Tag: advice

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How To Avoid The Radiology Comparison Culture (Don’t Become A Victim!)

comparison culture

Type A personalities, typical graduates from medical schools, tend to compare themselves to others in their residency classes. These residents often ask the following questions: Am I performing better than everyone else on the in-service examinations? Do I read films as fast as everyone else? Have I written more papers than my colleagues? These questions asking how you perform relative to your colleagues make up what I call comparison culture.

Do you further your career by joining the comparison culture and comparing yourself in this way to others? Sure, it can stimulate some friendly (or unfriendly!) competition. You can work hard to make sure your in-service score beats all others. And yes, you can write your umpteenth paper to shove it in your colleague’s face. But, these motivations only improve metrics that do not correlate with qualities that make a better radiologist, such as the desire to learn continually. And over the long term, a resident cannot sustain these motivations. I mean, who wants to study for the sake of getting a higher in-service score year in and year out? It’s a recipe for misery and burnout.

So, what motivations should we seek to make ourselves better radiologists who love our chosen profession? Let’s go through some long-term motivators to avoid the pitfalls of the comparison culture.

Love Learning

After years of testing and the comparison culture, many students forget or never learn what it is like to enjoy learning. When I read, I do it because reading helps me in some way with my practice or because a specific topic interests me. Reading and studying should not be about getting one up on our colleagues. Instead, understanding is a reward in and of itself.

Solve Great Questions

Nothing is more rewarding than solving that bizarre case or coming up with a twist that leads the clinicians to take a different direction than they had initially expected. Call me crazy, but there is something special about being that “go-to” person when anyone has a problem that needs to be solved. And solving interesting questions begets more interesting questions from your fellow clinicians.

Work To Improve Patient Care

For many radiologists, the ultimate satisfaction comes from improving our patients’ lives. Even though many of us are in the background, we can feel the difference we make when clinicians treat patients appropriately because of our calls, improving patients’ lives. Many of us derive immense joy from the vital work we perform.

Embrace The Excitement Of New Technologies

Many of us, as radiologists, went into the field because we like more significant and sophisticated toys. Whether it’s that new SPECT-CT or the latest and greatest 7T MRI, we should derive pleasure from learning these technologies’ significance and applying them to patient care. It pays to keep a youthful spirit and keep our eyes wide open in amazement as we conquer the next great technology for the betterment of others. Heck, we can even make a career out of it!

Enjoy Playing Part Of A Team

And finally, many of us enjoy our roles in forming a team and operating flawlessly as a unit. Only through interaction among team members that we come up with our best ideas and perform to our fullest. Working by yourself limits us to boundaries instead of expanding our knowledge. Playing a role in a team defeats the hazards of the radiology comparison culture.

Avoid The Comparison Culture

Ultimately, the comparison culture only gives radiologists and trainees a short-term benefit. Instead, loving to learn, solving our colleagues’ clinical dilemmas, embracing new technologies, and playing an essential role in a team can help us derive long-term happiness from our work. Avoid the comparison culture to love what you do. Radiology is a marathon, not a sprint.

 

 

 

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When To Say No At Nighttime (A Resident Guide)

no at nighttime

Radiology residents can expect disagreement with a nurse, fellow resident, or attending on any given night. Due to lack of sleep, tempers flare, and we magnify minor problems into large ones. Ultimately, we mostly accommodate our colleagues and perform the study they request as we should! Sometimes, however, saying no at nighttime can be one of the most important yet challenging responsibilities of a radiologist on call that we need to learn. We don’t want to offend our colleagues’ sensibilities or upset the attendings of other clinical services. And we want to ensure that we complete studies promptly to increase ER turnover. Yet, there is a time in all radiologists’ careers when the right thing to do is say no.

But, at what point should you say no, I won’t comply with your request? Let’s explore this issue of when to say no at nighttime. We will discuss some of the most common circumstances for the radiologist to refuse a request appropriately. For each case, we will discuss how you should proceed instead.

Studies That Would Cause Undue Patient Risks

Out of all the reasons to refuse a study, most importantly, we must ensure that we comply with the Hippocratic oath, “First do no harm.” This oath is priority number one. For all of us, a time will come when a resident or attending will ask us to perform a study or procedure that can potentially harm the patient. It could be an unnecessary CT scan on a pregnant woman or a biopsy on a patient with an elevated INR. As a physician, we need to prevent these procedures from getting completed. It is our first and foremost responsibility.

So, how do we stop a study when attendings or residents apply crushing pressure to perform the exam? First, we need to elaborate on the data behind why such a study would harm the patient. And then, most importantly, we need to do it in a way that does not demean or upset the physician. This technique is where the art and science of medicine meet in the middle.

Procedures That Would Jeopardize Your Safety

Not only do we have a responsibility to our patients. But also, we have a responsibility to maintain our safety. To take care of others, one must take care of oneself. So, to put yourself in significant danger, simply put, clearly does not meet the sniff test of practicing good medicine. The test could involve putting yourself in harm’s way with a combative patient or exposing yourself to undue radiation. Make sure to think about your situation first before going ahead.

How do you decide if the procedure would affect your safety for you to say no at nighttime? Always think about the potential consequences of a worst-case scenario. If you can think of a situation when you can get seriously injured from a study, it is probably not the best idea to complete the procedure.

Interpretations Or Procedures That Need An Attending

Sometimes we should not complete a test or procedure unless an attending can be present. You may be able to perform the exam adeptly. But, it is not in your best interest to complete the study for legal or ethical reasons.

How do you judge if the study may not qualify as a resident’s domain? If the procedure can result in significant harm unless performed by the appropriate personnel or a protocol establishes that a resident should not complete the study, hold off and call your attending. Let’s give you an example, such as a brain death study. Although easily interpreted by a resident many times, the consequences of “missing” can result in severe harm. Additionally, many programs have protocols for attendings to read this examination.

Inadequate Resources

This one may seem pretty obvious. However, we should not promise to complete a test if we don’t have the capability of finishing it. Often, residents unknowingly will offer a solution to a problem that may not exist in your institution. Or the institution cannot obtain the resources on the night of your call. For instance, you may promise the clinician that you can perform a V/Q scan, not realizing that the agents are in short supply. Unfortunately, this disrupts management, the timing of testing, and the formation of a patient’s final disposition. So, always make sure to check that you can complete a test before you allow the order. And, make sure to let the ordering doc know!

Nondiagnostic Studies

Occasionally, you find an adamant clinician or resident who demands the immediate performance of a test that will not assist in making a diagnosis. In a huff, these folks can propel you down the wrong road. In this situation, it pays to push back a bit. How? Data is your friend. Perhaps, the clinician insists they need a bleeding scan when the patient has a very slow bleed. Calmly, you need to explain why the test would not change the patient’s situation or add any additional significant information. Usually, the ordering physician will comply.

Things That Take Up Too Much of Your Time At the Expense of Patient Care

Often, students, residents, or even faculty will ask for assistance on all sorts of studies they may need help interpreting. However, your time can be minimal. A typical example: A resident asks for a reinterpretation of a cancer workup performed six months ago. Now, it may be essential to perform at some point. But, if you have 20 trauma cases that you still have not read, is it the correct decision to look at this sort of study? Probably not. So, politely tell the resident your situation. Trust me. This physician will go away and let you interpret your STAT cases.

Repeating Similar Previous Studies Without Good Reason

Finally, it is not uncommon to find orders for a repeat CT scan or fluoroscopic study after someone has recently performed it. Clinicians sometimes make errors in unknowingly repeating studies. I can’t tell you how many times this has happened. As radiologists, we are responsible for checking and finding out if these studies are indeed warranted. Again, you must calmly and politely let the ordering clinician know if this is the case.

Final Thoughts About Saying No At Nighttime

Saying no can take real guts when you are not the “authority.” But, when to say no at nighttime needs to be learned by all residents. It can be an art as well as a science. And the lessons stay with you for the rest of your career. So, if the situation arises that you need to say no at nighttime and it can affect patient care, respond gently and with the data to prove your point. The rewards of saying no can be immense.

 

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Partnership Track Behavior: A Primer

partnership track

Congratulations! You’ve nabbed the job you have always wanted. And your employer has placed you on a partnership track. But, you know that not all who started on the partnership track made it to the Promised Land. To prevent yourself from becoming the next casualty, you’ll do almost anything to ensure that one day you will become a partner with all its benefits. So, how can you entice your employers over the next two, three, or four or more years to take you into their fold? Having experienced the process and worked for many years as a partner in private practice, let me give you some basic tenets you need to follow.

Make Small Pleasant Waves, Not Large Ones

Let me tell you a little obvious secret. As much as the practice owners say they will treat you the same as other partners, please don’t believe a word they say. Until the day that you become a partner, any current partner can use any irritation or error against you. Worst case scenario, the upset partner can delay your partnership indefinitely!

So, my advice to you is: don’t rock the boat. Do what you must, but don’t push your views on others. Sure, consider changing a knee MRI protocol with the blessing of all the other MR readers in the department. But, don’t overhaul all the protocols on the magnet without their consent. Talk to the CT scan representative but don’t volunteer to become the promoter of the CT scan manufacturer without notifying the chairman. And so on. I think you get the picture.

Complete All Your Assigned Work And Some

Want to impress your fellow practice partners? Of course, you need to complete all of your work. But even more importantly, when you finish everything, help out your fellow radiologists. Over time your extra effort will get noticed. It certainly can’t hurt to have rave reviews from your cohorts when the time comes for them to vote you in as an equal shareholder. Who doesn’t want a fellow partner that always wants to take on additional responsibilities?

Pace Yourself

Many former employees never made it to partner: What do they have in common? Either they made too many mistakes because they read films too fast. Or, they become so worried that they will miss essential findings that they take forever to read and dictate the studies. Especially at the beginning, you don’t want the partners to categorize you as either of those sorts of radiologists. So, take your time. But remember, you don’t have all the time in the world!

Avoid Saying Anything Bad About A Partner

This advice seems obvious but is a common reason for ending a partnership track or, even worse, your employment! Never. Never utter a bad word about your superiors to anyone else. Trust me. Trash talking about your colleagues is a cardinal error that will bite you when you least expect it. Indeed, that partner you were talking about will not want to hear that he is lazy when the time arrives to decide on your future!

Don’t Complain Unless It’s Unavoidable

OK. Maybe, that PACS system keeps malfunctioning. Or that technologist always to forgets to put the measurement of the spleen on the worksheet. Try to deal with these minor situations yourself before running them by the partners. No one likes a constant complainer. And, who wants to make that person your fellow partner? Indeed, not your employers!

Volunteer For Practice Building

You are taking on a partnership track for a reason. Of course, you expect to play a role in not just the daily reading of films and performing procedures. Instead, you desire to involve yourself in the other facets of the business. In that vein, nothing looks better than taking on Grand Rounds talk that no one else can or wants to do. Or volunteer for the hospital credentialing committee. Perhaps, you should become the point man for the CT lung screenings in your community.

Practices usually do notice these additional activities. But most importantly, the partners appreciate the extra effort when the time comes to vote on your final disposition.

The Psychology Of The Partnership Track

Like any other path that you have undertaken in your career, you have to first start at the bottom. Beginning a partnership track is no different. So, put your tools to the grindstone and prepare to work hard for the time you are on a partnership track (and hopefully beyond!). Only then can you increase your chances of reaching your final goal of reaping a partner’s added rewards, prestige, and respect!

 

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How to Make a Good Impression as a First Year Radiology Resident

impression

It may be your first day, your first month, or maybe you started residency several months ago. Perhaps, you want to make that great first impression on your program director. Or, maybe things are not going as well as you might have liked during your first year. Having worked with numerous first-year residents rotating in our residency and having completed a full four years of residency, I have learned the ingredients you need to become a great first-year resident. As a former resident, I wish I had a list of tips on how to start my radiology resident experience on the best footing possible.

Well, now it’s here. I have a list of 12 ways to improve your radiology residency experience starting in the first year of your diagnostic radiology residency program. Also, I will give you examples of what not to do (these scenarios are real!). Then, I will explain how to make the best of each piece of advice. To all- ENJOY AND HEED THIS ADVICE!!!

Be Enthusiastic

On your first day of radiology residency, you walk into the reading room for the first time, and you are nervous and hesitant. You begin to yawn, mouth wide open. An attending sits in the corner about to read films. You slink back and worm your way into a corner. You don’t introduce yourself for fear of disturbing the attending radiologist. Instead, you start talking to your resident colleagues. Is that a way to start your career? By all means, NO!!!!

My words of advice:

Always make sure to put on your best face forward toward your staff. What does that mean? Well, it’s pretty much common sense. Always introduce yourself. Always ask how you can help. And, always volunteer to participate in a readout or procedure. You have only one chance to learn the things you need to know before practicing as an attending, and that way is RADIOLOGY RESIDENCY. Make it the best learning experience you can, and that involves going that extra mile to show your enthusiasm/interest.

Be On-Time

You wander into the reading room, and it’s 10 AM. When you see your attending radiologist reading out films, he pauses for a moment. You decide to say, “When can we start reading out together?” The attending looks at you with a confused quizzical face. Was I supposed to have a resident today?

My words of advice:

When you arrive in the morning, always let your attending know that you are today’s resident. If you have to step out for a few moments, let him know that you need to leave. It is a sign of respect to let your attending see that you are going to be around to help out, learn, dictate, and ask questions. It will go a long way to establishing a rapport between yourself and your residency staff!

Be Nice to Everyone

It’s your first day, and you walk into the residency coordinator’s office. You sit in her chair, never having seen or met her. And then, you start playing games on her computer. The coordinator walks into the office and stares at you and is thinking: who the heck is this guy?

My words of advice:

Make sure when you are beginning that you are kind to everyone!!! I don’t care if it is the residency coordinator, janitor, technologist, attending, senior resident, or nurse. We are all part of the same team. Moreover, we always hear about our resident’s behavior, good or bad. As residency director, we receive 360-degree evaluations, reviews of the residents from potentially all these sources, and more. I can tell you that if you want to destroy your reputation as a resident, the worst thing you can do is misbehave with your team members, especially the residency coordinator!!!!

Dress Appropriately

You are upstairs on the floors in a t-shirt and ripped jeans. Your ID badge sits in your back pocket with the list of patients to consent. In your morning haze, you stumble up to the door of the 3rd patient with informed consent in hand. You introduce yourself to the patient, and she gives you that look- who are you really, and what are you doing here? You go through your pat explanation of the procedure, the risks, and the alternatives. The patient warily signs the consent form. Great! The last consent of the morning.

Later that afternoon, the program director calls you into the office. It turns out, the patient was the wife of a hospital executive and called the emergency hotline. The program director now has two complaints about this resident, one from the patient’s husband and another from the doctor in the hallway. Both are furious because they did not know who you were and felt uncomfortable confronting you. The program director states, “Go home and change immediately!”

My words of advice:

Always make sure you look and play the part of a physician. Some patients and physicians are easily offended by an inappropriate appearance/uniform. In our world, radiology is a service-oriented profession. Furthermore, appearances fortunately or unfortunately lend credence to your skills, personality, and the department. Please make sure to represent your department in the best light!

Play the Role of An Attending From Day One- Take Responsibility for Your Patients and Department

You roll on into the nuclear medicine department and arrive at the department early. Briefly, you look at the list of patients in the computer. A bone scan and a gallium scan lies waiting as unread. You think to yourself, I know those topics well. I also know it would be much more productive to read a nuclear medicine book on a new subject. As you are waiting for your attending to arrive, you pull out your text and learn about nuclear medicine. The attending walks through the door a few minutes after you started to read and says, “Have you looked at the cases from last night?” You reply, “I was hoping to get my reading done for the day. Didn’t get a chance to look at the cases.”

My words of advice:

When you are on any service, good learners become great radiologists by reading lots of cases. You may know a given topic well, but you can only learn normal from abnormal by reading thousands of cases in different contexts. Unfortunately, you cannot learn this from merely reading a book. The only way to get that experience is to look at lots of cases every day. Take an active role as if you are an “attending.” Radiology is not a spectator sport!

Be Knowledgeable

You are in the second week of your first CT rotation. So, you sit down with the CT attending to go over the day’s work. The attending goes through each of the cases slowly. Finally, she happens upon an abdominal CT scan. You stare at the images, and she asks you about an ovoid cystic density structure just inferior to the liver. You blurt out, oh, that’s easy. It’s an aorta!!! Your attending begins to shake her head slowly and becomes silent. She doesn’t say much for the rest of the day.

My words of advice:

There’s an old radiology adage. The difference between a bad, OK, good, and great radiology resident is the amount you read every night. A bad resident doesn’t read. An OK resident reads 1 hour a night. A good resident reads 2 hours a night. And, a great radiology resident reads 3 hours a night. Don’t be that bad radiology resident! When you start, I encourage you to read a lot, especially emphasizing the basics and anatomy!

Read a Lot, but Make Sure to Study the Images

It is your first day on the new chest film rotation. You have just finished reading an entire textbook on chest radiology. As you start looking at the cases with your attending, you figure that you will try to impress him with your in-depth knowledge of the findings associated with sarcoidosis. So, you start going through a small presentation about your newfound knowledge based on the textual information. After your serenade, he begins to look at the first few cases of the day. Then, he pauses as he starts on the third case of the day.

He asks, “What do you think about this chest film in front of you?” You stay silent as you search the film up and down, left and right. Nothing seems to register as abnormal ton the film. Your attending points out a significant opacity obliterating the vessels behind the heart and obscuring the left hemidiaphragm. He then asks, “Where is the opacity located?” You realize that you have read tons of information on pneumonia but never looked at the pictures. Uh oh! You cannot identify the location based on a mental reference point. Your heart sinks as you realize you have more reading to do…

My words of advice:

Reading a radiology text differs dramatically from reading an internal medicine book, a novel, or other sorts of written information. The most important features of a radiology textbook are usually the pictures and captions below the pictures. So, it behooves the resident to concentrate on these films, often more than the text itself. Of course, you need to understand and remember the disease entities, but radiology is most often about the images!

If a Radiology Attending Asks You a Question, Always Look Up the Answer

So, it’s the end of the day, and you are sitting with your favorite attending. For the few days that you have worked with her, she has a habit of teaching interesting topics while taking cases. It feels like you just read an entire book without even touching a page. She enthusiastically asks you a question about a patient with breast cancer. She says, “I wonder what a sclerotic metastasis would look like on a PET-FDG scan? Maybe you can look it up, and we will go over it tomorrow.”

You go home exhausted and fall asleep slumped over your computer, without even getting a chance to read a word about the topic. You get up in the morning and realize you are running late. Hurriedly, you grab your stuff and arrive barely on time. Sweating profusely, you run into the reading room. Your attending almost sits down at her workstation. And she says, “Did you look that topic up for me?” Unfortunately, you don’t have a satisfactory answer. For the rest of the day and weeks afterward, she barely spends time on her cases with you. You’ve lost many opportunities to learn with your mentor.

My words of advice:

You sow what you reap! When someone, specifically a radiology attending, takes the time out of the day to teach. And, she goes over cases with you out of his/her own free will, it is essential to pay back that person with attention, diligence, and care. By under-appreciating the attending’s time, you change the willingness of a teacher to teach. Remember, most hospitals do not pay radiologists stipends for their time with their residents. Teaching emanates from the goodwill of the staff!

Always get a good history

It is late in the day, and you are about to read the last hepatobiliary scan of the day. But you have to do it quickly because you need to get home to your family. Instead of entering into the electronic health records, you promptly peruse the one-word order on the top of the dictation page. It says pain. So you start reading and dictating the case promptly for the attending with that one-word history. In a few minutes, you finish the dictation.

You walk back to the reading room and begin to go over the case with your attending. Subsequently, he opens the case, looks at your history/dictation, and begins to look at it as the surgical team walks by to get the radiologist’s interpretation. The surgeon asks, “What do you think?” The radiologist says, “With a history of pain, it looks like the gallbladder fills nicely without findings suggesting cholecystitis.” The surgeon responds curtly, “We just took out the gallbladder!!”

My words of advice:

Always take the time to get a great history. As a resident, you should take the time to gather all the information. Without a good history, trust me, you will get burned. So, avoid the inevitable, take your time, and always get all the necessary information!!!

Establish a search pattern for all modalities

The day’s attending sends you out of the room to read a new CT scan of the abdomen. The patient has right lower quadrant pain, and the emergency doctor wants you to rule out appendicitis. So you look through the CT scan quickly and ramble into the Dictaphone about the case. Your eyes move here and there without any specific pattern. Finally, you see some terminal ileum wall thickening and put in your impression- findings suspicious for terminal ileitis/inflammatory bowel disease. Happily, you trot back to your radiology attending to go over the case. Within 10 seconds, your attending says, “You missed the 4 mm obstructive stone in the right ureter!”

My words of advice:

Believe it or not, almost every experienced radiologist has a rigorous search pattern and mental checklist in every case. With this checklist, they don’t miss any findings that may be relevant to patient care. You might not know they have a search pattern/checklist because they have been doing it for so long. And, they rapidly read the cases. But, I can guarantee you will miss plenty of significant findings if you do not go through an organized approach to looking at a film. It happens all the time!!!

Always check for priors

The radiology attending just left the service for the day. You are now on call for the night. The emergency department continues to call the nuclear medicine department every 10 minutes to get the result. Annoying, isn’t it? It is time to give a STAT interpretation of a pulmonary V/Q scan. So, you look at the scan and the associated chest film. And, you see three large mismatches without corresponding findings on the chest film. You call the ER and tell them the scan is positive for pulmonary embolus. You feel good because you think you made the right call for sure.

The next morning at the readout, your attending starts to look at the case. He notices that you didn’t compare to the prior scan. It seems the same. His interpretation- no findings to suggest new pulmonary embolus. He says, “Call the ER right now to make sure the patient doesn’t get more anticoagulants.” You feel like an idiot for missing the correct diagnosis!

My words of advice:

I can’t emphasize enough how important it is to compare priors. Priors will bail you out many times. And, comparing with them makes the difference between shoddy and outstanding patient care. If you want to become a resident star, always make a concerted effort to check for prior studies!

Learn about things that can kill a patient or are common first. Zebras can usually stay at the zoo!

You are taking your first independent call and start to look at your first ultrasound of the evening. It is a 2-year-old pediatric patient with right lower quadrant pain. Looking through the ultrasound images, you see a target like structure in the right upper quadrant. You recently read a large text and saw a case of Henoch Schonlein Purpura affecting the bowel. It happened to look just like it. Your differential reads Bowel thickening from Henoch Schonlein Purpura before anything else. Ten minutes later, the pediatric surgery team trots up the stairs toward your workstation and says, “What are you talking about? We were looking for a large bowel intussusception!”

My words of advice:

Stick to the most common two or three items within the differential diagnosis. You will often be right more than not. As I said, zebras can usually stay at the zoo!!

Making A Good Impression

I’m sure almost all of you want to make your best impression on the staff that you are going to work with for four years. One or two mistakes toward the beginning of your stay can make your life very difficult for the rest of your radiology training. Unfortunately, it is effortless to leave the wrong impression on the staff, but it is harder to correct. To avoid these blunders, I highly recommend you follow these rules. Don’t be the brunt of your residency’s jokes!


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What To Look For In A Radiology Residency?

residency

No perfect radiology residency program exists for radiology residency applicants, and no one size fits all. Each candidate has their own needs, wants, and learning style. And each program has its positives and negatives. Therefore, each applicant should strive to match with the appropriate residency. In doing so, the positives of the program should fit well with the applicant’s needs. And, the negatives should be minor and not detract from the overall radiology resident experience.

My goal for today is to discuss the essential ingredients for choosing a radiology residency. Most online overviews do not address many of these crucial factors to look for in a radiology residency program. So, I thought it was critical to include them. Included in my discussion will be of the highest importance to most minor importance: residency culture/hierarchy, location/proximity to family/friends, intimate insider knowledge of a program, rotations/equipment/procedure volume, university vs. community programs, private vs. academic run departments, graduating resident fellowships, conferences, research, mentorship programs, and board passage rates.

In the end, the overall residency experience will allow you to become a great radiologist. So, I will put it all together at the conclusion to help you to make a final decision. To do this, I have assigned an individual point score for each factor. It would help if you recorded for each residency you are considering for ranking. In the end, add up the points. And then, compare to the other residencies on your rank list. When you finish, rank each accordingly.

Residency culture (5 points)

Residency culture is probably one of the most critical factors to think about when choosing a residency. However, it is also one of the most difficult to define. The difference between happiness and misery in a program first and foremost often lies with the colleagues that you have. No matter how excellent the overall “experiences” of a residency program, you will not want to come to work if you hate the people you work with. On the other hand, if the residency is marginal, but the people you work with are fantastic, the four years of residency will not be so bad.

What To Look For

The problem with using this factor for choosing a residency is that it is a moving target. From year to year, residencies accept new residents, and old ones leave. So, the residency culture today may not be present tomorrow. However, the attending, technologist, and coordinator support structures of the residency often remain relatively similar. So, it would help if you got to know the residents and the leaders and purveyors of the program.

In addition to getting a sense of the “happiness” of the residents, you should determine the residency leadership style. Some programs prescribe processes for everything that happens in the program. Other programs have a more laissez-faire attitude. Some programs have one or two leaders at the top that act as “benevolent dictators.” Others have each of the attendings with equal say over residency issues.

No one structure is “correct.”. If you are the type of person that needs a well-defined structure, the hierarchical culture would fit better. On the other hand, if you like to create your path and define your schedule, you may prefer a program with an equal footing.

Location and Proximity to Friends/Relatives (4 points)

Over my years as an associate program director, I have found how important it is for residents to have a social outlet. Although not a “resident related experience” per se, this factor can be just as important. Being near loved ones can make the difference between a terrible residency experience and a great one. A support structure can be just as crucial as the residency program itself. I find that the best residents have a healthy support structure outside of residency. Therefore, the location and proximity to loved ones can be essential factors, just as the residency quality. For instance, who would want to be in Manhattan if your children/spouse are in California? If asked by medical students, I will usually mention that they need to consider location seriously.

Insider/Intimate Knowledge of a Program (4 Points)

As a medical student, it helps to rotate through the radiology residency program you may want to attend. Suppose you know the residents and attendings before starting a program. In that case, you already know the residency program’s upsides and downsides and where “the skeletons are hidden.” Knowledge can be worth its weight in gold. It can be challenging to tell what the true nature of a residency program is like before starting a program. Therefore, having insider knowledge can help you when you begin your residency because “you know what you are getting into.” These residents often are some of the most successful because they have a distinct advantage of knowing the attendings, residents, and the hospital system, even before beginning their residency. Do not dismiss insider knowledge as a factor for making this big decision.

Rotations/Equipment/Procedure Volumes (4 points)

I am lumping these factors into one conglomerate. Why? Naturally, the residency must have all the resources you will need to be comfortable with to practice radiology. If you are in a program where the diversity of patients and patient volumes are sorely lacking, you will be at a loss when you are out in practice and have not seen those cases in your area of practice. Likewise, if the faculty does not perform procedures such as arthrograms or your program doesn’t have a 64 or 256 multidetector CT scanner for the interpretation of cardiac CTAs, you will certainly not feel comfortable performing these procedures when you are an attending.

So, you must make sure to search for a program that has all the necessary resources to allow you to learn all the imaging and procedure skills you will need to become a competent radiologist. Furthermore, as summarized in another post, Best Radiology Electives for the Senior Resident, it is imperative that you can rotate in areas of weakness or interest during your residency. Why? Because hiring practices are looking for residents who can do a subspecialty and are competent in most areas of general radiology practice. So when you are in interviews or looking up information on the web, make sure to look into these factors. Once you have started a residency program without all the crucial resources to make a great radiology resident, there is no going back!!!

Community vs. University Programs (3 points)

Incoming medical students tend to put more weight on attending a “university program” rather than a “community” program. However, both programs give distinct advantages that applicants do not realize before choosing a residency program. A sizeable academic university program does not fit everyone’s career path. So, what are the advantages and disadvantages of each?

Depth Of Resources

Large academic university programs tend to have resources in specific subspecialties and have several attendings that practice in a particular subspecialty. On the other hand, the smaller community programs tend to have more general radiologists that cross cover multiple specialty areas. So, as a resident attending a university program, you will get a more in-depth experience focusing on individual subspecialties. As a community program resident, you will get a more private practice and “real world” hands-on experience. So these programs should attract different types of radiology residents.

Beauracracy

Also, at community programs, you tend to have more accessibility to your attendings and will more likely work one-on-one with that individual. Also, if you have a specific need, it is more likely to be addressed personally without having to go through “bureaucracy” to get there.

At a sizeable university program, more physicians will intercede with direct attending teachings such as senior residents, visiting fellows, fellows, and junior attendings. You may also need to get through bureaucracies to obtain specific resources within your program. However, some electives and rotations may not be available in a smaller community program, such as connections for abroad electives or other opportunities.

Summary

So, this factor should play a role in your decision. But, it depends on the type of practice you want when you leave the system. One is not better than the other for all.

Private vs. Academic Run Departments (3 points)

This factor is often not mentioned or included as a factor in making a residency program decision. But having worked at private, hybrid, and academic programs, I think it should be essential.

I completed my residency in the private/academic hybrid model, and I found some real advantages to this sort of residency program. We had to get through a specific number of cases each day to meet the appropriate caseload. It was a more “real world” experience that allowed me to hit the ground running when I started my first job. I was dictating loads of cases from the beginning and had tons of experience by the time I graduated. My experience was very different from some of my more academic-run department-trained colleagues that I knew. Some of them had more difficulty getting through lots of cases during the day and felt a bit more uncomfortable at their first community radiology job. It made a difference in the long run for me, as it allowed me to become a more efficient general radiologist.

Academic run departments with attendings hired by the hospital emphasize different qualities. These departments may have more resources dedicated to teaching daily. For the resident interest in a purely academic job, it may be heaven!!! But, they may not simulate the real world. They can perseverate on a few cases for an extended period. So, for the radiology resident interested in private practice, a residency such as this may not be the right fit.

Conferences (3 points)

The ACGME theoretically requires all residencies to have at least a daily conference. But, not all are created equal. Some programs have additional morning conferences, while others have the resident prepare for and present at interdisciplinary conferences. And, even others have residents prepare medical student teaching conferences. The styles and types of meetings can vary widely at each program.

Additionally, you should ask if the attendings regularly show up to give their conferences. Please beware of the program with many on paper, but in reality, it does not have the number they suggest.

The importance of the number and type of conference depends on the individual resident. Some residents learn better with didactic sessions, and others benefit from hands-on direct radiology experience. So, the importance of this factor will vary with the individual applying.

Graduating Resident Fellowships (3 points)

It is critical to check where the former residents have gone to fellowships. Are the residents not able to get into competitive subspecialties? Are they going to “no-name” programs? Do the attendings at the institution have connections and networks with other fellowship programs throughout the country? These are questions that you should ask when you get to your residency interview. Or, you should check online for this information. Knowing where prior residents have attended can show you if they get into competitive subspecialties and fellowships.

Research (2 points)

For the academically oriented, research can be an essential factor in selecting a radiology residency. For the community-oriented, it is less so. But, when you look for jobs, having done some research implies an interest in and commitment to radiology. So, it is essential to have had some experience on your resume to get both the academic and private practice job. Therefore, research within an institution should play some role in your decision.

To make this assessment, it helps to get a list of the resident research output over the past five years. You can see what kinds of studies the current residents have completed. Are there retrospective studies, case reports, or large prospective trials? Is each resident finishing lots of projects? And, does the program have research conferences to support the resident? These findings should help you decide if the residency has a curriculum that encourages residency research.

Mentorship Programs (2 points)

Some residency programs have a dedicated teaching program that helps out first-year residents and gives didactic lectures. Others assign an attending mentor to the resident that is the “go to” person for all issues during their four years of residency. When added to the other factors, applicants can use these perks to help make a final decision.

Board Passage Rates (1 point)

I will include board pass rates last because I believe that studying for the new core exam is more of an individual’s responsibility. Of course, you need to pass your boards. But, I think that the overall residency experience becomes more critical in making you into a great radiologist than the board passage statistics. On the other hand, a radiology residency program should have primary resources for residents to pass the exam. They should have learning materials and books as well as board reviews. Great residencies have had lower board pass rates, large academic institutions, and small programs over the past few years. In the end, the examination is very different from the practice of radiology, but it is another hurdle to overcome.

Putting It All Together

No one factor should make or break your decision to go to a specific program. But instead, the different factors should be weighed based on the individual applicant’s needs and wants. So, add up the numerical point totals for each program next to each section and develop a final score to create a final rank list for every residency program.

To summarize, though, for most residents, I sincerely believe that you need to take the residency culture to be one of the most critical conditions for ranking a program in the residency match. And, location can have a significant effect on your happiness or misery during those four years. But, a quality residency culture and a suitable place without adequate training resources would not be enough. So, be careful when you factor each into consideration.

A great radiologist is the sum of one’s experiences that often stems from radiology residency as the initial building block. Ensure that the foundation will provide you with the training you need to become the best you can be. It can be a difficult choice, but I hope I have provided you with the tools you need to make that decision. Good luck with the match!!!

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Top 10 Things To Do When The PACS Goes Down

pacs

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

1. Call Up IT To Fix The PACS

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

2. Network

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

3. Study For The Boards

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

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

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

5. Arrange Elective Time

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

6. Observe Department Processes

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

7. Research Projects

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

8. Walking/Exercise

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

9. Grab Your Lunch

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

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

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

 

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

 

 

 

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Which Radiology Meeting Should I Attend?

radiology meeting

Residents need to make a big decision. At some programs, each resident can attend one academic conference during the four years of residency without presenting a poster or paper, all expenses paid. It may be toward the end of your tenure as a resident, and time runs out to take advantage of the situation. You can “go big” and attend the largest radiology meeting out there- RSNA. On the other hand, you may want to “go small” and consider a subspecialty meeting to delve into your area of interest. Or, perhaps you want to check out the academic conference and hobnob with the faculty at the most critical educational meeting- the AUR. How do you make this difficult choice? Well, if you are in this enviable situation and need to make a decision, this article is for you!!!

“Going Big”- The RSNA

Plan Ahead

RSNA is the radiology meeting that most radiology residents decide to attend. It is a meeting that has “something for everyone,” literally. Traditionally, the RSNA is the largest of all radiology meetings and covers every subspecialty within radiology. But this also presents a problem: how do you decide what to attend when you are there? Because of the vast conference size, I would recommend following a road map before arriving. Know what meetings, poster presentations, or other areas of interest you will attend before arriving. Suppose you do not outline a plan before arriving. In that case, you will likely miss half of the more relevant, informative, and exciting presentations since the conference is so enormous. The different activities can be far, far away from one another.

Lots Of Activity

In addition, if you are in the process of studying for the core examination and the timing is right to attend a conference, this may be the conference for you. There are usually loads of activities for residents, including review courses that may be helpful for the resident scheduled to take his/her boards. It is possibly even more important than the review course itself. You will also network with other residents in a similar situation, allowing you to learn the best resources to study for examinations and learn about other programs throughout the country. In many practices, at least one attending from your group will be present at this conference. Mingling with the faculty also allows the resident to take advantage of the possibilities of dinners or other engagements scheduled with vendors.

The one significant disadvantage of a conference like this one: it tends to be a bit more impersonal than some of the available smaller meetings. Impersonal may not be an issue for a radiology resident, depending on your fellow attendees and how you schedule your days.

“going small”- The Subspecialty Conference

My preference is this sort of conference. I usually attend the Society of Nuclear Medicine Conference every other year, an example of a particular subspecialty conference. I find that this conference is the best for learning the intimate details of a specific subspecialty. The newest information in subspecialties tends to get presented for the first time in these sorts of conferences.

If a particular subspecialty interests you and you want to choose a fellowship in the conference subject matter, you can utilize these subspecialty meetings to network with the physicians in the subspecialty. These conferences offer this possibility because they are smaller and give more of a “feeling of camaraderie.” Why? Conference members tend to be more involved in specific subspecialty activities with fewer numbers.

AUR Meeting- The Academic Radiology Conference

Every year in our program, the program has funded and allowed the chief resident to participate in this conference. It is a wonderful conference to find out the state of academic radiology throughout the country from a resident perspective as they have specific programs available for the chief residents. As a program director, I also tend to go to this conference once per year to keep up with the changes in radiology academics every year. (although I have not made it the past few because of Covid!)

In addition to the potential relevancy, the conference is not that large. It is hard to get lost at this meeting like you can at the RSNA. You can quickly get to know the players in the academic world. I would highly recommend this conference if you are interested in academics or are the chief resident in your residency program. Residents attending this conference obtain an invaluable source of information about all residency programs throughout the United States that they can share with their resident colleagues when they return.

The “Pure” Board Review/CME Conference

Lastly, there is the board review or CME conference. Usually, these conferences are for board review or a specific topic/selection of topics. In our residency program, many residents attend local board review courses before taking the core exam. It is a good resource as a means to review the information learned from studying.

Other sorts of CME conferences are also widely available throughout the United States and abroad. Typically, the attendees of these conferences are more likely to be fully trained radiologists. And, they want to learn more about a particular area or may want to travel to a specific destination. (I recently went to a conference at Disney World like this to learn about digital breast tomography!) In general, radiology residency daily conferences usually cover similar material. So, the yield of this conference for a radiology resident may be slightly lower. From my experience, most trainees that attend these conferences are at the institution responsible for the meeting.

Best Radiology Meeting To Attend During Residency

Like almost everything else in this world, one size does not fit all when deciding to attend a conference. RSNA is an excellent introduction to the world of conferences as it is the largest and the most general. Subspecialty conferences are great for networking, especially if a particular subspecialty or fellowship interests you. The AUR meeting is an excellent option for academic sorts and chief residents. And finally, board reviews/CME conferences are a great tool to review studies for the boards/core examination. Many decisions to make and so little time… Hopefully, this article will give another perspective on making this big decision!

 

 

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How To Prepare For Interdisciplinary Conferences As A Radiology Resident

prepare for interdisciplinary conferences

You get the email… There is a urology interdisciplinary conference on Tuesday at 7 AM, and you are responsible for showing 4 cases with multiple radiological studies. You’ve never done this before! How do you know which images to display to prepare for interdisciplinary conferences? Is there a logical order to the pictures? Will I be able to answer the questions posed by the clinicians in the room? Your heart beats a bit faster as you contemplate the issues.

This situation is common for the beginning radiology resident. Frequently, radiology programs thrust first-year radiology residents into their first interdisciplinary conference without much preparation. However, even though initially nerve-racking as an experience, these conferences are an excellent opportunity to get to know your non-radiological colleagues as well as a way for them to find out about how knowledgeable you are! Learning how to prepare for interdisciplinary conferences pays off big time!

Presenting for interdisciplinary conferences is slightly different from preparing for typical conferences. Your audience will be a bit more sensitive to mistakes that the presenter makes because decisions can often directly affect patient care. Therefore, today I will discuss some of the common questions that arise when you encounter your first interdisciplinary conference to make you feel more comfortable. These topics include how to sort through what is essential, what to discuss, and when to ask for additional help to prepare for your first solo interdisciplinary conference as a radiology resident. So let’s get started…

Selecting Cases To Prepare For Interdisciplinary Conferences

When going through a case, clinicians like to have the relevant initial diagnostic images and the subsequent follow-up images. So, it is imperative to get the correct history for the primary diagnosis. When you check the computerized records, make sure to find all studies that support the principal diagnosis. Then, you will need to look for the earliest studies of this sort. If the diagnosis is breast cancer, find the first mammogram and breast MRI present on the record. If the topic is metastatic colon cancer, look for the first CT scan showing the metastatic disease.

Next, you need to find the first post-treatment studies. So, find the next series of relevant images. If the topic is a retroperitoneal bleed, see the first series of post-intervention cases, such as the post embolization ct scan. These will usually be the second from the beginning.

And, then finally, look for the most recent relevant studies. If this was a case of metastatic colon cancer, find the most recent CT scan of the abdomen and pelvis to show the final consequences of treatment or lack of treatment.

Selecting Individual Images

There are two ways to show images during a presentation for interdisciplinary conferences. First of all, you can go to the source images in the PACs system and flip through the pictures directly. Or, you can select individual images and display them on a PowerPoint presentation. I would recommend doing the latter. Why? , You leave less interpretation by the audience, and you will get a lot fewer questions regarding things that you are not sure about during the presentation.

Additionally, the clinician will less likely ask about information and findings that are irrelevant. For instance, you are less likely to get a question about that borderline enlarged node on the corner of the film that was not mentioned but is present on the PACs display. By choosing the PowerPoint format, you have much more control over what is displayed, and it keeps the discussion centered on the essential topics.

Also, there is less chance for technical issues. PACs tend to go down when you most need it since it relies on an internet connection. A PowerPoint presentation is much more reliable since you do not have to rely upon the internet.

Also, when choosing individual images, make sure to look for the relevant information without the fluff. For instance, if it is a metastatic colon cancer patient, take those pictures only of the liver metastasis without the volume averaging artifact. If the case is a retroperitoneal bleed, show only those images containing the bleed without other distracting findings on the film. And so on…

Discussions

When it is your turn to discuss a case, keep the discussion targeted. You want only to start discussing those issues that are relevant to the clinician’s question. If they need to know if the metastatic colon cancer lesion is better, worse, or unchanged, provide the clinician the relevant information such as the measurements. If they want a differential diagnosis, offer it. But do not go off on a tangential vector! If you go off-topic, clinicians tend to get angry because of the limited time you will have during the morning to discuss patient care and other cases. So, please don’t do it!

Also, try to look up relevant information on the topic during your preparations before participating in the conference. If you want to look like a star, gain additional knowledge on the relevant issues so that you can answer those questions intelligently and with authority. Then, you will establish an excellent reputation for yourself during the conference. Imagine how you will sound describing the features of colon cancer metastasis if asked rather than muddling through and stuttering.

When To Ask For Help?

So, you’ve gathered your studies and selected your images. When is appropriate to ask your attending for some assistance? Here are some specific circumstances: You have never rotated through a particular modality, and you are presenting those images during that case. You are not sure that the report description is the same as the information on the images. You do not understand the disease entity issues they will discuss at the conference.

I always like to know about any questions the resident may have before completing preparations for a conference. Better to be safe than sorry!!!

How To Prepare For Interdisciplinary Conferences!

Preparing for your first interdisciplinary conference can be stressful, especially if you do not have much essential guidance. Hopefully, this summary will allow you to make more sense of the necessary preparations involved. Good luck with your next conference!

 

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The Uncooperative Patient- The Radiology Resident’s View

uncooperative

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

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

Patient Rapport and Motivation

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

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

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

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

A Couple of Special Situations

The Combative Uncooperative Patient/Family

The Situation

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

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

What To Do

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

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

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

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

The Obtunded Uncooperative Patient

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

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

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

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

Lessons We Need To Learn About The Uncooperative Patient

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

 

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The Chief Radiology Resident- An Insider’s Perspective

chief radiology resident

Every year around the dead of winter in our program, the program directors sit around a table and discuss who will be the next year’s chief radiology resident. For many of you, this process may seem like a mystery box. Why do we even have a chief resident anyway? What exactly does she do? And, how do we make this decision? These are some of the questions you may be asking.

To enlighten you on the world of the chief radiology resident, I will answer these questions. To do so, I will talk about all the nitty-gritty details such as the myriad roles of a chief resident, the perks and downsides of the job, why some years it can be easy or challenging to decide who should be the chief, and how many programs make a choice.

What is the Role of a Chief Radiology Resident?

Roles and responsibilities may vary slightly from program to program across the country. But the essence of a chief radiology resident usually remains the same. The chief resident is the liaison between the resident program and the program directors/attendings. Residents will bring issues that arise among their classes first to the chief resident and then to the program director or responsible attending. Likewise, faculty will bring problems that occur to the chief resident’s attention first, then disseminating the information to the residents.

The duties of a radiology resident include administrative scheduling of residents, scheduling noon conferences, scheduling board reviews, running review courses for medical students and junior residents, voting as a member of the educational committee, attending chief resident conferences such as the AUR meeting, scheduling guest lecturers, planning budgetary arrangements for the residency, interviewing medical students, and more. The responsibilities are significant, and the chief resident needs to command both the attendings’ and residents’ respect alike.

Downsides and Benefits

Like any role with essential responsibilities, there are significant ups and downs to being the chief resident. Let’s start with the downside. The chief resident is often held responsible for conflicts among the residents and between the attendings and residents. They are front and center in many of these issues. Usually, there are no perfect outcomes. Also, the role of the chief resident can be time-consuming and challenging. The scheduling of residents alone is often fraught with lots of emotion and charged conflicts. Each resident wants the best possible schedule for himself/herself, and many times not everybody can be accommodated. The chief resident may be held accountable.

However, there are some significant perks to the role. First and foremost, it can’t hurt to have the words “chief resident” on your resume when applying for fellowships and later attending radiology positions. Sometimes the chief may get to participate in free conferences or get an additional stipend at some programs. Other times, they benefit from getting inside information about the residency program’s inner workings before any other residents. Occasionally, it may help to get a position within the hospital or private practice where the residency is situated.

What Do We Look For In A Chief?

The first most critical feature of an excellent chief resident is to command respect among fellow residents and attendings. We do not want to pick a resident that shows up late, gets involved in numerous conflicts with other attendings or residents, or who is not a “team player.” Second, we look for a resident who has generally performed well academically and can handle the additional load of chief resident administrative responsibilities. And finally, we look for a chief resident who possesses a calm demeanor and is likable by all.

All these personality traits and features will allow the residency to continue to run smoothly and reduce the potential for significant conflict that can make the program director’s job even more difficult. Also, it gives the program directors an additional “ear to the ground” and an advisor that can be extremely useful to prevent miscommunication.

What Makes The Decision To Find A Chief Resident Easy or Difficult?

Assessing who is to become chief is not a decision that we take lightly. An earnest discussion ensues every year among those that make the final decision. Some residency years, one or two residents have been responsible for organizing the class, settling issues within the program, and are performing well academically. And, you may have several interested parties in performing the role and responsibilities of chief resident. When these stars align, the choice to make chief resident is straightforward.

Other years, you have many interclass conflicts, or there is no clear leader that makes decisions for the class. On occasion, we have a year with no one interested in performing the chief resident’s role, knowing there are additional responsibilities. These factors can make it very difficult to come up with a final choice.

How Do Programs Choose The Chief Radiology Resident?

Different programs have distinct policies regarding the installation of a new chief resident. In our radiology residency, the faculty and program directors choose the chief resident during the third year with attendings’ and residents’ input. The chief resident will typically begin his/her duties when the final year starts in July. Some years we have had both educational and administrative chief radiology residents, and other years we have had a single chief resident that takes care of both responsibilities. 

Other programs have a democratic policy, with the residents forming a voting body that may vote upon individual or multiple chief residents. The bottom line: there is no right or wrong way. But instead, the individual culture and traditions of the residency often determine how they choose the chief resident.

“To Be or Not To Be” A Chief Radiology Resident

The chief resident has a significant role in the smooth running of a residency program. The responsibilities can be overwhelming for some and can be an excellent leadership opportunity for others. If the program chooses you to be a chief resident, it is undoubtedly an honor. But, it also involves a lot of extra work and hard choices. Make sure you are up to the task!!!