Tag: advice

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Reasons To Check In With Faculty Early In The Morning!

check in

Radiology residency programs differ widely in the independence that they allow their residents. Some let their residents do most procedures almost entirely by themselves. And others are more stingy with giving permission. Regardless of your situation, however, it is critical to check in with your scheduled cases before the day begins with your attending as a young learning physician. These include rotations, especially fluoroscopy and interventional radiology. And it’s not just to say hi! It is excellent for education and patient care. Let me give you multiple reasons why.

Getting A Good History- Filling In The Gaps

Sometimes residents either do not know the right questions to ask. Or other times, radiologists may have discussed the case with the ordering physician already. Each of these different circumstances provides information that the resident does not already have. These critical facts can change the direction of the case. For instance, if you already know that a patient is here for dysphagia, you would perform an esophagram that would critically analyze the upper esophagus instead of mainly the stomach or duodenum. Why not check in with your attending to confirm what is going on?

Increase Learning

By going over the schedule with your faculty in the morning, attendings will most likely discuss the disease entity that you will need to know. All this discussion is the best way to reinforce what you have already learned. Even better, it is a great way to introduce you to new topics and issues you may face when performing the case. And, it’s an easier way to learn what you may need to know for the boards.

Check-In For The Collaboration

Working with your attendings allows you to get to know them better. A team-based approach is usually better than going at it alone. Teamwork usually leads to a better relationship over the year. Who knows? Maybe, you will eventually ask this faculty member for a recommendation!

Attending May Not Realize Case Is On The Worklist

Sometimes cases can get lost, even on PACS systems nowadays. Accession numbers and MRI numbers can be incorrect. Or, the tech can batch a case on the wrong worklist accidentally. By going over the morning case, your attending now knows what she can expect on the wordlist during the day. And, if it is not there (for whatever reason), either you or your faculty can look into it. It is one surefire way to make sure that the case does not slip through the cracks!

Performing Studies The Way The Faculty Likes It

Every faculty member likes cases done in different ways. Some may want a few extra views of the stomach on an upper GI series. Others expect a thorough workup of the esophagus. Regardless, you will now precisely know precisely what you should do before even starting the case. All this diligence prevents the attending from bringing the case back and ensuring that you perform it appropriately. In the end, it is your attending’s name on the report and takes full responsibility for everything you do!

Check-In With Your Faculty First Thing In The Morning

It is more than just lip service to check in with your attending in the morning. Checking in serves many practical purposes, including getting better and more valid information, learning about diseases, preventing cases from falling through the cracks, and ensuring you complete the procedure correctly. So, pick up the phone or stop by your attending’s office. And let your faculty know what is on the schedule before starting. It is an excellent way to augment learning and improve patient care!

 

 

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Benefits Of A Career At Your Home Residency Institution

home residency

If there were not enough reasons to take your home residency seriously, here is another big one: faculty members running residency programs usually look for great candidates to fill their practices. And that person that they are looking for might be you!

But why would programs want their residents to stick around? Doesn’t that decrease the diversity of experience of the faculty training? Well, yes and no. First, not everyone you recruit will be from the residency program. Newly hired residents mostly go to fellowship programs outside of the residency institution.

Yes, the resident does miss out on the nuances of working at different sites when you never leave your home residency program. However, let’s be honest. There are numerous benefits to holding on to your residents and not just recruiting outside the institution. Let’s go through the distinct advantages of the residency program and the residents becoming faculty at the same site as their residency.

The Resident’s Perspective

You Know What You Are Getting Into

Familiarity is the number one reason to stick around at your home base. You are much less likely to be surprised by the business if you know them beforehand. I can’t tell you how often I have heard of practices withdrawing partnership positions at the last second, a month or two before the scheduled start time. Or, some imaging businesses may be less savory than you think. These disasters are much less likely to occur when you learn about your future job as you train during residency.

It Feels Like Home

It is comforting to work for a practice you know. You wake up and go to work with colleagues that you already respect. And, by now, you probably have many connections and friends in the same place you went to your residency program. You can’t find that as quickly if you move to a new radiology practice in a new locale!

You Know Your Location Beforehand

Sometimes, folks move to a new job to find out they want to live in a different environment. Perhaps you thought you might like to live in a rural community and then discovered that you enjoyed the suburbs better. Or, you decide to live farther away from your family, only to realize that you should have been living closer. You answered all these questions while living near your home residency program beforehand. Your surroundings are already familiar.

The Program’s Perspective

You Know What You Are Getting Into

Just like for the resident, I believe this one is the biggie. One of my favorite phrases is, “Better off with the devil you do know than the devil you don’t!” And that phrase doubly applies when recruiting from inside the system. If you are hiring from within, you already know all the quirks of the applying candidates. On the other hand, an unknown outside entity can throw your practice into disarray if you find out that the person you are hiring is not as it seems. I can’t tell you how many radiology businesses hire an “unknown” candidate only to find out once they start that they do not do mammography after saying that it might interest them during an interview. And other new candidates are not as good as they seem. These sorts of issues occur much less often when you recruit your own!

You Can Recruit For The Specialty You Need

Say that your practice is short of MSK radiologists. If you run a residency program and you like a candidate, you can tell them you will have a job if you complete an MSK fellowship. By targeting great candidates for your practice, you can also guide these individuals into areas your business may need. Of course, residents may not want to do what your imaging practice requires. But, if you choose between several fellowships that you might like the same, it would not hurt to complete the one that helps your future practice.

You Can Choose Those Resident Features That Will Grow Your Practice

If you are looking to hire, your practice probably needs certain types of faculty. Perhaps, many of the faculty members in your hospital are introverted, and you need a future extroverted leader to run the business. Or, your desired resident is a techie, and you require someone who knows their way around a RIS system and PACS. Recruiting residents who will help build the practice in these respects can fulfill all the niches you might need in the future.

Working At Your Home Residency Base

Don’t dismiss the possibility of working for the institution where you have trained. Even though the grass may seem greener on the other side, staying put has distinct advantages. Take into account all the opportunities that arise as you make your choices for your career. But your original experiences working at the same site as where you trained may be the best!

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How Can I Prevent Low Imaging Volumes From Causing Me To Lose My First Job?

low imaging volumes

Question About Low Imaging Volumes:

Hi. I am an R2. I’ll most likely do a fellowship in body imaging (mostly because I haven’t felt a click with any particular specialty). I keep reading about practices firing radiologists because of low imaging volumes due to COVID. I’m concerned that this will affect me when I apply for jobs because I am only interested in private practice. I want to position myself with some advantages, and I need your advice on how to do this. I particularly enjoy the IT aspects of radiology (troubleshooting PACS, EMR, making software more efficient, automation, computer hardware). In my residency, there is a faculty member who is the “Director of IT.” And, I might be interested in a role like this.

My question is, do you think this is something that is even an advantage if you are seeking private practice? If so, how can I enter this space? Is there a course? Do I do research? If this is a bad idea, are there other things I can do during residency to give myself an advantage when it comes time to apply for a job in private practice? 

What should I do?

 

Answer:

Armaments To Prevent Job Loss

These are excellent questions, and I have a few answers! Let’s start with the first one about practices firing employees because of low imaging volumes. First of all, this Covid situation will most likely all but disappear by the time you graduate residency. Nevertheless, one of the best protection against getting canned is to become invaluable in whatever area that you practice. That niche can be informatics/IT. However, it all depends on the type of practice where you work.

If you aim to work at a small private practice somewhere, it will probably not help all that much. If you work for a larger institution or an academic center, it can help a lot, depending on what you do. In an educational sort of setting, if you are pumping out tons of papers and creating lots of programs/IT solutions for your colleagues, no one will want to let you go. Alternatively, if you are in charge of a massive corporate IT program, and the business cannot function well without your knowledge, they will not fire you. On the other hand, if the IT services you provide are just a little help, and the clinical work that you provide to the practice is not so much. Well, then you will not have the same job security.

At this stage of your career, work hard, and perform well in residency regardless of your fellowship. Learn about all aspects of radiology as much as you can so that you can establish a niche for yourself when you leave your residency. To repeat, most folks that are good at what they do will be the last to be fired.

How To Get Into Information Technology

Next, how can you enter this IT space? Well, some of it depends on how much experience you have in IT already. If you don’t have the knowledge that you would need to take over the IT at a practice, you would probably want to look into the Informatics fellowship. This fellowship will give you the basics of what you will need to know about IT for radiology practices. There, you can establish connections that you would need to find a career. Additionally, research in your area of specialty is never a bad idea during residency or fellowship, especially if you want to follow the more academic path.

Final Advice

So, there you have it. Work hard, learn as much as you can about radiology, consider an informatics fellowship (if that is what you want), and perform a niche in a practice that others have a hard time filling. These are the ingredients that will keep you in practice regardless of the Covid or any other unfortunate situation that may arise to lower imaging volumes for radiologists.

Good luck,

Barry Julius, MD

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Forgot To Look At The Priors? Disasters Can Happen!

priors

There are a few tenets in radiology that are unbreakable. One of these doctrines is to always look for priors. So, what are some real stories about what can happen to you if you forget them? To bring home this point, I will give you four examples of what can happen if you leave out the prior exam. The results speak for themselves. And these are just the tip of the iceberg!

The Phlebolith That Just Gets In The Way

New radiologists, especially, will often have a disease called happy eye syndrome. They make a diagnosis and forget about everything else. One of these critical steps they forget is remembering to look at priors. And, one such resident happened to do just that. One night, a resident saw a calcification probably in line with the ureter. And the urinary tract collecting system was slightly prominent. And, she called it an obstructing 6 mm stone.

The next day, the overnight attending looked at the case and saw the same calcification at the same location four years ago on a previous with and without contrast CT scan. And, it was not even associated with the ureter!

So, what happened to the patient? The surgeon sent the patient for surgery. But fortunately for the patient, they never got to operating suite. A well-placed phone call from the morning attending prevented an unnecessary operation. But, that was surely a close one!

The Overnight V/Q Scan- Not Just A Harmless Test!

Very commonly, the resident at nighttime use the V/Q scan as a means to sharpen their skills. But, it is not necessarily a safe test if not used the right way. One night, a resident called multiple mismatches at both lungs with a negative chest x-ray as a study highly suspicious for pulmonary embolus. And, correctly so, of course, if they didn’t have the priors!

So, the overnight physician started the patient on a course of coumadin. Guess what? The next day before the attending came into the hospital; this patient developed a change in mental status. And, the CT scan showed a focal hemorrhage. Now, whether the cause of the bleed was this coumadin dosage is debatable. But, once again, it demonstrates the power of the prior!

The Angry Oncologist (And Patient)

Typically, oncologists order studies to decide whether or not their patients should get a change in chemotherapy. In one such case, one attending read a lung cancer oncology chest, abdomen, and pelvis. There were lesions in the bone, liver, and lung. He reported the results, never bothering to check the script and the request for comparison to priors.

It turns out this patient was on an experimental protocol that demanded precise timepoint interpretations compared to the previous study. Due to the lack of description of change on the CT scan compared to the priors, the oncologist could not determine what to do next. Since the new results did not come back until after the deadlines, the study removed the patient from the treatment protocol! Bye-bye successful therapy!

The Thyroid Nodule From Hell

Thyroid nodules seem to be a common indication for a thyroid ultrasound. And, many of us consider ultrasound to be a relatively benign informative examination. But, so not so much for this next unfortunate bloke.

One radiologist interpreted an ultrasound thyroid examination as a suspicious 1.5 cm nodule at the right lower pole of the thyroid. And, he decided to recommend a biopsy. Of course, in small letters at the bottom of the technologist’s report, the technologist said the patient has two different MR numbers, and please compare these to the priors. Unfortunately, the radiologist missed this statement.

So, the endocrinologist sent the patient for a biopsy. Also, unbeknownst to the interventional radiologist, the patient never knew that the patient had priors. Well, what happened? Of course, the radiologist completed the biopsy, and the patient developed a large hematoma in the neck with associated complications. And, only afterward, the referring physician realized that the patient did have another study. Guess what, the nodule was stable all along and didn’t need a biopsy. The patient was stuck with a needless nasty hematoma!

Priors: Don’t Forget Them!

I think you get the point. But as painful as it may be to hear the same recommendation again, it is worth repeating over and over, don’t forget the priors. These are just a few of the potential disasters that lie in wait for you if you break this tenet of radiology. And, it’s a great way to disrupt the chain of excellent patient care!

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Are Two Fellowships Too Many? Probably Most Of The Time!

two fellowships

Since most job seekers look for new jobs for only a few years and the majority of those job seekers are fellows, the collective consciousness of the radiology job market at any given time rapidly fades away. And, when the job market changes, we often forget about what new radiology residents had to deal with only a few years ago. But, talk to radiologists that graduated around 5 or 6 years ago. You will find that many of these folks had experienced a 180 degree opposite job market of today’s when they started to look. Moreover, if you ask them which fellowships they have completed, you shouldn’t be shocked to hear that they finished two of them. In all likelihood, that may have been the norm!

So, the question I pose for today, is there still a role for completing two fellowships? Are there any economic advantages to finishing two advanced subspecialty programs? And, what circumstances should lead a new resident to achieve more than one? You should find this discussion enlightening!

Why Should Anyone Complete Two Fellowships?

OK. From a monetary standpoint, it no longer makes much sense. Most folks can receive the same pay regardless of whether they have completed one or two, let alone none! And, indeed, the job prospects don’t change all that much nowadays if you have finished one or two. So, let’s scratch that reason off the list.

What about future job security? Well, again, I believe that folks that fellows that have completed two fellowships are just as likely to get canned as those have finished one. If you are an excellent radiologist, it should not matter much. And, you can be a lousy radiologist regardless of if you have one or two fellowships. Additionally, I can make the argument that some less competent radiologists have completed two advanced programs because they did not feel comfortable initially starting in the job market with just one. So. let’s nix that reason as well.

How about allowing you to do what you want in practice? No, most jobs have a niche that they need to fill. And, they will meet the demand regardless of the number of fellowships you complete. Sure, you may find a job that advertises for someone that could perform two specialties competently. But, by no means in most cases, do you need to complete two fellowships to fill the position. Those positions tend to be more general. And, it probably does not matter if you have graduated from two subspecialty programs.

So, When May Two Fellowships Come In Handy?

Honestly, I could come up with three main reasons for completing two different fellowships in the market in general. And, one reason specifically for economic reasons.

So, let’s start with the economic reason. (Does not apply for the current market!) When the job market is terrible, you may need two fellowships to stand out from the crowd. And, precisely, that situation happened five or six years ago. It was not uncommon to find these applicants at that time.

Next, some folks choose the wrong fellowship from the get-go. I know of one interventionalist that never really liked it much. And, this person practiced for years and years with the hope that one day she would grow into it. It never happened. So, she chose to start from scratch at a different fellowship. That could make some sense in certain situations.

What else? Say you want to bolster your academic credentials. Well, in the game of academics, numbers of papers, lectures, abstracts, and even degrees matter. And, yes, having an additional fellowship is like having an extra degree. It has the potential to boost your academic prospects in that sort of venue. (A bit different from my world!)

Is More Than One Fellowship Too Many?

Based on our short discussion, the answer is sometimes. And, for most people today, that want to set out into the world of radiology, two fellowships is most likely overkill. But, there is a time and a place for the second fellowship. The question is: is it yours?

 

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Why Breast Ultrasound Should Only Be Performed In The Breast Imaging Department!

breast ultrasound

How often have you heard the following from an outside clinician, “My patient has a breast lump? Maybe, while they are in the emergency department for abdominal pain, she can go ahead and get a breast ultrasound to take a look.” And, as a new radiologist yourself, you may wonder why, out of convenience, you should not say yes. I mean, what’s the big deal, right? How hard can it be to do an ultrasound of the breast while the ED docs are taking care of the patient for something else? It’s a two-minute procedure!

Well, there is a lot more to that simple breast ultrasound than you might think at first glance. And, believe it or not, you may be doing a lot more patient harm than you think if you are using an ultrasound machine in the emergency department.  So, let’s talk about some of the factors, more specifically, that you should consider before making that decision to allow breast imaging outside of the breast department!

Wasted Health Care Dollars

If you scan a patient for a lump in the emergency department, what are the chances you are going to need to do it again? Close to 100%! Why? Breast ultrasound techs have a particular skill set that is unique to their specialty. Plus, the Sonosite is not the same as the hardcore breast ultrasounds used for breast imaging. Who wants to pay for both a wholly inadequate test and an additional appropriate exam in the breast department the following day?

Inferior Equipment

Now, for the next point. Most Emergency Departments don’t stock themselves with the latest and greatest equipment for imaging of the breast. How many times do inferior machines create masses when there are none? A lot! And how many lesions are missed due to poor penetration of the tissue or lower resolution? A ton! It pays to wait.

Technologist Performing Cases Without Experience

Most technologists in the breast department have been performing breast ultrasound for years. It’s not quite the same when you ask a technologist without this experience (which you might have at nighttime!) to complete the case. It is very easy to under call  and overcall a breast ultrasound without the appropriate qualifications.

Radiologists Interpreting Cases Without Breast Experience

What are the chances that you will get a radiologist with a ton of breast experience on call? Maybe 50-50 at best? In truth, most of the die-hard mammographers don’t even take emergency calls. And, now you are asking a second rate breast radiologist to do your exam. It makes no sense!

Additional Procedures With Untoward Harm

Inferior equipment and inexperienced ultrasound users lead to further tests that the radiologist or imager will recommend. More importantly, however, inferior exams are not harmless. Quickly, an inadequate breast ultrasound can lead to an unnecessary biopsy or aspiration with potential complications such as bleeding and infection. Or even worse, a pneumothorax (I’ve seen it before!)

No Knowledge of BI-RADS/Patient Letters

Nowadays, the government heavily legislates breast imaging, and they regulate the process down to the result letters that you send. What are the chances that the radiologist uses the appropriate lexicon for the exam? And, is the ED radiologist prepared to create the proper letter to the patient when he completes the test? Probably not! You may not be following the letter of the law!

Are There Any Exceptions?

OK. For every rule, there is an exception. And, I can think of one condition off-hand that may “qualify” as a “breast emergency.” That diagnosis would be a breast abscess. But, even this exception is debatable. Some radiologists would say you can sometimes drain it the next day in the breast imaging center as an outpatient.

Breast Ultrasound Is Generally Not An Emergency Procedure- Don’t Perform It Outside The Breast Department!

For the most part, however, there are many ramifications to performing breast ultrasound outside the breast center. And, you don’t want to contribute to poor patient care. So, please, I implore you. If you are ever pushed to complete a breast ultrasound outside the breast imaging department for a lump, tell your colleagues why it doesn’t make sense!

 

 

 

 

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Have A Professionalism Violation: Can I Still Get Into Radiology?

professionalism violation

 

Professionalism Violation Question:

Hi, I don’t want to give too many details, but I’m finishing up my last year at a top 25 med school w/ step 1>240, multiple pubs, and a mix of honors and high passes except family medicine which is a pass. I have a professionalism violation by my school that will appear on my MSPE – how do I deal with this and move forward in the best way? The breach was for missing out on several clinic days without approval from my dean. What are my realistic chances for matching DR?

I’m pretty crushed because it seems like my goals are no longer within reach, so I need some honest advice on how to proceed

Thank you in advance,

Crushed Radiology Dreams

 

Answer:

A professionalism violation can be more difficult to remedy than a lousy grade or mistake that you made with a patient. The only way to increase your chances of acceptance into radiology residency would be to own it. What do I mean by that? The professionalism violation will show up on your application. And, that is the first item that most residency directors look for on the ERAS forms. So, you need to be ready to explain the offense, whether in person or the personal statement.
Additionally, you should be able to show deep-seated remorse. But, most importantly, you need to be able to say why this was a “one-off” event. And, you must convince the faculty why it will not happen again.

Biggest Concerns For The Program Director:

What would be the most significant concerns for most residency directors (from my end)? First, this person will not show up for rotations. Or second, this resident will try to weasel out of his obligations because he doesn’t like them. Most residency directors have had residents like this, and that is the last type of resident that they would want to take. In truth, many residency directors would rather have a resident with some academic deficiencies than a resident with recurrent professionalism violations.

Potential Solutions:

Therefore, you need to reassure your interviewers that you follow through with all the activities that you accomplish. How can you do so? Well, some places in the application that may help would be: comments on your Dean’s letter from your rotations, or other letters of recommendation testifying that the event was atypical for your personality. Regardless, you need to make sure not to cast any further doubts on your application and your character. If the readers of your application sense that you have a recurrent pattern of professionalism violations, you will not receive any interviews or rankings.
Bottom line: you are not going to be able to make the issue magically go away. But, you can mitigate some of the damages. All is not necessarily lost.
Hope that gives you some insight,
Barry Julius, MD
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Should Radiology Residents Be Chronic Overcallers?

overcallers

In an ideal world, radiologists, in particular, would like to get all the cases right all the time. But, in reality, we know that can never happen since radiologists are people. And, we deal with imperfect technologies. Some findings will go undetected, and others misinterpreted. But that is the way of the world.

So what can we control? Well, we can adjust our sensitivities. Increasing our sensitivity allows us to make more findings at the expense of causing all our patients to receive too many additional tests. Subsequently, they would receive elevated doses of radiation and too many biopsies.

Decreasing our sensitivity sets us up for missing findings. These same misses can lead radiologists down the path of patient care issues and lawsuits. So, we continually set our internal thermometers to call cases toward either overcalling or under calling to get to that perfect mean. And, radiology residents must learn to do the same.

How Do We Adjust Our Internal Thresholds?

So, what causes us to change our sensitivities and become overcallers? Well, have you had a recent lawsuit or a bad mistake? You probably will overcall a bit for fear of missing findings. Do you have a large population with healthy hearts and read cardiac nucs. You probably are under calling a patient’s cardiac disease, knowing that most patients have none.

Additionally, we are continually tweaking our internal standards all the time. Should we call that skin fold over the chest as a pneumothorax? Or, is there a trace subarachnoid hemorrhage near the calvarial fracture site? These are the questions that we face daily. And how we choose to answer them affects the patient care we deliver.

What About Radiology Residents Versus Attendings?

Moreover, radiologists and radiology residents practice in two alternative universes. And, their pitfalls differ substantially. To that point, what can dramatically affect an attending’s care can barely impact a resident and vice versa. For instance, chronically overcalling lung nodules on chest films as an attending can anger your referrers. In a worst-case scenario, a practice may even decide to fire overcallers over the issue.

On the other hand, it may be desirable to overcall those same nodules as a resident. Your attending may want you to call the finding to alert them to whether it should make a clinical difference. She can always discard it in the final report if it does not change management.

So, Where Should Residents Lie Within The Spectrum During Residency?

In general, under calling as a resident, can be particularly dangerous for many reasons. First and foremost, residents have a lack of experience upon which to rely. After your 10,000th case of pneumonia, you will have probably have seen enough to almost instinctually know what most types of pneumonia look like on a chest film. Residents don’t have that background on which to make a judgment. So, when you don’t call pneumonia, you are more likely going to miss the signs of one.

Second, the hazards of under calling far outweigh the benefits of overcalling. If you are on an overnight shift and you are not sure whether your patient has a bleed, you can cause much more damage by sending the patient home with a bleed. The consequences of keeping the patient in the hospital with that more sensitive call are much less devastating. This philosophy goes for most serious disease entities.

And then finally, you make your attendings happier when you overcall rather than under call. I would much rather see a resident make all the findings of equivocal tiny nodules and questionable hepatic cysts. Although part of the spectrum as overcallers, these residents make findings that can help me to pick up lesions I may miss as a radiology attending. A pair of second overly sensitive eyes can be an excellent accessory screening tool to ensure that the radiologist does not miss the findings as well.

Chronic Overcalling Can Lead To A Difficult Attending Transition

But, this chronic overcalling can lead to a problem at your first attending gig. You have accustomed yourself to overcalling findings as a resident. Now, as radiology faculty, that same sensitivity point may not work well to allow you to flourish in your career. But, you have worked at this threshold level for a while. Not so easy. Habits die hard. We see this issue all the time with new radiologists.

What’s The Point Of This Conversation About Overcallers?

Well, residents need to be aware of their thresholds for making findings. Yes, it is worth it to start as overcallers based on less experience and the consequences of missing critical diagnoses. But, be wary about maintaining the same thresholds as you move along in your career. Be mindful of slowly trying to increase your limits for detection over time using your increasing experience and knowledge. The goal is to get you closer to the perfect sensitivity in an endless asymptotic curve. So, be ready to adjust your approach as an attending. It may save your career!

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DR Versus DR-IR Application Questions

DR-IR application

Question About A DR Versus DR-IR Application Dilemma

Hi! Love reading your blog, you’ve been a great source of information,

I’m a current M3 interested in both DR and IR. I genuinely like both fields, but it seems like there is a growing sentiment in both areas to define themselves as separate. I’m currently working on research in IR with my IR faculty, but I don’t want to lock myself out of DR programs, which is what I’m noticing has happened this cycle for some of my M4 colleagues. Applications IR weighted are not receiving much love from DR programs even if they do quite well for IR programs.

What thoughts do you have about the growing divide between fields, and what advice can you give for a medical student interested in both? Should I also do some DR research? I like the way IR is currently practiced, where IR folks will do a mix of IR and DR, but it seems like most IR leadership and PDs are interested in furthering the distinction.

Thank you!

DR And DR-IR Application Weary

 

DR Versus DR-IR Answers:

How To Apply

Having gone to the recent APDR/AUR meeting, I can tell you that you are right about some of your reported sentiments in some programs. Some programs/program directors take it in stride that many folks will be applying to both IR/DR and DR programs. But, other DR program directors did not have such favorable opinions about those applicants that are applying to both. I believe that if you are not sure about which program to choose at this point (as is normal!), the best bet would be to apply to a DR program that has IR/DR and ESIR slots. Applying to DR programs that also have both will allow you to hedge your bets a bit and give you the most flexibility. In these programs, they can usually flip a DR spot to DR/IR or ESIR or vice versa. Also, it doesn’t lock you into the IR pathway if you are not sure you want it. DR/IR is a big commitment and works if you are sure about it. If not, you can regret your decision because you will have less diagnostic radiology, and it will be a tough slog.
Also, DR research can never hurt an application and can only serve to enhance your chances of getting into a program. It demonstrates an interest in the field. And, it gives you a bit of radiology research experience. Who doesn’t want that?

The Growing Divide Between DR and IR

More and more practices are indeed allowing or requiring the interventionalists to do only interventional. However, some imaging companies still have the model of doing DR and IR work (that’s the way our practice works). It is hard to tell how difficult it will be to find a job in a practice with DR and IR in the future. But, I would imagine there should still be a role for these folks in more rural and smaller less subspecialized practices. But if corporatization of radiology takes root everywhere, that model could become rare. It remains to be seen.
My 2 cents,
Barry Julius, MD
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Techniques To Mitigate The Effects Of Sleep Deprivation

As physicians, and more specifically as radiologists, we all face the issue of sleep deprivation at one time or another. And, lack of sleep is unavoidable. Between late shifts, family issues, studying, and a late-night out with friends during the week, how does any of us get enough of it?

Moreover, we know that sleep has some potent effects on cognition and judgment. Just take a look at this link to an AJR article from 2008 about the liability of sleep deprivation. So, since we know lack of sleep is unavoidable and has potent effects, what techniques can you use to decrease its influence on you at nighttime? Let’s delve into some techniques I have used when I have been exhausted at work.

Know Your Stuff Cold

The more that you know search patterns reflexively, the more likely that you will not skip the findings, even when you are the most exhausted. Think of it as an insurance policy. When the eyes start to droop, the skills that you lose are those that are not second nature. So, take the time to learn radiology as you would understand the multiplication tables in elementary school. You should be able to spit out your search pattern as you look at the anatomy ad nauseum.

Also, make sure that you know all the most critical and common diseases that affect the population that your imaging cold. You are not going to have the wherewithal to look up everything when you are so tired that you barely keep your eyes open.

Concentrate Harder On The Key Elements

Pneumothorax, pneumothorax, pneumothorax. These words should be part of a mantra when you look at a chest film. And, that’s just one example. When you are sleepy, you want to concentrate very carefully on those entities that will make the most clinical difference for patient care. And, pneumothorax is one. But keep other critical diagnoses in mind when you are searching for findings on any new sort of study that you are reading.

Bounce Ideas Off Your Clinical Colleagues

If your mind is in a foggy rut from lack of sleep, sometimes it is helpful to talk to your clinical colleagues. That goes for both radiologists and non-radiologists alike to make sure you are keeping on the right track. Let me give you an example. Say you are staring at one site on a femur x-ray. And, you are not sure it might be either a fracture or a hallucinatory sleep-induced line. Well, give your ED doctors a call to find out if what you are looking at is even relevant to the case. Occasionally, another opinion can make the difference between a good and a bad call.

Take A Brisk Walk For A Few Minutes

When you are already sleepy, sometimes stagnation in a chair can lead to even more exhaustion. If so, think about getting up out of your seat and taking a brief walk for a few minutes. Sometimes, a brief interlude is all you need to rejuvenate your mind once again and get the adrenaline going.

Coffee (For Those That Can Handle It)

I am not saying that you should become a coffee fiend, relying on it until you get the jitters. Or, if you tend to go into cardiac arrhythmias, you should stay away. But, a dose or two at your most fatigued point, can help you to stay awake when you can’t seem to read the films. Plus, research has shown that coffee gives you some health benefits. Just take a gander at this article in Inc.!

Take A Five Minute Nap

Now, I am not suggesting that you should shirk your duties. That would be a disaster. Instead, if you get a moment, sometimes a five-minute nap can rejuvenate your mind to get back to a place where you can concentrate again on the work. Hell, it may save you time during the remainder of the night if it helps you to stay awake.

Sleep Deprivation Is Not Optimal, But We Need To Get Through It!

We live in an imperfect world. And, we participate in an error-prone specialty. Adding to the issues, we are forced to work when we are most exhausted. So, just don’t let the sleepiness take over. Fight back. Try some of these techniques to get you through the night. It may make the difference between a decent and hellish night!