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How To Combat A Difficult Radiology Job Market!

job market

Once again, like in many other economic cycles, the radiology job market has hit a bit of a pause. This time, it is due to Covid-19. Although the job market is not as bad as it was back around 2010, it certainly is not the same as it was at the beginning of this year. And, in many locales, the job market froze up entirely. Competition remains fierce in desirable practices on the east and west coasts. Even with some folks abandoning the cities for the more suburban and rural areas, you will likely find it very difficult to obtain a partnership position in San Fransisco or Manhattan!!!

How do you, as a graduating radiology resident or fellow, begin to approach finding a job in this competitive landscape? We are going to cover the essentials for finding a quality job in these problematic radiology markets. I will divide the essentials into the following sections: networking, diversification of skills, location, recommendations, and research/national organization involvement.

Networking, Networking, Networking!!!

Maintain Relationships At Home

Networking does not only begin when you start looking for a job. The search for the ideal job commences at home. What do I mean by that? The first and most important part of networking is maintaining good relationships with your colleagues and attendings.

Many attendings have their proverbial “ear to the ground.” More often than not, therefore, many can tell you about opportunities in the area. Moreover, they can guide you to those jobs. So, to get access to these high-quality jobs, you need to perform and be a good team player. The resident that has not been “playing nicely in the sandbox” during training will not receive those inside tips. More likely, the poorly behaved resident will need to fend for himself. On the other hand, residents who continuously strive for excellence and relate well to their colleagues will have first dibs on those desirable jobs with connections to your radiology attendings.

Keep In Touch

It also becomes more critical than ever to stay in contact with your colleagues and coworkers. When you are ready to leave your residency to go to your fellowship, keep in touch with your former colleagues, residents, and attendings. You never know when that next job lead is going to pop up. And, most former colleagues will happily give you a tip for a new contact. These connections will be the most likely to help with finding that next great job.

What about social media? Nowadays, professional-based social media groups such as LinkedIn can play a role in getting that next job. Besides, social media can keep you in contact with your former colleagues. And, social media allows you to let others stay aware of your current training and expertise. Therefore, residents should maintain at least one account. But be careful to keep the account relevant and correct. View it as a resume. If it is not updated and contains false information, it can be detrimental to finding that next great job. Otherwise, it can be a great way to contact your former colleagues as well as a way to obtain new leads.

Always Be Nice

Finally, even when you have started on that first job, whether it be a dream job or merely a stepping stone, make sure to be cordial and appropriate to your interviewees. I remember when I was interviewing, I met with a private practice attending who was touting the merits of his work to me. I subsequently found a job with a different practice. However, six months later, that same attending who interviewed me became an interviewee at my current practice. You never know what is going to happen!!!

Diversification of Skills

As a resident and fellow, try to do things in your field slightly out of your comfort zone. What do I mean by that? You never know what practices are going to want. Things change. Sometimes an imaging business may need a cardiothoracic radiologist but also require a radiologist that can also read mammograms. Other times, a practice may need an interventionist that feels comfortable with reading musculoskeletal MRI. To become the most competitive candidate in your class, you need to make sure that you feel comfortable in as many modalities as reasonable. Therefore, you should not just concentrate on your fellowship skills or areas of comfort, but also your weaker procedures/imaging areas.

As a fellow, it also becomes crucial to moonlight to maintain your skills in other general radiology areas, outside of fellowship. It can build your speed and accuracy. So, when you start your first job, you will be able to read studies at a reasonable pace. Moonlighting will allow you to have a higher likelihood of remaining at your first job after training!

Should Location Be The Sacrificial Lamb?

Sometimes the job market in some locations becomes so ultra-competitive that good jobs may not exist in your desired area. In that case, there are times when it makes sense to alter one’s expectations and apply to other locales outside of one’s original intentions. By switching locations, the applicant may significantly increase the job market choices that will allow her to practice her subspecialty or earn more income. However, an applicant should not take this decision lightly because personal or family issues sometimes can trump job selection. But, an applicant should consider all the alternatives before selecting a job.

Recommendations

As a radiology resident or fellow, obtaining a radiology job recommendation differs significantly from asking for one as a medical student. Instead of a formal letter, a radiology resident or fellow should let the attending know to expect a phone call from a radiologist at the practice where he had interviewed. Although informal, this practice gives more information to the radiology practice than a simple letter of recommendation. A radiologist can relay the real personality and information about a candidate on the phone more easily without legal repercussions. In this situation, no paper trail exists.

In the conversation, the caller may informally ask your supervising attending about your work ethic, whether you played well with your team, and more. Other times, a member of the practice may speak with a friend of theirs within your residency program to confirm that you would make a reasonable job candidate. Bottom line: it is good manners to let your attending and program know to expect a phone call!

Research/National Organizations

For those interested in academics, completing research projects can help to snag that first academic job. Although not as crucial for the private practitioner, it also can’t hurt to have completed research projects. As I’ve mentioned in a prior post on research, if practices have a choice between two equal candidates, they may sometimes choose the resident with more research experience. You never know…

Also, getting involved in national organizations, whether it be the ACR, RSNA, or AUR, can be a great way to learn about the politics of radiology as well to meet colleagues and practitioners. Residents should consider participation in these organizations.  It could be a stepping stone to find a great job or to become the next President!

Final Thoughts About The Job Market

If the job market is tight, all is not lost. Even in the most challenging markets, some practices will usually have a few jobs available. To increase your chances of getting one of these popular slots, you may need to work a bit more intelligently and focused so that you can become a desirable candidate. Networking, diversifying your skills, making sure to get great recommendations, finding the correct location, and participating in research and national organizations can help your cause. Ultimately, these practices will choose someone that fits the expected identity of an ideal candidate. If you follow these essentials, you have a much better chance that that person will be you. Good luck!!!

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The Presidential Executive Order And Foreign National Radiology Residents- Will Life Ever Be The Same?

In a medical resident’s life, he or she is so busy that politics rarely influences day to day work and living circumstances in the United States. But, this is no ordinary year and we are not in ordinary times.  A new presidential executive order has been issued. No longer can residents from the following countries: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen travel to the United States without the appropriate documentation. But, it turns out that the implications of the executive order run much deeper than just the inability to return to the United States. Resident physicians lives may be altered for many years to come.

On the surface, the executive order makes some sense. Prevent the bad guys from coming into the country by halting travel for all citizens of the designated countries, countries where there have been incidences of terrorist activities. Dig deeper and you realize that most of the foreign born nationals have already been in the United States for years legally, either with a green card or certain visas. A majority of these residents are not terrorists and are in fact, good people, hard working, and excellent physicians. Additionally, many other countries with histories of harboring terrorists were not included in the executive order.

Effects of the Travel Ban On Residency

So what are the potential effects of this executive order if you happen to have been away in another country? Since some of these residents are already abroad and cannot return to the United States, these physicians in training will have their training delayed by at least 90 days since they need to stay in their country of destination. On the surface, that does not sound so bad. But, it can have profound implications. Training will have to be delayed by over 3 months. This means that the resident cannot graduate from the radiology residency program on time at the end of the 4 years. And, he/she will potentially have a difficulty either beginning their chosen fellowship on time if they are scheduled to start at the end of residency. Others will have to delay finding a fellowship potentially for over a year.

Furthermore, many foreign medical students from these targeted countries have recently interviewed for residency positions. Program directors are either ranking these medical students lower on their rank lists or are being placed in the “do not rank” category due to the uncertainty that these prospective residents may not be able to start at their residency on time or perhaps not at all. This year’s residency selection is already being affected by the executive order. In the fact, the NRMP has already submitted a statement on the executive order recognizing these challenges.  (NRMP Statement on Immigration Executive Order)

Also, on top of the general work related issues, these residents can no longer visit their relatives abroad, for the risk of not being able to return to the country, giving them less of a support system during the time of their residency. Residency is time a time of significant emotional and intellectual stresses. It is also possible that the international travel ban can last longer than has already been stated, potentially making the stressors even greater. So, although well intended, the executive order is severely flawed.

What Needs To Be Done To Make The Executive Order More Effective And Reasonable?

First of all, the current blanket executive order needs to be made more targeted. Most of these foreign residents have already had their green cards for many years and have been working in the United States as productive employees for most of that time. If need be, these residents can be reinterviewed by the government, but should not be banned from travel abroad or from returning to the United States during this period of “vetting”. Why prevent these legal workers from contributing to the United States workforce and potentially causing shortage of labor in residency programs? We are only harming ourselves.

Second, those countries chosen by the executive order to be targeted is a random selection of “terrorist harboring” countries. Other countries that have traditionally harbored many of the terrorists were not included. So, if you are going to make an executive order to restrict travel and reinterview these residents, it does not make sense to only target a few of those countries.

And finally, vetting should be more individualized and reason based. If in fact, the vetting that was done was not so thorough upon the initial interviews when these foreign born residents came into the country, then by all means go ahead and do the appropriate procedures to make sure that they are in the United States legitimately. But, make sure to do it in a reasonable manner instead of targeting everyone without cause.

What Should You Do If You Are Specifically Affected By The Executive Order?

There are two groups of residents and resident applicants affected by the executive order: applicants who are already in the country and those who are abroad. For those residents that are in the country, I would recommend to avoid travel abroad until the situation clears- you may have difficulty getting back into the country if you make this decision.

For both groups of residents, I would also pay close attention to posts on the ACGME website if you are a resident and the NRMP if you are a applicant for residency. They are scheduled to have frequent updates with relevant information. Also, make sure to stay in close contact with the hospital, residency program, and program directors to receive any relevant updates or other helpful practical and legal advice.

Unfortunately, if you happen to be abroad since the executive order, depending on whether you have permanent resident status or not, you may or may not be able to return to the United States. I would recommend seeking the help of an immigration attorney to help with the issue of returning to the country.

Difficult Times For Foreign Nationals From the Targeted Countries

It is unfortunate how the executive order was issued without regard to the specific circumstances of the individuals affected. Regrettably, many excellent well trained and talented foreign national residents and applicants may be at least temporarily prevented from completing their training due to no fault of their own. However, I believe that once the flaws of the executive order have been worked out, order will be restored to the medical training process, most qualified residents will be able to return to their positions, and medical students will be able to reapply. Although it is only 90 days until a more logical system can be sorted out, these residents may be affected for a much longer time due to the unintended consequences of the order. Continued patience and perseverance is in order for these residents. Hopefully, this situation will eventually pass.

 

 

 

 

 

 

 

 

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Can I Be Sued As A Radiology Resident?

lawsuit

As radiology medical school applicants, radiology residents, and full-fledged radiologists, we all dread the possibility of a lawsuit when we begin to practice radiology. Very rarely discussed, however, is the possibility of being sued during radiology residency. The good news: it is very unusual! One article stated that there were only 15 legal cases and 10 law review papers that addressed physicians in training and standards of care on two large legal databases. And, these cases were not necessarily radiology residency specific. The bad news is that although a remote possibility, it has happened several times in the past. 

So, this makes for a relevant topic that is not frequently addressed but is certainly a possibility. In this article, I analyze a few different sources on the web and literature to understand the conditions you need to meet for a patient to sue a radiology resident. More specifically, we will analyze what standards of care a resident needs to breach. Also, we will go through several ways radiology residents can prevent lawsuits in the future.

The Grounds for a Lawsuit

For a lawsuit to be successful against any physician in general, three requirements need to be satisfied. According to a recent article in Diagnostic Imaging, these are breach, causation, and damages. Breach implies that the physician did not satisfy the requirement of the standard of care. Causation means that the breach of duty caused the malpractice. And, damages indicate that the event produced significant harm. 

In today’s article, I will explicitly discuss the issue of breach without discussing causation and damages. Why? Because the concept of breach makes a malpractice case performed by a resident different from a fully trained attending.

Resident Breach For A Successful Lawsuit

Due to the standard of care being different for a resident, the definition of breach for a resident involved in a malpractice event becomes a little more complicated. In fact, over time, the standards of what breach means for the radiology resident have become blurred. I will discuss several cases with different definitions of what the legal system considers “standard of care,” specifically for a resident in training.

Breach For The Intern

Some cases have involved the medical intern. There was one case where an intern failed to identify retained glass fragments and sewed a wound shut. In this case, the court concluded that the criteria for the standard of care should be based upon the standards for the typical intern’s skills. Subsequent lawsuits have demonstrated that the first-year resident needs to fail to do something that a “physician or surgeon of ordinary skill, care and diligence” would typically do to breach the standard of care rule. In other words, the legal system can require a first-year resident without a full license to meet the standards of a general practitioner physician in terms of standard of care.

Breach For The Subspecialist Trainee

For residents in a subspecialty level training program, breach of the standard of care is even more confusing. Some cases imply that the sub-specialized resident should meet the obligations of a general practitioner. Other instances suggest that residents should meet the demands of a more specialized physician. Adding more confusion to the issue, one relevant article’s author reported a radiology resident-specific case of a misread MRI of a newborn. In this case, the court was unable to determine a specific resident standard of care and ruled in favor of the defendant. So, this case did help to define the “standard of care” for this radiology/specialist. (1)

In another case with a radiology resident, an AJR article discussed an incident during radiology moonlighting. The patient sued the resident for missing an abscess and instead called it a bladder diverticulum on a CT scan. The parties eventually settled the lawsuit, but the court determined that the jury would decide the liability before the settlement. This settlement implies that a standard of care was breached at the level of an attending subspecialist/radiologist.

The Main Source of Confusion About Breach

So, according to the literature, the law sometimes considers residents to have lower than the typical standard of care for attendings. Other times they are considered to be at the standard of care of a general practitioner, and at other times the resident has to meet the standard of the attending in his subspecialty. Confusing, huh?

What Does This All Mean?/Primary Take-home Messages to Reduce Liability For A Lawsuit

So, now that all this information confuses you, what does this mean? 

Precept 1: Regardless of the definition of breach for the radiology resident, make sure to get help if you are unsure, and the case can lead to patient morbidity. Getting help can reduce the odds of getting sued for a questionable interpretation and allows your fellow attending to take responsibility for the case.

Precept 2: If moonlighting, make sure you have malpractice insurance. Misses do happen, and the courts may treat you as a fully trained radiologist. So, don’t catch yourself off guard without proper insurance. You need to make sure that your insurance will specifically cover you for moonlighting mishaps.

Finally, Precept 3: Although it is infrequent, lawsuits do happen to radiology residents, and you are certainly not immune from the ravages of the legal system. So, treat each case as if you are the responsible party and always provide your best effort to make the correct findings, diagnosis, and management.

Lawsuits And Residents

Although unlikely, patients can still sue residents for malpractice. Don’t leave yourself susceptible to the possibility of a lawsuit as a resident!

 

References

Clin Orthop Relat Res. 2012 May; 470(5): 1379–1385.

Published online 2012 Jan 26.

Medical Liability of the Physician in Training

Brian Wegman, MD, James P. Stannard, MD, and B. Sonny Bal, MD, JD, MBAcorresponding author

Radiologists, Expect to Get Sued Mar 03, 2016 | RSNA 2015, Practice Management

By Liza Haar

AJR1998;171:565 Malpractice Issues in Radiology: Liability of the Moonlighting Resident By Leonard Berlin

 

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Tackling Research- Basic Issues and Considerations for the Radiology Resident

research

Put an academic radiologist and a general community radiologist in the same room and start a conversation on research and radiology residency. How do you think that conversation would go? I bet there would be bitter debate and sharp words. It would likely be next to impossible to get them both to agree on the merits of radiology research.

The academic radiologist would point out the necessity of research to allow the resident to understand how to delve deeply into an area within radiology, understand the mechanics of making discoveries, and create and advance new areas of knowledge within our specialty. He would espouse the importance of statistically analyzing false positive and negative rates, ROC curves, sensitivities, and specificities, tools invaluable to becoming a good radiologist. Additionally, they would also likely say that without an understanding of the mechanics of the research process, companies can easily mislead you by marketing headlines for new software, contrast agents, radiology hardware, etc., that may, at best, marginally display the truth of an imaging process or at worst can be entirely incorrect.

On the other hand, the community radiologist would say that if you understand the fundamentals, can read films well, and know how to manage patients appropriately, what is the point of doing research? Let others develop new ways of interpreting films, creating protocols, or creating new contrast agents. Or in other words, “leave the research to the academics.” The community radiologist would also utter in the same breath that research is too time-consuming, costly, and incompatible with the day-to-day running of a revenue-generating practice. Why bother?

To What Extent Should You Pursue A Project?

So, given these diametrically opposite points of view, the big question becomes: to what extent should the radiology resident pursue research during residency? Should you make it into an all-consuming process or relegate research to satisfying your residency program’s requirements? Given the potential difficulties of making this decision for some residents, I will go through how to figure out for yourself whether you should follow the advice of the academic or community radiologist. In addition, if you go down the research pathway, I will give some sage advice about how to find a research mentor and what makes the best research projects.

How Much Research Should I Pursue?

Maslow’s Hierarchy of Needs

Ever read about Maslow’s Hierarchy of Needs? If not, I highly recommend you click on the previous Wikipedia link. Instead of Maslow’s Hierarchy of Needs, now picture the Radiology Residency Hierarchy of Needs. You might have to dictate films, study radiology material, and attend lectures at the base. At the apex, you would have radiology research. This point is so important: your own basic needs of a radiology residency must be satisfied before you tackle the research requirement. Therefore, you must answer some questions before starting a research project: Have you been studying enough, attending lectures, and learning the basics of radiology concepts? Are you performing well on your rotations? Do you have to concentrate on other issues, such as the USMLE? In other words, the resident must first focus on becoming a good radiologist and then their research. 

The entire pyramid will collapse without the essential elements of good radiology residency preparation. Why do I make this statement? Suppose the resident concentrates so heavily on research instead of learning all the imaging modalities and vital skills during their residency program. In that case, they will find it very difficult to perform well during residency. You want to ensure that you know the general skills of the radiologist first and foremost. Furthermore, too much emphasis on research can lead the resident to lose focus on other issues, such as passing the core examination. So, make sure not to forget about the main reason you are doing your residency: to become a radiologist.

The Rewards

On the other hand, if you can dedicate time to research because you can comfortably divide your time appropriately, by all means, go for it. The rewards are numerous from both a practical as well as academic standpoint. Significant research becomes essential if you are interested in academic radiology, love to come up with innovative ideas and enjoy writing publications. Publishing several papers and abstracts during residency and fellowship can help you get that first job if you want to pursue an academic career.

Even in private practice, performing research during your residency shows that you are interested in radiology. From a radiology job market perspective (although the community radiologist may not want to admit it!), if you have two equal candidates, one who has accomplished much research and the other who has done none, I believe most practices would choose to hire the former.

The bottom line- yes, research can be rewarding but make sure that it doesn’t interfere with your fundamental mission of becoming a radiologist!

How Do I Find A Research Mentor?

Most radiology programs have some attendings that are almost exclusively clinical and others that are more academic. I recommend you seek out mentors/attending with a decent amount of research experience. Although these clinical-based attendings can be great teachers and mentors for learning radiology, they will likely not be as valuable for understanding how to do research. They may express interest in helping you with research, but they cannot instruct you on completing a project. So, unless you have already had a lot of experience with radiology research, a more clinically based radiologist may not be the best choice for a radiology research mentor. There are a lot of radiology attendings out there that don’t have a clue how to structure a research project. (not that it makes them bad radiologists!)

Although not always possible, depending on the size and structure of your residency program, try to find a mentor in an area/subspecialty of radiology that interests you. It will more likely help you later in your career when you complete a project in your area of interest.

Finally, try to find a mentor that meshes with your personality. In addition to the grunt work of research, part of the research process involves bouncing ideas off one another and brainstorming. Exciting research can begin to seem more of a chore than a genuine passion if you feel you are not an equal participant. It shouldn’t be that way. Personality can become a significant issue.

What Makes The Best Projects?

My favorite research projects are those issues and problems that have constantly nagged at me or annoyed me over the years of practice that you have the itch to solve. In addition, I love research projects in an area of actual interest. These tend to be the best and most satisfying projects. I find that esoteric projects without relevance do not provide that spark to take the research to the next level. It also may dissuade the resident from pursuing other projects down the line.

I recommend that when you are involved in the day-to-day readouts, try to take notice of the issues that bother the attendings or questions that occur in the areas of interest you love. There are few things more satisfying than coming up with a question you thought about and then figuring out how to solve it.

Final Thoughts

Radiology research is an excellent avenue for understanding the mechanics of what we do as radiologists. We take many presumed facts for granted, whereas these facts may not be based on the best evidence available. Performing your projects allows the radiology resident to understand how to determine what information is genuinely facts and what information does not have a basis in science. This process helps the resident to read and interpret studies and critically define the accuracy of the information we use to analyze images daily.

Furthermore, delving into research by completing a project can be a very satisfying professional endeavor and become a capstone on top of our radiology residency training. Few things are more satisfying than answering your question, for which the body of literature did not provide an answer.

However, it is essential to remember that as a radiology resident, you must satisfy the basics of radiology residency first and foremost. Before deciding whether or not to become involved in a project, consider if you have the time and energy to pursue the project to its end. If a research project is very complicated and time-consuming, think twice about the project because your priority should be to become a well-trained radiologist. Radiology research can be rewarding, but only to the extent that you first satisfy the basic requirements of radiology residency training.

 

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The Post Interview Second Look – Is It Worth My Time?

second look

Every year after interview season ends, there is a brief interlude until the rank selection list is submitted. And now, during the life and times of covid, it may be more challenging to arrange a second look. However, with vaccines available to health care team members, students, and attendings alike, you may be able to schedule one. 

So, you may wonder at this time- Does it make sense to go back to a radiology program to take a second look? It may be a complicated decision and can depend on numerous factors. Therefore, I am going to take a look at this issue from a program director’s perspective. We will approach the problem by tackling a series of questions that will help you make this critical decision. Hopefully, it will be of some benefit to those of you that are involved in this process.

Who Is Most Likely To Benefit From a Second Look?

From a residency director’s perspective, the ideal candidate for a second look at a residency program is a student that has already interviewed, for which the admissions committee was unsure of its final disposition. For example, every once in a while, an application/prospective resident interview causes a stir among the committee. The interview may have gone well, but the application quality didn’t sync with the interview. Or, the application was excellent, but the applicant’s personality was questionable on interview day. Usually, it is some conflict in the committee evaluation process. These applicants can benefit the most from a second look because it may sway the admissions committee one way or another after the candidate returns.

Second, the marginal/below average candidate that has been ranked but did not have many interviews would also be an ideal candidate to return for a second look. Some programs will rank their returning applicants slightly higher for just showing interest by returning to the program. Usually, candidates don’t return unless they are earnest about a program. A slight increase in the rank list can make the difference between matching and not matching.

Finally, the other ideal candidate would be the interviewee who felt he/she didn’t get the best impression of a program and wants to make a more informed decision on the day he/she will submit the rank list. Maybe the program director was absent. Perhaps you have a spouse that wants to remain in the area, and you didn’t get the best impression on the interview, but the location would be ideal. Or, maybe you like the people you met, but you felt you didn’t meet the residency program’s key players on the day you interviewed. Whatever the case may be, the second look can help to reinforce that decision.

How Do You Know You Should Come For a Second Look?

Let’s first begin by stating: The worst situation for the residency applicant and the program is to have an applicant that has already been placed into the “Do Not Rank” pile return for a second look. It wastes the applicant’s time and money and the resources of the program director and staff. Also, it may not make sense for the individual applicant to return depending upon other applicant factors. So, here are some criteria that may help you to decide if you are in either of these situations:

  1. Did the interviewer suggest you come back for a second look? The program director will usually recommend to return for a second look if he/she is potentially interested in a candidate and think it may be of some benefit.
  2. Did you get the cold shoulder during the interview process? Some interviews don’t go well for multiple reasons. That will happen from time to time. Your instinct is probably correct if you feel that is the case. In this situation, it is perhaps not worthwhile to return for the second look.
  3. How far down is the program on your rank list? If the program is very low on the order of your rank list and you are a reliable candidate, it is probably not worth the effort to return for the second look.
  4. Is it reasonable to travel to the interview site? Some candidates live very far away from the prospective residency program. Suppose it will be disruptive to return to the program due to travel costs or significant inconvenience (maybe you are amid your medicine sub-internship and can’t miss a few days). In that case, it is probably not worth your effort.

 

How Should You Behave/Present Yourself On The Day Of The Second Look?

The program director or interviewer that asks you to return for a second look will often tell the candidate, “we would love to have you return for an informal second look.” It is important to remember that there is no such thing as an “informal” second look. A second look is a second interview day, and you need to treat it as such. Wear your best interview clothes as you would have worn for your first interview. Be on your best behavior and be friendly to all staff members, just as you would have done for the initial interview. Remember, you still have not been admitted to the program, and you are certainly not yet “one of the residents.”

What Should You Tell The Program Director Before You Leave?

Certain buzz words have significance to the program director when meeting at the end of the second look day. The program directors and admissions committees take these words very seriously. So, be careful what you say. If you say the wrong thing, it may cause a different result than intended.

If you are genuinely interested in the program, you can say, “I will rank the program first.” This phrase is specific and demonstrates your genuine intention to the interviewers. The program can verify this fact on match day when you either match the program or do not match it. So, your action will back up the facts. This truth will follow you from this point forward. If you ever decide you want to return to the community as an attending and you did not abide by your word, the program can blacklist you!!!

On the other hand, the phrase “I will rank your program highly” is a buzzword that means your program is nowhere near their first choice, and you will probably match elsewhere. Some applicants do not realize this. So, be careful!

If you are still not sure after the interview day, it is appropriate to say, “I really enjoyed my second look at the program, but I am still considering my decisions.” The program director/interviewer will usually understand. When/if you decide to rank the program first, you can always contact the program and let them know.

Final Thoughts About The Second Look

The second look can be an essential part of the residency interview process. It can provide a slight edge to your candidacy and may be worthwhile if approached the right way. On the other hand, it may not be the right move for all applicants. So, weigh the facts and make a final decision. The interview process will be over before you know it!!!

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The Informatics Fellowship- Bulletproof Your Radiological Future

Concerned about artificial intelligence taking over our jobs? Worried about the economic cyclicality of each of the radiological subspecialties? Do you fear the instability of your future radiology attending career due to corporate takeovers and mergers? Well, I have a solution for you (and no, I am not an infomercial!!!)… Welcome to the new fellowship called Informatics!!!

Why am I writing about the informatics fellowship and skipping all the other subspecialties? Well… the informatics fellowship warrants an independent post because it is truly the only radiology subspecialty that is in a permanent secular growth trend. It is also the only fellowship that has relatively little information published on the subject matter. In fact, once several of my residents and students heard about the existence of the fellowship program and understood its potential benefits, they began to salivate!!!

So, this article is dedicated to the topic of the informatics fellowship. Specifically, we will discuss the definition of informatics, what the fellowship entails, requirements for the fellowship, how to find where to complete the fellowship, and what job opportunities are available for graduates of these programs. I think once you understand the potential benefits of this fellowship program, you might consider it yourself!!!

Discussion of Definition and Importance of Informatics

So, what is the definition of informatics? According to Merriam Webster, it is as follows- “the collection, classification, storage, retrieval, and dissemination of recorded knowledge”. Prior to several years ago, I have to admit that I had never heard of the term or definition of informatics. In fact, I think I am probably not alone. It is only since the terms “the cloud” and “big data” have arrived into the mainstream, that I think the word informatics has been used more widely.

Why all of a sudden is this body of knowledge so important? In our age of electronic interconnectedness, large swaths of data are created and processed every day. Particularly in the radiology realm, there are numerous electronic/digital images and reams of clinical/health information. Someone has to both understand and manage all this information. Although computer engineers presently manage a lot of this information, they tend not to understand how to manage the data for physicians, administrators, and patients to understand. Herein lies the niche of the radiology informaticist, translating the imaging and clinical data from the computer engineer to the clinical realm.

What Do These Informatics Fellowships Teach?

Fortuitously, the same day that I started to write about informatics, I received a letter from the APDR explaining that there would be a new initiative to create a summary online 1 week course in informatics for residents. Some of the topics covered by the course as listed in the letter include Standards; Computers and Networking; PACS and Archives; Security; Life Cycle of a Radiology Exam, Data and Data Plumbing; Algorithms for Image and Nonimage Analytics; and the Business of Informatics. This course contained many of the topics that some informatics fellowship programs teach. But, the curricula of many of the informatics fellowships differed significantly from this course and were more expansive.

To add a bit more confusion, each individual fellowship program also covers differing topics from one another and varies the emphasis of each of these subjects.  Some of the topics that these fellowships include: RIS systems, Image Compression, Teleradiology, Quality Improvement, Operations, Clinical Engineering, HL7, Regulations, DICOM, Critical Results Reporting, Decision Support Systems, Radiation Dose Tracking, Mobile Health Applications, Image Segmentation, Imaging Room Ergonomics, 3D Printing, Natural Language Processing, Informatics Funding, Biostatistics, Health Policy, and Experimental Design. There was some overlap between the different programs. But coverage varied widely. I will also refer you to the ACGME formal program requirements in Clinical Informatics for a more formal explanation of all the areas of teaching required at all fellowships.

What are the Requirements To Become An Informatics Fellow?

The prerequisite requirements vary from program to program. Of the programs I visited on the web, most but not all, had a requirement to be board eligible in a specialty (not necessarily radiology), to be a graduate from an American Medical School, and to have an interest in the discipline of informatics. Most fellowships did not have a specific requirement for formal training in computer science. According to the ACGME, the program length was 1 or 2 years to graduate from a radiology program.

Where to Find the Fellowships?

I found several ways to find the informatics fellowships that are offered for diagnostic radiology program graduates. If you happen to be a member of the AMA, you can look up the fellowships on the FREIDA database. (It turns out I am not a member!) Alternatively, you can do a web search on informatics fellowships and many of the large institutions  describe their own programs. And finally, you can go to the ACGME website and look up informatics fellowships there.

Job Opportunities for the Informatics Fellowship Graduate

This is where things get really interesting… Job opportunities are endless. You want to be part of a large private practice or maybe a teleradiology practice?  Interested in becoming a practice leader?- It’s all yours! Not many employers can replace the only radiologist that can fix a PACS or RIS system and can also actually read films.

You want to become an entrepreneur and start your own company? You will have access to all the tools and methods to create a technological niche for yourself whether it be an app, a PACS addon, a new piece of software, or other countless unimaginable outlets.

You want to go into academics? The world is yours. Academics are desperate to have rads translate their IT department workings into something that is useful and efficient for clinicians. Think about the possibility of chairman or CIO.

You want to work for big business? Think Apple, Google, Cerner, and more! Large organizations are contstantly on the lookout for good talent that can translate the engineering esoteric data into clinical reality. You will be able to develop needed applications, improve health and radiology related products to get more clientele, and more:

Think about it… you will be at the forefront and crossroads of technology and clinical medicine- a job that only a few can currently fill. It will be very difficult to replace you.

Diagnostic readers can be outsourced to India. Robotics can replace human procedures. But humans will always be needed to rule the machines (unless our future is to be the same as The Terminator!)

Final Thoughts

Of course in the end, like anything else, you need to like what you are doing in order to be good at it. And, informatics is certainly not for everyone. But, if you have a remote interest in the intersection of computers and radiology, really consider this subspecialty. The possibilities are endless, job opportunities abound, and you have the ability to be in charge of your own destiny, potentially not subject to the whims of government or even private industry.  You can be your own captain!!!

 

 

 

 

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Buying vs Leasing A Car During Residency

leasing

Mass transportation is unavailable in all parts of the United States, unlike other countries, due to infrastructure issues and spread-out spaces. For this reason, many medical residents may consider buying or leasing a car during residency. It may not be such a simple question. Several times my residents have asked that I write a post on this subject matter. So, I will define what it means to lease a car and then explain how I would decide to buy versus lease a car with multiple thought experiments and comparisons.

What Is A Car Lease?

A car lease is a hybrid between buying and renting a car. It allows the lessor to spend a portion of the entire vehicle cost over a fixed period, usually with the option to buy the car at the end of the lease period at a depreciated amount. Monthly payments are typically less than a car purchase since it does not include the entire vehicle cost. The lease cost usually consists of the depreciating price of the car and monthly interest. The lease can contain additional fees in the monthly bill, including a charge for going over a fixed limit of miles and sometimes additional insurance costs not factored into a bought car.

The lessor will often put down a nominal fee at the beginning of the lease period. Bottom line- leasing a vehicle lets the lessee enjoy a more expensive car than they could typically afford with lower monthly payments. But the big question is- do they come at a significant cost?

Examples of Buying Vs. Leasing Cars

Whenever I make a financial decision, I like to take a mental picture of the different financial possibilities using thought experiments. Otherwise, it can be hard to understand the subtleties of the other arrangements. So, I am going to do just that with a typical car. I will assume the vehicle costs about 30000 dollars and that we will buy or lease the car over three years. Cars can be less costly if bought used, but for the point I am trying to make in this article, buying or leasing a new versus used car should not change the conclusions. In my first example, I will assume that we will hold the vehicle we purchased for over ten years and compare that to the costs of leasing for three years and buying out the lease after the three years are over. So, let’s do just that.

Scenario 1- Buying and Holding for 10 Years Vs. Leasing And Buying Out A Lease

Buying A Car

Let’s say the interest rates are 3% on the three-year loan for a new car and the lease. And, we will put down a nominal amount on the vehicle on both the car purchase and lease- say 2000 dollars on both. So, what are the monthly and total costs of buying a car over the entire period? To determine that, I will use one of my favorite financial programs in the world- a simple amortization calculator on the web from Bret Whissel called Amortization Calculator. So, the monthly payments on a bought car over three years after the nominal down payment is approximately 814 dollars for a total cost over the three-year loan of around 29313 dollars. The total cost of purchasing the vehicle will be 2000+29313 dollars or 31313 dollars.

Leasing A Car

How does this compare to the monthly payments on a three-year car lease? Let’s do the calculations. One of my favorite rules for determining the depreciation of a car that approximates reality is the rule of 10+9+8+7+6+5+4+3+2+1. For each year that you have owned the vehicle for up to 10 years, you can match the price of the car by taking the number of years that you have owned the vehicle, adding the numbers from highest to lowest for that period, and then dividing by the rule’s total (55). So, in this case, the amount of depreciation over three years would be 10+9+8/55 or 49%.

Alternatively, you can use a slightly more accurate calculator such as this one from Money-zine and develop a depreciation percentage of approximately 39%. For the sake of “accuracy,” we will use the more accurate calculator. The initial lump sum of 3-year monthly payments will be (0.39) (30000-2000) or 10920 without interest. Calculating interest at a 3% rate and using the amortization calculator, the monthly payments will be 317.57 dollars, and the total sum of payments over the three years will be 11433 dollars.

The Verdict

According to the calculations, the car’s residual value will now be 30000*(1-0.39) or 18300 dollars. Remember, the 2000 dollars you put down on the car does not contribute to the principal/cost basis of the vehicle. So, let’s finance the residual value payments over three years again at 3%. The monthly payments this second time around for buying the car out of the lease will be about 532 dollars, and the sum of the charges will be 19159 dollars. So, the total cost of the vehicle after leasing and then buying out the lease will be 2000+11433+19159 dollars for a total of 32592 dollars, not including additional leasing fees. The extra cost for leasing and buying out the car to get the lower payments vs. buying over three years is a mild difference of 32592-31313 or 1279 dollars total.

Scenario 2- Buying and Holding Vs. Continually Leasing for 10 Years

In the second example, I will compare leasing costs when you do not buy out the lease, continually leasing cars every three years over ten years, and compare that to buying and holding a car for ten years. So as in our first example, the initial cost of leasing the vehicle over three years will be 11433+2000 dollars. Let’s assume you will do that three and a third times over ten years. So, our total costs for leasing a car continually over the ten years would be 3.33*(11433+2000) or 44732 dollars.

For comparison, when we buy and hold a car for ten years, there will likely be increased repair costs for keeping a relatively older car. Let us then go ahead and add 500 dollars per year in repair costs after the initial three years of the loan for buying the vehicle. We will add that to the former loan price in the previous example or 31313+(7*500) or 34813 dollars. So, the additional cost for leasing a car continually over ten years compared to buying a car and holding for ten years would be 44732-34813 dollars or 9919 dollars, almost a third of the price of a car!!!

Scenario 3- Buying and Holding vs. Continually Leasing for 10 Years With Tax Deductions

In the third example, I will assume that the resident will moonlight and can deduct the car’s depreciated value from their total income annually at 25%. We will again compare the costs of releasing a vehicle every three years over ten years and compare that with buying and holding a car for ten years. Assuming you can deduct the depreciation from your salary, the new costs of leasing a vehicle would be [11433 (1-0.25) +2000]*3.33 or 35214 dollars over ten years. In this situation, the additional cost for continually leasing a car over ten years would be 35214- 34813 dollars or 401 dollars, which is more reasonable.

Scenario 4- Buying and Selling Over 10 Years vs. Continually Leasing Over 10 Years

In this example, I will compare what it would cost to buy and sell a new car every three years, assuming a 30000 dollar price tag for ten years without leasing vs. the cost of leasing cars over ten years. Most residents don’t like the hassle of constantly buying and selling cars, but it would be interesting to compare with leasing over the same time. So, let’s do the calculations.

Based on our initial scenario, buying the car every three years would cost 31313 dollars. So let’s assume we can sell the car every three years for 31313 dollars*(1-0.39) or the depreciated value of 19101 dollars. So, the cost over ten years would be 3.33*(31313-19100) for 40669 dollars. The additional cost for leasing cars over ten years vs. buying and selling cars over ten years would be 44732-40669 dollars or 4063 dollars, a moderate difference.

Scenario 5- Buying and Selling Over 10 Years vs. Continually Leasing Over 10 Years With Deductions

Finally, let’s compare the cost of leasing over ten years with the ability to deduct the depreciated lease value from your taxes compared to buying and selling cars every three years for ten years. The calculations were performed in several scenarios above, making these calculations easy. So, the total in this situation would be 35214 dollars for leasing and 40669 dollars for buying and selling over ten years. This scenario is one where it would be less costly to lease for a total savings of 40669-35214 dollars or 5455 dollars total.

What Can We Conclude Based on These Scenarios?

We have crunched all the numbers, and what can we conclude? The most stark difference under all these scenarios is between continually leasing a car for over ten years and buying and holding it for ten years. You would theoretically save 9919 dollars over ten years if you buy and own a vehicle, approximately 1/3 the car’s value. That’s a lot of money!!!

If you can deduct the car’s depreciated value from your income, then leasing a car every three years for ten years will be a slightly higher cost than holding on to a vehicle for ten years. If you like new cars, this proposition can make some sense.

Finally, the finances are almost always in favor of buying a car except for the one situation where you have to decide between leasing a car every three years for ten years and buying and selling a car every three years for ten years with the condition that you can deduct the depreciated lease value from your taxes because you are an independent practitioner/moonlighter/consultant. This situation would be highly unusual.

Final Thoughts

Always crunch the numbers based on your inputs (these may vary slightly from mine). But, for most residents, if you need a ride to work and must have a car- buy a car and avoid the lease. A lease will put you behind the eight ball over your initial working years, especially when getting rid of your student debt and beginning your savings/investments is crucial. On the other hand, if you can deduct the car’s depreciated value from other self-employment income, you can argue to lease instead of buy. And finally, if you are in the fortunate situation of being able to walk to work every day, perhaps you can do without a car altogether and save some money!!!

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Radiology Residency And The SOAP Match

It’s the middle of March, and every 10 minutes, you are checking your email to see if you have matched in one of the most competitive specialties out there; maybe it was dermatology or radiation oncology. You can’t eat or drink. Your mouth is dry. Suddenly, you get the dreaded email- “You have not matched for the ‘blank’ specialty in the regular match.” All these years of work, and what do I have to show for it? A wave of depression sets in. You want to stick your head in the sand.

Unfortunately, every year this scenario plays out. Each year the dynamics of matching in competitive specialties becomes more challenging due to increasing numbers of medical schools/American MD graduates and stagnant American residency positions. (1) Not everyone gets their first choice of specialty during the standard NRMP initial match. Since this time of the year is about to arrive, I thought it was essential to give you some guidelines/tips on approaching the issue if you are one of these residents.

Wash That Fit of Depression Away

It is crucial to get into game mode. The SOAP process can be time-consuming and exhaustive from both an applicant’s and a program director’s perspective. But, to be a viable applicant, you need to move on. As an associate radiology residency director, one of my biggest turnoffs in the SOAP process is interviewing miserable residents that do not show a bit of enthusiasm for their new specialty choice. It is not the end of the world, and it is a sign of mental toughness and grit if you can adapt to the unique circumstances. Things don’t always go our way!!!

If you are in this situation, it is also important to remember that you are not alone. Numerous qualified medical students don’t match. Often the overall quality of the applicants is better than the initial match. So, don’t take this as a sign that you are going to make a horrible resident. It’s just not true.

Think About Your Options

Residency is a long, arduous process. So, this decision should be well thought out, and all applicants need to step back. Don’t rush into applying to a specialty if you are not convinced that you have an interest. If you are not sure, there are other options, such as applying for a transitional or prelim year and then reassessing the application during the year of residency. Only apply for the specialty of radiology if you are genuinely interested!

Most Applications In The SOAP Are From Different Specialties

We often get former applicants from matches of the most competitive specialties. Presently, these would be radiation oncology, dermatology, and some of the surgical subspecialties. For many years these specialties are entirely matched with no slack. So, your two choices are to reapply another year after completing a year of preliminary medicine or surgical internship. Or, you can change specialties entirely. You take a risk either way. If you reapply, you may not match the following year unless there is a significant change in your credentials. On the other hand, if you decide to match in the SOAP for another specialty such as radiology, you may be matching in an area that you may or may not genuinely interest you. You will need to make that hard choice in a very brief amount of time.

Significant self-reflection and analysis are critical at this juncture. Sometimes, the right choice is to apply to another specialty. I believe that medical schools underexpose students to many different subspecialties. Frequently, the best fit for a prospective resident is different from the specialty he/she initially applies. So, think about the possibility of applying to another specialty than you initially chose.

Don’t Fret About Application Items Not Geared To Radiology

Don’t worry if some of your recommendations, personal statements, and application are not entirely “radiology-centric.” The program directors usually understand the predicaments of the applying residents at this point. However, the applicant should develop reasons for his/her newfound interest in radiology during the interview since enthusiasm for the specialty is critical. Make sure you have a logical argument prepared for the phone or “in-person” interview for why you would be interested in radiology. It will go a long way toward securing a spot in a radiology program.

The Early Bird Gets The Worm

Joining the SOAP right away is probably one of the most critical factors in the residency SOAP match process. If you are not early in the draw, you are going to miss out on the spot. Make sure your application is submitted to your SOAP specialty of interest as early as possible. Often, we find out about outstanding candidates only out after the SOAP match ends. Don’t let that be you!!!

Try To Schedule Onsite Interviews If Possible

In the SOAP process, it is a significant advantage to match the face to the application. Although it is not always possible due to distance or other circumstances, if you are interested in a position and want to maximize your chances of acceptance during the SOAP process, an onsite interview shows your interest and ups your chances of obtaining a spot. (although not as critical in the times of Covid!) I always would rather deal with the known vs. the unknown entity. You get a better feel for the applicant, usually when he/she is sitting in front of you (or on Zoom!) rather than in a phone interview conversation. We have accepted applicants over the phone, but your chance of acceptance “in person” is higher. Try to get to the interview if possible physically.

Use Your Connections

Any connection to the SOAP match program of interest is of significant help. We value the known vs. the unknown quantity when we are looking at SOAP applicants. So, if you have any connection to the program of interest, it will give you a leg up in the process. It could be a resident you met at some point earlier in your medical school training, a former mentor, or a friend of a relative. It doesn’t matter. Any connection is often better than no relationship. Use it!!!!

This Too Shall Pass

The SOAP process is short-lived but very stressful for all parties. Applicants and programs that did not match the first try will often find a happy end to this story. Be enthusiastic, get past your depression, put time and effort into the SOAP process, and, often, the SOAP process will handsomely reward you. Don’t take it seriously, be depressed about not matching into your initial specialty, or take a lazy approach and you won’t. Good luck with the match!!!

(1) http://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/2013/07/11/aspiring-med-students-face-growing-residency-competition

 

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The New Core Exam- An Associate Program Director’s Lament

What are the essential ingredients of a successful radiologist? – the art of oral and written communication,  being able to distinguish one study from another, the ability to successfully analyze the findings, the masterful arrival at a reasonable differential diagnosis, and the creation of insightful management recommendations.

The oral boards enabled residents for years to learn these essential skills of a good radiologist. As much as we had heard horror stories of the trials and tribulations of the test takers in Louisville, Kentucky, it lit a fire under all of us. By the end of our fourth year and completion of our oral board at the last month of residency, all of us were artful in the realm of oral and written communications and powerhouses of essential radiological knowledge. We were immediately able to practice competently as radiologists on day one after completing our radiology residencies. This bygone era is no more…

Instead, what does the new core examination teach radiology residents? It forces residents to learn some radiological knowledge. But, more importantly it reinforces the strategies of multiple choice and matching format questions. As a radiologist, I never have options a,b,c,d, or e on a piece of paper or a computer screen. I need to have a baseline sum of knowledge to make my own assessments. On occasion, I will google a question. But, the only reason I know what question to ask is: I know the fundamentals of radiology. The fundamentals are no longer emphasized.

The style of a test can be just as important as the content because it reinforces the process of learning and communication. Now, instead of concentrating on practicing the most common methods of disseminating information to others, radiology residents are now concentrating on methods that are never used by radiologists in practice. Think about it…  A good oral test that actually forced residents to study the essence of radiology has been converted to an examination that reinforces the learning of the art of testing taking. Is that what we really want to be teaching residents?

In the latter half of every academic year, we encounter nervous third year residents fretting about the mechanics of a test that are not even utilized in daily practice at the expense of learning the fundamentals of radiology. I can understand their stresses because their role as studying residents is split twofold: to study for a test that does not directly correlate with what we do on a daily basis as well as study the fundamentals of becoming a good radiologist. There is conflict between the two. Residents waste time and energy devoting themselves to two divergent causes. It shouldn’t be like this.

So why has the ABR decided to resort to computerized multiple choice testing and changing the timing of the examinations?  I have a couple of theories.

Cost Cutting/Increased ABR Income

What are some of the biggest advantages of converting an oral examination to a written test? No longer do you have supply the manpower to meet the demand on the days of the boards. It can be extremely expensive and time consuming to host tens of seasoned radiologists at a hotel anywhere to provide the services needed for creating an oral board exam. The costs saved in the short term are enormous. In addition, you don’t need to rent out a space to accommodate these radiologists for many days. Instead, the ABR can create fixed computers in a fixed site that can be used year after year in a few sites with less manpower to run the annual examinations. The cost savings can be significant.

Annual income from the dues can still be increased without a concomitant increase in annual expenses, significantly increasing the income of the “nonprofit” organization of the ABR. Salaries within the organization can be buttressed and maintained, a possible incentive for changing the examination.

Creating More Subspecialized Radiologists Working in Academic Radiology

Notice the change in timing of the general examination from the end of fourth year to the end of third year of residency. Why would an organization want to do this? If you think about it, radiology residents study most intensely prior to taking an examination, oral or computerized/written. Before, residents would go out to their first job with a significant body of knowledge fresh in mind on day one. Now residents have a full year to forget about the information that they learned for the core examination. Sure, they take a specialty certification examination after they finish fellowship. But, the studying and content is not the same. It is instead mostly dedicated toward the individual specialty What does that mean for the first year employee? These new radiologists are less capable to practice general radiology because their general radiology knowledge is more remote and they are less comfortable with “bread and butter” radiology imaging studies. This idea matches in practice what we are experiencing with new hires. They are more likely to stick to subspecialty work and less likely to want to practice general radiology.

This outcome is even more harmful for private practices throughout the United States. According to the AUR meetings and multiple papers on the subject (1,2,3), most practices need new radiologists that are sub specialized but can also cover generalize radiology work. Because  of the new core examination timing and the content of the core exam, the needs of private practices continue to be unmet and do not match with the newly minted workforce.

So, where are more new radiologists, less competent in general radiology, forced to work? These new residents either need to work at academic facilities that can afford to harbor a highly subspecialized workforce or very large private practices and teleradiology companies that can divide the subspecialty work among its employees, providing benefits mostly to the chairmen of academic departments and the heads of very large private practices.

Who was most responsible for the decision of creating the test? It is the same representative body- chairmen of large academic departments and the largest of the private radiology practices that most likely will benefit from these changes. This represents a conflict of interest between the creators of the examination and the needs of radiology practices throughout the entire spectrum of radiology.

Final Thoughts

Examinations are important not just because it should establish a baseline of competency in a particular subject matter, but also just as importantly because it guides how the student learns. This process can change the landscape of a profession for years to come.   In addition, prior to the creation of any examination, the foreseen outcomes should be match the needs of the specialty. In my opinion, the core examination has failed on all of these accounts. It deemphasizes the fundamentals of radiology, guides the radiology resident to learn information in ways that are not relevant, and leads to the outcome of weakening private practices by causing a mismatch between the needs of radiology practices and the differing abilities of the newly minted radiologist.

Unfortunately, the core examination has already become embedded in the radiology residency process and culture. Since so much time, effort, and expense has been dedicated to changing the examination and timing, it is very difficult to navigate back to a different format that will better match the needs of the radiology specialty. But, it is something that we should consider to make a better prepared radiology resident for the job market and to sustain our specialty for years to come. We are better than that.

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The Uncooperative Patient- The Radiology Resident’s View

uncooperative

As a radiology resident, the patient experience differs significantly from other specialty services. Typically, they see a patient for a single encounter or, even less commonly, a second or third chance episode. Rarely the radiology resident encounters the same patient more than that. Additionally, they have limited time to interact with the patients, even more so than other clinicians. Therefore, the trainee may not establish deep connections with patients like in other specialties. So, we have to view their experience through a very different lens.

In our “radiology world,” all of us will experience one of these dilemmas: The patient may refuse to drink barium, deny the imaging department the significant second portion of a test, physically combat the staff, refuse procedure consent, move during a study, or be noncompliant with our instructions. We often do not understand why the patient may not cooperate in these situations. So in this discussion, I will go through how you, as radiology residents, establish a rapport with these patients to motivate the patient to complete a test. Also, I will discuss some typical situations with “uncooperative” patients that you may encounter and how you can prevent them from escalating from bad to worse.

Patient Rapport and Motivation

As a human being, I can think of nothing less motivating than doing something for someone that I don’t know and for a reason that I don’t understand. Many times, this is precisely the situation that the patient experiences. Often, the floor will send a patient to our department without knowing what test they are having with people they don’t know. The staff may place the patient in confined quarters with minimal human interaction.

Think about it in your terms. Imagine coming down from one of the floors to have a procedure such as a barium enema. And, you see someone without any identification whatsoever. As a patient, I can picture the thoughts going through her head. Is this person qualified to do the procedure? Is someone going to butcher me that I don’t even know? Patients in this situation can often feel dehumanized and vulnerable. How can we minimize this poor patient experience? The first step is straightforward: introduce ourselves. Who are we, and why are we there? Making an introduction alone can motivate a patient to complete a study.

Second, explain the procedure. I have found that taking time to describe it will often go a long way to diffusing a potentially intense situation. Not only does explaining the procedure make the patient more comfortable and knowledgeable about their care, but it also establishes that you are a competent professional to perform a procedure.

And finally, let the patient know if you will perform the procedure. And, if not, at least you will be around to monitor them when it occurs. What a relief to know that someone in the department has your back!

A Couple of Special Situations

The Combative Uncooperative Patient/Family

The Situation

So, you are working in interventional radiology for the month. You are on your fourth consent for the evening before finishing your work. In the back of your mind, you think you are soon finally going home. You enter the room and introduce yourself to the patient and daughter. Subsequently, you start to discuss a PICC line consent that you have planned for tomorrow’s morning procedures, and you begin to rattle off the risks, alternatives, and benefits. As the discussion ensues, you notice on the room door a sign saying feeding precautions: Severe Risk of Aspiration- Do Not Feed the Patient!

You then look back to the patient/daughter and notice that the daughter is rapidly shoveling food from home into the patient’s mouth. You halt the discussion and tell the daughter, “You shouldn’t be feeding your Mom. She has aspiration precautions and can choke on the food you give her…” The daughter yells back, “How Dare You Tell Me How to Treat My Mom? She Has Not Eaten For Days, And I Will Give Her What She Wants!!!!” The patient then begins to cry, and the daughter gets right up into your face threateningly as if she will punch you.

What To Do

How would you deal with a possible real-world situation such as this? There are several options. But, as a radiology resident with limited knowledge of the uncooperative patient’s case, you need to treat it differently than a primary care doctor or specialist who sees the patient daily.

As a radiology resident, you first need to de-escalate the situation. You do not continue to argue with the patient’s daughter, as it could lead to physical confrontation or worse. Besides, there may be more to this situation than meets the eye. Perhaps, the daughter is responsible for the patient’s care and has an advance directive to feed the patient that the sign does not specify in the front of the room. You merely don’t know.

Second, you may want to reflect and say, “Sorry… I see you are upset. Why don’t I leave the room and get you someone who may know more about the situation and can help you.” You can then temporarily step out of the room and recruit the help of the caring physician or the nurse around the corner.

Your role as a radiology resident is not the patient’s total care. Instead, you become the physician ensuring the patient can undergo a procedure the following day. Therefore, letting the caring physicians and nurses know what is happening is appropriate. In this situation, if there is a potentially life-threatening emergency for the patient, it can be taken care of expeditiously. Do not argue with the uncooperative patient, as it can lead to a more active confrontation!

The Obtunded Uncooperative Patient

On interventional radiology rotations, this is a frequently encountered dilemma. You go upstairs to the floors and begin to consent a patient. And, As you are going through the motions, you realize that the patient doesn’t understand a word you are saying. What do you do???

First thing, check the charts. See if anything confirms that the patient is incompetent to make a decision. If not, what do you do? Make sure to think about whether the patient needs the procedure emergently. The consent can undoubtedly wait if it is not emergent.

On the other hand, if the procedure is essential, step out and ask the primary covering physician- what is the patient’s situation? Has the mental status changed? Is the patient on medications preventing them from understanding/responding to the consent? If you see a temporary change in mental status, you may reconsider consenting at a better time/place.

What is the next step if the procedure is emergent and you must complete it first thing in the morning? It is your responsibility to find the person responsible for the patient’s care when they are obtunded so that you can obtain patient consent. You may see an advanced directive in the chart explaining who is responsible for this patient’s care. Or perhaps, the nurse or physician may know who to contact in this event. In either case, contact the patient’s responsible decision-makers before getting consent. The consequences can be dire if you do a procedure and have “consented” a patient without the mental faculties. Legal action is a possibility! Never allow an obtunded patient to sign off on a procedure!!!

Lessons We Need To Learn About The Uncooperative Patient

The uncooperative patient is usually “uncooperative” for a good reason. As radiology residents, we are often not privy to all the information that may lead to the patient’s attitude or actions before or during a diagnostic or therapeutic radiology procedure. Also, remember that you are not alone in making decisions for the patient. Always get help from other clinicians when needed. And never make assumptions about the patient without getting the facts straight. Not following these guidelines can lead to patient care disasters!!!