Tag: call

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Can You Pass The 2019 Precall Quiz?

precall quiz

Once again this year, I am presenting 10 cases from our precall quiz. These cases will help to determine if you are ready for taking call at your institution. Each of these is the sort of the case you will likely encounter on call at some point. Sixty-five percent is passing. Partial credit is possible. Make sure to write down the answers on a sheet of paper and cross-reference them with the answers provided on the bottom of the page. See if you will be competent to take overnights or if you need to study a bit more before you are ready!

By the way, if you think you can score better the next time or if you want some more practice, check out the previous years’ precall quizzes. The links to the 2018 and 2017 quizzes are right below. Good luck with the exam!

2018 precall quiz

2017 precall quiz

 

Case 1:

 

 

Case 2:

 

Case 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 3:

What is the possible diagnosis?

How would you manage this case at nighttime?

 

Case 4:


Case 5:

Case 6:

 

 

Case 7:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 8:

 

Case 9:

What is the diagnosis?

What else would be of help to increase the specificity of the study?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 10:

 

 

Answers to Cases:

  1. Right-sided ileocolic intussusception
  2. Right perihilar mass with pneumothorax
  3. Possible diagnosis: fetal demise with conflicting images in M-mode, How to manage: scan yourself in real time with M-mode or cine
  4. portal venous gas, bowel pneumatosis, SMA thrombosis- call surgeons
  5. Proximal transverse colonic apple core lesion, suspicious for primary colonic neoplasm
  6. Normal CT brain
  7. Hill-Sachs deformity with a loose body (greater tuberosity overlying the glenohumeral joint)
  8. Mets with multiple levels of cord compression. Abnormal signal within the cord, suggesting ischemia.
  9. Findings suspicious for PE (High probability study- old verbiage), What would increase specificity? A prior V/Q SPECT
  10. Left distal ureteral stone with left-sided hydronephrosis and hydroureter and adjacent inflammatory change, porcelain gallbladder (increased risk for carcinoma)
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Calling For Help- A Sign Of Weakness Or Strength?

help

Back in the day (in the dark ages!), when I began taking call years ago, each radiology faculty member brought home the beeper on occasion to cover any resident issues from home. Meanwhile, the resident would give independent reads overnight without the attending help. Imagine no real nighthawk or night-attending coverage whatsoever!

Rarely, if ever, would a resident dial the attending (god forbid!) for some help. Moreover, if the resident spoke to the faculty member past 10 PM, he would place him on a blackball list. (Kind of like the McCarthy era) In essence, this resident’s name would ring throughout the department as “incompetent” and “childish” for having to make the phone call for the next several years.

Nowadays, at least at my program (and hopefully at most), the faculty members encourage phone calls at nighttime. If an event significantly affects the department, I, as a faculty member and associate program director, would rather hear about it at night than have a disaster in the morning. And that goes for all the radiologists in the department. Today, I consider the ability to know when to call an attending a sign of significant strength. But is there something useful about the old-fashioned approach? Or was it pure hazing, no more, no less?

Strengths Of Discouraging Nighttime Calls For Help (The Blackball Era)

Were there any net positives of feeling that you could not call your superiors for fear of a severe backlash? Well, I would like to say that it was all bad. But in reality, several net positives overwhelmed many of the negatives. And unfortunately, newer residents lose out on some of these experiences.

First, once you start having backups, whether a nighthawk, in-house attendings, or senior residents, you lose the independence of judgment. No longer do you worry about missing findings. Instead, you know an attending will eventually find it later.

Moreover, knowing you have a backup makes call a less practical learning experience. Knowing that your decision will make the difference between patient injury and a good outcome, you will treat the case differently.

In that same vein, the learning experience of call was much more intense. One of my attendings used to say, “pressure builds diamonds.” Well, I believe that statement contains some truth. Those evenings I spent making the tough decisions alone stuck with me for years. And I am thankful for that.

Finally, you developed a camaraderie with your fellow residents in other disciplines who were in the same boat. These connections carried through for the remainder of the residency. Today, it’s not quite the same. Each department in the hospital has its backup system. And in a sense, we rely on each other slightly less.

Weaknesses Of Discouraging Nighttime Calls For Help (The Blackball Era)

First and foremost, you can see why a junior resident commanding a whole radiology department cannot lead to the best patient care outcomes. And, rightfully so. I would rather have a seasoned attending reading my films than a junior resident.

That premise leads to the next issue, delays in patient management. ER attendings were less likely to allow the resident to make a final disposition. Often, they would keep the patient in the emergency department to wait for a “final read.” For instance, if a resident reads a case without backup, patients sometimes slip through the cracks. Based on an occasional discrepant radiologist read, an ER attending may occasionally fail to work up the patient appropriately. Or, the ER attending would rarely send patients with appendicitis or ectopic pregnancies home based on a faulty resident read. So therefore, some ER attendings would choose to delay management until the attending radiologist returns.

And finally, does a resident that seeks help from an attending deserve placement on a blacklist? Probably not. It is an unfair practice. I could easily compare it to a fraternity that requires its new members to guzzle a case of beer. It doesn’t make it right.

Preponderance of Evidence

So, which way serves the radiology resident, the patients, and the institution the best? Based on my arguments for both sides, this call is not as easy to make as you might think. However, as much as I learned from being discouraged from calling my superiors, I believe that patient care should take priority. We all took some form of the Hippocratic oath. And therefore, we should try to lower patient morbidity to the best of our ability. Also, decreasing the time spent in the ER improves patient outcomes. Even though today’s residents lose some of the independence we had not too long ago, trainees and faculty have to think of patients first.

So, call your attendings for help if you need it. And, faculty, please treat your residents respectfully after they call. We no longer live in the dark ages. Calling your attending is appropriate for the best patient care. And patient care should come first!

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Dealing With The Abusive Nighttime Physician: Rules Of The Road

abusive

Picture this scenario. A Napoleon-like 5 foot 2 verbally abusive surgeon enters the reading room. He begins to yell at you for not performing an intussusception reduction the way he likes. Moreover, a team of surgical residents stand behind him, each member turning red with embarrassment as he continues with his tirade. His verbal abusiveness becomes more and more aggressive. He uses terms such as “idiot” and “moron” to describe you as you attempt to get a word in edgewise. You feel like you want to strike your fist in his face. Does this situation sound vaguely familiar? How would you deal with this everyday but unfortunate situation when you are alone at nighttime?

#MeToo

First, no one should have to contend with harassment such as this. I don’t care if you are a resident, nurse, janitor, or attending. Unfortunately, although society has finally come to terms with refusing such abusive behavior and isolating these individuals, many hospitals still silently condone it. How and why? Perhaps, the hospital is understaffed and would rather have someone to fill the gaps even though he has an abusive personality. Or, the hospital may hire an inappropriate physician because she has a good reputation and brings many patients into the system. Regardless, the behavior is unacceptable and needs to be dealt with accordingly. So, let’s go through some of the processes you need to complete to prevent this harassment again.

Engage Softly With Team Response

The last thing you want to do as a resident is fight fire with fire. If you continue to raise your voice and tussle with this attending, you are making a containable situation into a nuclear bomb! Instead, what is the appropriate course of action?

You can say to this individual quietly, “I am just trying to help you care for your patients appropriately. We are in this together. I will talk to you again when you speak to me professionally so we can help your patient together.” Usually, the raving physician calms down if you maintain a quiet and calm demeanor. At this point, the situation usually de-escalates. Who knows? You may even receive an apology. But that may or may not be the case.

Document, Document, Document

So, what next, assuming the situation does not calm down? If the surgeon has been harassing you, it is most likely a long-standing observable pattern of inappropriate behavior. And this physician has likely affected many other employees within the hospital as well. Therefore, you should document the behavior in written form. State the time, place, and situation as objectively as you can. Then, place the document on the side for further use, if necessary.

Next, you may want to ask other observers, if present, to create a supporting document. This report lends credence to your inappropriate interaction. You are better off gathering multiple documents to establish a pattern of behavior.

And finally, for each time you encounter these behaviors with this individual, you create another document. You are making a paper trail that will help remedy this situation.

Speak To Your Supervisor

As for the next step, you must contact your residency director or associate residency director first thing in the morning. Speak to them and give them the documentation. If possible, leave the wheeling and dealing in the hands of the local administration. Why? Well, often, the lowly resident does not have the influence upon human resources or senior administration like a long-standing faculty member does. And, the administration can turn back the blame on you.

Last Resort- Human Resources

OK. So, your supervisor has not yet fixed the situation. Or, maybe she settled it for that one time, but the abuse is recurrent. Where do you go next? Sometimes you have to go right for the horse’s mouth. You may need to talk directly to human resources and hand in the documentation yourself. Usually, this will begin a full investigation into the matter. Of course, hopefully, you can avoid this situation. Unfortunately, on occasion, you need to act to protect yourself in this way.

Final Thoughts About The Abusive Physician

We all went to medical school and began training to become consummate professionals. Along the way, unfortunately, you will encounter abusive physicians that do not follow these rules of professionalism. Often they have issues of their own. But that does not excuse the actions of these individuals. We, as clinicians, should act according to the rules of civil behavior. And if these abusive physicians cannot play by the rules, either they need to change their ways, or they should not be able to practice medicine. So, we serve all by taking action and not remaining silent.

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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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Want To Be A Successful Radiology Resident? Learn To Triage!

triage

When program directors hear complaints about their residents, we find most do not stem from resident incompetence. Nor do the complaints relate to professionalism issues. Instead, a good majority arises from a lack of a timely response to reading cases. And these delayed reports result from a lack of appropriate triage. So, I think you know what we will talk about today. You guessed it! The topic is tadaaaa… how to triage your cases.

A Common Scenario

It’s 2 AM, and a bleary-eyed resident starts to pick off STAT CT scans from the worklist to catch up on his reading from the nighttime. A house physician rushes down from the floors to speak with the resident in a huff. She explains that she needs to discuss a case from a week ago that she must present for the tumor board the following day. The resident obliges. Thirty minutes pass, and the house physician leaves.

Next, a few minutes later, an ultrasound technologist stops by the reading room because she questions whether a renal cyst is simple or complex. Like a robot, the resident scans the patient in the ultrasound room to make the determination. Another 30 minutes go by.

While scanning the patient, the resident gets two beeps which he needs to call back. He gets to both those phone calls. One of the phone calls comes from a patient’s father, who asks a question about his son’s chest film from the previous day. The conversation drones on for 15 minutes, and the resident can barely get off the phone. But he does eventually. Right afterward, he quickly responds to the other phone call and promptly answers the nurse’s question on the other end.

The resident starts to reread the CT list, and a technologist interrupts his train of thought as he walks into the room. Solemnly, the technologist asks, “How much contrast should we give this patient with a slightly low GFR?”. Immediately, the resident attends to the technologist. However, the resident is unsure and looks through the literature to find the appropriate answer. After 10-15 minutes, he finds a piece of paper and says, “75 ccs of Visipaque.”

Finally, an angry emergency department attending calls to the radiology reading room, “Where the hell are the results from the nighttime CT scans? We have been waiting 4 hours. Sorry, but we are going to have to write this up as an incident in the morning!” Where did the time go by?

Ways To Triage In The Above Scenario

So, what could this poor weary resident have done differently to prevent himself from getting written up by the ER doc? Well, lots of things. For one, did he have to review the tumor board case with the house physician? No. Should he have spent 30 minutes determining whether the renal cyst was simple? Probably not. The resident could have delayed until the morning. Did the resident need to speak to the patient’s father for so long? I don’t think so.

To summarize some of the problems the resident experienced with triaging in the scenario above, I have divided some of the main concepts about radiology triage into the following paragraphs. Here are some general recommendations for triaging cases to avoid situations like this.

Keep Your Eye On The Prize

Remember… When you are on call, the first goal is not to kill anyone, and the second is not to injure anyone. By ignoring the STAT list and tending to other people’s “problems,” you are increasing your chances that something terrible will occur. Perhaps, the CT Abdomen/Pelvis for appendicitis with a positive study will get delayed. Or, you will miss that opportunity to catch that hemorrhagic stroke before it is too late. Delaying STAT reads can theoretically cause irreparable morbidity to your patients. Therefore… Keep your eye on the prize. Complete those studies that are urgent first!

Also, if the activity is not critical, you can delay it until the following morning. In the case of the ultrasound technologist questioning a cyst above, sure, it is an important question to answer. But not so much when you have a list of 5 or 10 STAT CT scans you need to look at. You always have the option of delaying such study until the AM.

It’s OK To Say No

At nighttime, you are going to get all sorts of requests. Some are important, and others are nonsense. Do not let your colleagues bully you into concentrating on peripheral activities that do not directly affect patient care. If you don’t have time to look at that tumor board case, simply say so. Sometimes saying no is just the right thing to do.

Attend To Your Study First, Then Your Colleagues

According to my previous blog, Should Radiologists Ignore The Phone?, residents pay a significant penalty when discontinuing their thoughts midstream. Error rates increase dramatically. More relevant to this post, however, the time to complete a study increases significantly, increasing your chance of causing an angry ER physician. Therefore, it is imperative that you briefly let your colleagues know that you need to complete the study first and will answer their questions as soon as you finish.

Triage And You

One of the most essential facets of the nighttime experience is learning to triage. Believe it or not, you will use these skills for the rest of your career regardless if you take call or not as an attending. What studies do you need to complete first? Who should you attend to? These are all triaging skills you need to learn to succeed. Using some basic triage concepts above, ensure your nights are shorter and safer!

 

 

 

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Ten Things Radiologists Cannot Tell The Ordering Clinician (We Wish We Could!)

ordering clinician

As residents and radiologists, we have all experienced frustrations that we cannot verbalize to an ordering clinician for fear of retribution. Perhaps, the ordering clinician may stop referring patients to us. Or, just maybe we will get written up in the middle of the night for performing unprofessionally. That would end badly! Regardless, I have created a list of ten things that all radiologists and radiology residents wish we could tell you, the ordering clinician, but cannot quite get up the nerve to do so. So, here we go.

Examine The Patient First

How frustrating is it that patients get a hepatobiliary scan to rule out cholecystitis, only for us to discover afterward that the patient had a cholecystectomy? Or, we receive a CT scan to rule out appendicitis, only to find out there is no appendix! Come on, guys, do your due diligence, PLEASE!!!

Throw Me A Bone- Give Me Some More History

You ever heard that saying called GIGO- garbage in, garbage out? Well, that certainly applies to us! Please, no more clinical histories with abnormal clinical findings or rule out? What does that exactly mean? If you want your reports to be somewhat valuable, throw us a bone!!!

I Cannot Read Your Handwriting- Write Something Legible Next Time.

Ever consider the amount of time we waste trying to mull over what you wrote on the prescription? Precious time that we could have used to get home earlier lost! Did you write CT w/ for contrast, or does CT w/o mean without contrast? This stuff matters!!!

Get An Answering Service, Bub!

Yes, there are times that we need to contact you. One of the most frustrating things in the world is to make that phone call that your patient has a pneumothorax only to find you, the ordering clinician, are out to lunch without anyone to contact. Please, please, please. If you are not around, find us someone who is covering!!!

Don’t Kill The Messenger

Hey, guys… We are only trying. Don’t get angry with us when we are doing you a service by letting you know that patient has an unforeseen pulmonary mass. Or, maybe we want to tell you that your patient has acute appendicitis. I don’t care if you are on vacation when we get you on the phone. Please show us a little bit of respect!

Just Provide The Relevant Facts, Man, We Don’t Have All Day!!!

We, too, have studies to read and patients to see. Could you not keep us on the phone? We have to hear about all the patient’s irrelevant labs, history, and physical examination. Keep it short and sweet, folks. We have lives that we would like to lead!

Don’t Send Us Your Patients At 4:55 PM!

Why do you like to send us your patients right before we are about to leave? Well, maybe, that patient with a GI bleed that you don’t want to work up because you want to go for the day. So, you send that patient for a GI bleeding scan instead of an endoscopy that you would typically do. The patient gets extra radiation, and then you delay the final diagnosis. Is that good patient care? NO!!!

We Are Not The Hospital Dumping Ground- Take Care Of Your Patients

So, your patient is giving you anxiety because he is combative on the floor. Therefore, you send the patient out to get a test so you can get a breather. Well, if you can’t handle your patients, we certainly can’t control your patient when they need to stay still. We are not the hospital dumping ground. At the very least, give your patient a valium if you send them down to our department!

If You See Us Dictating- Don’t Interrupt Us Until We Are Done!

You wouldn’t stop a surgeon in the middle of surgery. So why the heck would you want to interrupt us in the middle of our dictation? We provide essential information to our clinicians, and studies (1) show that interruption prevents radiologists from making all of the findings. Please… Appreciate what we do!

Give Us A Chance To Look At The Films Before Coming Up With A Final Opinion

So, you came down to our department to talk to us about the study you just ordered. Maybe, it is a CT scan of the abdomen and pelvis. Or perhaps, an MRI of the knee. If you know the nuances of reading these studies and you are telling us all the findings, then why did you come down in the first place? Did you do a 4-year radiology residency already? I think not. Give us a chance to make the correct diagnosis, not the one you want to tell us!

Final Words To The Ordering Clinician

We are clinicians, too, so we appreciate some professional courtesy. Do onto others as they would do to you!

 

  1. http://www.academicradiology.org/article/S1076-6332(14)00307-9/fulltext?cc=y=
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The Midnight Radiology Resident Discrepancy

discrepancy

If you haven’t had a discrepancy with the covering morning radiologist as a resident on call, then one of you encountered one of three outcomes. You either haven’t read enough cases. Two, you are the long-lost great-great-grandson of William Roentgen; Or finally, perhaps your name is Watson, the artificial intelligence computer, and you work for IBM!!!

The truth that very few attendings seem to admit is that everyone, including themselves, will miss something every once in a while. One study reported radiologists clinically miss something important between 2-20% of the time. (1) From my experience, that number looks pretty high, but the rate is significant enough. So, when, and notice, I don’t say if you miss something and have a discrepancy at night, you are an ordinary radiology resident. I would even go as far as to say that you are fortunate, in a sense, because you didn’t miss the finding as a full-fledged attending. You have someone to back you up, and hopefully, you will never forget that finding again.

Accepting The Inevitable Discrepancy!

The first step, of course, is to prevent major misses. The cases you need to study leading up to taking calls are the cases that are common and lead to significant morbidity and mortality. You want to view hundreds of different types of appendicitis, aortic ruptures, pulmonary emboli, and so forth so that when the time comes for you to take a call, the chance of missing the critical finding is significantly lower. Unfortunately, however, we can’t prevent all the inevitable misses, and frankly, we have to admit to ourselves first and foremost that this will be the case.

So, what do you do when you have a significant miss? Maybe you sent a patient home with acute appendicitis or a patient with a ruptured ectopic pregnancy. Perhaps you missed an early retroperitoneal bleed. There are specific keys to making the discrepancy in any of these cases, not just another horrible encounter, but rather a learning experience that is valuable for the remainder of your career. We will go through a few rules that you need to follow in the rest of this chapter.

Don’t Perseverate Over The Discrepancy

The first important point is how you emotionally react to the discrepancy. It is also a life lesson. We can’t undo what you did. You need to move on… Perseverating on a miss is counterproductive at best and, even worse, can cause future misses. Remember, just because you made a significant miss does not mean you are or will be a horrible radiologist. So, you need to get over it. The same rules apply to questions on written exams, future failures, etc. One miss does not a radiologist make!

Make Sure To Follow-up The Patient In The Morning

When you find out about the bad news, it is inappropriate to leave the department sulking, not attempting to make good on the miss you made. Try to do what you can to make sure that the physicians in the emergency room know there was a discrepancy. Or, you may need to call the patient back yourself, if need be. Bottom line… You need to make an effort to clean up your mess. It is partially your responsibility.

Read All You Can About the Miss To Not Make the Mistake Again

Reading about the disease, reviewing the films, looking at other similar cases: These are all the things you should be doing soon after the miss. This miss is a real opportunity to understand and fix the incomplete knowledge you had on the subject before, and, of course, to never make the same mistake again.

Teach Others

One of the most rewarding ways of compensating for the discrepancy is to make your fellow residents and junior residents aware of the miss. Teaching your colleagues protects them from making the same mistake that you have made. And, even better, it reinforces the knowledge you have, thereby making it much less likely that you will repeat the same mistake. Just like lightning, it rarely strikes twice!!!

Learning From Midnight Discrepancies

Midnight discrepancies are part of the everyday learning ritual for a radiology resident. It is not the discrepancy itself that is a problem. That is expected and is part of the typical routine residency learning experience. But instead, the issue is how you as a radiology resident learn and grow from the experience. Make the best of a challenging situation!!!

 

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Radiology Call- A Rite of Passage

call

Every year around the beginning of July, I see some of the most haunted radiology resident faces, right around 10:00 pm, just after the attending evening shift ends and the resident night shift begins. It is almost always a second-year radiology resident who happens to be starting their first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And most importantly, will I kill someone?

The resident only unlocks the answers to these burning questions on the first night. Only after this event does the resident and the program director know whether or not they can handle the burdens of a radiologist. Everything in the first year leads to this point: the precall quiz, the intense reading, the conferences, and the studying. It’s crunch time.

Just before the first night of the dreaded call, my famous last words are: you begin the night as a kid, and you will end the night as an adult. Why do I say that? Because I think the truth lies embedded in that statement. You can never become a full-fledged radiologist until you are responsible for independently making patient decisions. It’s like all those ancient traditions in all religions/cultures, like hunting that first wild boar, the confirmation, the bar mitzvah, etc. The residency now allows you to function as an independent, freethinking human being who can make decisions on your own. Until then, you are merely an observer, not an active participant.

Since taking night coverage is such an intense and essential experience, you must follow certain tenets to make it valuable and safe. I will enumerate eight simple golden rules of call I wish I had known before beginning those fated first nights to come. I urge that you follow all of them to enrich your education safely. Do not stir the wrath of your fellow staff members and program directors in the morning by breaching these rules!

Look at every film with these primary thoughts- what will kill the patient, and what is common?

I can guarantee that if you look at every film with these thoughts at the forefront of your brain and have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. If you see a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think of acute appendicitis. And so forth. Thinking about badness will prevent undiscovered horribleness in the morning.

Likewise, when you look at films, always think about the most common diagnoses first, and you will be right much more often than wrong. For instance: Opacity on a chest film- pneumonia, not Hampton’s hump. Restricted diffusion on a brain MRI- infarct, not ependymoma. Abnormality on a GI bleeding scan, think primary GI bleed, not Meckel’s diverticulum with bleeding gastric remnant. I can guarantee your attending faculty will look at you funny if you come up with too many zebras!

Always, always, always maintain your search pattern in every study.

In the radiology world, one of the main ways to miss something is not to look for it. Sometimes in the middle of the night, the pressure will seem impossible, and you must deliver an answer at that second. Perhaps, a team of 4 angry surgeons comes down and asks, “What is going on with the film?” and needs to know now! Or, an inpatient resident shoves a chest film in front of your face and says, “What’s going on here?” Maybe, the emergency medicine doctor calls incessantly to get a read on that CT chest for dissection.

In each of these cases, I don’t care how emergent and immediate they need the answer, always step back and go through your search pattern. Everyone makes this cardinal error at one time or another. Avoid it! Step back and say give me a moment. Go through each organ or region rigorously. You will look much less stupid than blurting a diagnosis/finding out only later to realize it was wrong because you haven’t thoroughly analyzed the study. One of the worst feelings is finding the doctor who just left your department with the wrong answer, who is getting ready to begin an unnecessary surgery on a patient, or a doctor who will discharge a patient that needs to stay in the hospital!!

If there is no harm to the patient, it is easier to do the study than to fight it.

Most residents take a while to learn this one piece of sage advice. At nighttime, you will have limited time for everything. Interruptions will pull you in fourteen different directions at once. You will receive calls from the emergency department, the floors, the surgeons, etc. And often, these events tend to happen all at once. So, I urge you that if a study is reasonable, do it.

You will spend more time and energy preventing a study from getting done than just completing it. Of course, if it significantly harms a patient, then obviously avoid it. But that is the exception rather than the rule. That fluoroscopy study to rule out a foreign body that you try to block after the resident ordered it: I can guarantee it will come back hours later when you are either exhausted or have lots of things going on at once. So, just do the study!!!

Don’t let your temper get the best of you. You will hear about it in the morning!

Every resident encounters a curt gynecologist, a rude surgeon, a loud, demanding resident, and so on at some point. You are likely going to be grumpy and tired as well. It may seem like a good idea to talk back to that person similarly rudely and unprofessionally. Or, you may want to take a swing at one of these annoying chaps. But don’t do it. One of the most common complaints at nighttime is a letter written by an attending or a resident colleague saying this radiology resident was unprofessional and handled the situation poorly under pressure. This complaint will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident’s file/record. Don’t let that be you!!!

Residents best handle resident matters. Attending matters are best handled by attendings.

At nighttime, many times, a clinician may need an attending radiologist. So, make sure you don’t go in over your head. Call your attending when necessary. The worst thing you can do in the morning is to perform a procedure that your attending should have done or make a phone call that really should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town in the department, not in a good way. An attending should always read a brain scan because of litigation issues. A faculty radiologist should always be present for an intussusception reduction. And so on. Don’t go over your head!

On the other hand, if you have a resident issue at nighttime, try to handle it yourself. If the Emergency Department asks you whether to give the contrast, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the more minor decisions by playing the role of a radiology resident.

Ask for help if you can’t handle something at nighttime.

Sometimes, the job may be too much to bear for one person. (A disaster happened with every patient getting a total body CT scan) Perhaps, it is a question that an expert needs to answer. (A subtle abnormality on an emergent Neuro CTA) And, other times, administrative issues that only your chair or program director can handle. (The MRI broke – should we recommend sending patients to another hospital?) If such problems arise at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it is a patient question that you are not sure about, ask your chief resident. Then, if they can’t answer the question, you may want to ask the assigned attending on-call. And, up the chain, it goes.

If you decide to handle everything yourself and it is inappropriate for your level, you can almost be sure that repercussions will occur in the morning. So please, ask for help when it is needed and appropriate!!

Always answer your beeper/phone/pager.

Occasionally, we hear about a resident sleeping and not answering their pager at nighttime. Unfortunately, those residents will often get written up in the morning for lack of timely dictation. So, jack up the sound on your beeper/phone/pager. And, take all calls!!!

Look at the films. Don’t rely on the ER or Nighthawk reads.

Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. So, do not repeat a dictation or reading that is already present. You should do everything de novo/from scratch, although you should look at their reads afterward. It also seems silly when the resident’s dictation matches the Nighthawk dictation verbatim and hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes that a resident used to check the cases even though others have looked at the study. And, it is not infrequent that our residents catch essential findings that the nighthawk didn’t notice. So please, do your independent reads/dictations!!!

Summary statement

Call is a challenging but integral part of raising a radiology resident right. It is a time of trials and tribulations. You can and will make it through this harrowing trial if you follow the golden rules. Good luck!

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Need some help with what you need to learn before taking call? Check out the following books on Amazon!

Emergency Radiology Case Review Series

Core Radiology

 

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This article is featured on auntminnie.com!!! Click here for the Aunt Minnie version of the article. 

 

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Can You Pass The Real Saint Barnabas Diagnostic Residency Precall Quiz?

Today you are in for a treat. Our first-year residents at Saint Barnabas have all passed my homemade Precall Quiz with flying colors. So I was thinking why not publish the same 10 cases with images/videos below so you can test yourselves? (Don’t forget to look at the links to the videos for questions 2,3,5,6,8, and 10 that are either after the images or are on their own!) I also gave each resident up to 5 minutes to come up with a final diagnosis and they had to get at least 80% correct to pass. Can you do the same? Check out the answers at the bottom of this page to see h0w you did. If you pass, you are ready to take call!!! Let’s begin!!!

One…

 

Two…

 

Case 2 movie

 

Three…

 

 

Case 3 movie

 

Four…

 

 

Five…

 

Case 5 movie

 

Six…

 

Case 6 movie

 

Seven…

 

 

Eight…

 

Case 8 movie

 

Nine..

 

April 4, 2016

 

 

April 4, 2015

 

 

April 4. 2015

 

Ten…

 

Case 10 movie

 

1. Free air and air tracking adjacent to the ascending colon.

2. Acute appendicitis

3. Type A Aortic Dissection- Call Vascular Surgery!!!

4. T10-11 Disc Herniation with acute cord compression and possible early cord edema.

5. Normal/ nonspecific mesenteric subcentimeter nodes- ? mesenteric adenitis

6. Right-sided UVJ stone with right-sided hydroureter and hydronephrosis.

7. Left MCA distribution acute infarct with MCA thrombus. Evolving right frontal infarct.

8. Bilateral pulmonary emboli and right pleural effusion/air space disease

9. Probable old trochanteric avulsion fracture- Key point- it is chronic (lesson- look at priors!!!)

10. Proximal sigmoid mass, probably subserosal with findings suggestive of large bowel obstruction. Additional mesenteric adenopathy.

 

 

 

 

 

 

 

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The Precall Quiz: Mechanics of The Test And Preventing Failure

It’s getting to be that time of the year. Spring… Ahhh… Birds chirping, snow melting, and oh yeah… of course… first year resident preparation for the first night of call. Often times this process begins with a bang called the Precall Quiz.  Although it is not a specifically required measure for being able to start call, it is a way that many residencies assess the functioning of the soon-to-be second year in a “real-world” situation. Sometimes the residency program sets up the precall quiz. Other times, the residents create it. Regardless of who prepares the exam, the first year resident needs to prepare the same. Since the contents of the examination are generally limited to call cases, he/she should be able to expect what is going to be present on the quiz and be able to pass it without question. In today’s post, I am first going to go over the mechanics of a proper recall quiz, whether prepared by the chief resident or program director. And then most importantly, we will talk about how a resident should prepare to pass the test and make sure to feel “comfortable” taking his/her call for the first time. Here we go!

For The Residency Program: What Is A Fair Precall Quiz?

A precall quiz should consist of both the material/contents needed for the first night of call as well as be similar to the way that cases are taken on a night call. What does that mean? Emphasized cases should be situations that could “kill or severely injure patients” or are very common. In addition, it should also contain a few normal variants. These components will most simulate a real night on call.

Furthermore, the style of the examination should be given in the same way that call is taken. In other words, it should probably be administered on a PACS workstation in the way that cases are usually evaluated. Some residencies may still use the PowerPoint format. But, I think there is a danger to giving an exam with cases in this style. Giving individual pictures in a PowerPoint presentation format only assesses knowledge base and not the ability to find lesions on imaging modalities. Both of these qualities need to be evaluated prior tuo beginning call. Or else, a resident that passes this sort of examination is not truly assessed on all the fundamental knowledge bases needed to assess call competency. In fact, these residencies may be setting up certain residents for failure without the appropriate learned “finding strategies” when night call begins.

For The Examinee: How To Pass A Precall Quiz?

Studying should theoretically begin when the resident starts residency. However, many times residents will often cram knowledge into a short period of time prior to an exam. Either way, the examinee should really concentrate on ER case studies prior to taking the test. These should be the killer diseases such as aortic ruptures, pnemothoracies, neurological bleeds and infarcts, and so on. Also, you should be looking at lots of cases that are very common with some morbidity such as appendicitis, diverticulitis, cholecystitis, and more. I would recommend the Emergency Radiology Case Review Series as one resource that would be very help for taking the taking quiz. But, of course, it just a starting point. Make sure to look at hundreds of versions of the common disease entities so that there are no surprises on your first call night. It can be as simple as Googling appendicitis and looking at all the ways that this disease entity presents. But, it is just as important to attend your rotations real time so you have the experience of knowing how to use the PACS system to scroll and find these disease entities in a “real word” setting.

How To Feel “Comfortable” On That Dreaded First Night of Call

OK. I lied a bit at the beginning of this post. The truth is that no trainee radiology resident ever truly feels comfortable on their first night of call, unless you were born with the genius gene or you are missing the emotion of fear! So, do not expect to feel entirely in your element. That being said, if you know cold the entities that will kill or severely injure patients, have studied appropriate cased base material, and attend your daily rotations it is very unlikely that you injure anyone. The knowledge that you passed your precall quiz and know the basics should put you in good staid. Remember that most radiologists before you have been through the same situation as you and most have made it through the first night of call unscathed. And if you listen to me,  just like them, you will make it through the process too!