the back row in the form of an applicant in a suit. My assumption is he is not interested in the residency program: suitable applicant but low-interest level. We rank him toward the bottom of the list.
Bottom line: It is imperative to get a good sleep the night before the interviews. Even if the applicant was only tired but interested in our program, sleeping during the interview shows a lack of interest and respect.
Ms. Robot
I warmly introduce myself to an applicant as she enters the room for the formal interview. Entirely devoid of emotion and empathy, she responds, “Hi” quickly. We sit down, and the applicant immediately launches into this speech about herself without any voice inflection or changes in tone or speed. I have the sense she has done this a thousand times before. There is no “conversation-like” tone to her speech. No interactive quality. Is this the way she will behave when I have to sit with her for hours at a time? Even though her application was excellent, the applicant committee decided to give her a do not rank assessment.
Bottom line: Practice interviewing with others. Pretend you are having a conversation and interacting with your interviewer. Perceived personality is vital!
Shy Radiology Residency Interview Guy
The applicant walks into my interview room and introduces himself, but I can barely hear what he says. He stretches out to shake my hand. His hand feels cold, limp, clammy, and weak. The interview starts, and I try to get him to respond to my questions, but it’s like “pulling teeth.” The answers last 10 seconds at most. I asked the residents sitting next to him in the conference room about the candidate, and they said he didn’t speak a word. No one was able to figure out his personality. Even though his application was OK, we felt we could not put him on the rank list.
Bottom line: You need to get over your fears and act and speak with confidence. It may involve practice, coaching, and psychological evaluation. If we can’t figure out who you are during your interview, we are not sure if we want to sit next to you as a resident!!!
Mrs. Bizarro
Across from me in the interview area sits a pleasant-looking woman dressed appropriately. Everything seems fine until our conversation begins. Her eyes start to bulge out. Smiles and giggles burst out inappropriately in the middle and end of sentences. Even though she answers my questions mostly appropriately, something is off.
After the interview, we meet with the selection committee, and the first thing I ask is: what’s with Mrs. Bizarro? All the committee members look at me and say, “We were thinking the same thing!!!” We quickly took her off the rank list.
Bottom line: Practice your interviewing skills in front of a mirror or tape yourself on an iPhone. You need to know that your expressions are appropriate for the interview context. This lady may have been an excellent radiologist, but we sure would not feel comfortable having her sit next to us!!!
Not Quite Right, Joe
Toward the end of the interview, we start to talk about extracurricular activities and hobbies. The applicant proceeds to say that he was into cow-tipping as a college student. And one time, the college dean reprimanded him for the activity. Automatically, mental bells start ringing. Who would mention something like that in an interview setting? Why would someone want to do that to a cow? Off the rank list, he goes!
Bottom line: We are not your friends in the interview setting. Do not release any information that could jeopardize your application and make you appear strange. We do not want any issues during residency that could cause probation, suspension, or worse!
The Guy all the Residents Hate At The Radiology Residency Interview
I am having a great conversation with one of the applicants. He tells me about some of his exciting research projects and hobbies. He seems to be a straight shooter and is very witty. We end the conversation on a high note with expectations that we will rank the candidate highly.
After our interview, we met with the rest of the admissions committee. The admissions committee consists of the residency director, associate residency director (myself), chief resident, and several other senior residents. We begin to discuss the candidate at hand. Every single resident states something negative like: “This guy was obnoxious”; ‘He was chauvinistic,”; “Really bitingly sarcastic.” The directors are dumbfounded. We place the applicant in the do not rank pile.
Bottom line: You need to play nice with all members of the staff, especially the residents. They have essential input in the residency application process and interviews. The wrong statement can get you kicked off the rank list!!!
The Cell Phone Gal
I started giving the introductory talk to the applicants about the program. Every minute or two, I notice a woman looking down at her lap. Oh well… I continued with my lecture.
An hour later, we meet for an interview, and we shake hands. We sit down, and I start asking questions. The applicant seems a little bit distracted. Again her eyes continue to float down toward her lap every few minutes. All of a sudden, I hear a ring. She picks up the cell phone and says to me, “I need to get this.” She is not interested in our program.
Bottom line: Shut off your cell phone. You are here to interview for a job. It is a sign of disrespect to use your cell phone at any time during the interview process!
Opaque Sam
We parse through an applicant’s resume and ERAS transcript. The package states that the resident had a DUI arrest when he was a college student. So, the interview begins after some ice-breaking small talk. Naturally, a DUI arrest is a big deal. It signifies that the applicant has the potential to be an alcoholic and engage in risky behaviors. So, I anxiously pop the question: Tell me about what happened with your DUI arrest when you were in college? The applicant bluntly states, “It happened. It’s over. I don’t really want to talk about it further…” A moment of silence ensues.
Flash forward to the selection committee meeting. All the interviewers received the same response from the applicant. There was no response of remorse. No explanation for the event. Nothing. Our committee put the applicant in the do not rank pile.
Bottom line: Candidates should address any adverse events upfront, or else an admissions committee may perceive the applicant as hiding something significant, whether true or not. Don’t be like Opaque Sam!!
Sabotaging Your Radiology Residency Interview!
Interviewing is often about what not to do as much as it is what you should say. Make sure you prepare for the interview day. And, don’t be like our ten catastrophic characters!!!
Good evening, I am an MS3 just starting to discover the excitement of radiology on my radiology selective. I am contemplating radiology as a career, but I have low Step 1 score (227) and I am also an international student requiring H1B visa for residency (I attend a top 40 US allopathic school and am not Canadian). Is radiology still an option realistic to consider given my circumstances (I hope to match into a university program)? What can I do now as I start my third year going forward to increase my competitiveness? Thank you for all your help!
Adele
Hi, Adele!
H1B And J1 Visa Issue
The answer to the question of your chance for getting into a program may hinge on the next few questions I am going to ask you. Why is it that you require an H1B vs. a J1 for getting a residency? What kind of visa do you currently have? This may make a big difference because universities are much less likely to support a resident with an H1B visa since it costs the university a lot of legal fees and time to support a candidate to obtain the H1B visa. Also, the federal government limits the numbers of H1B visas. Therefore, you significantly limit the playing field of choices of programs to apply.
Some of the larger academic university programs may allow applicants with an H1B visa. But, many smaller programs like ours do not take applicants with H1B visas for the reasons I mentioned (with a few rare exceptions). When applying, if you can’t get a J1 visa, I would definitely call the individual programs to see which ones would take an H1B visa.
Biggest Positives In Your Application
So, what do you have going for you? First, the fact that you are graduating from an American medical school will help your situation immensely. We, as program directors, selfishly like to get applications from American medical schools. At least we can vouch for the quality of the institution and compare to other applicants. Second, your scores are not bad. Many programs have cutoffs around 220 or 225. So, it should allow you to meet that requirement at many programs.
Other Recommendations
In addition to the recommendations above, I would also consider taking the next USMLE early, studying hard, and perhaps completing a USMLE Step II course so that you can show improvement from your 1st USMLE examination to the next one. Program directors like to see improving scores going in the right direction.
Thanks for the great question. I would be specifically interested in why you need an H1B. Let me know if there is any other information that you think I can help you with. I will post it on the website at some point because I think it would be useful for other applicants in your situation as well.
Regards,
Barry Julius, MD
Dear Dr. Julius,
Thank you for your reply and great advice.
I am currently on an F1 student visa and was advised against a J1 visa by my immigration attorney because of the requirement to return to my home country for 2 years. I am Singaporean and have been looking into the H1B1 visa for Singaporeans. It is similar to H1B, but has its own cap that has never been filled historically, can be obtained anytime throughout the year, and only requires the employer to file LCA (I-129 is not needed).
I am under the impression that it would be easier to approach programs that offer H1B already to ask about sponsoring for H1B1 visa, than programs that offer J1, since they may not be familiar with the H type visa. Is this likely to be true?
Also, how and when would you advise me to contact programs and discuss visa-specific issues/requests. Should this be done before I submit my residency application?
Thank you for all your help.
Best regards,
Adele
Thanks for the additional information. That allows me to understand the issues that you have and why you need an H1B1.
I would definitely make sure to contact the residency programs and the Graduate Medical Education (GME) office prior to applying because many of the programs will not even look at a candidate who has to get an H1B or H1B1 visa for a residency slot. Most programs are set up for the J1 visa. If you need an H1B or H1B1 visa to get into a program, it puts you into a different application pool.
You certainly don’t want to waste your time and money applying to those programs that only take J1s and not H1Bs. It makes sense to contact each of the individual radiology programs and the GME office prior to applying to save you a headache. Typically, the person to speak with would be one of the folks in the GME office who handles visa issues. And, you probably want to speak to the residency coordinator because occasionally the individual program policy can potentially differ from the GME office. ( the program may not take a resident with a visa issue, but the GME office may say it is OK) At our institution, this person is a secretary and is very knowledgeable about all things visa related since she has been doing it for a long time.
Hope that gives you a little bit more insight about when to contact the program and who to contact.
For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!
So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.
Personality:
You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.
I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.
Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology
Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology
Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology
Jack of all trades- Body Imaging, MRI, Nuclear Medicine
Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging
Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology
Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine
And so on…
Lifestyle:
So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.
Body Imaging/MRI-
Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.
Cardiothoracic Imaging-
Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.
Informatics-
Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty
Interventional Radiology-
Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours
Musculoskeletal Imaging-
Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic
Neurointerventional Radiology-
Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.
Neuroradiology-
Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty
Nuclear Medicine-
Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.
Pediatric Radiology-
More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty
Trauma/ER radiology-
Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.
Women’s Imaging/Mammography-
Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.
Money:
Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.
Location:
Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.
Application Competitiveness:
Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.
Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.
Trends/Countertrends:
So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.
Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.
Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.
On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.
Summary About Choosing A Radiology Fellowship:
Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!
During residency, most physician trainees are studying and working so hard that they vaguely realize what is in store for them when they finish their training and begin their first job. What they often expect differs dramatically from reality. So, I thought this would be the post to give you the lowdown on some expectations versus reality when you start as an attending. We will cover six employment topics: money, job performance expectations, the importance of the bottom line, teamwork, case sign-off, and feedback.
Money Issues
Scenario
You begin residency and see these large salaries that come across in your email from recruiters. And, you hear stories of friends doing well at their first job, making tons of money that they don’t even know what to do with.
The Reality:
Many residents consume themselves thinking about the relatively “large salaries” they will earn once they finish their residency. You may think, well, if I can do that for ten years, I will be out of debt and rich. However, every large salary comes with a price. Either you will be working like the proverbial “dog,” or you may be located in a place very far from your friends and family.
Other new attendings also do not realize the costs that accrue from debts, buying a house, and maintaining a luxury lifestyle. Often, these folks go into further debt, funding a lifestyle that they cannot afford. Don’t let that be you!
Job Performance Expectations
Scenario:
You have just graduated as a neuroradiologist, and you are ready to take your first job. The job post said you would be performing 50 percent neuroradiology and no mammography while on a partnership track. You are excited as can be not to have to read any mammography!!!
The Reality
As soon as you start, one of the partners asks you to help out reading mammography by taking a course and over reading one of the other radiologists’ mammograms. Since one of their mammographers left, they need the help until they can hire another.
This situation is commonplace in the world of private practice. Sometimes, undue circumstances arrive beyond the practice’s control, and your expectations for your work will not precisely align with reality. If you cannot be somewhat flexible, you may not become a partner in the practice!
Importance of the Bottom Line
Scenario:
Your academic nuclear medicine position at a high-powered center of excellence is about to begin in a few days. Since it is a large academic center, you figure you will have lots of administrative time to pursue your research interests. I can’t wait!
The Reality:
After a few days of working in your position, the institution issues rules regulating administrative time. If you cannot obtain a grant to support the institution, you will have very little administrative time.
Don’t assume that a large academic institution does not care about how much money it earns. It needs radiologists to financially support the institution by reading films just as a private practice needs to perform procedures and interpret enough films to stay solvent. An academic institution does not mean lots of free time!!!
Teamwork Expectations
Scenario
You are about to begin your first private practice job, and they told you that they treat all employees and partners equally. So, you are very excited to start a career with an equal footing to everyone else.
The Reality:
In your first week of work, a partner asks if you could help him out with reading some extra films because he and his wife want to go to a concert. You tell him that you had early dinner plans with your wife, but he continues to insist. You feel you have to stay to complete the work because he is an influential partner in the practice. Bottom line… Everyone is equal, but partners are often more equal than others!!!!
Case Sign-off
Scenario:
You are sick of waiting for your attending radiologist to sign off the reports you dictated a few hours ago. When you finish residency, now you will be able to complete your dictations whenever you are ready!
The Reality:
Now that you are the final reader and the buck stops with you, you become unsure of the findings and want to ask your colleagues before completing some of your more complex reports during your first days of work. Well, now you don’t have to wait for someone else to sign off your reports. Instead, you may need someone else to look at the cases for a second opinion before completing the study!!!
Feedback
Scenario:
The practice partners state that you will get immediate feedback about your progress after six months. Furthermore, they say that they can even tell who will be partnership material by the first year.
The Reality:
Six months roll around, and no one lets you know about your progress. You think you are doing well, but you are not sure. The patients and the clinicians seem to like you. After one year, no one lets you know if you will make a partnership after the three years they promised you. Unlike residency, feedback can be much more challenging to obtain since it is not designated. There is no guarantee!!!
Expectations For The New Attending!
Becoming a radiology attending is not like entering Shangri-La. There will be new challenges that you do not expect. Along with the added respect, you will have many additional responsibilities. So remember, as a radiology resident, try to prepare yourself for the reality of becoming a radiology attending. So, you will not be surprised about what to expect when you begin!!!
Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.
Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.
Resident Versus Seasoned Dictating
So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.
Residents Need More Formalized Guidelines To Learn Dictating
To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.
Templates:
When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.
In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.
Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)
Important Pitfall
However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.
Histories/Priors:
Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.
One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.
Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.
Technique:
I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.
Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!
Comparisons:
The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.
Comments:
If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.
One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.
Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!
Impressions:
The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.
In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.
Beware Of Technical Jargon
Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!
Stick To The Answers
Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely.MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.
If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.
What terms are most frowned upon in the impression?
Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.
But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.
Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!
In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!
Structured Reporting Dictating Versus Prose Dictating
Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.
I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!
Dictating Tips: A Final Conclusion
You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!
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Join our mailing list for free to receive weekly articles and advice on how to succeed in radiology residency, the best ways to apply, how to have a successful radiology career, and more. Also, get a copy of the free ebook Called The New Attending Physician Guidebook: How To Search For The Right Job And What To Do Once You Start.
