Tag: ACGME

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Am I Efficient Enough?

efficient

The ACGME requires all radiology residents to fill out a log of studies that they have reviewed in all radiology residencies throughout the country. Unfortunately, though, the onus is on the resident to assess for themselves if the numbers mean that they have learned enough to build their skills to the appropriate level. And, as most residency directors are aware, that number can significantly deviate among residents. Some residents fill out numbers that may reflect a glance at a study. Others give in the number of studies that they have dictated. These numbers can be high or low. Regardless, the gross number maybe not be so critical if you still cannot get through as many cases when you start in practice. In that case, how can you tell how efficient you are right now? And, where should you be at any stage of your training? Let me start by talking about rotation goals and objectives (because you might think that would help), and then I will give you a few guideposts that you may be able to use.

Can Goals And Objectives Tell You Where You Are?

Every program has written goals and objectives for each rotation that you should aim to complete before you finish it. As you scan through this list, you will probably notice a list of bullet points that you are supposed to do and know during any year. You can use it to figure out what information you have learned and where you need to focus. Nevertheless, I am the first to admit that it may not be all that helpful to determine efficiency. Additionally, the goals and objectives are often outdated. Or even worse, the residency program has copied it from other residency programs! So, the utility is equivocal for determining your efficiency.

Fundamental Ways To Tell You How Efficient You Are At Any Level During Residency

Clocking Speed To Become More Efficient

Clocking your reading speed can be an effective tool to determine how fast you are. But I bet many of you have never tried it. Take ten cases in any modality and read them like you usually would. And measure how fast you read them all. Then, compare with your peers. This technique can be a starting point to determine your actual speed. You may be surprised to learn that you are faster or slower than you initially thought!

Do You Have A Search Pattern That Is Second Nature?

If you are a long-time reader of my blogs, you have probably seen a pattern where I mention search patterns a lot. But, there is a reason for it. A search pattern is a primary tool that radiologists do to make the findings. So, think about your search patterns. Do you know them cold? Or, are always forgetting one or two parts of a film or CT scan each time you read. By the second year of your residency, the search pattern should become ingrained in your psyche. If not, think about reviewing them repeatedly until they become second nature.

Comfort Level Is Critical

If you dread reading certain studies or doing particular procedures, there is probably a good reason. Either you haven’t done the background reading for them. Or you have not participated in reading or doing them. So, assessing your comfort level in any rotation is an excellent way to determine if you are efficient at this point.

Can You Dictate Rapidly?

At this point in my career, when I have a dictaphone in hand, I will often go into a “holy chant.” It is a snappy banter that gets my point across in a relatively short amount of time. Most of you are probably not at this level because you have not read as many images. But, if you struggle to dictate a case at the end of your second year, there is a pretty good chance you are not all that efficient yet!

Am I Efficient Enough?

Anyone who poo-poos or ignores efficiency will have a problem when they get into practice. You will not be able to meet the hospital or imaging centers benchmarks. So, there is no better time than the present to measure how efficient you are.

Remember, you typically will want to avoid using goals and objectives as a primary resource. On the other hand, consider clocking speed, determining if your search patterns are second nature, and assessing your comfort levels and dictation speeds. Think about using these recommendations because efficiency is essential. Efficiency becomes more and more critical as you continue through residency and eventually on to your first job!

 

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Service Exceeding Education At Your Program? Do Something About It!

service exceeding education

All radiology residencies have an Achilles heel. In the pursuit of creating an excellent education for all radiology residents, programs need to balance the “service obligations” with the “educational” environment. Now, there is a lot of debate about service exceeding education. But, we all know of rotations where the service obligations seem to outweigh what you may learn on rotation. You may have a mammography rotation where your attendings need you to complete all the needle localizations at the expense of learning diagnostic and screening mammograms. Or, perhaps, you have an interventional rotation where you can’t get into cases because the technologists need the residents to consent all the patients. Regardless, what do you do when you find yourself not receiving the education you think you should receive?

How To Improve A Rotation With Service Exceeding Education? A Playbook!

Step 1- Be Specific About The Problem Of Service Exceeding Education

The first thing you need to do is to be specific and write down the particular problems in the rotation. In other words, what are the educational circumstances that your program is not meeting? If you believe that the residents don’t have enough paracenteses, write that down. If you find that the nuclear medicine attending is never in the reading in the room or is not giving enough lectures, make sure to add that onto the list. Make sure you enumerate each of those problems. Eventually, you will want to address the issues with the educational committee.

Step 2- Cross-Reference with The ACGME Program Requirements

Next, check the ACGME program requirements. See if the problem is one that directly contradicts the philosophy and regulations of the program requirements. If so, write down how the issue interferes with the program’s goals. This step is critical because programs must fulfill their educational objectives to their residents. If they do not, programs can meet repercussions from the ACGME. At worst, the ACGME may not reaccredit your program until they comply. Some corrections can be costly. You can expedite change if you document how the issues may prevent the program from meeting the ACGME bylaws.

Step 3- Document The Issues And Provide Data

Now that you have the specific issues and why they may interfere with the program’s goals, create a data trail. For example, if you are not receiving the right number of conferences every week, document all the faculty’s conferences. Or, figure out what number per week you have been receiving or the rate of cancellation of lectures every week. You will need to have some hard data when the time comes to present the issues. Objective data helps because you can eventually factually show that the fix can improve the problem.

Step 4 – Create A Plan To Fix The Problem

Come up with a financial or educational plan to solve the problem. Say your program lacks a statistician and you need one to satisfy the research requirement, come up with the potential costs of hiring one for the hospital or the program. Of course, it is a good idea to meet with your faculty to figure out satisfactory solutions. As a resident, you may lack the experience to know some of the costs and problems that the institution may encounter when they attempt to fix the problem. So, gather a team of folks that do know more about the area you wish to improve.

Step 5- Formally Meet With The Program Director, GME Committee, Etc.

Since you have already enumerated the problems, figured out how they interfere with the program education/requirements, provided accurate, objective data, and created a plan to fix the problem, now is the time to meet with the appropriate committee. You should submit the initial run through to the education committee or the program directors at the program level. Here the committee can discuss the issues and enact a plan. If the solution is not amenable to being fixed at this level, the education committee can submit the plan to the GME level, hospital level, etc. Nevertheless, you need to formally present a plan so that the program or hospital can make a solution.

Step 6- Implement The Plan

Now that the institution or residency is backing the solution, you should be part of the team that seeks to implement the solution. Make sure that the plan is working as stated and followup to check for a positive outcome. Most of the time, you will find a reasonable solution for the previous issues. (But not always!)

Step 7- Document Outcomes

Now that your institution has “repaired” the problem, you still have more work to do. Make sure that the fix is not worse than the problem itself. It is therefore vital to objectively document how the changes to the program have affected the outcomes. If the hospital institutes a policy that faculty members that miss lectures will receive a pay cut and the lecturers continue to miss giving noon conferences, the fix was not an adequate solution. So, this step is crucial to show that you have a viable solution to your original problems.

Why Bother With All This Extra Work To Remedy Service Exceeding Education?

Well, the answer to this question relatively simple. Your radiology residency program is the foundation for your future career. And, if your education is not adequate, it will reflect in your future employment.

Furthermore, this learning experience is not only good for learning how to fix your residency. It is also a great way to learn the principles to enact change in any career stage. You can adapt the same steps to almost any situation where you want to enact helpful change. So, figure out those areas in your program where service requirements overburden learning and think about ways to enhance your residency rotations using this seven-step guide. It is an exercise worth the effort!

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Radiology Residency Chain of Command

radiology residency

No, we are not the military, but there is a radiology residency chain of command! Lots of different entities in radiology residency are responsible for your day-to-day activities and training. It is more than your faculty and program directors. It is a whole hierarchy. And, it is was not until later on in my career that I understood the roles that each of these entities played in managing a residency program. But, it would have been nice to understand it all from the very beginning and know who to address for each radiology residency issue. To that end, in today’s post, I am going to define each of the different titles and offices in charge of your radiology residency training and describe the parts that they play. For fun, each role I will associate with a military position! Let’s start at the bottom and work our way up.

Radiology Resident (Private)

A radiology resident is the “lowest” but the most integral part of the chain of command. It is his/her responsibility to be trained in the art and science of diagnostic radiology during the four years of residency. To become a member of this club, he/she needs to graduate from medical school and complete one year of clinical training. After that, he/she answers to all the other “higher” positions listed next!

Radiology Chief Resident (Corporal)

Typically selected by the residents and program directors, this person is the first rung in the ladder of the radiology residency command (also previously discussed in a prior post). When there is a fundamental residency level issue or problem, he/she rises to the occasion. The chief resident is often responsible for scheduling, board reviews, interclass conflict, drinks with peers, performance issues, and noon conferences. In addition, any residency program issue that does not need to go to the attending is under the purview of the chief resident. And, the chief resident is also responsible for communicating faculty-related issues to the residents.

Radiology Residency Coordinator (2nd Lieutenant)

He or she is responsible for the day-to-day running of a residency program but is typically an administrator and not a physician. Most residency coordinators make phone calls, transcribe letters of recommendation, report issues to the faculty, send out evaluations, deal with class conflicts, ensure that the learning portfolios are complete, arrange end-of-the-year parties, and more. Some play a significant role in admissions committee screening. And, the coordinator is often the first-line resource for radiology residents when they have issues with colleagues or attendings. The radiology residency coordinator is an integral part of a radiology residency. (I think of this person like the Class Mom/Dad)

Radiology Faculty (Captain)

Full-time faculty members are responsible for the direct and indirect supervision of residents. The ACGME guidelines require all faculty members to teach. In addition, there are specific minimum numbers of faculty members that are necessary to run a residency program. Teaching involvement, however, varies widely by each faculty member. Residency programs expect all residents to follow the faculty lead when it comes to reading, procedures, and training in any of its forms.

Radiology Section Chiefs (Major)

This designation can be a bit technical. Theoretically, the radiology section chief for a radiology residency program can be different from the head of the section in a department. However, these individuals run the individual subspecialty rotations for a radiology residency. Individual faculty members answer to their respective section chiefs in one of many academic areas. The section chief may also perform many other duties such as setting up protocols for technologists, introducing new procedures, signing off on resident competencies and curriculums, ensuring that the subspecialty curriculum is appropriate, and more.

Associate Program Director (Colonel)

Although not an official designation by the ACGME, the Associate Program Director is the second in command for running the residency program. Suppose there are issues that the radiology chief resident, faculty, coordinator, or section chief cannot take care of. In that case, these problems fall into the lap of the Associate Program Director. He/she is also responsible for curriculum planning, enforcement of residency rules and regulations, maintaining education quality, dealing with residency conflicts, answering both the program director and the residents, and more. The Associate Program Director shares these responsibilities with the Program Director.

Program Director (1 Star General)

The ACGME designates this individual as director in charge of the residency program. He/she is ultimately responsible for most issues that occur during a radiology residency. In addition, the radiology Residency Program Director signs off on each resident that he/she is competent to practice diagnostic radiology after graduation. Clinical activity for this individual varies widely depending upon the program’s size, but most have some clinical duties. However, all Program Directors are responsible for monitoring the clinical teaching in the residency program and administering the radiology residency. So, this person is ultimately accountable for a radiology resident’s training.

Radiology Department Chairman (2 Star General)

The Radiology Department Chairman is the head of the entire radiology department. This person is responsible for dealing with all faculty issues and indirectly will usually help with radiology residency administration issues. When there are complaints about individual faculty members, new radiologists to hire, budgeting, and high-level resident problems, this person steps in to help manage the situation. Frequently, the program directors will consult with the chairman before making important decisions. The chairman sometimes holds the purse strings for some residency programs.

Designated Institutional Official (DIO) And The Graduate Educational Committee (GME) (4 Star General)

The DIO is the head of the hospital GME Committee. The radiology residency program director answers to the DIO for program-level issues and high-level resident issues. The types of problems that a DIO will often work with include accrediting residency programs, monitoring pass rates for programs, dealing with probation and suspension of individual residents, checking residency action plans, adding complements to residency programs, and more. In addition, he/she often gets involved in legal residency issues. And, this is just the tip of the iceberg. Typically, this is a full-time administrative position that is very busy! Individual programs bring many of these issues to the DIO’s attention, and they are subsequently voted upon by the GME Committee for approval.

American Board of Radiology (ABR) (Military Service Chiefs)

The ABR is a private organization in charge of testing for minimum competency for the individual radiology resident. All radiology residents need to pass the boards administered by the ABR to become board-certified radiologists. Although they are not directly in charge of residency issues, they play an essential role in determining the curriculum for the individual radiology residency program since they create the board exams (the core and certifying examinations more specifically).

Accreditation Council For Graduate Medical Education (ACGME) (Chairman of the Joint Chiefs of Staff)

Now we are talking high-level!!! The ACGME is a governmental-run body that is the watchdog of residency programs, a diagnostic radiology residency program. This organization accredits each radiology residency program. They have the power to put a residency on probation or suspension. As part of the ACGME, other committees, such as the Radiology Review Committee (RRC), are responsible for setting up the individual radiology residency guidelines and requirements. They are responsible for making the maximum duty hours, faculty requirements, and more. Overall, most residents do not have direct contact with this organization. However, it is crucial to follow the ACGME rules for the individual radiology resident to graduate from an accredited residency.

Now You Know The Hierarchy

That just about covers the basics of the different levels of responsible parties for a radiology residency program. Even though some institutions have additional positions that also play a role in managing a radiology residency, the ones I described are usually the most important. (Just don’t tell that to the research manager or the radiology liaison!) Of course, additional levels can get quite complicated. But at least you have the basics of who to turn to when you have a specific issue or question. So now you know your ABCs of the chain of the radiology residency command!!!

 

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Is It Still Possible To Become An ABR Certified Radiologist Through The Alternate Pathway?

Dear Barry,

I am also interested as Fiona in the alternate Pathway. My biggest question here would be, if I have any chances after ABR certification in actually pursuing a career as an independent radiologist in the US. As far as I understand, in many if not all states, you are required to complete a minimum time of postgraduate education, within an ACGME accredited program, before being granted the corresponding state license to practice as a physician. Considering the rule that you are allowed to take a fellow position in an ACGME accredited fellowship program ONLY if you graduated from an ACGME accredited residency program (this because of recent changes); how could any radiologist trained abroad be able to fulfill the state licensing requirement after doing the 4 year alternate pathway. (To my disappointment explained here by the SPR – Society for pediatric radiology – ¨ http://www.pedrad.org/Education/Fellowship-Directors/Pediatric-Radiology-Fellowship-Directors-Library ¨ )

The ABR clarifies that the changes introduced by the ACGME are not affecting the alternate pathway, which I understand and see as no impediment for certification, however I still don’t see clearly the possibility of full licensing. Why would a foreign radiologist be interested in ABR certification if the chances of practicing radiology in the US are so scarce or null in the future.

One last question: wouldn’t a fully trained radiologist from abroad be a good candidate to match through the traditional residency system, under your perspective as a program director?.

(Dear Fiona: Maybe we can get in contact and share our views and findings. Please email me if you are interested).

Thank you for reading this, cheers, Esteban.

 

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Here are answers to your two separate questions here. To refer to the other information about the alternate pathway go to the ask the residency director question at the following link: How To Complete The ABR Alternate Pathway As A Foreign Physician

 

Answer to First Question:

In order to be licensed in a state, you do not get your certification from the ACGME. Rather, the ACGME certifies the program that you attend as a resident, fellow, or attending. So, it is still possible to be certified by the ABR and to get a state license via the alternate pathway. However, as you mentioned in the new addendum in 2015 to the alternate pathway, you will have a difficult time getting into an accredited fellowship via the alternate pathway because of the new requirement (having to get an ACGME fellowship only after completing an ACGME accredited residency).

Regardless, it is still possible to use the alternate pathway to become an ABR board certified radiologist. So, how would that happen?

Two Ways To Satisfy The Alternate Pathway Requirements.

1. An ACGME accredited institution would need to sponsor the foreign radiologist for a junior faculty position for four years. In other words, the institution would be responsible for getting the H1B visa for four years so that you could work in the ACGME accredited institution in the United States. The problem with this- the sponsoring institution will incur lots of legal and immigration fees in order for the applicant to get the H1B visa and the junior faculty position. So, it is unlikely that the institution will take a foreign applicant unless he/she offers something special or is trained in a subspecialty area that is useful to the institution and a United States applicant cannot fill that need. Therefore, it is true that the institution is much more likely to take a United States applicant than a foreign applicant for a faculty position.

2. It is possible to get an unaccredited fellowship in an institution that has an ACGME accredited residency program. This year of unaccredited fellowship would be enough to count toward the requirement of having 4 years of training. You would need four such years as this. Through this pathway, you would potentially only have to deal with the issues of getting a J-1 visa, which is a bit easier than an H1b visa.

Issues For The Alternate Pathway Applicant

For both of these alternate pathways, there is a possible complication of some individual states not recognizing the training of foreign residents who do not complete an ACGME accredited residency/fellowship. This means that the alternate pathway training may limit which states he/she chooses to work.

As you can see, it is possible but a bit complicated to go through the alternate pathway via both methods. The ABR alternate pathway has become a rarely trodden method of obtaining a radiologist position in the United States. (It is not impossible, but very difficult and probably involves lots of connections!!!) In addition, there is a risk that your opportunities as an alternate pathway candidate, could be more limited.

Answer To Second Question:

From an associate program director’s perspective, I would love to take a candidate who has been trained as a full-fledged radiologist in another country. Our job becomes a lot easier since these residents are usually very independent. In fact, one our best residents has been a candidate such as that who attended our program four or five years ago. He was absolutely fantastic!

Again, however, there are several impediments for the foreign radiologist who wants to repeat a United States residency. First of all, many programs do not want to have to deal with the stresses of getting a J-1 visa sponsorship for their foreign applicants, even though a J-1 visa is usually not that difficult to obtain. And, second, there is a prestige issue for many programs. Some high-end university programs take pride in the fact they do not take foreign applicants to their program. (Even though they will not say it on their website or brochures)

Bottom line… It is becoming more and more challenging for the foreign applicant to obtain a spot in a United States training position to eventually become a United States ABR trained radiologist. It’s not impossible but it’s very, very difficult. The applicant that is successful is going to have to be at the apex of the foreign applicant pool and is going to have to be on top of the visa situation.

 

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