Tag: advice

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Don’t Skip Around! A Radiologist’s Mantra

skip around

Round, round, get around, don’t skip around. Reminds me a bit of the Beach Boys tune I Get Around. Regardless of the weak attention-grabbing first sentence, I think this advice is vital for the radiologist.  And it applies to us in many ways. First and foremost, it helps to ensure that you are covering all the findings. But, it is far more than this. Keeping reads in order without skipping around also will enable you to triage appropriately, allows you not to piss off your colleagues, and most critically, ensures that you don’t forget the reason for reading a study. So, let’s delve a little bit more behind each of the reasons behind the nitty-gritty of this philosophy.

Covering All The Findings

What is the best way to make your dictations less accurate? Well, have as many interruptions as possible! And what is it about these interruptions that cause missed findings? Typically, most radiologists will forget what they were doing before.

Since it is impossible to prevent all interruptions (although you can mitigate them), you can avoid loss of sensitivity by sticking to a routine without skipping around. So, the next time the surgeon barges into the room with a question while you are dictating, you will know exactly where to return your focus when the interruption ends. If you repeat a similar routine without skipping around, you will rarely lose your place for long!

Triage

What is it about skipping around through a list of patients that can cause triage issues? Well, it’s not fair to read a study first on a patient with similar urgency to others when he was the most recent one completed, right? How would you like it if someone cut in front of you in line at a supermarket? It’s the same philosophy.

But more critically, you should be reading the tech flagged positive findings first, the “STATS” second, the expedites third, and the routines last. Subverting this order can cause clinical disasters, potentially delaying reads on patients with positive results. Why would you want to read a routine oncology workup before a possible intracranial bleed after trauma? Finding a lung nodule is not equivalent to discovering an epidural hemorrhage. Triage in order and don’t skip around!

Order Among The Rank And File

When all members of a practice are working hard, they don’t want to worry about radiologists that are cherry-picking the most straightforward cases to spruce up their RVU numbers. How can a practice avoid such an issue? Well, have the readers read studies in order of when they were performed. Practices often perceive those members that skip around to be skirting the rules.  So, sticking to the list order can help morale!

Circling Back To The Impression

And then finally, to come up with an appropriate impression in any case you read, you should never jump to it without analyzing all the findings first. Skipping around and getting to the conclusion right away is a formula for disaster. Think of it like watching the end of a movie or novel without watching the beginning. How can you figure out the real answers to the clinician questions without going through an entire case? I know that just the mere description of the findings helps me to come up with an appropriate conclusion. Without that process, my impressions are more likely to be off-the-mark. Don’t’ skip this routine!

Following A Radiologist’s Mantra: Don’t Skip Around!

Order matters. Whether you are skipping around instead of using routine search patterns, reading cases in an illogical order, or creating an impression before looking at and analyzing all the findings, you can negatively affect both your partners and patients. We want to do the best for our patients and work partners. So, the next time you decide to accomplish a professional task out of order, think twice. It may not be the best for patient care!

 

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Should I Waste Time Looking For Tiny Lung Nodules At Nighttime?

lung nodules

One of my former residency mentors said the following as he proudly scrolled through the electric film panel reader without stopping as he dictated, “You can miss em’ fast, or you can miss em’ slow!”

And, the life of a resident works non-stop, just like this former radiologist, especially on a busy night of call during residency. At least at our institution, we can easily have a night of 40-50 CT scans, 10 MRIs, 20 ultrasounds, multiple plain films, and fluoroscopy consults. Even though it’s tough, we expect our residents to churn through all these images and more! Then finally, in addition to all of this, we require them to dictate the cases that they’ve previewed.

So, with all this work that the typical resident needs to complete on an average night, does it make sense to worry about every little detail? I mean, how bad can it be to miss a 2 mm lung nodule or a 3 mm hepatic cyst or hemangioma? Well, I don’t like to be dogmatic about what’s right before I review the evidence. So, let’s consider the pros and cons of what it means to skip the imaging details.

Pros Of Missing The Tiny Lung Nodules

So, let’s start with talking about why we can forgive our residents for missing a few lung nodules here and there. Well, who cares if the resident flies past a few nodules at nighttime, as long as she has picked up the big stuff, yes? If you pick up a pseudoaneurysm of the common femoral artery and you miss a renal cyst, you’ve done your job. You’ve prevented severe harm and injury to the patient. What more could a residency director ask?

Moreover, the attending usually picks up the other findings in the morning that the resident misses. Regardless of whatever the covering radiologist does, she can always count on the backup of another set of eyes.

Also, if you are so busy at nighttime searching for nodules and cysts, how will you have time to look through all the other cases as well. Indeed, it is not critical to find that next nodule, when you need to get to that next case that can potentially have free air and pneumatosis.

And lastly, what is the harm to the patient of missing the incidental small lung nodule? Well, that is also close to zero, right?

Cons About Skipping The Small Stuff

But wait, is that all? Can we miss these nodules with impunity? Stop there.

Do you want to become a fully-trained radiologist? A well-heeled radiologist will never skip looking for any of the potentially relevant findings. They will always look for all the nodules and cysts on a CT scan. By practicing forgetting to search for these nodules, you are encouraging yourself to miss the same findings when you complete your residency. If you want to become a great radiologist, you need to act one early on.

Additionally, not all small stuff is harmless. Occasionally, those 3 mm nodules turn into that 4 cm mass which happens to be lung cancer. I’ve seen that happen with my own two eyes frequently, having interpreted multiple rare cases for a contract research organization that had us read cases for numerous drug trials. The risks are real, albeit small.

And, finally, not all the nodules and cysts are picked up by the morning radiologist. Just like anyone else in any profession, we cannot be perfect. If you did not make these findings at nighttime, how do you know that the morning radiologist has also picked it up as well?

For And Against- Where Should You Lie?

Both camps have some excellent points to make. And, stepping back from the fray, they can both make some sense. However, I would argue that you need to make your judgments about what to do.

Of course, if you are having an insane night with busloads of patients getting scanned, you need to triage your reads. Getting through all the cases trumps the potential for missing a lung nodule.

On the other hand, on a reasonable night, why not look for all the findings? You are doing an extra service to the patient and the morning’s radiologist. And, just as critically, you are augmenting your radiological skills.

Nodules or no nodules, one of the essential skills a resident should pick up from their residency is learning the art of sound judgment. We should leave this task to you to help you grow as a radiologist. Every time we allow, you, the resident, to make up your mind, and see the consequences, you learn a bit more. And, that’s the point of nighttime call for a radiology resident, to decide to look for tiny nodules or not.  Let’s not forget that!

 

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New Radiologist Wanting Locum Work? Think Twice!

locum

Have you ever thought about living in different places for a little a bit at a time? Maybe you have always wanted to do some traveling before starting to work? Of course, it sounds exciting to go from Honolulu for six months and then onto Dayton for the next six. Indeed, I thought about the locum lifestyle when I first started.

But, are you missing out on by taking this route instead of the established full-time job career path? Potentially. As much as the ability to travel for your job may entice you, think twice before embarking down this infrequently traveled road as a new radiologist. Let me give you some good reasons for turning this opportunity down.

Pigeon Holed/Loss of Skills

Do you want your new practice to call you that temporary plain film reader gal? Unfortunately, this sort of attitude prevails among many groups. And, imaging groups tend to place you in a particular role based on the desperate needs of the practice. So, if you sign up for XYZ, the group may utilize you in Y capacity. Over the years, this is a surefire way to lose your skills in other areas that you trained for in residency.

Will The Good Times Last?

What do you think happens when the bottom drops out of the radiology job market? Perhaps, imaging reimbursements drop precipitously. Or, suddenly, the stock market crashes and older radiologists stay in the field. And, yes, unfavorable radiology job markets like this have happened in two separate cycles since I started medical school.

In these situations, what happens first? Well, the excess fat gets cut. And, what exactly is the excess fat? It tends to be the locums’ jobs! When you start, you certainly don’t want to be in that first wave of job cuts. It becomes challenging to recover.

Locums Looked Upon Unfavorably

At many practices, the question that arises when they consider a new locum radiologist is: WHY ARE YOU A LOCUM RADIOLOGIST? From my experience, many radiologists believe (rightfully or wrongfully so) that locums radiologists have a defect. Perhaps, they read to slow and cannot hold a job. Or, maybe, the individual cannot get along with others and drifts from job to job. So, if you have a track record of only holding locum work, you have painted a particular picture of yourself that may not be attractive if you ever want to find a longer-term career!

Never Quite Maximize Efficiency

When you drift from place to place, you never get to learn all the systems in place to maximize your output. PACs machines, paperwork, clinician demands, and technology continually change. And, they differ from one practice to another. By definition, you remain less efficient and slower just because you do not have the long-term knowledge you need to keep up with your colleagues at a job using the same technology for the past ten odd years!

Difficult To Establish Long Term Relationships

What do I value most from my current job? I treasure the relationships that I have made with my colleagues, residents, and fellow clinicians. How do you create and maintain these relationships as a locum? Well, it can become very challenging at the very least. You are new the kid on the block and will remain that way until your short term tenure as a locum radiologist ends.

Locum Work: A Dangerous Road To Travel

Now, locums can be an excellent opportunity for specific individuals. If you have a family and want to fill in some time with some extra hours, it can make some sense. Or, maybe you want to retire soon and desire some additional inconsistent or occasional work. Finally, perhaps, you are independently wealthy, and a full-time career does not matter for you. But, for the typical fresh graduate with a lot of debt and wanting to begin a new locum path, you will encounter many obstacles that can affect your future career and growth. So, think twice if you choose to become a locum radiologist when you start. It may become one of your biggest regrets!

 

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Why Residents Should Take Charge Of The Worklist

worklist

By the time you start your first radiology attending job, you should feel comfortable getting through a typical day’s work. So, how do you arrive at this point of comfort? Well, it is not via magic. Most successful starting radiologists will have adopted a formula for getting through a day’s trials and tribulations. Moreover, they know how to manage the worklist. And, the easy way to do so? You should have that experience during your radiology residency.

Now, not all residency programs work the same. Some residents plow through whatever cases the attending tell them to go through. In these sorts of residencies, the attending maintains the responsibility for the worklist. They make sure that either the resident or the attending read through the cases that they need to complete.

And at others, the resident starts the day by gathering the necessary cases together and dictating. Attendings will intermittently arrive at the department to read out the studies with the resident. However, the attending charges the resident with the responsibility of getting through the worklist for the day.

I would argue that the latter programs tend to be more helpful for starting in practice. Let me tell you why.

Most Practices Are Run By Radiologists

First of all, in most practices, who is in charge of the worklist? No, it is not the nurse, the technologist, or the radiology assistant. Instead, usually, the radiologist manages the worklist to determine who he should read first, second, and third. Even though artificial intelligence may one day take over some of this process, radiologists should have the background to feel comfortable owning a worklist.

Teaches You How To Get Help From Others

Let’s say that you start on your worklist and you find a case where you are not sure of the diagnosis. Who do you approach? And, how do you contact that person? Do you call or walk over to the other room? Do you interrupt their train of thought or do you wait until they finish up? Or, do you find a clinician in another specialty? These skills only come when you have to manage cases outside of your purview. And, these cases are much more likely to arrive when you control your worklist.

Learning How To Triage Work

In the same vein, when you have an unsorted worklist, how do you know what needs to be read first, second, and third? Sometimes, you arrive at a decision best when you have had the experience to make that conclusion. It takes time to figure out that you should read certain physician’s cases first or a specific type of STAT indication sooner. What better way than to manage a worklist as a resident?

Time Management Skills

Of course, when you learn to control your worklist, in the beginning, you may not realize how much time you have to complete all the work for the day. Unfortunately, you may find that you had less time than you initially thought. So what is the best way to hone your time management skills? Manage the worklist! You’ll eventually learn the ropes.

Patient And Physician Phone Calls

During the day, you are bound to receive multiple phone calls from both referring physicians and patients alike. How do you deal with them in the confines of a busy day when you have a whole bunch of studies to read? Well, when you manage your worklist, you get to figure that out. Do you spend an inordinate amount of time on the phone or do you hurriedly give them an answer? To determine how you should proceed, take charge of the work for the day!

Taking Charge Of The Worklist

It’s more than just lip service. Owning the worklist allows budding radiologists to hone their skills. Whether it teaches you to work with others, time management, the art of triage, or more, it will enable you to get through the day in a timely fashion. More importantly, when you learn all the skills of managing a worklist, you can hit the ground running at your first job. That’s where you want to be!

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A Rarely Utilized But Effective Tool To Make Sure A Residency Program Is Reputable

residency program

Recommendations for “good” residency programs about where to apply are a “dime a dozen.” Residents and attendings often give you their opinions about programs based on previous reputations. Or, perhaps, they attended or have friends within the residency. Rarely a faculty member knows the current residency program well enough to tell you if the perceived residency quality matches its current status.

Additionally, any program’s directors, chairpersons, faculty, and residents continuously change. So, these folks may know much about the residency from many years ago but not much about the current status.

So, how do you confirm whether a radiology residency program is reputable once you arrive on the interview day? To do just that, it takes one straightforward but rarely performed step: Ask residents and attendings from other departments within the same hospital about the residency program at the interview site.

Why Does The Opinion Of Other Department Physicians About The Residency Program Matter So Much?

Remember. When you apply for a residency, the residency has a vested interest in selling you a spot. The residency director, residents, and faculty want all applicants, regardless of rank, to select their program to get “the best residents.” So, asking a radiology resident or residency director whether she likes his residency is like asking a car salesperson if he loves the car he is selling.

On the other hand, other department members may work directly with the radiology residency. However, they do not have the same filter. They can say whatever they want about the program without being directly affected by the repercussions. Therefore, asking these fellow physicians can give you a more truthful answer.

Moreover, physicians within most other departments often work directly with radiology residents and attendings. So, they have great insight into the quality of the radiology department as a whole.

Why Do Applicants Rarely Perform This Step?

First and foremost, most residents never consider the option. Interview days are so chock full of activities that asking other departments would never cross your consciousness. You may also think you do not have the time to bother.

For others, however, it may involve stepping outside your comfort zone. It would help if you asked other physicians you don’t know about another residency. You may worry if they will even respond. But, you will likely find that most physicians will be happy to talk.

What Kind Of Information Can You Find?

Well, the information you may discover can be invaluable. What about a question to an emergency department physician like: Do you trust the reads of the residents in this program? This question can give you a lot of information about the quality of a training program. You will get a much more truthful answer than asking the program director about the program’s quality.

Or, how about asking the oncologists, do you get along well with your radiology colleagues? This question can tell you more about a radiology program’s culture than any pointed question you may ask the radiology residents or faculty.

My advice is to consider some pointed questions to ask after the interviews. And, then, try to find a few residents and attendings in another department to ask about these questions.

Making Sure A Residency Program Is Reputable

If a particular residency seriously interests you and you want to confirm its reputation, then you want to consider taking the extra time to step out of your comfort zone. Ask a few random attendings from different departments about the program. It’s a great way to ensure that the residency matches your expectations. You may find that all is not as it seems!

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How I Made My Decision To Go Into Radiology

decision

This post is different from most. I am going to discuss my start in this field. By writing about my beginnings, I hope to either help you with your specialty decision or keep you going in your residency if you are still unsure once you have started.

Unlike what you might have thought by reading my blogs, I was not initially gung-ho about radiology from day one. In fact, like many medical students, when I first began, I had no clue. As a student, I planned on going into internal medicine after a stimulating rotation in medical school during my third year. I loved my instructors, the academic discussions, the grand rounds, and the camaraderie of it all. I like to say that if you associate with the right people, any task or job could be fun. And that was what happened during that third-year rotation. The stars aligned. Perhaps, I would complete a residency in internal medicine and become a cardiologist.

My Subinternship

And then, wham! I started my subinternship in medicine, a fourth-year rotation at my medical school. On day one, my resident micromanaged everything. And, attendings loved her because her notes were over three pages long. On the other hand, if you worked under her as an intern or fourth-year medical student, you entered an alternate reality. She could not decide what to do next on the simplest of matters. It could be the difference between Tylenol or generic acetaminophen in a healthy patient. No matter. She could not handle the small decisions. We left unnecessarily late every single day.

Moreover, if you did something on your own, exhibited any independence in a decision, she would stare at you with a frown on her face. And, later that same day, she would go to her attendings complaining about her underlings. So, you would hear about what you did wrong. Ahh, the pain.

But, if that was all, I noticed that I spent more time spending hours on the phone with insurance companies and burnt out attendings than any patient-related matters. Additionally, the patient matters that I did take care of were not intellectually challenging. Instead, I worked with the mundane issues of uncompliant patients or patients complaining about the same problems over and over again (obesity, diabetes) but not doing anything to improve their status. Between my team and the actual work, I realized I could not do this for the rest of my life.

Enter The Radiology Rotation

So, I completed my subinternship depressed that my initial career choice did not fit my requirements for what I wanted to do for the rest of my life. Luckily, I had the opportunity to begin my radiology rotation next early in my fourth year. No, there were no epiphanies/signs from above to let me know that radiology was right for me. (although you would never know that from my personal statement!) Instead, I mildly enjoyed my rotation. Looking at images and making interpretations seemed to be the better option than a life of hell in internal medicine. And, what else was there that I wanted to do at the time? So, I started with the ERAS process to create an application for a residency in radiology. A few months later, I matched at Beth Israel Medicine for preliminary medicine and Brown University for radiology. I was mildly enthusiastic.

Prelim Medicine Year- Second Thoughts

Like many of you out there, as I started my internship year in preliminary medicine, I began to question my original decision to go into the field of medicine in general. As the year progressed, I became even more disenchanted with medicine. My disenchantment eventually bled over to my initial thoughts about becoming a radiologist. Was I making the right decision?

Once again, in the dead of winter, I can remember being in a rotation in infectious disease with another crazed medical resident as my supervisor. This time, he was exceptionally aggressive and irritating. He had reported me to the program director for insubordination. Fortunately, that complaint did not go anywhere. But, it left a bad taste in my mouth. After that situation, I thought about interviewing for financial jobs and even completed one. However, I realized that with the excessive debt that I had from medical school, it would probably not end well. So, I stuck it out and made it through to my first year of radiology residency.

Radiology Residency- A Hellish First Year

Again, you would think that I started radiology, and everything became as smooth as a diamond. But, you would be entirely wrong. I began my residency reading a lot. But, it did not show during noon conferences. Nor did it manifest itself on rotation. As I like to say in some of my other posts, I committed the cardinal sin of reading as a first-year in radiology. I did not emphasize the pictures but instead read through mostly text without the images. So, when it came time to interpret pictures, I was somewhat clueless.

Also, I was not so “procedurally inclined.” One of my instructors (who shall remain nameless!) made sure to make that well-known. He would talk about me behind my back. Instead of helping me to become better, for the first time, I found out about this on an evaluation six months later. To this day, it left a bad taste in my mouth.

As the year progressed, I can remember the faculty’s pressures, not believing that I would be able to perform well on call. Should they even let me? Fortunately, I barely passed the precall quiz. And, my adventures in the second year would subsequently begin.

The Rest Of Radiology Residency- I Could Do This As A Career!

So, when did my outlook on radiology change? My new world order started once I began taking calls at the start of my second year. For the first time, I had some control over the environment. I could make my own decision, and it mattered. Every night, I found that I became more intellectually challenged. With each call, I discovered difficult cases. Even the attendings were unsure about them. And I would enjoy looking at the images and arriving at appropriate differential diagnoses. Finally, I gained the respect of my faculty as a decision-maker and a colleague. I felt part of the team. The rest was history.

So, What Was The Point Of Telling You How I Made My Decision?

Well, I think it is critical that every one of you, whether in medical school, internship, or the start of residency, should realize that you will find a light at the end of the dark tunnel of medical training. Don’t expect that the long road will match your expectations along the way. Having doubts during the process of residency is OK. Nevertheless, try to give radiology a chance and stick it out for the long run. I think that most of you have probably made the right decision for your career. It was an excellent fit for me. And, I believe that if you can persevere, you will find that radiology as a career will reward you as well! Until next time…

 

 

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Eight Ways To Find Inspiration During Residency

inspiration

You wake up to go to work. Maybe, you grind through what seems like a hundred films with your attending. And then, you arrive home exhausted, only to start reading books and case reviews. The work of a radiology resident never ends. So, how do residents find the inspiration to get through the day, study for the core exam, and get through the entire residency? And, what can residents do to have a fulfilling four years? Unfortunately, very few radiologists have the time to consider the resident’s plight. But I plan to tackle these issues today. Think of this post as chicken soup for the radiology resident, concepts one needs to tough things out for four brutal years.

 

Yes, You Will Save Some Lives

Never forget this fact. Imaging saves lives. And who interprets the images? You! So, get yourself right out of that funk. And, remember, we are not financiers, accountants, or lawyers. We directly prevent significant injuries and death!

Have A Hobby/Life Outside Of Residency

As much as you may love radiology, actively seeking other interests is just as important. I don’t care if it is swimming, stamps, reading, or traveling. Having a hobby enables you to return to work fresh and ready for the next day. Sometimes, studying and working improve when you have an unencumbered mind with the same old studying routine. Studies have shown that creativity and productivity also improve when you pursue activities outside your main interests. Why not let that be you? (1)

Sometimes It’s Not Just About The Work; It’s About You!

Inspiration does not only come from your patients and your films. Instead, feeling inspired stems from your moods and wants. To take care of others, you must also take care of yourself. So, remember… You have a responsibility to yourself to cater to yourself at times. Take a little time to yourself when things become tough studying. Or, if you lose focus during the day, sometimes you need to step away for a few moments. To regain your concentration, you need to refresh yourself!

Maintaining Health

It sounds strange that maintaining health can inspire you to become a great radiologist, right? Well, if you do not eat well, exercise, and sleep, it becomes much more likely for a resident to burn out before finishing residency! So, make sure to treat your body right!

Learning From Mistakes Can Be Inspiring

Mistakes are depressing and ugly, correct? If you continue to think that way, you should not become a radiologist. Expect mistakes. It’s part of the risk profile of our job (Although attorneys would think otherwise!). One study reported a significant error rate that ranges between 2 and 20% of all radiologist reports. (Br J Radiol. 2001 Oct;74(886):949-51.)

So, we need to become inspired to do better. How do we do that? Well, think of each mistake you or others make as an opportunity to prevent significant errors from happening again. If we want to get closer to perfection, we must inspire ourselves to learn from these mistakes, knowing we will not miss that finding or commit that knowledge error again!

Appreciate What You Have Accomplished

Think about the goals you have met to become a radiologist. You have completed college, medical school, and an internship. And remember all those tests that you have aced and passed to get to this point. This successful journey is a real accomplishment! Be proud of what you have achieved. You are not an average Joe. Instead, you have done what many folks can only dream about. And, if you have already gotten this far, imagine how far you can go… If that doesn’t inspire you, I don’t know what will!

Think About The End Goal

Inspiration often does not come from what you are doing right now. Many times, it comes from dreaming about what will be. So, it’s not about repeatedly reading that same paragraph to remember or understand a single concept. Instead, it is about how this pertains to the final goal of becoming a great radiologist. Therefore, don’t get stuck in the minutia. It’s about the big picture!

Education As Fun

Education is about the journey, not the destination. That is because we never really arrive. There is always more to learn and see. And what can be more exciting than discovering new ideas and concepts and applying them to the practical world? As radiologists, that is what we do! So, take each pillar and block of knowledge to form new and exciting structures. This process involves taking new ideas to create research projects or looking at studies in a different way that no one has thought about before. You are only limited by your imagination!

Final Thoughts About Finding Inspiration

Inspiration is what makes us tick. It gives us the passion for completing our dreams and going one step further. However, it does not come from the daily grind. Instead, it comes from our beliefs, hopes, dreams, and goals. So, appreciate what you have accomplished, think about what you do daily (and yes, that includes saving lives!), and remember your goals for the future. It’s all pretty amazing. That should be inspiration enough!

 

(1) http://www.cofcogroup.com/want-more-productivity-get-a-hobby/

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Should I Join A Practice With A High Buy-in?

buy-in

As of the end of 2020, the job market is beginning to improve post-covid. And, for those of you considering your first job nowadays, you may receive offers from multiple practices. And, some of those offers may seem enticing. Perhaps, you hear that the partners make 600,00o, 700,000, or 800,000 dollars or more. And when you interview, the President of the private practice tells you that you will have to pay a large sum of money into the business. This sum of cash called a buy-in can range from zero to as high as into the millions. So, here are the questions you need to answer. Is a high buy-in ever worth your while? In fact, should you even entertain the possibility of starting at one of these practices that come with an enormous buy-in? Well, I am here to help you to answer these questions today!

 

 

The Hope

OK, all things considered, paying into a practice a large sum of money doesn’t sound so bad if the practice guarantees that you will bring in gobs of money each year, right? If you are paying a million to own a radiology practice’s technical shares, you can potentially receive outsized benefits in return. For one, your salary can become much higher. That initial sum of money that you add to the practice equity can significantly increase in value if the practice does well. You can also diversify your income a bit by collecting the professional fees and the technical component. These hopes can all come true.

But Then…

OK. There is always more to the story. Practices can dash hopes in an instant. Let’s say you don’t receive a share of the partnership during your partnership track. Where does that leave you? A lot poorer!

Or, perhaps, the practice equity declines as you finally earn the golden ring of partnership. Can a practice’s equity decline that much? Sure, can! Assets can not only decline to zero but can become a debt burden as well. Think about it. Equipment depreciates. And physical properties can decrease in value. The money you put in can no longer exist after you put all that equity into the business. And some!

Besides, you may overpay for the practice more than it’s worth. Who is to say that you have paid a fair price to become a partner? The practice partners? How do you know if they know how to value the practice. Or, maybe, they are trying to defraud you. You never know.

Weighing The Risks Versus Benefits Of A Large Buy-in

So, let’s see. The potential for large rewards versus the possibility of paying into something that is not worth it. What should you do? As always, this comes back to a trust and numbers game. Only by vetting the practice’s balance sheet and getting detailed information about the practice owners can you make the decision. So, how do you go about making this weighty decision?

Of course, you need to assess the people that run the practice. But how? Track record becomes very important. Have they strung along with multiple employees on partnership track to never make them a partner in the business? Are these physicians respected members of the radiology community? Do your residency and fellowship directors know something about the practice?

To get at the matter of trust, you must research the practice well. Check for lawsuits and hiring indiscretions. These can all become red flags that the imaging business may not be what you think.

And then get to the bottom of the balance sheet. Be wary of any practice that does not let you know what the partners have made in the past. Think twice if the practice does not allow you to talk to the business manager about the finances and the assets the practice owns. I know of several radiologists who had been through an extended partnership track to find out that they became partners in only the professional component, not the technical component/equipment and real estate. They were sorely disappointed when the time came to make “partner.” So, make sure to find out what you are really “buying-into”!

Finally, you need to consider the current environment of the practice. Are private equity firms or large hospitals in the area taking control of practices? Is the area economically growing or contracting? These factors may influence the risk of entering a partnership track that you may not be able to complete.

A High Buy-in And Your Final Decision

Depending on the situation and the practice, a high buy-in may or may not be worth the risk. Take into account not just the great potential of the business. Instead, you also need to consider the risks you need to take to earn that potential outcome. It might turn out well, but it might not. So, maximize your probabilities of success. Do your due diligence!

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Radiology Residency Day One – How To Start On The Right Foot

residency day one

Last week, I wrote about what to do on the first day on the job as a radiology attending. For those of you about to begin radiology residency, I thought it would be unfair to leave you in the dust. So, today, we will talk about what to do on day one of the radiology residency. For this discussion, we will disregard all the formal introduction courses from the hospital. Mostly, that is a passive activity. Instead, I need you to know what you must do on your first day in the department. So, let’s start!

Get To Work Early

On that first day, I recommend arriving early. Get to know the parking, the bathrooms, and the building. You never know how long things will take until you arrive. And as a resident, impressions become exceedingly important. The last thing you want to do is to arrive late on that first fateful radiology residency day one!

Introductions And Thank You

OK. This one does not differ much from your attending’s first day. Your new colleagues and faculty want to make sure they made the right choice when they selected you. So, do this right. Make sure to thank all the folks who helped to get you into the program. This gratitude goes a long way to building solid relationships for the next four years!

Don’t Stand Out Too Much

When you begin your first rotation, be careful about what you say. You certainly don’t want your attendings tagging you as the class troublemaker. That can lead to undue negative attention later on. So, if you think you may say something that may upset your new employers, I would hold back until they get to know you later!

Ask About Special Programs (If Interested)

Some radiology programs have Early Specialization In Interventional Radiology (ESIR) slots. If you do not inform your program directors early on that you maintain interest in the program, the program may fill up, and the ESIR program may exclude you. So, ask to sign up, if interested, on that residency day one.

Ask About Expectations For The Rotation

Different from starting as an attending, most of you have no clue what you should begin to do on residency day one. On day one of our nuclear medicine program, the technologist showed the residents how myocardial perfusion scans work. But, in the following days, you would sit with an attending to learn the basics. You certainly would not want to miss either of those opportunities. On the other hand, if you start on fluoroscopy, perhaps you need to watch a few esophagrams on the first day. And then, a few days later, the attending may expect you to attempt one on your own. Without these clear expectations, perhaps not in the manual, you will start your rotation at a disadvantage. It is hard to meet expectations you don’t have!

Learn The PACS

Like a new attending, you must learn how to look at cases at your institution. Therefore, it behooves you to play around with the PACS system a bit. Also, make sure to ask for tips from your colleagues and attendings. Many times, if you don’t ask at the beginning, you will only learn much later after you have wasted many hours. Remember: these tips can save significant amounts of time and headaches!

Start Learning How To Dictate

Again and again, you will hear that learning to dictate has a steep learning curve. Therefore, there is no time like the present to learn. Begin with a few simple cases. But start now if you can. As a resident, this activity is one of the most active ways to learn radiology. It reinforces the buttonology of the PACS and the learning of the basics of radiology. In addition, it can help the attending out during the daytime. So, why not start on day one?

Let Your Attending Know The Plans

On that first day, you will often need to attend several activities that are integral to starting but maybe off-rotation. As a courtesy, let your attending for the day know when and what you need to do. This act of doing this establishes a rapport between you and your faculty!

Listen Carefully To The Program Director (Or Associate Program Director) Welcome

Most programs have an early morning or noon conference from the program director or associate program director. This conference is crucial! Most of the time, the program directors will give you their expectations and requirements. Usually, they will not repeat the tips and advice you will get from this session. So, take notes, and don’t miss a beat!

Borrow, Rent, Or Buy Books

By the end of the first day, you should know what you will need to complete your first rotation successfully. Most of the time, you will discover what to purchase, rent, or borrow books from your colleagues in digital or print form. So, make sure to get these necessary resources on day one!

Radiology Residency Day One- Final Thoughts

As with any first day of a new job, the first day of residency can become a nerve-racking experience. But don’t let it be. Instead, try to absorb all the unique experiences that you encounter. So, make sure to take in the new situation, the people, and your place of work. And most importantly, don’t be too hard on yourself. The staff and your colleagues have low expectations for the residents on your first fateful day. Later on, you will have many more days ahead of you to stress about giving that next tumor board or taking the core exam. For today, you can relax and enjoy!

 

 

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Top 10 Resident Issues That Radiology Faculty Wants You To Know But Can’t Say

Top 10 Resident Issues

Most radiology attendings want their residents to succeed. However, etiquette rules cause many to withhold their feedback about some of the resident issues that they encounter on a daily, weekly, or monthly basis. Unfortunately, for that reason, they keep many of you in the dark. However, please learn from their mistakes and enlighten you all. So, to prevent you from continuing with these resident issues, I thought I would create a top 10 list that the faculty wants you to know but may not say… Here we go!!!

You’re Too Aggressive

Are you overcalling everything or coming down hard on a final diagnosis without any other differential? Are you accustomed to the surgical mentality? No longer can you just nod in agreement, but you push, push, push? Everything is an argument. And, your attending does not have the time to talk back. Gosh darn it, perhaps you are more aggressive than you should be at this stage of the game!

He Misses Everything

When your attending sees that you are missing all the findings during the night, he may not feel so great telling you about all these errors. How will that help anything? And I mean, he doesn’t want you to feel bad about it when he tells you, does he? Unfortunately, you may miss out on some of these learning experiences. But, your attending may not let you know!

She Has Poor Hygiene

Poor hygiene can be just plain embarrassing. But, sometimes, your faculty may become very uncomfortable dealing with malodors or unkempt appearance. It often needs to be said to the resident but doesn’t. And, all the other faculty and residents suffer from this resident’s poor hygiene!

You Just Don’t Listen

The attending keeps on telling the same resident the same old thing. But, time after time, nothing changes. No longer can the attending tell you what to do anymore because it does not seem to work? So, your attending does not bother you anymore. What’s the point of hurting your feelings?

He’s Way Too Enthusiastic

Don’t get me wrong, but it is great to be enthusiastic. And, your attending certainly does want you to become excited about radiology. But, too much of anything is no good. And sometimes too much enthusiasm can be a bit too much. It can wear on your techs, nurses, and attendings. So, temper that enthusiasm just a bit!

You’re Just Plain Dumb

Often, your attending will ask you questions to see if you have been reading enough. And it is OK to get some things wrong. However, on occasion, a resident does not know anything that he should. Is your attending going to tell you that, maybe or maybe not? Who wants to say to the resident that she is just plain dumb?

She’s Getting A Bit Too Chummy For My Liking

On occasion, our residents can become a little too familiar with us if you catch my drift. It can all be a little too “touchy-feely.” So, think about how you communicate with your attending. Is it appropriate? Or are you trying too hard to become his best friend?

He Wants Always To Be Spoon Fed

Most residents want to learn from their attendings. Some residents expect all the learning to come from their attendings with no work on their part. If you desire to breed ill-will, you can do just that. Don’t help out your attending. Instead, just expect them to teach. It can be very irritating!

You’re Always Abandoning Ship When The Work Is Not Done

Excuses, excuses, excuses… You have to get to a wedding. Or, maybe you need to go on a date with that new beau. Well, your attending does not want to be the one to break it to you. He does not want to be the unfeeling guy that ruins the resident’s time. But, is it right that you are always missing all that work?

He’s Preventing Me From Getting Anything Done

Some residents like to talk a lot. And, most attendings like a good conversation as well. But, sometimes, it can interfere with the daily work that needs to get completed. How can your attending break it to you when she likes you a lot. Well, it can be challenging at times!

Final Thoughts About Resident Issues That Faculty Want You To Know But Can’t Say

Rightfully or wrongfully so, many taboos exist that prevent faculty from telling you, the radiology resident, what is going on. And even though attendings are supposed to evaluate and give direct constructive criticism and feedback, that is not the reality of the situation. So, if you think that you may have one of these ten resident issues listed above, try to change it on your own because you may never get the real story!