Tag: radiology resident

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Which Radiology Meeting Should I Attend?

radiology meeting

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

“Going Big”- The RSNA

Plan Ahead

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

Lots Of Activity

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

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

“going small”- The Subspecialty Conference

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

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

AUR Meeting- The Academic Radiology Conference

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

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

The “Pure” Board Review/CME Conference

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

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

Best Radiology Meeting To Attend During Residency

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

 

 

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How To Prepare For Interdisciplinary Conferences As A Radiology Resident

prepare for interdisciplinary conferences

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

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

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

Selecting Cases To Prepare For Interdisciplinary Conferences

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

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

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

Selecting Individual Images

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

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

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

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

Discussions

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

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

When To Ask For Help?

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

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

How To Prepare For Interdisciplinary Conferences!

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

 

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Technological Essentials For The Radiology Resident

Technological Essentials For The Radiology Resident
By Daniel Choe

 

In an era of exponential technological growth, it is essential that trainees use the latest technology to improve their educational experience. Demands increase every year for the trainee to remain up to date. Moreover, the resident needs to access information seamlessly. So, let’s talk about a few technological essentials that enhance the graduate training experience for the radiology resident. Different from many articles out there, I have no direct financial disclosures about the products I mention in this article.

 

Smart Phone/Tablet

 

It seems like a no-brainer to have a smartphone/Ipad. However, believe it or not, I once had a colleague who started residency with a blackberry!

Regardless, the Ipad or tablet may serve as a surrogate or mobile substitute for a laptop/notebook. However, it has limited storage and computational power. While upgrading them is easy due to its backup/sync features, it often lacks in ease of use for programs that require hardcore graphics rendition or multi-program use. It is ideal for mobile use of editing online documents, viewing online lectures, storing a limited number of pdf files, and running apps for question banks. Several anatomy learning apps are available and extremely useful for a fee. There is a separate section on apps later on.

 

Cloud Services

 

Most users already have cloud services. In fact, that is often the problem – there seem to be too many online storage services. Google, Amazon, Dropbox, OneDrive to name a few. An elegant solution that helps consolidate all of the different clouds you may use is a service such as odrive. It is free, encrypted, and allows you to automatically sync when you copy files to the odrive folder on your computer. The caveat is that to use the sync feature, you must have enough space on your hard drive.

My suggestion is to invest in a cloud service that offers unlimited space and only the folders that you open most frequently. Obtaining a cloud service is essential for the resident who is continually doing research and keeping tabs on what lectures and videos he watches. Alternatively, if you use a pdf reader, it can keep track of which page you were on in one of the many textbooks you will inevitably read.

 

Computer

 

Regardless of whichever camp you fall into, Mac or PC, your home computer or laptop/notebook should be the workhorse for your education and work. I could write an entirely separate article on this topic. Nevertheless, for the sake of simplicity, a home desktop is not essential, but rather a plus. Because cloud services work seamlessly and storage space is a problem of the past, your desktop is a great way to consolidate your work and use programs that require slightly higher computing power and graphics rendition. For example, I use a remote desktop to do a majority of my preparation for tumor board research, presentations, research projects. Moreover, I have my computer permanently connected to my flat screen TV as a secondary monitor so I can multitask.

Also, I can watch lectures on my TV. Watching them on TV affords greater detail and helps when trying to take cases.

Finally, I recommend swapping out your primary hard drive for a solid state drive (SSD). As well, add a secondary storage drive. They are becoming more affordable these days. Keep in mind, much of the work can be accomplished with a laptop, MacBook, or even tablet/PC as well, at the cost of overall computational power and storage.

 

Universal Password Program

 

I use a password and personal information storage program. Using these tools cuts out approximately 50 hours a year in retyping and resetting passwords. For convenience, I have over 200 passwords stored. Moreover, I can routinely change and generate new complex passwords to maintain security. Password programs also allow you to store credit card information and secured notes for passwords and sensitive information. There are many services out there. I would select the one that suits your needs. It is definitely worth the money.

 

Remote Access

 

Most institutions provide remote access for its residents. If not, it behooves you to suggest that the residents have access to remote PACS and EMR. Remote access is critical not only for learning purposes but effective workflow in preparation for interdisciplinary rounds. Your time is better spent working or studying than having to schlep to the department or stay late (unless you are actively trying to avoid home for a particular reason).

 

Shared Network Storage

 

My institution did not initially provide shared in-network storage. However, since its inception, we have been able to provide essential resources for all residents and staff. More importantly, it serves as the institutional memory for a growing and developing residency program by eliminating the possibility of losing critical learning resources. It is also an excellent way to circumvent the elaborate HIPAA clauses in your IRB research protocol.

 

I also include in this topic the necessity of a secured (password protected) USB drive as a conduit for transferring secure data between machines. Your program or IT department may provide one for you. It will serve you well in the long run as it allows you to transfer sensitive documents from your personal computer to a secured hospital network.

 

Apps

 

There are so many great apps available, but I can only mention a few that are technological essentials for the resident. A document reader is critical. Specifically, it should be one that allows you to maintain a “bookmark” for each document you upload. Also, it should open and save highlights and notes you want to review later. This document reader is worth a few dollars because it allows you to carry your library wherever you go, saves highlights directly onto the document, and remembers your page position. I use Goodereader for my Ipad, because it was one of the best at the time, but there may be new readers out there that suit your preferences.

 

Several of my colleagues purchased a group subscription for e-anatomy. This app is a comprehensive anatomy atlas with corresponding radiology images.
Radiology Assistant has recently developed a new app, which is an adaptation to its website. The app allows you to review all the content on their website while offline if the data is pre-downloaded. If you like the website as a resource, it is an even better tool as an app.

 

The different learning apps available can turn your phone into an instant tutor with quiz programs such as Chegg or Anki to name a few. Also, most of the decks relevant to your training probably already exist. I found over 500 premade CORE exams cards. Use at your own risk since you cannot vet them all throughout your review. You can download and edit them as you go if you find the information is not up to date.

 

Conclusions About Technological Essentials

 

The bottom line is that your training experience relies heavily on how you learn. You may get by without some of the technologies mentioned above, so it’s entirely up to you to decide what you need. The items I have mentioned I recommend so that the resident, from day one, can optimize the use of time with relatively cheap resources (or otherwise covered/subsidized by your program). John Stuart Mill wrote, “there are many truths of which the full meaning cannot be realized until personal experience has brought it home.” Hopefully, my experience with these technological essentials serves its purpose to jump-start your journey through residency.

 

 

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Can Clinical Decision Support Systems Help To Improve Radiology Resident Education?

During my residency only a little bit more than 14 years ago, I can still remember grabbing a ream of sheets from the bin to check the day’s CT protocols. We would quickly read through each one to make sure that the appropriate test was indicated as was ordered by the referring physician. Somehow, I think this process is currently an anachronism at many radiology residency programs. The pressure to complete studies in rapid fashion have changed the way things are done. It seems almost all the cases come directly from either the emergency room or from the referring physician directly to the scanner. No longer is the resident an intermediary in the process (a potential delay in the system). Instead, there is a corresponding increase in tests with incorrect indications and/or wrong technique, only to increase radiation dosages and the cost to the system. The ordering physicians, not the imaging experts, have hijacked what should be the domain of the radiologist: to decide if imaging examinations are appropriate.

Why do I bring this topic to our attention? First and foremost, of course, patient care suffers. But also, as today’s topic implies, it also affects the education of the radiology resident. So how do we get control back over the reins of imaging from a standpoint of improving resident education? Initially, we have to understand the role of protocols in the education of the radiology resident. And then, I will briefly discuss what imaging clinical decision support systems are and how clinical decision support systems can potentially enhance the education of residents as well as the appropriate use of imaging.

Protocols And Educational Implications For The Radiology Resident

One of the most important roles of radiologist is to be a consultant for the appropriate use of imaging. As I described above, the process of checking protocols significantly enhanced my knowledge on this topic.  What may have seemed at the time as a questionable activity bordering on scut, I now see as invaluable. Related to my prior experience with protocoling CT scan studies, I now understand when contrast should be administered, how certain studies are typically performed, and most importantly, what are good indications for a study to be completed. At many programs, this educational opportunity is no longer available due to financial and political pressures upon radiology departments to get through the system. Any study ordered must get done in a timely fashion, no matter whether the study is indicated or not! It only matters that it was ordered. Correspondingly, resident involvement in this process has significantly decreased over time.

So, how does removing this educational opportunity for radiology residents change the knowledge base of the radiology resident?  First of all, you are taking away important practical knowledge that can reduce the value of new radiologists as a consultant for determining appropriateness of individual imaging studies. Second, new radiologists will be less likely to understand how to tailor individual studies to the indications of the ordering physician. And finally, the potential implications of issues like when to use intravenous contrast can be underestimated, both from a contrast complication and an appropriate indication point of view. So herein lies the potential savior to return the educational opportunities of protocoling back to the radiology resident- The Clinical Decision Support System!

The Clinical Decision Support System

Here is the definition of clinical decision support systems according to the government– “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”

In terms of imaging, the potential implications of a clinical decision support system from a cost and educational standpoint are myriad. No longer are all imaging studies going to be ordered without the approval a computerized system. When can this potentially occur? How would the radiology resident role going to be affected by the implementation of such systems? Let’s talk about both of these questions…

Institution of Clinical Decision Support Systems And The Potential Effect Upon The Radiology Resident

At first, institution of electronic clinical decision support systems were going to be mandatory as January 1, 2017. The date was subsequently changed to January 1, 2018. We will see if this date is going to be the finalized implementation deadline.

But let’s say that a good quality clinical decision support system became mandatory at all institutions for ordering imaging studies at the beginning of 2018. How would that affect the residents? First thing that would you notice, bogus indicated studies would all of a sudden significantly decrease dramatically. The system should theoretically block anything that has a questionable indication from getting through from the clinician order to actual practice. Second, there could potentially be a flood of phone calls. Since any study with a questionable indication or a complex protocol would not be able to get through the system, instead, clinicians would be forced to ask the radiologist what kind of protocol should be implemented for these cases. Not only would this be a boon for patient safety (decreased radiation dosages) and appropriateness of imaging, clinical decision support systems can actually bring the control of image ordering back to the radiologist. More specifically, a good quality clinical decision support system can theoretically allow the radiology resident to protocol examinations appropriately in concert with the ordering physician and tailor examinations to the indication that is needed. Resident protocol education can be restored!!!

Interestingly, a clinical decision support system for imaging was actually one of the few parts of the health care bill that actually had the potential to decrease costs and quality of care in addition to improving resident educational experiences. Ironically of course, it may never be implemented depending upon how the political situation in Washington affects health care.

Clinical Decision Support Systems For Imaging Can Be The Resident Radiologist’s Best Friend

In summary, clinical decision support systems have the potential to be one of the true benefits to the health care system, in terms of costs and quality of care. But, one of the most overlooked implications is actually the potential educational benefits to the radiology resident. No longer would ordering be in the hands of untrained ordering physicians. Instead, control will again lie in the hands of the radiology resident allowing him/her to protocol patients once again appropriately and giving the radiology resident the education he/she needs to become a true imaging expert.

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The Presidential Executive Order And Foreign National Radiology Residents- Will Life Ever Be The Same?

In a medical resident’s life, he or she is so busy that politics rarely influences day to day work and living circumstances in the United States. But, this is no ordinary year and we are not in ordinary times.  A new presidential executive order has been issued. No longer can residents from the following countries: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen travel to the United States without the appropriate documentation. But, it turns out that the implications of the executive order run much deeper than just the inability to return to the United States. Resident physicians lives may be altered for many years to come.

On the surface, the executive order makes some sense. Prevent the bad guys from coming into the country by halting travel for all citizens of the designated countries, countries where there have been incidences of terrorist activities. Dig deeper and you realize that most of the foreign born nationals have already been in the United States for years legally, either with a green card or certain visas. A majority of these residents are not terrorists and are in fact, good people, hard working, and excellent physicians. Additionally, many other countries with histories of harboring terrorists were not included in the executive order.

Effects of the Travel Ban On Residency

So what are the potential effects of this executive order if you happen to have been away in another country? Since some of these residents are already abroad and cannot return to the United States, these physicians in training will have their training delayed by at least 90 days since they need to stay in their country of destination. On the surface, that does not sound so bad. But, it can have profound implications. Training will have to be delayed by over 3 months. This means that the resident cannot graduate from the radiology residency program on time at the end of the 4 years. And, he/she will potentially have a difficulty either beginning their chosen fellowship on time if they are scheduled to start at the end of residency. Others will have to delay finding a fellowship potentially for over a year.

Furthermore, many foreign medical students from these targeted countries have recently interviewed for residency positions. Program directors are either ranking these medical students lower on their rank lists or are being placed in the “do not rank” category due to the uncertainty that these prospective residents may not be able to start at their residency on time or perhaps not at all. This year’s residency selection is already being affected by the executive order. In the fact, the NRMP has already submitted a statement on the executive order recognizing these challenges.  (NRMP Statement on Immigration Executive Order)

Also, on top of the general work related issues, these residents can no longer visit their relatives abroad, for the risk of not being able to return to the country, giving them less of a support system during the time of their residency. Residency is time a time of significant emotional and intellectual stresses. It is also possible that the international travel ban can last longer than has already been stated, potentially making the stressors even greater. So, although well intended, the executive order is severely flawed.

What Needs To Be Done To Make The Executive Order More Effective And Reasonable?

First of all, the current blanket executive order needs to be made more targeted. Most of these foreign residents have already had their green cards for many years and have been working in the United States as productive employees for most of that time. If need be, these residents can be reinterviewed by the government, but should not be banned from travel abroad or from returning to the United States during this period of “vetting”. Why prevent these legal workers from contributing to the United States workforce and potentially causing shortage of labor in residency programs? We are only harming ourselves.

Second, those countries chosen by the executive order to be targeted is a random selection of “terrorist harboring” countries. Other countries that have traditionally harbored many of the terrorists were not included. So, if you are going to make an executive order to restrict travel and reinterview these residents, it does not make sense to only target a few of those countries.

And finally, vetting should be more individualized and reason based. If in fact, the vetting that was done was not so thorough upon the initial interviews when these foreign born residents came into the country, then by all means go ahead and do the appropriate procedures to make sure that they are in the United States legitimately. But, make sure to do it in a reasonable manner instead of targeting everyone without cause.

What Should You Do If You Are Specifically Affected By The Executive Order?

There are two groups of residents and resident applicants affected by the executive order: applicants who are already in the country and those who are abroad. For those residents that are in the country, I would recommend to avoid travel abroad until the situation clears- you may have difficulty getting back into the country if you make this decision.

For both groups of residents, I would also pay close attention to posts on the ACGME website if you are a resident and the NRMP if you are a applicant for residency. They are scheduled to have frequent updates with relevant information. Also, make sure to stay in close contact with the hospital, residency program, and program directors to receive any relevant updates or other helpful practical and legal advice.

Unfortunately, if you happen to be abroad since the executive order, depending on whether you have permanent resident status or not, you may or may not be able to return to the United States. I would recommend seeking the help of an immigration attorney to help with the issue of returning to the country.

Difficult Times For Foreign Nationals From the Targeted Countries

It is unfortunate how the executive order was issued without regard to the specific circumstances of the individuals affected. Regrettably, many excellent well trained and talented foreign national residents and applicants may be at least temporarily prevented from completing their training due to no fault of their own. However, I believe that once the flaws of the executive order have been worked out, order will be restored to the medical training process, most qualified residents will be able to return to their positions, and medical students will be able to reapply. Although it is only 90 days until a more logical system can be sorted out, these residents may be affected for a much longer time due to the unintended consequences of the order. Continued patience and perseverance is in order for these residents. Hopefully, this situation will eventually pass.

 

 

 

 

 

 

 

 

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Can I Be Sued As A Radiology Resident?

lawsuit

As radiology medical school applicants, radiology residents, and full-fledged radiologists, we all dread the possibility of a lawsuit when we begin to practice radiology. Very rarely discussed, however, is the possibility of being sued during radiology residency. The good news: it is very unusual! One article stated that there were only 15 legal cases and 10 law review papers that addressed physicians in training and standards of care on two large legal databases. And, these cases were not necessarily radiology residency specific. The bad news is that although a remote possibility, it has happened several times in the past. 

So, this makes for a relevant topic that is not frequently addressed but is certainly a possibility. In this article, I analyze a few different sources on the web and literature to understand the conditions you need to meet for a patient to sue a radiology resident. More specifically, we will analyze what standards of care a resident needs to breach. Also, we will go through several ways radiology residents can prevent lawsuits in the future.

The Grounds for a Lawsuit

For a lawsuit to be successful against any physician in general, three requirements need to be satisfied. According to a recent article in Diagnostic Imaging, these are breach, causation, and damages. Breach implies that the physician did not satisfy the requirement of the standard of care. Causation means that the breach of duty caused the malpractice. And, damages indicate that the event produced significant harm. 

In today’s article, I will explicitly discuss the issue of breach without discussing causation and damages. Why? Because the concept of breach makes a malpractice case performed by a resident different from a fully trained attending.

Resident Breach For A Successful Lawsuit

Due to the standard of care being different for a resident, the definition of breach for a resident involved in a malpractice event becomes a little more complicated. In fact, over time, the standards of what breach means for the radiology resident have become blurred. I will discuss several cases with different definitions of what the legal system considers “standard of care,” specifically for a resident in training.

Breach For The Intern

Some cases have involved the medical intern. There was one case where an intern failed to identify retained glass fragments and sewed a wound shut. In this case, the court concluded that the criteria for the standard of care should be based upon the standards for the typical intern’s skills. Subsequent lawsuits have demonstrated that the first-year resident needs to fail to do something that a “physician or surgeon of ordinary skill, care and diligence” would typically do to breach the standard of care rule. In other words, the legal system can require a first-year resident without a full license to meet the standards of a general practitioner physician in terms of standard of care.

Breach For The Subspecialist Trainee

For residents in a subspecialty level training program, breach of the standard of care is even more confusing. Some cases imply that the sub-specialized resident should meet the obligations of a general practitioner. Other instances suggest that residents should meet the demands of a more specialized physician. Adding more confusion to the issue, one relevant article’s author reported a radiology resident-specific case of a misread MRI of a newborn. In this case, the court was unable to determine a specific resident standard of care and ruled in favor of the defendant. So, this case did help to define the “standard of care” for this radiology/specialist. (1)

In another case with a radiology resident, an AJR article discussed an incident during radiology moonlighting. The patient sued the resident for missing an abscess and instead called it a bladder diverticulum on a CT scan. The parties eventually settled the lawsuit, but the court determined that the jury would decide the liability before the settlement. This settlement implies that a standard of care was breached at the level of an attending subspecialist/radiologist.

The Main Source of Confusion About Breach

So, according to the literature, the law sometimes considers residents to have lower than the typical standard of care for attendings. Other times they are considered to be at the standard of care of a general practitioner, and at other times the resident has to meet the standard of the attending in his subspecialty. Confusing, huh?

What Does This All Mean?/Primary Take-home Messages to Reduce Liability For A Lawsuit

So, now that all this information confuses you, what does this mean? 

Precept 1: Regardless of the definition of breach for the radiology resident, make sure to get help if you are unsure, and the case can lead to patient morbidity. Getting help can reduce the odds of getting sued for a questionable interpretation and allows your fellow attending to take responsibility for the case.

Precept 2: If moonlighting, make sure you have malpractice insurance. Misses do happen, and the courts may treat you as a fully trained radiologist. So, don’t catch yourself off guard without proper insurance. You need to make sure that your insurance will specifically cover you for moonlighting mishaps.

Finally, Precept 3: Although it is infrequent, lawsuits do happen to radiology residents, and you are certainly not immune from the ravages of the legal system. So, treat each case as if you are the responsible party and always provide your best effort to make the correct findings, diagnosis, and management.

Lawsuits And Residents

Although unlikely, patients can still sue residents for malpractice. Don’t leave yourself susceptible to the possibility of a lawsuit as a resident!

 

References

Clin Orthop Relat Res. 2012 May; 470(5): 1379–1385.

Published online 2012 Jan 26.

Medical Liability of the Physician in Training

Brian Wegman, MD, James P. Stannard, MD, and B. Sonny Bal, MD, JD, MBAcorresponding author

Radiologists, Expect to Get Sued Mar 03, 2016 | RSNA 2015, Practice Management

By Liza Haar

AJR1998;171:565 Malpractice Issues in Radiology: Liability of the Moonlighting Resident By Leonard Berlin

 

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The Informatics Fellowship- Bulletproof Your Radiological Future

Concerned about artificial intelligence taking over our jobs? Worried about the economic cyclicality of each of the radiological subspecialties? Do you fear the instability of your future radiology attending career due to corporate takeovers and mergers? Well, I have a solution for you (and no, I am not an infomercial!!!)… Welcome to the new fellowship called Informatics!!!

Why am I writing about the informatics fellowship and skipping all the other subspecialties? Well… the informatics fellowship warrants an independent post because it is truly the only radiology subspecialty that is in a permanent secular growth trend. It is also the only fellowship that has relatively little information published on the subject matter. In fact, once several of my residents and students heard about the existence of the fellowship program and understood its potential benefits, they began to salivate!!!

So, this article is dedicated to the topic of the informatics fellowship. Specifically, we will discuss the definition of informatics, what the fellowship entails, requirements for the fellowship, how to find where to complete the fellowship, and what job opportunities are available for graduates of these programs. I think once you understand the potential benefits of this fellowship program, you might consider it yourself!!!

Discussion of Definition and Importance of Informatics

So, what is the definition of informatics? According to Merriam Webster, it is as follows- “the collection, classification, storage, retrieval, and dissemination of recorded knowledge”. Prior to several years ago, I have to admit that I had never heard of the term or definition of informatics. In fact, I think I am probably not alone. It is only since the terms “the cloud” and “big data” have arrived into the mainstream, that I think the word informatics has been used more widely.

Why all of a sudden is this body of knowledge so important? In our age of electronic interconnectedness, large swaths of data are created and processed every day. Particularly in the radiology realm, there are numerous electronic/digital images and reams of clinical/health information. Someone has to both understand and manage all this information. Although computer engineers presently manage a lot of this information, they tend not to understand how to manage the data for physicians, administrators, and patients to understand. Herein lies the niche of the radiology informaticist, translating the imaging and clinical data from the computer engineer to the clinical realm.

What Do These Informatics Fellowships Teach?

Fortuitously, the same day that I started to write about informatics, I received a letter from the APDR explaining that there would be a new initiative to create a summary online 1 week course in informatics for residents. Some of the topics covered by the course as listed in the letter include Standards; Computers and Networking; PACS and Archives; Security; Life Cycle of a Radiology Exam, Data and Data Plumbing; Algorithms for Image and Nonimage Analytics; and the Business of Informatics. This course contained many of the topics that some informatics fellowship programs teach. But, the curricula of many of the informatics fellowships differed significantly from this course and were more expansive.

To add a bit more confusion, each individual fellowship program also covers differing topics from one another and varies the emphasis of each of these subjects.  Some of the topics that these fellowships include: RIS systems, Image Compression, Teleradiology, Quality Improvement, Operations, Clinical Engineering, HL7, Regulations, DICOM, Critical Results Reporting, Decision Support Systems, Radiation Dose Tracking, Mobile Health Applications, Image Segmentation, Imaging Room Ergonomics, 3D Printing, Natural Language Processing, Informatics Funding, Biostatistics, Health Policy, and Experimental Design. There was some overlap between the different programs. But coverage varied widely. I will also refer you to the ACGME formal program requirements in Clinical Informatics for a more formal explanation of all the areas of teaching required at all fellowships.

What are the Requirements To Become An Informatics Fellow?

The prerequisite requirements vary from program to program. Of the programs I visited on the web, most but not all, had a requirement to be board eligible in a specialty (not necessarily radiology), to be a graduate from an American Medical School, and to have an interest in the discipline of informatics. Most fellowships did not have a specific requirement for formal training in computer science. According to the ACGME, the program length was 1 or 2 years to graduate from a radiology program.

Where to Find the Fellowships?

I found several ways to find the informatics fellowships that are offered for diagnostic radiology program graduates. If you happen to be a member of the AMA, you can look up the fellowships on the FREIDA database. (It turns out I am not a member!) Alternatively, you can do a web search on informatics fellowships and many of the large institutions  describe their own programs. And finally, you can go to the ACGME website and look up informatics fellowships there.

Job Opportunities for the Informatics Fellowship Graduate

This is where things get really interesting… Job opportunities are endless. You want to be part of a large private practice or maybe a teleradiology practice?  Interested in becoming a practice leader?- It’s all yours! Not many employers can replace the only radiologist that can fix a PACS or RIS system and can also actually read films.

You want to become an entrepreneur and start your own company? You will have access to all the tools and methods to create a technological niche for yourself whether it be an app, a PACS addon, a new piece of software, or other countless unimaginable outlets.

You want to go into academics? The world is yours. Academics are desperate to have rads translate their IT department workings into something that is useful and efficient for clinicians. Think about the possibility of chairman or CIO.

You want to work for big business? Think Apple, Google, Cerner, and more! Large organizations are contstantly on the lookout for good talent that can translate the engineering esoteric data into clinical reality. You will be able to develop needed applications, improve health and radiology related products to get more clientele, and more:

Think about it… you will be at the forefront and crossroads of technology and clinical medicine- a job that only a few can currently fill. It will be very difficult to replace you.

Diagnostic readers can be outsourced to India. Robotics can replace human procedures. But humans will always be needed to rule the machines (unless our future is to be the same as The Terminator!)

Final Thoughts

Of course in the end, like anything else, you need to like what you are doing in order to be good at it. And, informatics is certainly not for everyone. But, if you have a remote interest in the intersection of computers and radiology, really consider this subspecialty. The possibilities are endless, job opportunities abound, and you have the ability to be in charge of your own destiny, potentially not subject to the whims of government or even private industry.  You can be your own captain!!!

 

 

 

 

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The Uncooperative Patient- The Radiology Resident’s View

uncooperative

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

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

Patient Rapport and Motivation

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

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

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

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

A Couple of Special Situations

The Combative Uncooperative Patient/Family

The Situation

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

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

What To Do

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

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

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

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

The Obtunded Uncooperative Patient

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

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

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

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

Lessons We Need To Learn About The Uncooperative Patient

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

 

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Taking Oral Radiology Cases- A Lost Art?

oral

The lights go down as the radiologist in front of the classroom prepares the computer for a case presentation. A switch is flicked on. Suddenly, a black and white PowerPoint case begins to shine brightly on the screen in front of you. The radiologist glances about the room looking to see who would be the best fit for this next case. You begin to sweat and fidget with your hands, praying your faculty will not call on you next. The attending’s glance remains fixed upon you. He says, “Tell me about this patient with a 2-year history of a cough!”. You become flustered and unsure what to say.

The scenario above occurs commonly in radiology residencies across the country. However, since the oral exam has disappeared, I have noticed an overall decrease in proficiency in how residents present each radiological case. The art has been lost. You can blame some of it on poor teaching. Decreased time allotted to education may cause some of it. Some of it can relate to the emphasis on the new board examination system. And, perhaps the new radiology residency culture may be responsible for some of the changes.

In whatever case, it is a shame. Taking oral cases is a crucial step to becoming a well-rounded radiologist. You need to relate to your colleagues’ images in a timely, logical manner, no matter what you are looking at. If you want to look like a star, you need to have this process down cold. To enable you to have the tools to get through a radiological case, I will go through the basics, including determining the kind of study, presenting descriptive findings, coming up with a differential diagnosis, and ultimately determining proper management.

What The Bleep Am I Looking At?

Whenever your attending introduces you to a new oral case, the first thing you need to do is determine what you are looking at. Take your time and think about what kind of images you see. You often lose the case discussion even before you have begun because you never identify the correct study. Is it an ultrasound, CT scan, MRI, x-ray, or nuclear medicine study? Is the examination performed with or without contrast? During what phase?

For nuclear medicine studies in particular, if you can identify the study before going through the case, you have already completed 80 percent of the heavy lifting. You have already isolated the differential diagnosis if you can identify the radiopharmaceutical. If you are not sure, you should start describing the physiological distribution of activity to determine the type of study. Often the act of defining the distribution helps the resident to understand the kind of study.

Also, scan the images for any identifying information. If it is an ultrasound, it will often tell you which organ you are looking at. I have found it can become difficult to tell the testes, ovaries, and kidneys apart on a single image. Usually, the ultrasound technologist labels these studies so you can differentiate among the options.

Finally, make sure to look at the top of the film to see if you can find the patient’s age and sex. This information can also further help you to hone in upon the correct differential diagnosis.

Describing The Findings

This part of the oral case is when the newer residents fall short compared to residents studying to take the oral boards. Residents tend to stop very quickly at the description part of the puzzle and then enter rapidly into a differential diagnosis. Often, a poor quick description leads to a poor differential diagnosis. Again, you need to take your time to describe all the salient points.

So, what should you include in this part of the case? Always describe the location, the size, the intensity (if nuclear medicine), the shape, the density, and borders. Describe its effect upon adjacent structures. Make sure to use buzzwords if available. If you see an angry-looking mass on a CT scan that looks like a star, you may want to use the words spiculated or stellate. If a lesion enhances with rim nodularity and fills in from the edge to the center, use peripheral nodular enhancement with centripetal filling. These buzzwords connote certain types of differentials in the minds of the radiologist listeners. They provide information on the kind of disease entity even before going through a differential diagnosis.

Finally, don’t get happy eye syndrome. Look for other findings that may support or refute your differential diagnosis. I can’t tell you how many times a resident will stare at one section of the film to forget to look at the rest of the images or film. He loses the forest for the trees.

Concise Relevant Differential Diagnoses

A novice and more seasoned resident starkly differ when they give a concise and relevant differential diagnosis. The beginner will have no idea what to say. Or, she will continue to drone on about multiple different possibilities for the final diagnosis. She does not even differentiate between the zebra and the most common diagnosis.

Again, take your time before speaking. Before even starting this process, you should go through broad categories of differential diagnosis in your mind. Is it neoplasm, infection, inflammation, iatrogenic, congenital, etc.? When you have come up mentally with some reasonable possibilities, make sure to talk about no more than three etiologies of the most likely diagnoses. And start with the most feasible and then go down to the least likely. This process will allow you to speak logically. Also, it will enable you to show that you have thought about the differential analytically.

What Next For The Patient?

Three options exist for the further management of the case after you have completed the basics of determining the findings and differential diagnosis. The first possibility: the patient needs no further workup, and you have made a final diagnosis. One example would be an adrenal nodule with a Hounsfield unit of 2. This finding is consistent with an adrenal adenoma—end of story. No further workup is needed.

Alternatively, it may be imperative that you need another step to work up the case. For instance, if you need to determine the matrix of an aggressive osseous lesion on a musculoskeletal MRI without a final diagnosis, make sure to recommend a plain film. Otherwise, you may never determine the final disposition of the patient.

And lastly, you may find a lesion with low clinical significance but needs to be followed over time. This category includes the small lung nodule or the nonaggressive indeterminate liver lesion.

You can almost always categorize your case into one of these three groups. And, it will show that you thought about the ramifications of the imaging upon the clinical picture of the patient.

Final Thoughts: Taking Oral Cases Should Be Fun!!

Taking oral imaging cases should not be a difficult or embarrassing process. It should become something that you should look forward to, building your confidence and becoming a better radiologist. It sums up the essential ingredients needed to make an excellent radiologist: the ability to make the findings, synthesize the data, develop an outcome, and communicate the clinician’s results.

Unfortunately, in many programs, the radiologist just expects you to know how to take an oral case despite not having been taught the process. If so, now you have a framework of the fundamentals of how to take a case outlined above. Like anything else, being adept at taking oral cases is simply a matter of practice and knowing the process. Once you have the process down and the base knowledge, you can more easily build upon your abilities and become better and better over time. You, too, can become a star at taking cases!!!

 

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