Not all ordered procedures make sense. Perhaps, the clinician decided on you performing a biopsy based on an incorrect typographical error in a report from the radiology department. Or, even though the clinician thinks that a carotid stent would be helpful, you conclude that the risks of a procedure outweigh the benefits. In the end, these decisions to perform or cancel a study are ours to make, not the referrers. And, sometimes, canceling a procedure for a good medical reason is the best we can do for the patient, end of story. You can feel good about yourself, doing right for the patient. Plus, you have one less procedure for the day!
But wait. Is that all? Well, you have not completed your work yet. What is the one way that you can get yourself into loads of trouble even though you canceled a procedure for a good reason? Hint! You can look at the title above, or instead, check out what I am about to tell you in capital letters: CALL THE CLINICIAN! And, let me tell you why.
It May Delay Clinical Treatment
Even though you serviced the patient well by canceling a procedure, it may not have benefited the patient as you thought if you do not notify the ordering physician. Let me give you an example. You were planning on performing an angiogram to determine the location of a GI bleed. And now, you have canceled the examination because the GI bleeding stopped. And let’s assume you did not contact the ordering physician. Well, perhaps, the treating physician had delayed treatment for hyperthyroidism based on the assumption of your administration of intravenous contrast material. Look what you did! Now, the patient had her treatment hindered for many weeks by your lack of communication.
Potential Increasing Risks To The Patient
Sometimes patients temporarily stop necessary medications before a procedure. For instance, many patients take Coumadin as preventive medicine for stroke if they have a prosthetic valve because they are at increased risk for blood clots. Therefore, typically, you need to withdraw the patient from anti-coagulants to prevent bleeding during or after a procedure.
And, when you cancel a procedure, many times, the patient will not return to their regular scheduled regimen until the doctor reorders it. Moreover, the patient’s risk for stroke can increase each day he does not receive the medication. Therefore, it behooves you to let the ordering physician know. Why would you want to enhance a patient’s risk for further morbidity?
It’s Offensive Not To Notify The Ordering Physician
One of our prime roles as physicians is to communicate results (or lack of results) to our colleagues and patients. By withholding critical information from the ordering physician, you disrupt the link. And, yes, canceling a procedure counts as “critical information.” If you want to make sure not to get repeat customers in your department, be sure not to pick up the phone and call!
You Can Ruin Your Reputation
Technically, you may be the best neuro angiographer in the world. But, if you cannot let your colleagues know that you decided to cancel that stent placement procedure, then, who cares about how good you are? You are not giving patients the best medical care. And, you certainly do not want to establish that reputation.
There’s More To Do After Canceling A Procedure!
Practicing quality radiology involves more than just making quality clinical decisions and performing appropriate procedures well. Just as importantly, we also need to maintain the links of communication with our clinical colleagues so that we can give the best possible care to our patients. And, if sometimes, the best decision for the patient is to cancel a test, make sure to contact your fellow physician. Don’t spoil your excellent patient care with a lack of communication!
In honor of today’s holiday, here is the second radsresident annual Halloween special: a top ten list of the scariest situations for radiology residents! See if you agree…
It’s final. President Trump has signed a bill approved by the Congress to overhaul the U.S. tax system. And, it will take effect starting January 1, 2018. However, I am a bit irritated by the misinformation out there. Watching network TV would make it seem that the tax plan will increase everyone’s tax liability. But as usual, I delved a bit deeper into the facts behind the plan.
To find out what is really going on, I have compared the new and old tax brackets and the different deductions based on the new and old tax bills. We will go through these numbers and calculate what you would have paid through the old tax system versus the new tax plan. More specifically, we will look at a few scenarios. These include a single radiology resident making the median radiology resident salary with no kids; a married couple each making a median radiology resident salary; and a married couple each making a radiology resident salary with 2 kids.
Today, we are going to emphasize federal taxes alone since every state is different and most state taxes have not significantly changed. In addition, we will assume that most of you do not own a home (since that is the minority of residents!). And, we will say that you will pay off the maximum amount of deductible student loan debt. Finally, we will estimate that each resident makes the median salary of 54,378 dollars. (1) I bet you’re curious. So, let’s start with the calculations!
Single Resident, No Kids
For 2017, we used the turbo tax taxcaster software and the median radiology resident salary of $54,378. And, we are assuming that you are paying down the maximum student interest. With this information, your tax liability would be $6634 with a marginal tax rate of 25%.
For 2018, using the calcxml.com software and the median radiology residents salary, your tax liability would be $4,713 dollars with a marginal tax rate of 22%.
So, the truth would be a $1,921 decrease in federal taxes. Not too shabby!
Married Resident, No Kids
For 2017, we used the turbo tax taxcaster software and the median radiology resident salary of $54,378 for both spouses ($108,756). Again, we are paying down the maximum deductible student interest. This time your tax liability would be $13,372 with a marginal tax rate of 25%.
For 2018, using the calcxml.com software and the median radiology resident salary for both spouses, your federal tax liability would be $9,975 with a marginal tax bracket of 24%.
In this case, the decrease in taxes would amount to $3397, slightly less than double the amount for a single resident with no kids.
Married Resident, Two Young Kids
In this situation, we will assume that your children are getting childcare amounting to $5000 dollars per year. For 2017, the federal tax liability based on a median salary and maximum student deductible interest payments would be $8347. The marginal rate would be 25%.
For 2018, using the same software and the median radiology resident salaries, the total tax liability for the family would be $5975 with a marginal tax bracket of 24%.
For comparison, the decrease in taxes would total $2372. Also, much different than what the pundits will have you believe.
My Conclusions About Most Residents And The Tax Plan
For most residents out there, you will take home a small windfall, anywhere from $1921 to $3397, based on a typical radiology residency situation and assuming you maximize the student interest deduction. (To get the best tax deal you should take advantage of it!) Of course, a few radiology residents may not fare as well. For instance, if you own an expensive home or have a spouse that makes a lot of money, you may be in a special situation. But for the most part, you can ignore the pundits. You will do much better with Trump’s tax bill. Just another example showing that we all need to tune out biased media. It pays to check the facts and do the calculations on your own!
Most of us know other radiologists that fit into the category of second-guesser. Perhaps, you trained or are training under someone like this. Consistently, they debate whether to call a pulmonary nodule or vessel on every other chest x-ray. Or perhaps, when a nurse asks a question about intravenous contrast amounts, they equivocate for what seems like hours. Clinicians don’t know how to proceed. The staff becomes upset. Worst of all, even though these radiologists tend to be very smart, they are targets to lose their job because no one is comfortable with their decisions. You know the type. In today’s post, I will give you some tips to avoid becoming a second-guesser.
Think In Terms Of Highest To Lowest Probabilities
Second-guessers often think about differentials that could be this or that with no differentiation between “this” or “that.” What do I mean? All the different options have the same probability as one another. It is rare for all the differentials to be just as likely as one another in the real world. In less than one out of a hundred cases, there are multiple diagnoses with equal probability of an outcome. So, if it makes sense, stick your neck out a little bit in your conclusion and make your impression the most likely diagnosis. Mention the differential in the comments sections with a description of what is most likely, less likely, and outright unusual. Typically, you will find that you are hemming and hawing much less.
Little Decisions Deserve Little Time; Big Decisions Deserve Big Time
When a nurse walks into the room to ask you how much contrast you should give to a patient with a GFR of 59, you need to decide quickly. Sure, it is somewhat important. We do not want to cause a patient renal failure. But, the difference between giving a patient 100 ccs versus 75 ccs of contrast is unlikely to make much of a difference. This decision is worth no more than 10 seconds of my time in my book.
On the other hand, let’s say you need to decide whether you should biopsy a lesion in the liver. Now, this decision has significant consequences. Biopsies can cause bleeds, infections, and more problems. You really may need to spend some time making this decision. If you have to think through the problem for a while, it makes some sense.
Don’t confuse the little decisions with the big decisions. It goes a long way to preventing you from transforming into a second-guesser.
You Can Miss Em’ Fast Or You Can Miss Em’ Slow
A great radiologist from my residency quoted me the following as he scrolled through a panel of plain films very rapidly, “You can miss em’ fast, or you can miss em’ slow.” I take this statement to heart. Sometimes, when reading cases, there comes the point that looking at a film for a while longer makes no difference in terms of perception. Your first look can be your best look. During the first few milliseconds of looking at a film, your brain unconsciously analyzes the film and can tell if something is off better than staring at an image for hours. Use your gut. Don’t perseverate too long!
Not Every Pixel Is The Same
What do I mean by this? Certain parts of a study are high yield, and others are low yield. For instance, in a patient with breast cancer, metastatic disease likes to go to the bone and liver. So, spend more time looking at these organs. On the other hand, metastatic breast disease does not tend to spread to the spleen. So, use your time accordingly. Spend the appropriate amount of time on each pixel. Pixel selectivity is a tool to prevent you from second-guessing yourself.
If All Else Fails, Make A Decision
Finally, sometimes there are no right or wrong answers. Although not perfect, both directions will allow the clinician to proceed appropriately with a workup instead of perseverating. Sometimes, clinicians need that push to do the right next step for the patient. In this situation, go ahead and make a final decision. You’ll be glad you did!
Avoiding The Second-Guesser Syndrome
Sound advice for avoiding second-guesser syndrome is not emphasized in the radiology curriculum. That’s why I’m here! So, avoid the pitfalls of the second-guesser. Go ahead and create a differential with your most likely diagnosis; utilize the appropriate amount of time for the decision, go with your gut, and spend the right time on each part of the images. You, too, can avoid the second-guesser syndrome and become a decisive radiologist!
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!
All told, on any given day as radiologists, we may receive tens of phone calls from our colleagues, technologists, fellow clinicians, administrators, friends, spouses, and patients. We are constantly bombarded with phone calls. So much so that I always wondered about the rate of interruption in a radiology practice. Well, I found one such paper. Confirming my suspicions, a study from Radiology Business(1) looked at 1000 minutes of radiologist observation and found that radiologists were interrupted 94 times or 2.4 minutes per interruption. That sounds about right! So, we are a specialty with lots of distractions.
Some of these distractions can be very important. Others not so much. Regardless, many of us feel obligated to pick up the phone to answer questions and resolve all sorts of issues. However, at what point does a phone call interfere with our concentration? Do these phone calls hamper our performance at the job? Should we always pick up the phone or just let it ring? Or, maybe is it worth our while to hire someone to pick up the phone for us? Let’s look at some of these issues and see if we can develop some suggestions for you, the radiologist or radiology resident, as we peruse the data.
Literature Review On Interruptions In The Workplace
Let’s start with the most general and go to the most specific. We know from multiple sources that distractions can severely hamper correct interpretations. Here are a few of those studies. The first study (2) looked at 54 students creating essays with a control group (no interruptions) and two experimental wings (interruptions during outlining or writing the paper). The authors found that writers reduced the word number and quality in the groups with interruptions.
Another article (3) looked at workers participating in a simulated submarine tracking program. In this study, the researchers interrupted the participants for 20 seconds with a blank screen. They found that the interruption significantly impacted situation awareness. These participants were significantly slower and less accurate in making decisions.
Next, let’s look at some healthcare studies. This point is where it gets even more relevant. An excellent review paper (4) looked at distractions in the healthcare environment. Two of the most pertinent studies discussed in the report included an article that found that drug dispensing errors increased by 3.42% with interruptions. Then, another article showed a relationship between surgical errors and the number of disruptions.
Most relevant to us, a paper referencing radiology residents looked at the error rate of reads. They correlated the error rate with the number of phone calls in any given hour. This study showed a correlation of an increased error rate of 12 percent with each additional phone call received on call. They concluded that telephone call interruptions might negatively impact on-call radiology resident accuracy (5).
Applicability To The Radiologist
So, how applicable is this information to us, the radiologists? Let’s take these studies to heart. We know based upon the literature above that distractions are not so great for essay writing, situational awareness, drug dispensing errors, surgical errors, and most importantly, film reading. These are activities that have a direct relationship to our daily work. I think, therefore, that these studies are directly applicable to our situation.
What Do We Do About The Phone Calls?
Now, this is the million-dollar question. We know that it is part of our job to take phone calls, interact with people, and deal with sticky situations amid our work. However, with this information in mind and the knowledge that interruptions cause problems, we as radiologists reasonably need to mitigate many distractions in the workplace. What does this mean?
Well, perhaps, we should have systems that allow other employees to field some of the administrative responsibilities. Radiologists should not be triaging phone calls. Administrators should ensure that only the appropriate phone calls get to the radiologist’s desk.
In addition, we need to be mindful of the impact of distractions on our work. And we need to make appropriate adjustments. If the phone is ringing off the hook and we don’t have administrators to take these phone calls, perhaps, we should not be trying to answer the phone when we are reading a case. Instead, we should answer the phone only when we have completed reading a study.
Summary
Based upon our whirlwind tour through the world of phone calls, distractions, and our work, we now know that phone calls are a significant issue in our workplace. Next time the phone rings, think twice before you answer it!
Dictating is a rarely touched upon but vital tool in radiology. Over a radiologist’s 30-year career, they may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, the dictation usually spurs clinicians to act on their patients. In my experience, out of 100 cases, clinicians only act on a couple of them using other forms of communication such as conversations with a radiologist or interdisciplinary conferences. Moreover, just like a manufacturing company that creates automobiles, dictations form the end product of the radiologist’s service. We leave over only the dictation in the medical record after we are gone.
Learning dictating indeed has a “steep learning curve,” meaning that residents rapidly incorporate dictation techniques. And, they acquire a lot after the initial year of training. But it takes years and years of experience for a radiologist to fine-tune their dictations to the point of maximum utility for their readers.
Resident Versus Seasoned Dictating
So, how do a radiology resident/newly minted radiologist and seasoned radiology attendings’ dictating differ? Well, certainly every rule has its exception. But for the most part, when you look at a resident or new radiologist’s dictations, you see a more verbose conclusion and a comments section that contains more irrelevant findings. And that perfectly makes sense. Why? Because it takes time for new radiologists to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.
Residents Need More Formalized Guidelines To Learn Dictating
To top things off, many radiologists assume that their residents will know how to dictate appropriately after a short period. And, many believe that a radiology resident just learns to dictate by osmosis. But, in reality, if you want a resident to know the right way to dictate, we need to provide as much guidance as possible. So, that is my goal in this post. To do so, first, I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.
Templates:
When I was a resident just starting, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictating. And then, we would dictate the information on tape recorders to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. It is easier than ever to gather templates from other radiologists for dictation when you are starting.
In the beginning, numerous template choices can complicate how to decide on using a template for a dictation. So, I would recommend finding the best template for a given type of study. Then, stick to this one type of template when you are starting. Sure, some radiology attendings will insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because, in the end, it is your faculty’s report. Overall, just try to be consistent. The more you use a given template, the more likely you will remember all the items you need to include in a dictation.
Even as a seasoned attending, templates are still handy. Why? They save time. In addition, you can use them as a checklist to make sure you have looked at all the different organs and physiological systems within a study. (As I often do!)
Important Pitfall
However, you will encounter a few pitfalls with templates. So, you need to be wary. The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports with the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you see the beginning of the comments section and the impression, the dictation says there is a cystic mass in the kidney. These inconsistencies confound the clinician, leading to phone calls and medically ambiguous outcomes and lawsuits. So always make sure to check your work twice before the dictation is signed off/completed.
Histories/Priors:
Over time, requirements for histories have drastically changed. When I first began my radiology residency, attendings expected a history to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be comprehensive. Our billing managers recommend putting as much relevant data as possible in the history to ensure that the study is fully reimbursed.
One example: When I first started, the attendings frowned upon putting the patient’s age in the dictation history. Now, suppose I don’t add the patient’s age in my cardiac nuclear medicine dictations. In that case, the hospital cannot send the report to the accreditation body for our hospital nuclear medicine department to continue with cardiac nuclear medicine accreditation. So, try to put in as much relevant/appropriate data as possible in the history. In addition, more history can also sometimes help the clinician formulate a proper conclusion to the clinical question.
Finally, make sure to put relevant information from prior studies in this section. Often, instead, residents will add this information to the body of the report. The body of the report should not contain the history. Why? Because the clinician can confound the timing of the findings in your dictation, potentially changing management. Remember, you can refer to the history from the body, but the history does not belong in the body of the report.
Technique:
I consider the technique section the stepchild of the dictated report. The clinician and radiologist often ignore this section. But on occasion, it comes in very handy. Moreover, as a radiology resident, you should report it accurately. Why? For instance, you may say there is a 5 mm axial slice thickness on CT scan. Suppose you didn’t see a pulmonary nodule on that study, and the subsequent study has a slice thickness of 2 mm. In that case, the pulmonary nodule may have been on the prior study but not visualized because of the differences in technique. And, if you do not state the method accurately in the dication, it can confuse the clinician and the radiologist. So, do not ignore this section.
Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will create a fantastic dictation. Then, I look back at the technique section. It is wrong. Of course, the resident did not change the standard technique template format. This dictating error happens more often than physicians realize. Make sure to pay attention!
Comparisons:
The site of placement of the comparison section varies from radiologist to radiologist. I will state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it makes your comments and impression much easier to understand. The reader always knows which study you are referring to for comparison when you state something is worse, better, or improved.
Comments:
If you want to “go to town,” I recommend doing it in the comments section. Here you should place all the pertinent negatives and positives. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. And, if you see an essential finding, make sure to put the slice number in the dictation. Over the years, I have found it much easier for the attending radiologist to pick out the abnormality you are reporting, especially when the finding is subtle.
One issue confounds the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also say the reasons why you think your final diagnosis is what it is. You can hone and tighten that information in the impression section later.
Again, I can’t repeat enough, be careful with using templates. As mentioned above, we often see inconsistencies in the report because standard template statements remain in the dictation. Make sure to erase the pre-populated statements in the comments section if you state a finding that differs from the standard normal template. Be very careful. Remember the report is a legal document. The attorneys can use it against you in a court of law!!!
Impressions:
The impression becomes the standard-bearer and the central representation of the quality of the report. To accomplish that, it should contain the information that most pertains to the clinical question. For instance, if the symptom says lymphadenopathy/possible sarcoidosis, you should place the relevant answer concisely in this section. Always think of the impression as the answer to the study; if you do that, your impressions will become relevant and valuable to the clinician readers.
In addition, clinicians will almost always read the impression. (If not, they should work in another field!) Many of them skip over the remainder of the report. So, I would like to say that the impression exists for the clinician. The rest of the report is for the radiologist. So, make sure to spend the most time on this section. Check this part repeatedly to make sure what you are dictating makes sense and you state it with brevity and relevance. Also, make sure to put your conclusions in this section of the dictation. And, don’t forget to put here anything else that you think the physician will need to know, such as management or follow-up.
Beware Of Technical Jargon
Don’t use technical jargon in this part of the report. What annoys radiologists the most? You got it… Getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many silly phone calls!!!
Stick To The Answers
Finally, the impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely.MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization.
If you notice in the last paragraph, I have placed the most likely conclusion and the recommendation for further study in the impression section. You can leave the other information in the body of the report for further reading if necessary. This way, the clinician knows what you are thinking. Additionally, you have guided her on what to do next without the excess verbiage to potentially confuse the clinician.
What terms are most frowned upon in the impression?
Avoid the usage of cannot be excluded. This statement does not help the physician. Moreover, it does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This event cannot be excluded!!!! If you enjoy angering your colleagues, this statement will work the best. Many clinicians will need to order additional unnecessary tests since she has to work up an improbable possibility.
But, I do like to give one exception to this rule (as always!) In a positive pregnancy test and a negative pelvic ultrasound setting, I will say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. Otherwise, make sure not to use this phrase in the dictation.
Also, do not use the statement clinical correlation is recommended. We, as radiologists, need to correlate the radiological findings with the clinical findings. Clinicians consider this phrase to be a lazy, unhelpful statement almost all the time. Don’t make the radiologist look bad!!!
In addition, you will discover other terms that may irk some radiologists. Others may not care as much. I remember one attending who hated the phrase lung zone and the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologists’ reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!
Structured Reporting Dictating Versus Prose Dictating
Structured reporting itemizes the different findings in list form. Most structured reports are organ-based. And typically, you will create the report as a fill-in-the-blank or menu choice of items the radiologist needs to pick. Using structured reporting vs. prose dictation styles has become an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations, and seasoned radiologists tend to use a more flexible prose style. But, you will find a significant cross-pollination of both techniques at all points in the career of radiologists.
I found a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) In fact, I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation, regardless of the style, is to remember to create your mental checklist and stick to the same program each time you do a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!
Dictating Tips: A Final Conclusion
You will learn the basic mechanics of dictation rapidly. However, learning to dictate concise, relevant, and valuable reports for the clinician takes four years of residency and beyond to hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!
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!
Good evening. My name is Susana, a 3rd-year medical student, very interested in your radiology residency program. I would like to know, if possible, what is the average Step I USMLE score of your PGY1, to know if mine qualifies for your program? Thank you.
Thanks for the great question! It’s a common misconception about how USMLE Step I board scores are used to rank applicants in the match. The board scores are generally not about the average score, but rather the minimum cutoff. The point of using the board scores to help with the match ranking process is to make sure that the candidate can pass the written core exam taken at the end of the third year. And, that is really the only role of the board scores. Most programs such as ours take into much stronger consideration the Dean’s Letter, interviews, and extracurriculars once the applicant has met that specific cutoff.
At our institution we use a cutoff of 220 for the USMLE Step I. However, we have made multiple exceptions over time. First of all, if you perform poorly on the Step I Boards but do well on the Step II Boards, we will often ignore the Step I board scores or average out the two boards scores. Again, the point of the boards for us is the correlation with passing the core examination. A good step II score proves you can pass the boards. Also, if there are exceptional candidates that have other special activities, have had extenuating circumstances for not doing well on the boards, or have proven themselves already by completing a rotation with us, we will on occasion forgo using the cutoff. As an answer to your specific question, if I was to take the average USMLE Step I score over the past few years, it would probably be somewhere in the 230-240 range. But, again I think the average number is irrelevant.
Hope that answer helps!!! Again, thanks for the great question!
If you are just starting practice as an employee with a physician group, you may think you don’t really need to know that much about malpractice insurance. Few physicians have the resources available to defend against a malpractice claim when legal services can cost tens of thousands of dollars and damages or settlements can be hundreds of thousands of dollars. When deciding on a malpractice insurance policy, there are two types to take into consideration: a claims-made policy or an occurrence-based policy.
An occurrence-based policy provides insurance against incidents that occurred during the term of the policy regardless of when the claim is made. A claims-made policy covers the insured for any incidents that occur during the policy period, as long as the claim for the incident is also filed during the policy term. Neither of the policies will provide coverage for incidents that occur before the inception date of the policy.
Tail insurance refers to a policy that the insured can purchase when he discontinues his claims-made policy. The tail allows the insured to report claims for incidents that occurred during the time the policy was active (from the retroactive date to the policy expiration date) even though the policy has been terminated. Tail insurance is generally a onetime payment.. If a physician decides to change employment, wants to continue practicing medicine, and requires a new malpractice policy, tail insurance will be required to continue coverage for all incidents that may have occurred under the old policy. Many claims-made policies offer “free” tail coverage for death, disability, or permanent retirement.
Based on this information alone, it would seem logical that an occurrence-based policy is the best option. However, the two types of policies vary greatly. Depending on how mature a policy is, and the specifics of the policy, the sum of all claims-made premiums along with the cost of tail insurance can approach the sum of all occurrence-based premiums over the same period. If it can be determined that a physician will be eligible for free tail coverage (i.e., he is covered by the same policy through retirement), claims-made insurance is usually the most cost effective. If a physician knows there is a high likelihood of changing employment and malpractice insurance, he may want to compare pricing of the two options including the cost of the tail coverage in his calculations. For example, a physician may want to consider an occurrence-based policy if he knows he is going to work at a location for a short amount of time and will not be able to take the coverage with him.
What To Look For In A Carrier:
While premium costs can’t be ignored, a company’s fiscal soundness, claims handling, and sensitivity to policy holders are also important considerations. Ask about the carrier’s A.M. Best rating. Given the current state of the medical malpractice climate, a rating of A minus is good. Your state insurance commissioner’s office can provide information about insurers licensed in your state and may also be permitted to give information about complaints that have been filed against the insurer.
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Join our mailing list for free to receive weekly articles and advice on how to succeed in radiology residency, the best ways to apply, how to have a successful radiology career, and more. Also, get a copy of the free ebook Called The New Attending Physician Guidebook: How To Search For The Right Job And What To Do Once You Start.
