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Barium Slinging And The Radiology Resident- Is It Really An Educational Activity?

barium

Barium slinging not too long ago was representative of the world of radiology. Now it seems, we relegate it to a tiny part. (1) When I started, I remember having many fluoroscopy days filled with double-contrast barium enemas, upper GI series, small bowel series, and esophagrams. Today’s barium work has changed radically, at least in our institution. It is exceedingly rare to catch a resident performing a barium enema. We complete a few daily upper GI series and esophagrams, but not nearly as many as when I was a resident. And, we seem to do bariatric post-intervention studies by the dozens (I remember only doing a few during my residency!). I am also sure the mix of studies has changed radically at many other institutions, not just mine.

Although the fluoroscopic exam mix has changed over the years, we think of a GI day as more service-oriented than educational. Some residents may go as far as to say it is a waste of time. Here is my goal for today: to show you why barium slinging is not just a scut activity but also an essential part of a radiology resident’s education.

Direct Contact With Technology And Patients

Much of radiology brings the radiology resident further away from patient contact than ever before. CT scans and plains films most times have become an almost independent activity. On the other hand, barium slinging is one of a few modalities (like mammography and interventional radiology) that keep the resident in the clinical realm, a critical skill for a future radiology practice. You need to tailor the examination to history and think on the fly. These are invaluable skills that serve the resident for years to come.

Also, you need to keep the patient reasonably happy and comfortable during the examination, both mentally and physically. Keeping patients engaged is a crucial characteristic to learn for getting informed consent and doing more complex procedures. Moreover, you can learn these skills under relatively benign conditions. (Complications from a barium study are infrequent!)

Closer Contact With The Referring Physicians

Before the days of PACS, clinicians would regularly return to our department to go over films. Now a clinician sighting is much rarer. In the realm of barium slinging, you are much more likely to interact with your referring physicians. The clinician often needs a particular question answered, and you need to respond to it rapidly. Perhaps, they need to know if there is a leak or small bowel obstruction. Regardless, you have to deal with the heated interactions that often come along with barium studies. Without barium slinging, it is possible to lose sight of who looks at our reports!

Additionally, these interactions prepare residents for calls. Having a surgical team come down to review a STAT study occurs fairly regularly at nighttime. When a first-year resident works in fluoroscopy during the daytime, they often come in direct contact with the ordering physician since they order these examinations STAT. For instance, esophagrams for foreign bodies, bariatric postoperative patients for GI leaks, and esophagrams for pneumomediastinum need immediate attention. Additionally, these studies require direct communication with the ordering physician’s team. How to relay this information to a rushed team or an angry surgeon quickly and transparently is a critical skill.

And finally, some clinicians ask for barium studies without realizing what they are ordering. They often ask for an upper GI series when what they want is a small bowel series. These subtleties allow the resident to learn when to call the physician to clarify the point of the study. Also, they discover how to tailor the procedure tailored to the history.

Developing Radiological Hand-Eye Coordination

When you start, “barium slinging” is a tremendous first rotation to learn how to position patients while holding on to a tower and snapping pictures. You are using your eyes, hands, and perhaps feet to get the correct images. Committing to fluoroscopy early in residency is a significant first step to learning more complicated interventional procedures later in residency. These principles are the same and build on what a resident knows during those first few fluoroscopy rotations.

Managing And Learning About Radiation

Today there is an enormous public outcry to decrease patient radiation dosage. Techniques such as intermittent fluoroscopy and last image hold are integral parts of managing patient radiation exposure. What better place than fluoroscopy to learn this? Just as importantly, fluoroscopy reinforces the physics studying for the core examination. There is nothing better for education than when the theoretical meets the practical.

Barium Work Is Not Sexy- But It Is Important!

Barium work is the stepchild of the radiology department. It commands little respect and is not as sexy as many newer “more exciting” modalities. Yet, it remains an integral part of the radiology resident’s education. For those who say there is no educational value in barium slinging, take a look at this article!!!

 

 

 

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Ten Surefire Ways To Destroy Your Radiology Experience (And Your Colleagues’ Too!!!)

radiology experience

I have seen it all. Some radiology residents make sure to glean every last drop of radiology experience from their residency so that by the time they graduate, they are ready to hit the ground running. But then other radiology residency graduates never quite live up to their full potential during their residency training. Many of these folks are great people, but when they are about to leave, I am not quite sure if they will handle the pressures of radiology practice.

In the end, I have learned some residents are late bloomers and do pull themselves up by the bootstraps once they leave residency, but a large percentage unfortunately constantly shift from job to job. Many of those folks are the same ones who seemed to do whatever they could to destroy their own residency experience during their four years of residency. And yes, we hear about them again when the paperwork comes back to us each time they change jobs when out in practice. Today I figured I would talk about those characteristics that are a surefire way to ruin your residency radiology experience. Don’t make those same awful mistakes!

Sweat The Small Stuff

In the heat of battle, it is effortless to forget the end goal of radiology residency, to be well trained and ready for practice when you leave. Remember… residency is only a 4-year experience. However, some residents get caught up in the moment and forget about the end game. They concern themselves with relatively minor things such as rising prices in the cafeteria, having to do a few extra shifts, or hearing some disheartening comments from one of their annoying colleagues. Sure, there is a place and time to worry about those things. But, it should not become an all-encompassing mission. Some never get over these issues and forget to learn what they need to know when they leave residency. In the process, they also upset their colleagues, distracting everyone from their training. Get over it!!!

Argue With Your Colleagues

Some residency classes always get along. Others have permanent hatred toward one another. The inability to get along spills over to other areas in a radiology residency. Studying suffers because some folks are left behind, and no one seems to care. Tempers flare and prevent classmates from covering each other when they need it. Everyone becomes exhausted and upset. Next thing you know, residency is over, and everyone is worse for the wear. Do whatever it takes to get along! It is not worth four years of frustration!

Sabotage Your Team

Every once in a while, one resident does not play fairly in the sandbox. Perhaps, he/she refuses to help out with a call. Or maybe, this person does not show up to work and constantly needs to have additional coverage. Not playing nicely with others affects the entire team. If you want to ruin the experience for everyone, it is elementary. But in the end, it will haunt you when you need your residency team the most!

Don’t Read

Radiology residency is a marathon, not a sprint. That means you constantly need to keep up with reading books and articles. I can guarantee that you will fall behind your classmates if you do not adequately read enough starting year one. You will not comprehend or perform well at conferences. Likewise, your call and board experiences will suffer. And, your colleagues will not want to have you’ve as a study partner since you are so far behind. You came to radiology residency to become a radiologist. Part of learning radiology is reading a lot. Why would you want to sabotage your training?

Always Compare Yourself To Others

Everybody learns and reads at different rates; and, some residents click with the material earlier than others. That is OK. As long as you are doing your due diligence during radiology residency, you will eventually get to the promised land of radiology competence and graduation. Don’t worry if some of your colleagues always seem to get things right and you don’t. The quickest path to misery is worrying about how everyone else is doing. Undue competition ruins the experience for everyone. Care first and foremost about your progress!

Don’t Show Up To Readouts

There are two main pillars to becoming a great radiologist, knowing the material and experience. If you were going through the hassle of completing a residency, why would you shortchange yourself and not try to get as much experience as possible? You will never understand the context of reading radiology without having the readout experience. Not being at the readout also affects your mentors’ day. Sit down with your residency mentor, and don’t miss the readout. You are only hurting your career and your relationship with your superiors. You never know when you will need their recommendations!

Do Not Improve Upon Your Weaknesses

You have been getting inadequate evaluations in the area of mammography. So, what do you do about it? Nothing. The complaints continue to come streaming in from attendings. But, you persist in not reading the material or studying your misses. Behaviors become habitual and will likely continue even after you graduate if you do not learn from your mistakes. These folks are the same folks that can never keep a job and never improve their lot. Ignoring practice-based improvement hurts you, your patients, and your colleagues. Residency is all about self-improvement to become the best you can so that you can help your patients. Why would you not pursue the same avenues during training?

Procedures Are Not For Me!

Some residents hate procedures and will do whatever they can to avoid them. I understand these folks may not become interventional radiologists. But, they still need to know the basics of specific procedures such as needle localization, arthrograms, and more. Sure, they can get away with this during residency. But, when they try to land their first job, they may have frustrations as they find the only jobs available require “light interventional” work. Not learning procedures may affect your future partners and colleagues. By not trying to feel comfortable with procedures during residency, you are only hurting yourself!

I Am Always Right

Some residents do not accept criticism. Residency is the time to learn and change harmful behaviors before they become ingrained in practice. We are in the game of treating people, not always thinking we are correct. Why would you not want to correct what you are doing wrong? It makes no sense. You are only hurting your patients and colleagues. There is no room for not accepting criticism both during and after residency!

Don’t Take On Extra Responsibilities

Each year of radiology residency, you accrue new responsibilities. Shirking your responsibilities is a surefire way to become a needy radiologist when you graduate. When the technologist comes along to ask a question, please don’t send them to someone else to answer it. Take charge of your situation and section. Those folks that never take on those additional responsibilities never learn to become an independent radiologist!!! Go forth and makes your path.

Avoid Destroying Your Residency Radiology Experience

It is far easier than one might think to destroy your own residency radiology experience. Sometimes you have to put a bit more effort in to get more out of residency. Please, please, don’t succumb to the pitfalls and traps that can prevent you from growing and improving as a person and a radiologist. Get over your issues… It is not worth it!

 

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eBooks vs. Printed Radiology Books- A Death Match Part II

books

The days of radiology residents lugging ten-pound textbooks around the department are over. I, too, prefer having a list of books to access at any time on my Ipad for convenience. I even reviewed and studied my Mettler textbook for nuclear medicine on my Ipad just before my recertification ABR examination a while back, and it worked out just fine. But based on recent literature, maybe we should not be giving up on carrying around that 10-pound book. Today I will review the arguments for and against buying and reading electronic radiology books versus carrying around and reading those unseemly heavy old-fashioned radiology textbooks.

Arguments For Reading Physical Radiology Books

Comprehension Retention Issues

When it comes explicitly to reading and retaining knowledge from radiology-specific books, I could not find much information on the web. However, significant studies discuss comparing the retention of general information from print materials vs. e-readers. Some of these studies are generally applicable to the radiology resident audience. In addition, some other issues can support the use of printed texts over e-readers.

Back in 2013, in the International Journal of Educational Research, lead author Anne Mangen in an article, studied 72 tenth graders and compared reading retention in PDF format on a computer screen and in print. She found that students reading the texts in print had significantly better retention of the material than those reading the material electronically. However, there are some differences in applicability to the radiologist. We tend to read images and look at the captions and text. So, perhaps there is some difference regarding the radiology resident.

Subjectively, there are also several surveys of readers touting the comprehension advantages of printed books. In an article in Scientific American, one survey reported a conclusion that “when it comes to reading a book, even they prefer good, old-fashioned print,” and another stated that readers “prefer to read text on paper as opposed to on a screen to ‘understand it with clarity.'” So, maybe there is something to the perception of increased retention with old-fashioned printed texts.

Miscellaneous Other Issues

In addition, you may have difficulty getting to sleep after reading with an electronic device. A study called “Sleep and use of electronic devices in adolescence: results from a large population-based study” concluded a negative relationship between the use of technology and sleep. Now, radiology residents are a bit past adolescence for the most part, but I still think you can generalize this information to the insomniac radiology resident, knowing how I feel after reading the news on my iPhone just prior to bedtime.

Also, there is the issue of eyestrain and reading eBooks. The information here is a bit more mixed as to the amount of eyestrain using eReaders vs. printed text. But, there was an interesting article presenting some of the issues regarding eye strain called “eReader Vs. Printed Book: Which Is Better For Your Eyesight?” They reported that Computer Vision Syndrome (CVS) is an actual entity that can affect readers using electronic readers. However, the claim that backlit devices and softer e-readers like the Nook and Kindle may help some readers counterbalance this argument.

And finally, there is the issue of diversion. When you read a printed textbook, you certainly do not have to worry about essential emails popping up, your spouse calling you, a silly text from your friend, or the thought that you need to click on the most recent exciting blog from radsresident.com! Instead, you can concentrate on the information with much less interruption.

Arguments For Reading Electronic Radiology Texts

Here I think the first and foremost issue supporting using the eReader is sheer convenience and instant availability. Carrying 1000 books in your pocket or your hand is a remarkable technological achievement. Furthermore, at any given moment, you can easily click on a link from your text and go directly to a source document you can confirm on your iPhone. You can’t do these sorts of things in a printed textbook.

Multiple new e-readers use different proprietary technologies to reduce eyestrain. In fact, one article reports eInk from the Kindle and the Nook is a significant improvement over other e-readers. Also, according to the same article, people with poor eyesight tended to read better with a backlit screen than on paper. In addition, for those with poor vision, one can easily adjust the text size with an e-reader, allowing the reader to enjoy an electronic text that they may not be able to read in the printed version.

Once you write on a printed text, you alter the text forever. On the other hand, you can highlight or write electronically in an ebook’s margins without worrying about destroying the book. Furthermore, you cannot write in someone else’s printed book without vandalizing someone else’s property. Another win for the electronic device!!!

This borrowing of books brings me to the next significant advantage of eReaders- sharing. Sharing a chapter, phrase, or critical point with a fellow reader is easy. All it takes is clicking a button with a message or email; many people have the same information. Printed text is just not the same when it comes to sharing.

And finally, there is the issue of bookmarks. Most eReaders automatically bookmark the last page that you look at. If you lose your page on a standard text, there is a good chance that if you return to it without a bookmark, you will not remember the last page you read. At least, this is a significant advantage for me!

So Who Wins This Death Match?

Unfortunately, convincing someone about how to read a radiology book is challenging. We all have our set ways and opinions about how to read and what is more effective for us as an individual. And there are real advantages and disadvantages to both. Although not conclusive, the body of evidence points to increased retention for paper, but for many, the convenience of e-texts outweighs the incremental retention. You can easily share an eBook, but you may have more eyestrain reading the same book. So what do you do in today’s world? I think it depends upon you as an individual and the available resources. The bottom line as a radiology resident is to read a lot regardless of the book type. It will serve as a permanent foundation for the rest of your career!

 

Other relevant articles

http://www.huffingtonpost.com/the-national-book-review/drop-that-kindle-10-reaso_b_8234890.html

 

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Radiology Textbooks Vs. Case Review Books- A Death Match

textbooks

One question that often arises is: what material should I study since there is so much information to learn? But I think a more appropriate question may be: how can I get the most bang for my buck when there are so many reading materials out there? In this post, I will address this issue by talking about when you should be reading textbooks and when you should emphasize case reviews since both play a role in getting up to speed during radiology residency or learning about a new area of interest as an attending. (This is our death match!!!)

Why Textbooks?

Sometimes you lack any understanding of a modality when you begin a residency program, are starting a new rotation, or are attempting to learn a new modality such as MRI, perhaps not covered in your residency. For instance, when they begin, most radiology residents have no clue about ultrasound: how it works, and the images the technologist takes. Therefore, starting to read a case series on ultrasound may not be helpful when beginning.

Instead, a general introductory textbook such as Ultrasound: The Requisites makes more sense at this point to understand the basic principles of ultrasound and the key images that need to be taken and interpreted during a renal ultrasound, Ob/Gynecology ultrasound, etc. Another example would be reading CT scans of the chest. Most residents, when they start, do not have a search pattern for reading chest CT scans. Nor do they know their CT chest anatomy well. An introductory textbook on chest CT scans, such as Computed Tomography and Magnetic Resonance of the Thorax by Webb, would be appropriate before reading a case series.

In addition, good textbooks usually better outline the fundamental knowledge needed to interpret images better than a case review series can. Textbooks are better organized by topics, whereas case review series tend to be more haphazard. For example, it may be more direct and efficient to learn the fundamentals of determining whether an intracranial mass is intra-axial or extra-axial once in a textbook than reading 10 case series on the topic and trying to figure the same approach out.

How To Read Textbooks

When you read a textbook, you should emphasize the images, read the captions, and then read the text to get the most out. Reading in this manner reinforces the information that you need to know better than starting from the text first. This process differs vastly from reading a medical school general medicine textbook, where the text is usually more important than the images. You are now a radiology resident, so you have to think differently!

Why Case Review Series?

In our field, we solely exist because we are image interpreters. So, it makes sense to learn those images and what they mean. What better means to reinforce and understand radiology than with a case series? But, this assumes that the reader has some background knowledge on the topic and can understand the basic principles/fundamentals/meanings behind the images in the case review series.

In addition, case review series tend to have more of a “real word bent.” The images we read daily tend not to follow in an orderly manner by topic. Usually, an almost random distribution of cases comes through our departments. Going through a case review series is usually more similar to going through many images in no particular order.

How To Approach Case Review Series

It would help to start the case review series as soon as you have the fundamental knowledge to understand the modality, anatomy, and primary disease processes on imaging. On each initial rotation, you should aim to start reading at least one case review type of book after you have learned the fundamentals from lectures and textbooks. Do not wait too long to get started, however. Going through the case review series will be more helpful and applicable than most textbooks when you read out cases with attendings and when taking cases at noon conferences. But remember- it often does not summarize the fundamentals of a given subject as well as a textbook.

The Moral Of The Death Match

Both textbooks and case review series are at the beginning resident’s learning armamentarium. Be wary of someone that tells you that you can get through residency by just reading textbooks or case reviews by themselves. Each has its place, and you should use the correct one depending on your level and knowledge base. Now become great radiologists: go forth and read!!!

 

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Top Traits Of Great Radiologists (They Might Not Be What You Expect!)

traits

Over the years, I have discovered that the best radiologists often do not comply with the stereotypical traits of one. For instance, you would think that the best radiologists all embrace technology. However, it is sometimes the opposite. Some of the best radiologists I know are the least technologically adept people you would ever meet, not able to conjure up an email password or conquer a new PACS system.

You would say that they would be masters of video games and spatial puzzles. Well, again, you would be squarely wrong. I know many-a-great-radiologist who find video games distasteful or who have no interest.

You would guess that the best radiologists have an “eye” for radiology from day one of radiology residency. Again, you would be incorrect. Some great radiology residents that I have trained had no clue how to read a film or make a finding on day one of residency.

So what is it that makes up the traits of the best of the best radiologists? Based on my experience, it is the following: enhanced clinical training, grit and determination, extreme organization, singular focus, and the passion for learning and maintaining scientific interest in our field. So, let’s go through each of these traits. Then, I’ll give you examples of how each allows some of the best radiologists to perform above and beyond the average radiologist. Finally, I will go through some recommendations on how you can train to be this great radiologist. Try to incorporate some this additional training or these personality quirks and traits into your daily practice.

Enhanced Clinical Training In Other Medical Fields

Some of the most incredible radiologists that I met had initially trained for a different medical subspecialty. The ones I know have either completed a second residency or participated in a residency in internal medicine or pediatrics for more than the required solitary clinical year. These radiologists have a complete understanding of the clinical issues involved in the patient’s films that they are reading. They take a step past the interpretation of the image and make it relevant for the clinician on the other end. They tend to know how to manage patients to a tee and use their skills to better the patient’s welfare. Excellent clinical management for a radiologist is a rare skill.

How can you add these traits to your practice in radiology? Participate in electives that involve interdisciplinary management. Question your fellow clinicians about the clinical significance of your interpretations. Shadow physicians in other specialties.

Grit and Determination

These excellent radiologists are folks that overcame incredible odds to get to where they are today. By sheer determination of will, they take an interpretation of a film to a new level, farther than the typical radiologist. They look into clinical issues more deeply than others. They don’t just stop at the conventional differential diagnosis. And, they can tell you the hows and the whys of what they find. When a clinician stops by, they are mesmerized by the litany of what these clinicians seem to know.

How can you add these incredible qualities to your arsenal? Don’t stop at the mere interpretation of the film. Look further into clinical history. Read up everything about the disease entity. Find out facts that would be clinically relevant to your patient’s care. Always look at priors that may have relevance to your case. Don’t be lazy with any of your imaging cases!

Incredible Organizational Skills

I have never met a great radiologist who has poor organizational skills. Conversely, the great radiologists I have met all have incredible organizational skills. These radiologists tend to keep track of all the patients they have ever seen. They use this information to interpret images and extrapolate the information to other patient’s circumstances. You can ask them about a case they may have seen a year ago, and they can go into their written or mental records and find it. They use all of this information for the betterment of patient care.

How can you become organized as a radiology resident? Always keep track of your unusual cases. Take pictures of the cases you see. Maintain a written or online notebook of what you learned. All these organizational skills will come in handy when you complete your residency and have questions about challenging cases.

Persistent Focus

Some of the most incredible radiologists have a single-minded focus that allows them to read cases, do research, or teach with such precision that they are best in their fields. They are not distracted by the daily minutia, the irrelevant red herrings, and the rumors of the day. They concentrate on their work and their work alone. These radiologists tend to miss very little. They are the type of radiologists that seem to have very few reports with errors and mistakes.

How can you maintain focus on your daily rotations? Maintain awareness of what you are doing at all times. Keep conversations and distractions to a minimum when you sit or stand to read multiple cases. The patient should be first and foremost on your day’s schedule. That is why we are here- to help people!

Passion For Learning/Maintaining Scientific Interest

Finally, the best radiologists I have encountered have a mission to either teach, research, or learn. They enjoy every minute of these processes and convey their passion to others in the specialty, whether they are fellow attendings, residents, nurses, techs, or patients. Moreover, their enthusiasm is infectious and inspires others to want to be the same. These are a rare breed and help overcome the problem of burnt-out physicians through teaching and personality. These radiologists go a step farther not because they have to, but because they enjoy radiology.

How can you become passionate about radiology? Don’t let the folks that complain all the time get you down. Find your path and what interests you. Don’t look to the negative, as those folks tend not to be the successful ones. People that love their specialty tend to become excellent at what they do. So, find your interests and passions and go with them all the way.

Final Inspiring Words

It is not typical traits such as being a techie, having “an innately good eye,” or being a puzzle master that makes a great radiologist. Instead, it is often those skills that we can work on that make us better than the average radiologist out there. So, go forth and learn about other specialties, keep determined, stay organized, maintain focus, and develop a passion for learning and radiology to become the best radiologist you can be!!!

 

 

 

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Five Reasons Why The First Year Of Radiology Residency Can Be The Most Difficult

first year

Second-year radiology residents become overwhelmed and burdened by call. Third-year radiology residents feel exhausted from studying for their core radiology examination. And, the fourth-year radiology residents fret about all the things they need to know before starting their career. But, what about the plight of the first-year resident? Many non-radiology physicians and some long-practicing radiologists think that these residents have it easy since he does not have many responsibilities. He can merely sit and watch the radiology attending to learn the practice of radiology, right? However, in this post, I am going to dispel that notion. I will go through five reasons why I think the 1st year of radiology residency is usually the most difficult.

Little Medical School Background In Radiology

Unlike internal medicine, surgical, ob/GYN, and psychiatric residents, most beginning first radiology residents have had almost no experience in the mechanics of all things radiology. Sure, they take a few courses during medical school. However, they are usually surveys. Also, they do not provide the vast experiences needed to function as a full-fledged radiology resident.

On the other hand, internal medicine residents have worked up patients with histories during their medical school training. Ob/GYN residents have usually delivered a few babies in medical school before beginning. Surgical residents have assisted in multiple surgeries and have worked the floors before their first day of residency. And psychiatry residents have interacted with numerous patients before starting. These initiated residents can almost entirely function from day one.

Instead, new 1st-year radiology residents cannot dictate, review films to be read, or finish the procedures that we perform daily. Since a first-year radiology resident cannot complete most of the functions to be “of use” to the senior radiologist, many first residents feel inadequate until they can begin call as a second-year. At that point, they can function much more independently. However, the lack of training certainly can make for a problematic initial year.

Incredible Amounts of Reading For The First Year

More so than other specialties, radiology requires a boatload of reading during the first year. You need to understand internal medicine, surgery, obstetrics/gynecology, orthopedics, neurology, and more to become a respectable radiologist. Unlike other specialties, you cannot get away with little reading and learn only from your experience with others. If you do not read for hours every day, you will fall behind and not pass the core examination. Many residents do not know the requirements before starting and take a long time to adjust to the nightly reading regimen, a painful process.

Dictations- A Difficult Road

Imagine your frustration as you first start with never having held a Dictaphone. You click the wrong buttons and feel unsure of yourself as you talk into a stick!!! This routine is typical for the first year that starts to dictate. Not only does the first-year resident have to get the physical mechanics of learning dictation, but they also have to create a report that makes sense. This process often occurs with little instruction or regimentation. It becomes hard to put ourselves in the shoes of the first-year resident. However, as an associate residency director, I regularly recognize how hard it is to start from scratch what we routinely do as radiologists daily.

Frustrated Attendings Who Don’t Want First Years Around

Unlike more independent senior residents, radiologists typically have to take extra time out of their day to teach a first-year radiology resident. Given the increasing workloads of radiologists, many attendings see this as a burden. They would instead get home to their family on time in the evening. Additionally, the attending does not know the first-year resident well. Therefore, he cannot figure out how much responsibility to give. Other radiologists feel forced and have no desire to teach. The frustrations of many attending radiologists reflect in the personal interactions with the first-year resident. Often, the resident gets the sense that he/she is not wanted around. Depressing, huh…

Noon Conferences- A Foreign Language

Have you ever listened to a conversation in a language that you do not understand? That is the feeling that the first-year radiology resident often gets when he/she goes to the first noon conference. Attendings give noon conferences on topics such as ultrasound or MRI. Yet, these radiology residents have never seen these images. On top of that, they use language that is not common vernacular.

Moreover, the findings are incomprehensible to the uninitiated resident. Many attending radiologists do not recall what it is was like to attend these conferences. However, these esoteric conferences are standard for first-year residents.

The Final Upshot For The First Year Resident

Senior radiologists can easily dismiss and forget the challenges that first-year radiology residents face. However, please don’t discount the first-year radiology resident’s frustrations, experiences, and anxieties, as they are genuine. It takes an extended period of adjustment to acclimate to the daily work experienced by radiology residents and attendings. Give the lowly first-year radiology resident a chance!!!

 

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The Precall Quiz: Mechanics of The Test And Preventing Failure

It’s getting to be that time of the year. Spring… Ahhh… Birds chirping, snow melting, and oh yeah… of course… first year resident preparation for the first night of call. Often times this process begins with a bang called the Precall Quiz.  Although it is not a specifically required measure for being able to start call, it is a way that many residencies assess the functioning of the soon-to-be second year in a “real-world” situation. Sometimes the residency program sets up the precall quiz. Other times, the residents create it. Regardless of who prepares the exam, the first year resident needs to prepare the same. Since the contents of the examination are generally limited to call cases, he/she should be able to expect what is going to be present on the quiz and be able to pass it without question. In today’s post, I am first going to go over the mechanics of a proper recall quiz, whether prepared by the chief resident or program director. And then most importantly, we will talk about how a resident should prepare to pass the test and make sure to feel “comfortable” taking his/her call for the first time. Here we go!

For The Residency Program: What Is A Fair Precall Quiz?

A precall quiz should consist of both the material/contents needed for the first night of call as well as be similar to the way that cases are taken on a night call. What does that mean? Emphasized cases should be situations that could “kill or severely injure patients” or are very common. In addition, it should also contain a few normal variants. These components will most simulate a real night on call.

Furthermore, the style of the examination should be given in the same way that call is taken. In other words, it should probably be administered on a PACS workstation in the way that cases are usually evaluated. Some residencies may still use the PowerPoint format. But, I think there is a danger to giving an exam with cases in this style. Giving individual pictures in a PowerPoint presentation format only assesses knowledge base and not the ability to find lesions on imaging modalities. Both of these qualities need to be evaluated prior tuo beginning call. Or else, a resident that passes this sort of examination is not truly assessed on all the fundamental knowledge bases needed to assess call competency. In fact, these residencies may be setting up certain residents for failure without the appropriate learned “finding strategies” when night call begins.

For The Examinee: How To Pass A Precall Quiz?

Studying should theoretically begin when the resident starts residency. However, many times residents will often cram knowledge into a short period of time prior to an exam. Either way, the examinee should really concentrate on ER case studies prior to taking the test. These should be the killer diseases such as aortic ruptures, pnemothoracies, neurological bleeds and infarcts, and so on. Also, you should be looking at lots of cases that are very common with some morbidity such as appendicitis, diverticulitis, cholecystitis, and more. I would recommend the Emergency Radiology Case Review Series as one resource that would be very help for taking the taking quiz. But, of course, it just a starting point. Make sure to look at hundreds of versions of the common disease entities so that there are no surprises on your first call night. It can be as simple as Googling appendicitis and looking at all the ways that this disease entity presents. But, it is just as important to attend your rotations real time so you have the experience of knowing how to use the PACS system to scroll and find these disease entities in a “real word” setting.

How To Feel “Comfortable” On That Dreaded First Night of Call

OK. I lied a bit at the beginning of this post. The truth is that no trainee radiology resident ever truly feels comfortable on their first night of call, unless you were born with the genius gene or you are missing the emotion of fear! So, do not expect to feel entirely in your element. That being said, if you know cold the entities that will kill or severely injure patients, have studied appropriate cased base material, and attend your daily rotations it is very unlikely that you injure anyone. The knowledge that you passed your precall quiz and know the basics should put you in good staid. Remember that most radiologists before you have been through the same situation as you and most have made it through the first night of call unscathed. And if you listen to me,  just like them, you will make it through the process too!

 

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Should A Resident Physician Apply For A Credit Card When Already In Significant Debt?

credit card

Credit is a very touchy subject with resident physicians in all specialties. And it makes sense. Student debt seems to be increasing exponentially over the years. When I graduated, I thought I had a lot of debt from student loans. But that number pales compared to the debt that most current medical residents hold. Confirming this suspicion, I did a miniature survey of almost 100 medical students at my hospital. Student debt sums were as high as 600,000 dollars. These medical students had not yet completed their four years of training. So, the amounts were going to be higher than that. These sums of money are not insignificant. Instead, the debt will be life-altering for many of these future physicians for years. On top of that, add a high-balance credit card, and you may head toward financial ruin!

This enormous debt burden brings me to the next question. Does it make sense for a resident to apply for a credit card after accruing so much debt? This question came up in the past year with a resident who had not started to get credit in his name. It caused all sorts of issues for him at the time they needed it. And it will probably continue to cause problems for years to come until he establishes a good credit record. So, the simple answer is yes. But in this post, I will explain why setting up a few credit card accounts makes sense even with significant debt. And I will briefly discuss how residents should establish credit.

Why Do Resident Physicians Need A Credit Card?

Laying out Money

A radiology resident often must lay out a significant amount of funds for travel or a large purchase such as a car. What do you do if you do not have a credit card or do not have a credit card with enough credit? Nowadays, most travel is booked online with credit cards. For many websites, the only form of payment is a credit card. You are now stuck with either relying on others to book your flight or not going on the flight. Once you reach a resident’s level, these issues arise often.

Establishing a Track Record For Large Future Expenses (Mortgages, Car Loans, Etc.)

To purchase large items such as a house or a car without cash (and most residents don’t have lots of money on hand!!!), you need to obtain a mortgage or a loan. How will some company provide you with a loan if you do not have a long track record of making payments? Sure, you have your student loan as some background. But that is not enough. You must also have at least one revolving credit account (a credit card) to increase your credit score to obtain these large loans. A credit card is an excellent way of establishing this background.

Cash Back Credit Card

Finally, many credit cards offer incentives in the form of airplane miles, gifts, and cash. Cash has the most value out of any of these rewards. When you make a purchase, you can get a certain amount refunded on every purchase. Some cards give you 5% on specific items or 2% on all items you purchase. So, it really can add up over time. If you use credit wisely, it can pay back dividends!

How To Establish Credit Without Breaking The Bank

If you have a poor or no credit history, finding a good credit card company willing to give you a credit card can be challenging. Even with these issues, there are several ways to establish credit. You can apply for cards backed by your savings or find cards with very low maximum balances. Either of these sorts of cards will allow you to occasionally use the card to make small purchases such that you can begin to establish a credit history. And remember to use personal credit hygiene: Pay your balances off monthly and try to use a small percentage of the credit allotted. These small steps will allow you to establish a good history without spending too much.

Summary

Even though resident physicians already have vast amounts of debt, establishing a credit card account becomes very important from both a practicality and utility standpoint. You can do it in a way that does not cause additional debt burdens or hardship. Bottom line: Establish credit now rather than later when you need the credit!

 

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Up To Date Book Reviews For The Radiology Core Examination

Studying for the ABR Core Exam is undoubtedly a daunting task. Not only can the sheer amount of material one needs to learn seem overwhelming, but also the vast amount of resources available can be more of a burden than an asset. I often see my fellow residents scrambling to make time to go over every single review book out there, in an effort to have all of their bases covered. This strategy is not only nearly impossible but is likely counterproductive. Rather, one should focus on one “comprehensive” review book while supplementing with case review books and question banks that work best for them.

 

When asking my peers about their thoughts on different study resources, I could never get a good consensus on what was best. Different people had the same success passing the exam with very different approaches. However, one commonality I did notice amongst those who had success on the exam was that their approach was comprehensive (covered all categories tested) and diligent. With that being said, it is best to first peruse a resource to make sure it is useful for your style of learning before fully committing your time (and money) to it. Also, it should be noted that none of these are substitutes for a comprehensive textbook (such as Brant and Helms or the Requisites series). Review books are most effective when they are, in fact, used as a review and not a primary source of learning.

 

Below are reviews for the resources my colleagues I used, some more than others, to prepare for the ABR Core Exam.

 

COMPREHENSIVE REVIEW BOOKS

 

Core Radiology: A Visual Approach to Diagnostic Imaging

 

This is an excellent review book that can be used as a single source for reference and overview of salient points. It contains lots of good quality images and diagrams (in color!), as well as tables summarizing differential diagnoses with easy ways to differentiate one entity from another. As with any review book, it may not delve into as much depth in any single topic. Supplementation with Brant and Helms, StatDX, or Radiographics articles may be required for certain topics that require more depth or clarity. This book can be easily understood by junior residents throughout their first or second years of residency, not simply just for those reviewing for the Core Exam.

 

One drawback of this textbook is its size. At 895 pages, it can be a pain to lug around. Also, compared to Crack the Core, this text lacks humor and motivational quotes. Rather it’s more of a traditional, no-nonsense, well-organized review.

 

Crack the Core

 

Written under a pen name by “Prometheus Lionheart,” this series includes two main volumes, together encompassing the main sections covered on the Core Exam. In addition to the main two-volume set, Lionheart has also written a separate dedicated physics review book as well as a case review book (which I will cover separately). This two-volume set is another excellent review source. While it covers much of the same material as Core Radiology, this text is geared specifically for passing the Core Exam by incorporating test-taking strategies in addition to providing factual information. Lionheart interjects jokes and motivational phrases to keep the reader entertained while studying (not an easy task!). This book is much more simplified than Core Radiology, but serves as an excellent review for someone with solid background knowledge of the topics included. The physics and non-interpretive skills chapters in Crack the Core is much more robust and comprehensive than in Core Radiology. Additionally, Lionheart has a video lecture series to supplement his books (at an additional cost, of course), which can be useful depending on your style of learning.

 

One of the main drawbacks of the Crack the Core series is the abundance of typos in the text. While the typos generally don’t alter the context, they can be an annoyance. Another downfall of Crack the Core is the image quality and lack of color diagrams. The supplementary video lecture series does have improved image quality and nice color diagrams and animations, however.

 

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CASE REVIEW BOOKS

 

Core Review Series (Thoracic, GU, GI, MSK, Breast, Cardiac, Nuclear Medicine)

 

The newest of the main case review books, the Core Review Series has separate books in Thoracic, Genitourinary, Gastrointestinal, Musculoskeletal, Breast, Cardiac, and Nuclear Medicine. Each book is broken down into chapters, with each chapter covering a specific subcategory (usually starting out with fundamentals of imaging for that category or normal anatomy).

 

The good: The breakdown by chapter and multiple questions per chapter allows you to hone down your studying to a specific topic and to do multiple questions in a relatively short time period. Image quality varies by book but is generally very good. Most books have online access with an easy interface for doing questions (almost feels like a Q bank). The descriptions of the answers are excellent. I feel that these books best prepare you to think the way they want you to think about the test; to understand the process of why an answer is right rather than regurgitate memorized information. Many of the books even have physics concepts integrated into the questions, which is a tactic the ABR often employs on the Core Exam.

 

The bad: When using the physical books, it can be tedious to flip between the questions and the answers (which are located at the end of the chapter). This problem is alleviated with the online versions, where the answers are available immediately after taking the question. Also, because not all subjects are covered, other sources must be used to supplement these areas (such as Interventional, Neuro, and Pediatrics)

 

 

Rad Cases (Cardiac, GI, GU, Interventional, MSK, Neuro, Nuclear Medicine, Pediatrics, Thoracic)

 

Rad Cases offers a case-based approach (rather than the more question/answer format of Core Review Series) with approximately 100 cases per book. Each case shows images and a clinical presentation on the first page. The next page then goes over the imaging findings, differential diagnosis (with brief descriptions of each diagnosis and how it may or may not explain the imaging findings), essential facts about the disease entity, other possible imaging findings, and finally pearls & pitfalls.

 

The good: This series really does a good job of allowing the reader to come up with a systematic approach to a case. The explanations do a good job of highlighting how one may have fallen into a trap or how one should tailor their thought process when approaching a case. All of these are essential aspects of passing the exam, but relate

 

The bad: While learning how to approach an unknown case is necessary to tackling exam questions, this text appears more driven to prepare residents for the old oral boards. One could argue that a more rapid-fire question/answer format is more useful when it comes to preparation for the Core Exam.

 

 

Case Review Series (Neuro, Head and Neck, Spine, Breast, Cardiac, Emergency Medicine, GI, GU, MSK, Nuclear Medicine, Pediatrics, Thoracic, Interventional)

 

CRS is another case based review, with each book separated into three different difficulty levels. The cases at the beginning of the book, “Opening Round,” are easiest, the next level of difficulty in the middle of the book is termed “Fair Game” and the most difficult cases at the end are in the “Challenge” section. Each case shows images and is followed by four questions pertaining to those images.

 

The good: The book offers excellent cases with good image quality. The multiple questions per case really force you to learn several aspects of a case. When it comes to the Core Exam, knowing the diagnosis alone usually does not suffice. Thus, being able to answer questions from several angles about a case is a valuable learning tool.

 

The bad: Similar to Rad Cases, CRS appears to be more driven toward oral board prep. While this may help with expanding one’s knowledge base, it lacks the multiple-choice question/answer that is necessary for the Core Exam. Also, the Challenge sections are often too difficult/esoteric and are often beyond the scope of the exam. It would behoove you to do only the Opening Round and Fair Game sections in order to save precious study time.

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PHYSICS/OTHER

 

Huda’s Review of Radiologic Physics

 

This is the physics review book by Walter Huda, who administers yearly review courses in radiologic physics throughout the country. It is in bullet point form and aligns closely with his course.

 

The good: The book has pretty much everything you need to know for physics for the Core Exam, with review questions at the end of each chapter and online access. It is formatted in bullet point form to be intended for quick review. I used this book while at Huda’s review course and immediately after it in order to reinforce the concepts he taught.

 

The bad: While all the facts you need to know may be in this book, there is very little in the way of explanation. You will have to use other, more thorough sources for a deeper understanding. Also, the questions at the end of the chapter serve to reinforce some basic topics but are unlike anything you will see on the exam.

 

 

Radiologic Physics “War Machine” by Prometheus Lionhart

 

This is the dedicated physics book by the Crack the Core author, with a very similar layout to Crack the Core.

 

The good: This book was a great resource for studying physics. It really simplifies topics and makes them easier to understand, and therefore memorize. He does a good job of explaining what physics is relevant to the test and what is not, which is extremely valuable (the last thing we want to do is study more physics than we need to).

 

The bad: Again, the typos. Also, there is a lot of overlap between this book and the physics section of the Crack the Core book. I have not examined them in detail, but I just studied the section in Crack the Core without using the War Machine book and felt it was more than adequate preparation.

 

 

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QUESTION BANKS

 

RADPrimer

RADPrimer is the question bank associated with StatDx and has an abundance of questions (2,221 Basic and 3,747 Intermediate level questions).

 

The good: Lots of questions with mostly very good explanations. Good image quality. What I found most useful about RADPrimer was the ability to hone the focus to exactly what I wanted to study. For example, if I had just read a section in a review book about CNS Infections, I could create an exam and do those specific questions in order to solidify what I had just read.

 

The bad: Many of the questions are too straightforward for what you will see on the test. Rather it should be used as a learning tool to reinforce recently studied material and not a means to simulate the Core Exam. Also, while there are some physics questions, there are not enough to use this as the sole source of physics practice.

 

 

 

BoardVitals

 

BoardVitals is an online question bank that offers subscriptions based on different time increments ($399 for six months, $229 for three months, $139 for one month). There are 1500 questions broken up by general category.

 

The good: The questions better simulate the real exam than RADPrimer. The explanations on most questions are good. There are more physics questions than on RADPrimer and this bank also includes non-interpretive skills questions (which I found very helpful). What I also found very helpful was that the interface was well-suited for use on mobile devices. Whether I was in a line somewhere, on a train, or on a bus I could bang out a few BoardVitals questions with ease.

 

The bad: Some of the answer explanations were one line without much information. These were once in a while but did occur and could be frustrating at times.

 

 

Face the Core

 

Face the Core is another online question bank, with 35 different modules. Each module has about 75-100 multiple-choice questions. Modules consist of several cases, with each case having approximately 4-5 associated questions. Modules can be purchased individually for $10 each or you can purchase all 35 modules for $250. Modules must be completed in full (all 75-100 questions) before you could go over the answers (no “tutorial” mode).

 

The good: I used this question bank at the end, to brush up on my weaker areas, so I liked that I could purchase just the modules I needed rather than forking over $250. The explanations were pretty good. Some of the modules even had video explanations, which was nice because they would go into more detail. The physics modules on Physics Artifacts and MRI Sequences were very helpful.

 

The bad: The main drawback is the fact that you have to do the entire module before you can go over the questions. This made the process very time consuming (at least 2 hours per module). The image quality was poor and the layout appeared somewhat haphazard. Overall it is a good resource to use at the end, to cover areas of weakness.

 

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I know it seems daunting with all the resources out there. Don’t be afraid to use many, but use them wisely. Below is a rough plan of how I approached studying for the exam. And it worked for me:

 

My approach:

6-8 months before the test

  • Used Core Radiology early and often as primary source
  • RADPrimer questions (based on exactly what I was studying in Core Radiology)

4-6 months before the test

  • Continued above
  • Started Crack the Core Physics (supplemented by various YouTube videos)
  • Started BoardVitals Questions
  • Core Review Books

2-4 months before

1-2 months before

  • Skimmed Crack the Core to fill any gaps/get different perspective
  • Continued BoardVitals
  • Started Face the Core on weak areas

< 1 month

  • Crammed facts
  • Reviewed notes
  • Questions, questions, questions

 

 

 

 

 

Good luck!!!!

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Top 10 Things To Do When The PACS Goes Down

pacs

In 2021, almost every radiology residency in the country operates with a Picture Archiving And Communication System (PACS). It has become essential for the daily functioning of the radiologist and the radiology resident. Even though PACS has made our practices more efficient, we all experience a breakdown at some point. Maybe it’s information overload, an electrical surge, or an internet/cloud outage that causes the problem. Regardless, it will happen at one time or another. Sometimes, it may take a few minutes or hours for the system to come back up. During this time, people usually mull about and complain about the PACS being down. It becomes a handicap. Instead, what if we did something useful with our time? So, I thought I would write an article about the top 10 most valuable things to do when the PACS goes down. Let’s begin!

1. Call Up IT To Fix The PACS

Over the years, I have noticed when the PACS goes down: everyone assumes that someone knows about it and will take care of it. Sometimes that is the case. Other times, no! It never hurts to give IT a call to find out what is going on to make sure they get started fixing the issue. Furthermore, they may be able to tell you a timeframe for when they can complete the repairs. Then, you can have an idea about what you can accomplish during this downtime!

2. Network

What is a better time to network than when everyone has time? Now that the PACS is down, people can talk to you and listen!! This period can be a time to speak to your favorite faculty, technologist, nurse, residency coordinator, or janitor. And, no, it is not a waste of time. It brings goodwill to the entire establishment. In addition, getting to know your fellow employees gives excellent morale to the department. Who knows? The janitor may come to your department to clean up first because he likes you!!!

3. Study For The Boards

While at work, you should not waste a minute. One great way to occupy your time: get cracking on those books that you need to read. Start reading a chapter on what you would be doing if the PACS system were working. Or, maybe go over something that you don’t know. Regardless, this is a freebie. Now you will have less time to read when you get home!!!

4. Talk To Your Referrers Instead Of Staring At A Dead PACS

Maybe you have a burning question you need to ask one of your referring clinicians regarding a finding on a film and what that means for one of your patients. Or perhaps, you need to forward a message about a result. Well, now you have some time to do it. Don’t just sit there and complain about the PACS. Pick up the phone!

5. Arrange Elective Time

Perhaps, you are a 3rd resident and are pondering what you want to do for the following year’s mini-fellowships or electives. Now you have a real opportunity to plan something. Take a walk to your area of interest- perhaps neurosurgery, orthopedics, or pediatrics, and prepare a rotation for the following year. It will add an incredible experience to your training. What better time to do that than the present!

6. Observe Department Processes

The PACS system is down, but that doesn’t mean all patients stop arriving in the department. This time is an excellent opportunity to watch the technologist, secretary, or nurse in action. Learn how they take histories, process the patients, and what they do daily. It never hurts to learn about the processes within your radiology department. You never know when some of these skills will come in handy when you are a radiologist who owns an imaging center!

7. Research Projects

Downtime is a perfect opportunity to process the data on your iPad or research some articles for the following paper you will write. Edit your article. Less time needs you will need to spend in the department or your house on this work!

8. Walking/Exercise

You’ve been slouching on your chair all day until the PACS system went down. What better time than now to prevent a DVT and burn some calories! Climb those stairs. Walk around the grounds. Now is your time to get into shape!

9. Grab Your Lunch

Maybe the PACS went down around lunchtime. This respite is a perfect opportunity to get the lunch that you would have interfered with your day otherwise. Now, this PACS downtime no longer wastes your time!

10. Forget The PACS. Go To Radsresident.com!

Of course, what kind of article would this be if I didn’t add some shameless promotion? Take a look at my articles and learn something about radiology residency lifestyle issues that you may not have ever known otherwise. Enjoy this author’s great sense of humor!!!

 

Now that you know what to do when the PACS system goes down, you will no longer whine and complain. Instead, look forward to this inevitable period. This extra time is a blessing in disguise!!!