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When Should I Change My Search Pattern?

search pattern

Heraclitus, a Greek philosopher, has been quoted as saying, “change is the only constant in life.” And that concept also extends to how radiologists should commit to a search pattern. Yes, I have stated that you should affix your search patterns so that you make sure to remember to go through all parts of a study. Of course, we don’t want to forget about the images and organs that we need to report. However, every once in awhile the tide changes and we do need to modify our search strategies to incorporate new information.

Sometimes, protocols change. And other times, how you report disease can vary. Now, that does not mean that you should entirely forego your old search pattern. Instead, you can consider adding the new concept to your old one. Based on this thought process, let’s give you some examples of how and when I have accommodated a new change in my search patterns over my career lifetime. Hopefully, these modifications will provide a better idea of when you should make the change as well.

Coronal/Sagittal imaging

Believe it or not, CT scans at one time were only imaged and reconstructed in the axial plane. In fact, there was a big uproar when we decided to add these images to our studies. The techs, administration, and radiologists said there would be too many images to look at and store. But, it turned out that these reconstructions are critical for the interpretation of CT studies. Often, the appendix only shows up well on the coronal images. And, you can have a challenging time catching many sorts of vertebral body fractures on the axial view. Additionally, I’ve seen a few renal and colon masses that you could only pick up on the coronal view. Scary stuff if you decide to neglect these reconstructions.

So, like most radiologists, I had to add these recons to my search pattern to improve my sensitivity for picking up disease. And, this also goes for other sorts of studies. Remember, different planes can be helpful on MRI to catch glenoid labral tears. So, I no longer neglect the reconstructed images and have added them to my search pattern!

TI-RADS

I figured I would also add an example of a required reporting change that had changed my search patterns for a thyroid ultrasound. Previously, I would only make a brief description of a thyroid nodule’s size and cystic/solid consistency. Now, knowing more characteristics that make thyroid nodules more suspicious for thyroid cancer, I incorporate these findings into my reports. In my mind, I run through all the attributes of each nodule using TI-RADS criterion so that I don’t miss critical descriptors.  Unfortunately, in the interest of time, I can’t always put a TI-RADS rating for each nodule. But, all the nodules have the description needed for the clinician to make that assessment. New reporting systems will often change how you look at and report the images.

“New” Techniques- Diffusion-Weighted Sequences

And, finally, as an example, new techniques and sequences can also alter your search patterns. They force you to look at new images that you had not seen before. In that regard, the diffusion-weighted technique was a game-changer for acute infarct imaging. Naturally, I always look at them first before any other to make sure patients have no acute infarct. Before the advent of this sequence, our sensitivity for detection of acute ischemia was much lower. Anytime a new technique helps with improving patient care; you need to incorporate it into your search pattern.

“Change Is The Only Constant In Life”: An Application To The Search Pattern

Like this great quote implies, we, as radiologists, cannot rest on our laurels. We need to go with the flow to improve patient care. So, when you have new ways of looking at imaging studies that help with diagnosing or treating patients, make sure to add it to your search pattern. Whether it be, different reconstructions, changing reporting systems, or entirely new techniques, our patients will be better for it!

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Full-Time Practicing Primary Care Physician: How Do I Get A Radiology Residency Slot?

primary care

Question:

 

Hi.
I am a physician in a primary care specialty looking to go back to residency, specifically in radiology. I have been in practice for ten years and have realized that I do not want to practice primary care for the rest of my life. Have you had a resident in a similar situation? What factors do I need to consider? How does Medicare funding for residency come into play?

Thank you so much for your blog and the book. I realize this is a rather late stage to make a change, and I would appreciate your input.

 


Answer:

So, this is the deal: I would love to have physicians that have previously trained in other specialties. They make the best radiologists because they understand the clinical implications of diagnostic imaging. Some of my best radiologist mentors had completed another specialty first.

However (and this is a big caveat), it does become more challenging to obtain a slot because of the Medicare funding situation. Once you have graduated from a U.S. residency and start to practice medicine, Medicare does not fund the additional years of training.
But all is not lost. If I were you, this is what I would do. Some residencies throughout the country have their spots funded by private sources in addition to Medicare. For instance, I know in New Jersey that University Radiology Group supports several residency slots privately for the Robert Wood Johnson program. These are the slots that you would need to find. You may want to try calling the departments up individually to find out if they would take a previously trained physician. Otherwise, you will potentially waste your time and money applying to places that would not enroll you regardless of how excellent your application.
And finally (and perhaps most critically), you need to be ready to go through the mental and financial hardships of repeating another residency. Depending on your family situation, you need to make sure that all members are “on board” with the change. It’s certainly not an easy four years. But, I can tell you that going into radiology was one of the best decisions I have ever made!
Good luck with the decision process,
Barry Julius, MD
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What Might Happen With A Residency Merger?

residency merger

Throughout the country, businesses grow to keep costs down. One of the ways that they accomplish this task is by merging. And, if you think that residencies are any different, you would be wrong! Similar to many businesses, you may have noticed that residencies have grown bigger and bigger over the years. While it was once rare to hold ten residents per year per class 30 years ago, a radiology training program of that size is no longer unusual. So, what happens if you begin a radiology residency program and it merges during your four years? Will the residency approach you like a second-class citizen? Or, would you notice some fringe benefits from the process? We will treat these issues and more as we summarize the benefits and downsides of a residency merger!

Benefits Of A Residency Merger

More Residency Resources

First and foremost, you may notice that soon after a residency merger, you may be able to rotate through new departments. Or, you may have access to a simulation center that you did not have before. Furthermore, you may find new grants for residents to start research projects. And you may have at your fingertips a more extensive staff to choose from as your mentor or research partner. That doesn’t sound too bad.

Increased Prestige Of The Residency Merger

Before the merger, you might be in a small community program without “name recognition.” Now that you are part of a larger entity, you may find that hiring practices that want graduates from high-powered programs may be willing to look at your resume for your first job. There is more to a name than you might think!

Faculty With More Time To Teach

Sometimes, faculty at a hospital may no longer have the responsibilities to run their program as they did before. You may find that the staff can now dedicate more time to teaching and residency responsibilities.

Downsides Of A Residency Merger

Loss of Special Programs

As programs grow, they relook at areas in the budget that they can cut so that the senior administration can save some dollars. Perhaps, your residency may have had different outside rotations that you no longer “need” since the entity provides the same service. Or, you may have had a foreign travel program that the original institution sponsored. You know what they say in business: “Cut the fat!”

One Program Director For Many Sites

No longer, you can go to the same program director in charge of everything at your one site. Now, you have one program director for an entire system. What does that mean for you? The program director may have less time to focus on individual residents. Instead, they have multiple sites to “keep in line.” So, you may find that the director caters less toward you.

More Bureaucracy In The Residency Merger

On that same note, now that you have a more extensive system, you may find it more unwieldy for the Institutional Review Board (IRB) approval for research projects. Or, you may have more difficulty getting reimbursed by the system for expenses. With a larger institution, you exponentially multiply the “red tape.”

Increased Traveling Distances

Now that you have multiple sites within a more extensive system, you will likely need to travel to each location. If you live in the city, you may need to go to work via subway, train, or bus. You may need a new car if you live in the suburbs across from your original hospital. Unfortunately, you have a new budget item!

Some Disgruntled Attendings

At most hospitals, the faculty does not like change. Moving around resident call schedules and increasing the responsibilities of the staff can induce resentment among the mix. So they may be less willing to participate in the residency process. Or depending on how the system arranges coverage, attendings may have less time to teach. No change is perfect!

Less Intimacy

Remember that three-person class you had before when you learned each member’s quirks and foibles? Well, that is no longer the case. Now, you will have to contend with colleagues and attendings you will not get to know during your remaining years of residency. When your program touted a small program feel during your interview, they didn’t meet your expectations!

Dilution Of Resources

You remember what your teacher taught you in kindergarten- you need to learn to share! Perhaps, you had a fantastic faculty teacher on service. Or, your program had a one-of-a-kind pathology rotation within the institution. Now that you have a more significant residency, you may have less opportunity to use these resources because they need to be utilized by a larger body of residents.

Change And Residency Mergers

Change is hard. There is no way around it. And, when you enter a residency, some alterations from a merger are beyond your control. But, as you might initially think, a residency merger is usually not all bad or good. Instead, it will afford you some new opportunities and come with some additional palpable downsides. So, what is my advice? Make the most of a changing situation. Learn about the new lay of the land. You never know. Now that your program has included you in a more extensive system, you need to know it well. And make the most of its new opportunities even though they may have some downsides!