Tag: radiology

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Top 10 Common And Silly Mistakes Of Neophyte Radiology Residents

radiology residents

Each year, new radiologist residents repeat the same mistakes as their previous counterparts. These mistakes often make radiology residents feel ridiculous and appear ignorant to the emergency department physicians and hospital staff. I thought it was high time to get these common mistakes out in the open to avoid them, so you don’t have to feel ridiculous. Here we go!!!

Uterus Vs. Prostate Gland

No one ever seems to tell the neophyte radiology residents that, on occasion, enlarged prostate glands can look like uteri and vice versa. Invariably, we get a call from the downstairs physician- “How can this patient have a uterus? He is a male!!!” It happens every year. How can you prevent this from happening to you? Just look at the sex in the patient description region, silly!

Hydronephrosis Vs. Obstruction

Toward the beginning of every year, there is usually at least one resident who does not understand that hydronephrosis does not equate to urinary tract obstruction. You can get hydronephrosis (dilatation of the renal collecting system) from other causes such as reflux or congenital enlargement. So please, do not tell the physician that a patient with a dilated renal collecting system is obstructed if you see it on ultrasound. You need to do another test (renal scan or Whitaker test) to determine if hydronephrosis is related to actual mechanical urinary tract obstruction!!!

Calling A Kidney A Testicle

Often, the resident briefly looks at an ultrasound, and the images may be very nondescript- easily mistaking a kidney for a testicle. You may have no idea what the technologist is looking at unless you make a concerted effort to read the ultrasound technologist captions/notes. I can’t tell you how many times a resident breaks this cardinal rule, especially as a first-year resident. Don’t leave the clinician up in the air wondering what kind of radiologist you are. Always read the fine print!

Overcalling Plain Film Artifacts As Radiology Residents

I can’t tell you how many times I’ve seen first-year residents intricately describe plain film findings that seem to appear on film after film. Mainly, I remember one cartridge with the same ring-like finding producing film findings time after time. Some residents thought the patient ate something strange, and others thought there was a foreign body. If you see the same markings on many films in a row, think artifact!

Not Doing A Rectal Exam Before A Barium Enema

Not performing a rectal exam is a cardinal embarrassing and uncomfortable mistake that also seems to recur every few years. Invariably, one resident forgets to do a rectal exam before inserting a rectal tube and pushes barium into the patient without checking. If you want to get yourself into trouble and perform a “vaginogram” instead of a barium enema, this is the way. Be careful!!!

Radiology Residents Calling Aortic Rupture Vs. Aneurysm Vs. Dissection

For some reason, this is a simple but important distinction that frequently seems to confuse junior/neophyte radiology residents with potentially dire consequences. Remember… Aortic rupture is a surgical emergency characterized by a breakdown of the entire wall of the aorta with free-flowing blood. An aortic aneurysm is an enlarged aorta (sometimes with increased risk of rupture) with intact walls. And, aortic dissection is a tear in the intima of the aorta with a true and false lumen. This diagnosis can sometimes be a surgical emergency, depending upon its location. Get your facts straight!!!

Calvarial Suture Vs. Fracture Confusion

The first time you are a radiology resident on call, there is a 50-50 chance you will get a pediatric head CT scan. And, you will see linear defects all over the place. I can’t tell you how many times I have seen residents overcall fractures on these studies. A. Make sure to look for symmetry of the defects… B. Look for adjacent hemorrhage C. Refer to A! If there is symmetry at the calvarial defect, it is doubtful to be a fracture. Be careful and don’t overcall!

Transverse Sinus Bleeds

Many times, neophyte residents report a dense curvilinear region to another clinician deep to the posterior calvarium and call it a subdural hemorrhage. Well, sometimes, the transverse sinus is the culprit. Look for the other sinuses and see if they merge into this region. Don’t keep the patient overnight for normal anatomy!!!

Appendix Vs. Terminal Ileum Confusion For New Radiology Residents

This is a big one. So many new radiology residents have a hard time differentiating between these two normal anatomical structures. Unfortunately, not making this distinction can sometimes be dire! An appendix is a blind-ending tube extending from the cecum. The terminal ileum is the end of the small bowel, and you can continue to follow it down to the remainder of the small bowel proximally. Don’t confuse appendicitis for terminal ileitis!!!

Calling Flow Artifact Vs. SVC Thrombus

Depending on the timing of the contrast bolus, this timing issue can lead you into trouble! Usually, where the azygous vein meets the SVC, you will get an intraluminal filling defect due to the contrast within the SVC and the non opacified blood entering the SVC from the azygous vein. A few times a year, I see residents call this defect a thrombus. This “pseudo-finding” has significant treatment implications. Don’t let that be you!!!

Establishing Credibility As Radiology Residents

These ten mistakes may seem silly or something that you might never do as a budding neophyte radiologist, but they happen every year. Avoid these ten mistakes, and you will certainly enhance your credibility. If you do not heed these ten pearls, you are doomed to repeat these cardinal mistakes lest your referring physicians will never take you seriously!

 

 

 

 

 

 

 

 

 

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Curriculum/Teaching Issues In The United States And Abroad

curriculum

Question About Curriculum And Teaching In United States And Abroad:

Hello Barry,

Thank you for your outstanding posts and the constant stream of current topics promoting the dissemination of Radiology as both a profession and a collective guild. I’ve been hanging on every word you’ve written, and it’s almost as if you anticipate my questions in advance. So, I am very much encouraged by the relevancy of your blogs and posts.

I am a Canadian who is a first-year diagnostic radiology resident in Targu Mures, Romania. Here, we follow a five-year path outlined by the EU and the European Society of Radiology (ESR). The problem is that the actual ” teaching ” element is virtually non-existent, and the program expects us to follow or shadow senior residents all day and read on our own. I am lost and overwhelmed by all the modalities I see here daily. For example, a typical day involves spending a few hours in an ultrasonography clinic, seeing conventional or plain film radiography cases, and a CT or MRI following a patient scan.

Most often, the radiologists on staff consult with other physicians, and it’s not like they have the time to point out things. I’ve decided to follow a structured plan and would appreciate your curriculum. What should I cover in my first two years? I know I’m asking a lot of you. Perhaps you can abbreviate your own institution’s plan for me? The first thing I’ve begun to do is revisit skeletal anatomy, including the head and neck. I don’t have a lot of textbooks here (in English, that is), but I have a ton of PDF books on my PC. This lack of physical textbooks is another problem because I miss the tactile experience of actual texts, and looking at a laptop all day is tiring. I will digress and hope to hear from you. Take your time 🙂

Sincerely,

A Tired Romanian Resident

 

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Answer:

 

Thanks for the great compliments. It is much appreciated and makes writing these posts all worth it!

Teaching Differences

Interestingly, you mention that teaching is “non-existent” in Romania. It’s almost the opposite problem in the United States, where everything seems regulated by the government. We need to have x number of noon conferences, etc. I almost wish we had a model for teaching somewhere between the Romanian and the United States models. Residents seem to get bogged down by the regulations and spend less time learning by reading films. (It’s an essential ingredient for radiology!!!!) So, in a sense, you can consider yourself lucky, but you are also missing out on some types of the more didactic teachings.

Curriculum

Regarding the curriculum, the plain vanilla answer is that residents study all the material on the ABR website under the core study guide. It would help if you looked at that to understand everything you theoretically need to know. However, I find it a bit overwhelming, and you need to focus on studying for your time as a resident. So, in the real world, I recommend reading some of the basic overall books in each modality when you begin a rotation each month, such as Mettler for nuclear medicine and the requisite series for some other subjects. You can check out some of the curriculum and books on the web in U.S. Residency programs to get an idea of what you need to know and the books they use. You can also look at some of the books my residents like in the book links section of radsresident.

Most importantly, emphasize the pictures and captions and then secondarily look at the text to understand the images and captions. And keep in mind the ABR blueprints and core material when you are studying. Subsequently, go through the case review series to learn how to go through cases once you have the fundamental knowledge of each primary modality. This process will reinforce all that you studied.

You also make an essential point about missing the tactile experience of textbooks and looking at laptops. It happens to be the subject matter of my next article!!! PDF articles are great because you can download them easily. On the other hand, retention rates for PDFs are probably not as high as reading directly from a printed textbook.

I hope this helps a bit,

Barry Julius

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Barium Slinging And The Radiology Resident- Is It Really An Educational Activity?

barium

Barium slinging not too long ago was representative of the world of radiology. Now it seems, we relegate it to a tiny part. (1) When I started, I remember having many fluoroscopy days filled with double-contrast barium enemas, upper GI series, small bowel series, and esophagrams. Today’s barium work has changed radically, at least in our institution. It is exceedingly rare to catch a resident performing a barium enema. We complete a few daily upper GI series and esophagrams, but not nearly as many as when I was a resident. And, we seem to do bariatric post-intervention studies by the dozens (I remember only doing a few during my residency!). I am also sure the mix of studies has changed radically at many other institutions, not just mine.

Although the fluoroscopic exam mix has changed over the years, we think of a GI day as more service-oriented than educational. Some residents may go as far as to say it is a waste of time. Here is my goal for today: to show you why barium slinging is not just a scut activity but also an essential part of a radiology resident’s education.

Direct Contact With Technology And Patients

Much of radiology brings the radiology resident further away from patient contact than ever before. CT scans and plains films most times have become an almost independent activity. On the other hand, barium slinging is one of a few modalities (like mammography and interventional radiology) that keep the resident in the clinical realm, a critical skill for a future radiology practice. You need to tailor the examination to history and think on the fly. These are invaluable skills that serve the resident for years to come.

Also, you need to keep the patient reasonably happy and comfortable during the examination, both mentally and physically. Keeping patients engaged is a crucial characteristic to learn for getting informed consent and doing more complex procedures. Moreover, you can learn these skills under relatively benign conditions. (Complications from a barium study are infrequent!)

Closer Contact With The Referring Physicians

Before the days of PACS, clinicians would regularly return to our department to go over films. Now a clinician sighting is much rarer. In the realm of barium slinging, you are much more likely to interact with your referring physicians. The clinician often needs a particular question answered, and you need to respond to it rapidly. Perhaps, they need to know if there is a leak or small bowel obstruction. Regardless, you have to deal with the heated interactions that often come along with barium studies. Without barium slinging, it is possible to lose sight of who looks at our reports!

Additionally, these interactions prepare residents for calls. Having a surgical team come down to review a STAT study occurs fairly regularly at nighttime. When a first-year resident works in fluoroscopy during the daytime, they often come in direct contact with the ordering physician since they order these examinations STAT. For instance, esophagrams for foreign bodies, bariatric postoperative patients for GI leaks, and esophagrams for pneumomediastinum need immediate attention. Additionally, these studies require direct communication with the ordering physician’s team. How to relay this information to a rushed team or an angry surgeon quickly and transparently is a critical skill.

And finally, some clinicians ask for barium studies without realizing what they are ordering. They often ask for an upper GI series when what they want is a small bowel series. These subtleties allow the resident to learn when to call the physician to clarify the point of the study. Also, they discover how to tailor the procedure tailored to the history.

Developing Radiological Hand-Eye Coordination

When you start, “barium slinging” is a tremendous first rotation to learn how to position patients while holding on to a tower and snapping pictures. You are using your eyes, hands, and perhaps feet to get the correct images. Committing to fluoroscopy early in residency is a significant first step to learning more complicated interventional procedures later in residency. These principles are the same and build on what a resident knows during those first few fluoroscopy rotations.

Managing And Learning About Radiation

Today there is an enormous public outcry to decrease patient radiation dosage. Techniques such as intermittent fluoroscopy and last image hold are integral parts of managing patient radiation exposure. What better place than fluoroscopy to learn this? Just as importantly, fluoroscopy reinforces the physics studying for the core examination. There is nothing better for education than when the theoretical meets the practical.

Barium Work Is Not Sexy- But It Is Important!

Barium work is the stepchild of the radiology department. It commands little respect and is not as sexy as many newer “more exciting” modalities. Yet, it remains an integral part of the radiology resident’s education. For those who say there is no educational value in barium slinging, take a look at this article!!!

 

 

 

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Ten Surefire Ways To Destroy Your Radiology Experience (And Your Colleagues’ Too!!!)

radiology experience

I have seen it all. Some radiology residents make sure to glean every last drop of radiology experience from their residency so that by the time they graduate, they are ready to hit the ground running. But then other radiology residency graduates never quite live up to their full potential during their residency training. Many of these folks are great people, but when they are about to leave, I am not quite sure if they will handle the pressures of radiology practice.

In the end, I have learned some residents are late bloomers and do pull themselves up by the bootstraps once they leave residency, but a large percentage unfortunately constantly shift from job to job. Many of those folks are the same ones who seemed to do whatever they could to destroy their own residency experience during their four years of residency. And yes, we hear about them again when the paperwork comes back to us each time they change jobs when out in practice. Today I figured I would talk about those characteristics that are a surefire way to ruin your residency radiology experience. Don’t make those same awful mistakes!

Sweat The Small Stuff

In the heat of battle, it is effortless to forget the end goal of radiology residency, to be well trained and ready for practice when you leave. Remember… residency is only a 4-year experience. However, some residents get caught up in the moment and forget about the end game. They concern themselves with relatively minor things such as rising prices in the cafeteria, having to do a few extra shifts, or hearing some disheartening comments from one of their annoying colleagues. Sure, there is a place and time to worry about those things. But, it should not become an all-encompassing mission. Some never get over these issues and forget to learn what they need to know when they leave residency. In the process, they also upset their colleagues, distracting everyone from their training. Get over it!!!

Argue With Your Colleagues

Some residency classes always get along. Others have permanent hatred toward one another. The inability to get along spills over to other areas in a radiology residency. Studying suffers because some folks are left behind, and no one seems to care. Tempers flare and prevent classmates from covering each other when they need it. Everyone becomes exhausted and upset. Next thing you know, residency is over, and everyone is worse for the wear. Do whatever it takes to get along! It is not worth four years of frustration!

Sabotage Your Team

Every once in a while, one resident does not play fairly in the sandbox. Perhaps, he/she refuses to help out with a call. Or maybe, this person does not show up to work and constantly needs to have additional coverage. Not playing nicely with others affects the entire team. If you want to ruin the experience for everyone, it is elementary. But in the end, it will haunt you when you need your residency team the most!

Don’t Read

Radiology residency is a marathon, not a sprint. That means you constantly need to keep up with reading books and articles. I can guarantee that you will fall behind your classmates if you do not adequately read enough starting year one. You will not comprehend or perform well at conferences. Likewise, your call and board experiences will suffer. And, your colleagues will not want to have you’ve as a study partner since you are so far behind. You came to radiology residency to become a radiologist. Part of learning radiology is reading a lot. Why would you want to sabotage your training?

Always Compare Yourself To Others

Everybody learns and reads at different rates; and, some residents click with the material earlier than others. That is OK. As long as you are doing your due diligence during radiology residency, you will eventually get to the promised land of radiology competence and graduation. Don’t worry if some of your colleagues always seem to get things right and you don’t. The quickest path to misery is worrying about how everyone else is doing. Undue competition ruins the experience for everyone. Care first and foremost about your progress!

Don’t Show Up To Readouts

There are two main pillars to becoming a great radiologist, knowing the material and experience. If you were going through the hassle of completing a residency, why would you shortchange yourself and not try to get as much experience as possible? You will never understand the context of reading radiology without having the readout experience. Not being at the readout also affects your mentors’ day. Sit down with your residency mentor, and don’t miss the readout. You are only hurting your career and your relationship with your superiors. You never know when you will need their recommendations!

Do Not Improve Upon Your Weaknesses

You have been getting inadequate evaluations in the area of mammography. So, what do you do about it? Nothing. The complaints continue to come streaming in from attendings. But, you persist in not reading the material or studying your misses. Behaviors become habitual and will likely continue even after you graduate if you do not learn from your mistakes. These folks are the same folks that can never keep a job and never improve their lot. Ignoring practice-based improvement hurts you, your patients, and your colleagues. Residency is all about self-improvement to become the best you can so that you can help your patients. Why would you not pursue the same avenues during training?

Procedures Are Not For Me!

Some residents hate procedures and will do whatever they can to avoid them. I understand these folks may not become interventional radiologists. But, they still need to know the basics of specific procedures such as needle localization, arthrograms, and more. Sure, they can get away with this during residency. But, when they try to land their first job, they may have frustrations as they find the only jobs available require “light interventional” work. Not learning procedures may affect your future partners and colleagues. By not trying to feel comfortable with procedures during residency, you are only hurting yourself!

I Am Always Right

Some residents do not accept criticism. Residency is the time to learn and change harmful behaviors before they become ingrained in practice. We are in the game of treating people, not always thinking we are correct. Why would you not want to correct what you are doing wrong? It makes no sense. You are only hurting your patients and colleagues. There is no room for not accepting criticism both during and after residency!

Don’t Take On Extra Responsibilities

Each year of radiology residency, you accrue new responsibilities. Shirking your responsibilities is a surefire way to become a needy radiologist when you graduate. When the technologist comes along to ask a question, please don’t send them to someone else to answer it. Take charge of your situation and section. Those folks that never take on those additional responsibilities never learn to become an independent radiologist!!! Go forth and makes your path.

Avoid Destroying Your Residency Radiology Experience

It is far easier than one might think to destroy your own residency radiology experience. Sometimes you have to put a bit more effort in to get more out of residency. Please, please, don’t succumb to the pitfalls and traps that can prevent you from growing and improving as a person and a radiologist. Get over your issues… It is not worth it!

 

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Is It Still Possible To Become An ABR Certified Radiologist Through The Alternate Pathway?

Dear Barry,

I am also interested as Fiona in the alternate Pathway. My biggest question here would be, if I have any chances after ABR certification in actually pursuing a career as an independent radiologist in the US. As far as I understand, in many if not all states, you are required to complete a minimum time of postgraduate education, within an ACGME accredited program, before being granted the corresponding state license to practice as a physician. Considering the rule that you are allowed to take a fellow position in an ACGME accredited fellowship program ONLY if you graduated from an ACGME accredited residency program (this because of recent changes); how could any radiologist trained abroad be able to fulfill the state licensing requirement after doing the 4 year alternate pathway. (To my disappointment explained here by the SPR – Society for pediatric radiology – ¨ http://www.pedrad.org/Education/Fellowship-Directors/Pediatric-Radiology-Fellowship-Directors-Library ¨ )

The ABR clarifies that the changes introduced by the ACGME are not affecting the alternate pathway, which I understand and see as no impediment for certification, however I still don’t see clearly the possibility of full licensing. Why would a foreign radiologist be interested in ABR certification if the chances of practicing radiology in the US are so scarce or null in the future.

One last question: wouldn’t a fully trained radiologist from abroad be a good candidate to match through the traditional residency system, under your perspective as a program director?.

(Dear Fiona: Maybe we can get in contact and share our views and findings. Please email me if you are interested).

Thank you for reading this, cheers, Esteban.

 

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Here are answers to your two separate questions here. To refer to the other information about the alternate pathway go to the ask the residency director question at the following link: How To Complete The ABR Alternate Pathway As A Foreign Physician

 

Answer to First Question:

In order to be licensed in a state, you do not get your certification from the ACGME. Rather, the ACGME certifies the program that you attend as a resident, fellow, or attending. So, it is still possible to be certified by the ABR and to get a state license via the alternate pathway. However, as you mentioned in the new addendum in 2015 to the alternate pathway, you will have a difficult time getting into an accredited fellowship via the alternate pathway because of the new requirement (having to get an ACGME fellowship only after completing an ACGME accredited residency).

Regardless, it is still possible to use the alternate pathway to become an ABR board certified radiologist. So, how would that happen?

Two Ways To Satisfy The Alternate Pathway Requirements.

1. An ACGME accredited institution would need to sponsor the foreign radiologist for a junior faculty position for four years. In other words, the institution would be responsible for getting the H1B visa for four years so that you could work in the ACGME accredited institution in the United States. The problem with this- the sponsoring institution will incur lots of legal and immigration fees in order for the applicant to get the H1B visa and the junior faculty position. So, it is unlikely that the institution will take a foreign applicant unless he/she offers something special or is trained in a subspecialty area that is useful to the institution and a United States applicant cannot fill that need. Therefore, it is true that the institution is much more likely to take a United States applicant than a foreign applicant for a faculty position.

2. It is possible to get an unaccredited fellowship in an institution that has an ACGME accredited residency program. This year of unaccredited fellowship would be enough to count toward the requirement of having 4 years of training. You would need four such years as this. Through this pathway, you would potentially only have to deal with the issues of getting a J-1 visa, which is a bit easier than an H1b visa.

Issues For The Alternate Pathway Applicant

For both of these alternate pathways, there is a possible complication of some individual states not recognizing the training of foreign residents who do not complete an ACGME accredited residency/fellowship. This means that the alternate pathway training may limit which states he/she chooses to work.

As you can see, it is possible but a bit complicated to go through the alternate pathway via both methods. The ABR alternate pathway has become a rarely trodden method of obtaining a radiologist position in the United States. (It is not impossible, but very difficult and probably involves lots of connections!!!) In addition, there is a risk that your opportunities as an alternate pathway candidate, could be more limited.

Answer To Second Question:

From an associate program director’s perspective, I would love to take a candidate who has been trained as a full-fledged radiologist in another country. Our job becomes a lot easier since these residents are usually very independent. In fact, one our best residents has been a candidate such as that who attended our program four or five years ago. He was absolutely fantastic!

Again, however, there are several impediments for the foreign radiologist who wants to repeat a United States residency. First of all, many programs do not want to have to deal with the stresses of getting a J-1 visa sponsorship for their foreign applicants, even though a J-1 visa is usually not that difficult to obtain. And, second, there is a prestige issue for many programs. Some high-end university programs take pride in the fact they do not take foreign applicants to their program. (Even though they will not say it on their website or brochures)

Bottom line… It is becoming more and more challenging for the foreign applicant to obtain a spot in a United States training position to eventually become a United States ABR trained radiologist. It’s not impossible but it’s very, very difficult. The applicant that is successful is going to have to be at the apex of the foreign applicant pool and is going to have to be on top of the visa situation.

 

Director1

 

 

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Radiology Textbooks Vs. Case Review Books- A Death Match

textbooks

One question that often arises is: what material should I study since there is so much information to learn? But I think a more appropriate question may be: how can I get the most bang for my buck when there are so many reading materials out there? In this post, I will address this issue by talking about when you should be reading textbooks and when you should emphasize case reviews since both play a role in getting up to speed during radiology residency or learning about a new area of interest as an attending. (This is our death match!!!)

Why Textbooks?

Sometimes you lack any understanding of a modality when you begin a residency program, are starting a new rotation, or are attempting to learn a new modality such as MRI, perhaps not covered in your residency. For instance, when they begin, most radiology residents have no clue about ultrasound: how it works, and the images the technologist takes. Therefore, starting to read a case series on ultrasound may not be helpful when beginning.

Instead, a general introductory textbook such as Ultrasound: The Requisites makes more sense at this point to understand the basic principles of ultrasound and the key images that need to be taken and interpreted during a renal ultrasound, Ob/Gynecology ultrasound, etc. Another example would be reading CT scans of the chest. Most residents, when they start, do not have a search pattern for reading chest CT scans. Nor do they know their CT chest anatomy well. An introductory textbook on chest CT scans, such as Computed Tomography and Magnetic Resonance of the Thorax by Webb, would be appropriate before reading a case series.

In addition, good textbooks usually better outline the fundamental knowledge needed to interpret images better than a case review series can. Textbooks are better organized by topics, whereas case review series tend to be more haphazard. For example, it may be more direct and efficient to learn the fundamentals of determining whether an intracranial mass is intra-axial or extra-axial once in a textbook than reading 10 case series on the topic and trying to figure the same approach out.

How To Read Textbooks

When you read a textbook, you should emphasize the images, read the captions, and then read the text to get the most out. Reading in this manner reinforces the information that you need to know better than starting from the text first. This process differs vastly from reading a medical school general medicine textbook, where the text is usually more important than the images. You are now a radiology resident, so you have to think differently!

Why Case Review Series?

In our field, we solely exist because we are image interpreters. So, it makes sense to learn those images and what they mean. What better means to reinforce and understand radiology than with a case series? But, this assumes that the reader has some background knowledge on the topic and can understand the basic principles/fundamentals/meanings behind the images in the case review series.

In addition, case review series tend to have more of a “real word bent.” The images we read daily tend not to follow in an orderly manner by topic. Usually, an almost random distribution of cases comes through our departments. Going through a case review series is usually more similar to going through many images in no particular order.

How To Approach Case Review Series

It would help to start the case review series as soon as you have the fundamental knowledge to understand the modality, anatomy, and primary disease processes on imaging. On each initial rotation, you should aim to start reading at least one case review type of book after you have learned the fundamentals from lectures and textbooks. Do not wait too long to get started, however. Going through the case review series will be more helpful and applicable than most textbooks when you read out cases with attendings and when taking cases at noon conferences. But remember- it often does not summarize the fundamentals of a given subject as well as a textbook.

The Moral Of The Death Match

Both textbooks and case review series are at the beginning resident’s learning armamentarium. Be wary of someone that tells you that you can get through residency by just reading textbooks or case reviews by themselves. Each has its place, and you should use the correct one depending on your level and knowledge base. Now become great radiologists: go forth and read!!!

 

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Should A Resident Physician Apply For A Credit Card When Already In Significant Debt?

credit card

Credit is a very touchy subject with resident physicians in all specialties. And it makes sense. Student debt seems to be increasing exponentially over the years. When I graduated, I thought I had a lot of debt from student loans. But that number pales compared to the debt that most current medical residents hold. Confirming this suspicion, I did a miniature survey of almost 100 medical students at my hospital. Student debt sums were as high as 600,000 dollars. These medical students had not yet completed their four years of training. So, the amounts were going to be higher than that. These sums of money are not insignificant. Instead, the debt will be life-altering for many of these future physicians for years. On top of that, add a high-balance credit card, and you may head toward financial ruin!

This enormous debt burden brings me to the next question. Does it make sense for a resident to apply for a credit card after accruing so much debt? This question came up in the past year with a resident who had not started to get credit in his name. It caused all sorts of issues for him at the time they needed it. And it will probably continue to cause problems for years to come until he establishes a good credit record. So, the simple answer is yes. But in this post, I will explain why setting up a few credit card accounts makes sense even with significant debt. And I will briefly discuss how residents should establish credit.

Why Do Resident Physicians Need A Credit Card?

Laying out Money

A radiology resident often must lay out a significant amount of funds for travel or a large purchase such as a car. What do you do if you do not have a credit card or do not have a credit card with enough credit? Nowadays, most travel is booked online with credit cards. For many websites, the only form of payment is a credit card. You are now stuck with either relying on others to book your flight or not going on the flight. Once you reach a resident’s level, these issues arise often.

Establishing a Track Record For Large Future Expenses (Mortgages, Car Loans, Etc.)

To purchase large items such as a house or a car without cash (and most residents don’t have lots of money on hand!!!), you need to obtain a mortgage or a loan. How will some company provide you with a loan if you do not have a long track record of making payments? Sure, you have your student loan as some background. But that is not enough. You must also have at least one revolving credit account (a credit card) to increase your credit score to obtain these large loans. A credit card is an excellent way of establishing this background.

Cash Back Credit Card

Finally, many credit cards offer incentives in the form of airplane miles, gifts, and cash. Cash has the most value out of any of these rewards. When you make a purchase, you can get a certain amount refunded on every purchase. Some cards give you 5% on specific items or 2% on all items you purchase. So, it really can add up over time. If you use credit wisely, it can pay back dividends!

How To Establish Credit Without Breaking The Bank

If you have a poor or no credit history, finding a good credit card company willing to give you a credit card can be challenging. Even with these issues, there are several ways to establish credit. You can apply for cards backed by your savings or find cards with very low maximum balances. Either of these sorts of cards will allow you to occasionally use the card to make small purchases such that you can begin to establish a credit history. And remember to use personal credit hygiene: Pay your balances off monthly and try to use a small percentage of the credit allotted. These small steps will allow you to establish a good history without spending too much.

Summary

Even though resident physicians already have vast amounts of debt, establishing a credit card account becomes very important from both a practicality and utility standpoint. You can do it in a way that does not cause additional debt burdens or hardship. Bottom line: Establish credit now rather than later when you need the credit!

 

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Up To Date Book Reviews For The Radiology Core Examination

Studying for the ABR Core Exam is undoubtedly a daunting task. Not only can the sheer amount of material one needs to learn seem overwhelming, but also the vast amount of resources available can be more of a burden than an asset. I often see my fellow residents scrambling to make time to go over every single review book out there, in an effort to have all of their bases covered. This strategy is not only nearly impossible but is likely counterproductive. Rather, one should focus on one “comprehensive” review book while supplementing with case review books and question banks that work best for them.

 

When asking my peers about their thoughts on different study resources, I could never get a good consensus on what was best. Different people had the same success passing the exam with very different approaches. However, one commonality I did notice amongst those who had success on the exam was that their approach was comprehensive (covered all categories tested) and diligent. With that being said, it is best to first peruse a resource to make sure it is useful for your style of learning before fully committing your time (and money) to it. Also, it should be noted that none of these are substitutes for a comprehensive textbook (such as Brant and Helms or the Requisites series). Review books are most effective when they are, in fact, used as a review and not a primary source of learning.

 

Below are reviews for the resources my colleagues I used, some more than others, to prepare for the ABR Core Exam.

 

COMPREHENSIVE REVIEW BOOKS

 

Core Radiology: A Visual Approach to Diagnostic Imaging

 

This is an excellent review book that can be used as a single source for reference and overview of salient points. It contains lots of good quality images and diagrams (in color!), as well as tables summarizing differential diagnoses with easy ways to differentiate one entity from another. As with any review book, it may not delve into as much depth in any single topic. Supplementation with Brant and Helms, StatDX, or Radiographics articles may be required for certain topics that require more depth or clarity. This book can be easily understood by junior residents throughout their first or second years of residency, not simply just for those reviewing for the Core Exam.

 

One drawback of this textbook is its size. At 895 pages, it can be a pain to lug around. Also, compared to Crack the Core, this text lacks humor and motivational quotes. Rather it’s more of a traditional, no-nonsense, well-organized review.

 

Crack the Core

 

Written under a pen name by “Prometheus Lionheart,” this series includes two main volumes, together encompassing the main sections covered on the Core Exam. In addition to the main two-volume set, Lionheart has also written a separate dedicated physics review book as well as a case review book (which I will cover separately). This two-volume set is another excellent review source. While it covers much of the same material as Core Radiology, this text is geared specifically for passing the Core Exam by incorporating test-taking strategies in addition to providing factual information. Lionheart interjects jokes and motivational phrases to keep the reader entertained while studying (not an easy task!). This book is much more simplified than Core Radiology, but serves as an excellent review for someone with solid background knowledge of the topics included. The physics and non-interpretive skills chapters in Crack the Core is much more robust and comprehensive than in Core Radiology. Additionally, Lionheart has a video lecture series to supplement his books (at an additional cost, of course), which can be useful depending on your style of learning.

 

One of the main drawbacks of the Crack the Core series is the abundance of typos in the text. While the typos generally don’t alter the context, they can be an annoyance. Another downfall of Crack the Core is the image quality and lack of color diagrams. The supplementary video lecture series does have improved image quality and nice color diagrams and animations, however.

 

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CASE REVIEW BOOKS

 

Core Review Series (Thoracic, GU, GI, MSK, Breast, Cardiac, Nuclear Medicine)

 

The newest of the main case review books, the Core Review Series has separate books in Thoracic, Genitourinary, Gastrointestinal, Musculoskeletal, Breast, Cardiac, and Nuclear Medicine. Each book is broken down into chapters, with each chapter covering a specific subcategory (usually starting out with fundamentals of imaging for that category or normal anatomy).

 

The good: The breakdown by chapter and multiple questions per chapter allows you to hone down your studying to a specific topic and to do multiple questions in a relatively short time period. Image quality varies by book but is generally very good. Most books have online access with an easy interface for doing questions (almost feels like a Q bank). The descriptions of the answers are excellent. I feel that these books best prepare you to think the way they want you to think about the test; to understand the process of why an answer is right rather than regurgitate memorized information. Many of the books even have physics concepts integrated into the questions, which is a tactic the ABR often employs on the Core Exam.

 

The bad: When using the physical books, it can be tedious to flip between the questions and the answers (which are located at the end of the chapter). This problem is alleviated with the online versions, where the answers are available immediately after taking the question. Also, because not all subjects are covered, other sources must be used to supplement these areas (such as Interventional, Neuro, and Pediatrics)

 

 

Rad Cases (Cardiac, GI, GU, Interventional, MSK, Neuro, Nuclear Medicine, Pediatrics, Thoracic)

 

Rad Cases offers a case-based approach (rather than the more question/answer format of Core Review Series) with approximately 100 cases per book. Each case shows images and a clinical presentation on the first page. The next page then goes over the imaging findings, differential diagnosis (with brief descriptions of each diagnosis and how it may or may not explain the imaging findings), essential facts about the disease entity, other possible imaging findings, and finally pearls & pitfalls.

 

The good: This series really does a good job of allowing the reader to come up with a systematic approach to a case. The explanations do a good job of highlighting how one may have fallen into a trap or how one should tailor their thought process when approaching a case. All of these are essential aspects of passing the exam, but relate

 

The bad: While learning how to approach an unknown case is necessary to tackling exam questions, this text appears more driven to prepare residents for the old oral boards. One could argue that a more rapid-fire question/answer format is more useful when it comes to preparation for the Core Exam.

 

 

Case Review Series (Neuro, Head and Neck, Spine, Breast, Cardiac, Emergency Medicine, GI, GU, MSK, Nuclear Medicine, Pediatrics, Thoracic, Interventional)

 

CRS is another case based review, with each book separated into three different difficulty levels. The cases at the beginning of the book, “Opening Round,” are easiest, the next level of difficulty in the middle of the book is termed “Fair Game” and the most difficult cases at the end are in the “Challenge” section. Each case shows images and is followed by four questions pertaining to those images.

 

The good: The book offers excellent cases with good image quality. The multiple questions per case really force you to learn several aspects of a case. When it comes to the Core Exam, knowing the diagnosis alone usually does not suffice. Thus, being able to answer questions from several angles about a case is a valuable learning tool.

 

The bad: Similar to Rad Cases, CRS appears to be more driven toward oral board prep. While this may help with expanding one’s knowledge base, it lacks the multiple-choice question/answer that is necessary for the Core Exam. Also, the Challenge sections are often too difficult/esoteric and are often beyond the scope of the exam. It would behoove you to do only the Opening Round and Fair Game sections in order to save precious study time.

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PHYSICS/OTHER

 

Huda’s Review of Radiologic Physics

 

This is the physics review book by Walter Huda, who administers yearly review courses in radiologic physics throughout the country. It is in bullet point form and aligns closely with his course.

 

The good: The book has pretty much everything you need to know for physics for the Core Exam, with review questions at the end of each chapter and online access. It is formatted in bullet point form to be intended for quick review. I used this book while at Huda’s review course and immediately after it in order to reinforce the concepts he taught.

 

The bad: While all the facts you need to know may be in this book, there is very little in the way of explanation. You will have to use other, more thorough sources for a deeper understanding. Also, the questions at the end of the chapter serve to reinforce some basic topics but are unlike anything you will see on the exam.

 

 

Radiologic Physics “War Machine” by Prometheus Lionhart

 

This is the dedicated physics book by the Crack the Core author, with a very similar layout to Crack the Core.

 

The good: This book was a great resource for studying physics. It really simplifies topics and makes them easier to understand, and therefore memorize. He does a good job of explaining what physics is relevant to the test and what is not, which is extremely valuable (the last thing we want to do is study more physics than we need to).

 

The bad: Again, the typos. Also, there is a lot of overlap between this book and the physics section of the Crack the Core book. I have not examined them in detail, but I just studied the section in Crack the Core without using the War Machine book and felt it was more than adequate preparation.

 

 

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QUESTION BANKS

 

RADPrimer

RADPrimer is the question bank associated with StatDx and has an abundance of questions (2,221 Basic and 3,747 Intermediate level questions).

 

The good: Lots of questions with mostly very good explanations. Good image quality. What I found most useful about RADPrimer was the ability to hone the focus to exactly what I wanted to study. For example, if I had just read a section in a review book about CNS Infections, I could create an exam and do those specific questions in order to solidify what I had just read.

 

The bad: Many of the questions are too straightforward for what you will see on the test. Rather it should be used as a learning tool to reinforce recently studied material and not a means to simulate the Core Exam. Also, while there are some physics questions, there are not enough to use this as the sole source of physics practice.

 

 

 

BoardVitals

 

BoardVitals is an online question bank that offers subscriptions based on different time increments ($399 for six months, $229 for three months, $139 for one month). There are 1500 questions broken up by general category.

 

The good: The questions better simulate the real exam than RADPrimer. The explanations on most questions are good. There are more physics questions than on RADPrimer and this bank also includes non-interpretive skills questions (which I found very helpful). What I also found very helpful was that the interface was well-suited for use on mobile devices. Whether I was in a line somewhere, on a train, or on a bus I could bang out a few BoardVitals questions with ease.

 

The bad: Some of the answer explanations were one line without much information. These were once in a while but did occur and could be frustrating at times.

 

 

Face the Core

 

Face the Core is another online question bank, with 35 different modules. Each module has about 75-100 multiple-choice questions. Modules consist of several cases, with each case having approximately 4-5 associated questions. Modules can be purchased individually for $10 each or you can purchase all 35 modules for $250. Modules must be completed in full (all 75-100 questions) before you could go over the answers (no “tutorial” mode).

 

The good: I used this question bank at the end, to brush up on my weaker areas, so I liked that I could purchase just the modules I needed rather than forking over $250. The explanations were pretty good. Some of the modules even had video explanations, which was nice because they would go into more detail. The physics modules on Physics Artifacts and MRI Sequences were very helpful.

 

The bad: The main drawback is the fact that you have to do the entire module before you can go over the questions. This made the process very time consuming (at least 2 hours per module). The image quality was poor and the layout appeared somewhat haphazard. Overall it is a good resource to use at the end, to cover areas of weakness.

 

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I know it seems daunting with all the resources out there. Don’t be afraid to use many, but use them wisely. Below is a rough plan of how I approached studying for the exam. And it worked for me:

 

My approach:

6-8 months before the test

  • Used Core Radiology early and often as primary source
  • RADPrimer questions (based on exactly what I was studying in Core Radiology)

4-6 months before the test

  • Continued above
  • Started Crack the Core Physics (supplemented by various YouTube videos)
  • Started BoardVitals Questions
  • Core Review Books

2-4 months before

1-2 months before

  • Skimmed Crack the Core to fill any gaps/get different perspective
  • Continued BoardVitals
  • Started Face the Core on weak areas

< 1 month

  • Crammed facts
  • Reviewed notes
  • Questions, questions, questions

 

 

 

 

 

Good luck!!!!

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Top 10 Things To Do When The PACS Goes Down

pacs

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

1. Call Up IT To Fix The PACS

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

2. Network

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

3. Study For The Boards

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

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

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

5. Arrange Elective Time

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

6. Observe Department Processes

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

7. Research Projects

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

8. Walking/Exercise

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

9. Grab Your Lunch

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

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

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

 

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

 

 

 

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Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?

private practice

The herculean question up for debate: is a private practice career path worth the extra money? To answer this question, you have to know your career options. Suppose you are talking about standard career options for the radiologist (not the alternative career paths discussed in a prior post). In that case, you can divide it into three main choices: private practice, academic/government, and the hybrid model.

Lucky for you, if you are reading this article and you are now making this decision, you have come to the right place. I have worked in the world of academics as a fellow and dabbled in private practice at my first job out of training at Princeton Radiology. Now, I work at Saint Barnabas Medical Center, where we operate with a hybrid model (I was also formerly a resident at a program with a hybrid model-Brown University). Since I’ve been through it all, I am uniquely qualified to talk about how to decide between each option. So, I am going to do just that!!! (Don’t let other posers fool you!)

Are There Income Differences?

What is the difference in income for an academic practice radiologist versus a private practice radiologist? If you look at the Medscape Radiologist Compensation Report from 2016 (later surveys did not have this information!), the academic radiologist made around 262,000 dollars (in this category also is included the military and government physician). On the other hand, some of the other private practice type radiologists made significantly higher amounts: the office-based solo practitioner- 434,000 dollars; the office-based single-specialty group practitioner – 386,000 dollars; and the typical hospital compensated radiologist- 381,000 dollars. So, suppose you take these debatably inaccurate academic and private practice numbers into account. In that case, a pretty substantial difference exists between the income of private practice and academic radiologists (almost 100-150 thousand dollars per year).

It’s Not Just About The Income Though!

But not so fast! In terms of numbers alone, the actual compensation may not account for other benefits like pension and health care. Employees that work for the government or large institution academic hospitals can sometimes receive substantial fringe benefits such as a pension of 70-80 percent of the final salary. Or, they can get incredible health care insurance that you cannot earn elsewhere. Finally, some have other perks, such as free tuition for children in college.

Moreover, the typical smaller radiology private practice will not give these perks. If you take the pension alone, that could amount to a guaranteed (0.8)(262000 dollars per year) or about 210,000 dollars for the rest of your life based on 2016 salary numbers. You would need to have 5.24 million dollars in the bank to have that kind of money guaranteed annually, assuming a 4 percent relatively risk-free return. So, the difference may not be as substantial as initially thought at first glance.

So, now that I have debunked some of the income-based differences (there are always exceptions to every rule!), let’s talk about the different models and decide which option is the right one for you. Let’s start!

The Academic/Government Model

In the purely academic or government model, the primary goal is not reading films and making money. Instead, you will need to publish, teach, or exist (if you are talking about a place like the VA hospital!). Prestige and promotion results from these activities. For comparison, the typical private practitioner couldn’t give a lick about these job requirements. The philosophy is often: publish or perish!

The typical academic sort writes a lot, obtains grants, and is responsible for his/her residents’ teaching and welfare. He/she typically reads fewer studies and sees fewer patients than a typical private practice radiologist. But, that may vary depending upon the institution for which you work. He/she gives many conferences, travels all over the country/world to give lectures, mingles with other academic sorts on all different types of committees, and plays a significant role in directing the future of radiology. Many of these radiologists have outside ventures and partnerships with various companies and academics centers since they do not only occupy themselves with the standard day-to-day role of reading films. Some of the associations may be based on their research or area of expertise.

The higher-up academic radiologists manage their staff as chairmen. These individuals may be responsible for budgeting, hiring, and firing depending upon the institution. Again, your mileage may vary depending upon the role that you have in the institution. The almighty dollar has less control over your day-to-day work. (Although many would say it still plays a nice-sized role!)

The Pure Private Practice Model

What about private practice? In general, private practice wants to maximize income and the number of patients that go through your system. Of course, excellent radiology businesses have an element of quality. But quality exists to increase profitability, and the almighty dollar tends to rule the day. And, of course, all roads lead back to the almighty dollar. Employees and owners grind out films daily, day in day out. The philosophy: if you do not work, you do not make money.

Now, of course, the private practitioner also accomplishes other activities in trying to make money. These folks may perform some or all of the following practice needs: advertising, buying and selling equipment, strategic partnerships, and mergers, maintaining relationships with hospitals, hiring and firing an army of numerous employees (possibly radiologists, technologists, janitors, nurses, physicists, and so on), maintaining and purchasing real estate, payroll, billing, legal issues, parking, and utilities. On the other hand, academic hospitals/ institutional facilities typically take care of most of these issues. Therefore, you need to enjoy playing many different hats and roles and being a self-motivated entrepreneur.

The Hybrid Private Practice/Academic Model

I currently work in this role. I like to think that I get the best of both the private practice and academic world. (Although some would like to say that is the worst!) The hybrid practitioner’s philosophy: A dabbler who enjoys elements of both private practice and academia, but not in such depth.

So, how does the hybrid model work? First of all, you have a few variations on a theme. In my situation, I am involved in a hospital-based private practice with a residency program and multiple covered hospitals and imaging centers. For another type of system, the hospital may employ you, but the hospital may tie you to the private practice world via output bonuses. In essence, the practice expects you to teach, do a little bit of research, and maximize your work output. Thereby, you create income by grinding through studies. Most of these practices are not involved in purely academic activities such as obtaining grants. And, you will probably not involve yourself in typical pure private practice issues. For instance, you will probably not need to maintain the building utilities.

The hybrid practitioner/dabbler likes to do a little bit of everything without delving into some hardcore academic and pure private practice issues. I was never interested in writing grants, but I certainly wanted to teach. I was not interested in dealing with some of the fundamental problems of private practice, such as hiring/firing technologists. Yet, I was interested in the mechanics of business and private practice. For the sort of person that likes to be a bit more generalist, the hybrid model can be a great career path.

How To Make The Final Choice?

I think the final choice becomes a personality-based thought process, not one based on the different income constructions of each career model. If you hate business in all forms, work for the government or academia. If you hate writing and teaching, a private practice may be for you. On the other hand, if you love doing a little bit of everything, think about the hybrid model. Bottom line: You need to be true to your self. Do what you like, not what others will think you will enjoy. If you follow these precepts, you will make a great choice and have a fantastic career!

Comments are welcome!!!