Tag: radiology

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Is Radiology Still A Career Or Just A Job? And What Does It Mean?

job

What exactly is a career? If you listen to the internet authority, Wikipedia, it is “an individual’s metaphorical “journey” through learning, work and other aspects of life.” And, what is the definition of a job? Again, if you listen to “all-knowing” Wikipedia, a job is an activity, often regular and often performed in exchange for payment (“for a living.”)

So, which definition does radiology meet today, a career or a mere job, a transaction made to make a simple living? Many long-standing radiologists and outsiders would say that radiology is a career. You spend countless years learning and practicing the art and science of radiology. Moreover, when you finish, you live and breathe the profession. You strive for professional excellence. More importantly, it becomes ingrained as part of your persona.

These everyday thoughts are an oversimplified answer to whether radiology is a career or a job. As such, the response has transformed itself over the past ten to 20 years.

Changes To The Equation of Job Versus Career For Radiologists

So, what has changed over the past decade or two that has morphed the answer to this question? First, the landscape of medicine has dramatically shifted. Students that formerly completed school with reasonable amounts of student loans are now graduating with hordes of debt. Additionally, external pressures from governmental bureaucracies have dramatically increased. The number of films radiologists need to read, and procedures they must perform have exponentially climbed. Some may say that the numbers have far surpassed what is safe for patients.

Finally, different demographics have joined the profession. Today, many radiologists want to practice part-time to raise a family or pursue other interests. Years ago, this type of radiologist was much less common.

Individually, each of these factors plays a role in the change. In the following few paragraphs, we will go into more detail about the reason for each.

Reasons Radiology Has Become A Job For Many

Student Debt

Let’s start by talking about the noose of enormous student debt hanging around the shoulder of new radiologists. In the past, radiology residency graduates could afford to pick and choose where and what to practice based on the merits of the post-residency job alone. No longer is that the case. Now, it becomes more important to make sure you can afford the debt service payments and the day-to-day living expenses of the region of practice. For many, finding work is about desperately needing to make ends meet. So, radiology merely becomes a means to this end.

Increased Bureaucracy

We all feel the weight of increased paperwork and regulations we must follow. To that end, maintenance of certification has become more stringent (although, more recently, it has been slightly letting up). Requirements for accreditation have been increasing exponentially. Also, the maze of insurance requirements to complete a study keeps rising. Moreover, these factors are the tip of the iceberg. For many radiologists, many bureaucratic factors lead them to resign themselves to practice radiology as a job.

The Work Treadmill

Nowadays, many radiologists are hostage to the ever-increasing number of studies they need to read. Public expectations for the delivery of results promptly and efficiently have climbed. Also, time to transcription has become the holy grail of the hospital administration. In these conditions, how can some radiologists perceive their work as more than just a cog in the wheel to make ends meet?

Changing Demographics

Finally, we need to also talk about why different radiologists pursue radiology. No longer do all radiologists fit the same mold. For some, their role in raising a family has become more crucial than the position that they may play in running a radiology practice. So, these radiologists merely want to fund their lifestyle and not get involved in the professional aspects of radiology.

What Does This All Mean?

Well, to start with, we know that the most consummate professionals invest heavily in their careers and see their profession as a calling. These are the incredible clinicians, the movers, and the “shakers.” Moreover, they perform groundbreaking research, make improbable diagnoses, teach their residents, and create radiology systems and businesses to promote the profession.

However, based on the new pressures on individual radiologists, we cannot expect all radiologists to see their original “calling” as a “career.” Instead, many other factors play into the equation. Student debt burdens some radiologists. Alternatively, the chains of bureaucracy and increasing workloads prevent the pursuit of their interests and infringe upon the professional lifestyle of a radiologist.

Regardless, we should not talk badly about radiologists who need to work in the profession merely as a job. Many radiologists have excellent reasons for that. Instead, we should work to fix those factors that have changed to make radiology into a job so that we can improve the quality of our profession and return it to a career for all.

 

 

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How Much Does It Take To Start A Radiology Imaging Center?

imaging center

Ever get a question that goes something like this, “Why don’t you start up an imaging center?” Well, in the land of pixie dust and chocolate-covered mountains, that may work. However, in an expensive world with loads of student debt, only the rare physician can gather enough cash to begin a new radiology practice. Additionally, who is to say that you will have enough patients in your location to survive? In any case, that got me wondering how much does it take to create an imaging center startup? So guess what? That is my insane plan for today. We will calculate the annual capital expenses to start/run your practice. So, at least, you will have a response that you can give to those naive friends and relatives of yours!

First, let’s sort out what kind of imaging center about which we are talking. Well, I am thinking about the average Joe diagnostic center with one of each piece of equipment. And let’s skip interventional and nuclear medicine for the sake of simplicity. Perhaps, this center will have an MRI, a CT scanner, an ultrasound unit, a mammogram tomography unit, and an x-ray apparatus. We will also assume that you locate your practice in an average part of the country with mediocre building costs. Let us say that we will amortize the sizeable capital-intensive equipment for over ten years. Finally, we will amortize the building for thirty years.

Most importantly, these calculations are made on “the back of the hand,” meaning that I would not rely on them to create your imaging center. Numbers can vary widely. Nevertheless, I am doing this so that you can get a sense of the costs involved.

What are the fixed capital costs for an imaging center?

Building

So, we will begin with fixed expenses. What are the most considerable fixed costs of an imaging center? Of course, these include the building that houses the equipment and staff and the imaging machines that make up the imaging center. Concerning the structure, we will assume that it is around 5000 square feet. So, how much is it annually to pay for an average space measuring 5000 square feet? It turns out I was able to find the average cost per square foot of retail and industrial space throughout the country. Based on the realtors website chart, the average industrial area would measure 6.92 per square foot, and the average retail space would be 17.12 per square foot. The building we would need could be in an industrial space but would need to be accessible to customers, so let’s make our cost 10 dollars per square foot or 50,000 dollars per year.

Not only do we need to pay for the building, but we also need to renovate the building before beginning our center. Designing the construction would involve spending on an architect to create the renovations—figure on another 20% of the building’s cost or 100,000 dollars. Let’s amortize over ten years and say that it will cost around an additional 12,000 dollars per year.

Then, of course, we need to pay property taxes. Let’s figure that the number is around 2% of the price per year or 10,000 dollars. Also, we need to insure the building and business. Let’s tack on another 10,000 for good measure.

Moreover, finally, the structure and practice need to be certified and inspected. So, let’s add another 10,000 dollars.

Total= 82,000 dollars per year

Machines/Service Contracts

How much is an MRI? Well, the answer to that is that it varies widely. However, we are talking about the average MRI, maybe even used. So, based upon this MRI price guide, let’s say that it costs around 200,000 dollars. That would amount to a monthly payment of about 2,000 dollars or 24,000 dollars per year. You will also need a service contract to maintain the system. That would run another 100,000 dollars.

Next, let’s take the price of an average CT scanner. Based on information on the lbnmedical website, it would cost around 100,000 euros or 116,000 dollars for a typical CT scanner. Again, amortized over ten years, we are talking approximately 1,200 dollars per month or 14,000 dollars per year. However, that is not the only significant expense for the MRI and CT scanner. You need a service contract. That service contract goes for around another 100,000 dollars per year per machine based on the blockimaging website.

Next, let’s look into the price of an average mammography unit. That would cost somewhere in the realm of 250,000 dollars (or 30,000 dollars per year) if we use the data from tractmanager with a service contract costing around 50,000 dollars per year.

Also, we need an x-ray unit. That would be around 100,000 for a digital machine, according to the blockimaging website(or 12,000 dollars per year). Finally, let’s say service would cost another 50,000 dollars per year.

Total= 380,000 dollars per year

PACs system/RIS

Naturally, our center will need an information system capable of handling all the studies that we are performing. That does not come for free! So, how much does that cost? For an average “smallish” imaging center like ours, the website purview.net states it costs around 1500 dollars a month or 18,000 dollars per year for a cloud-based solution, including IT. Not so bad, right? Well, you also need an information system management package to schedule, manage dictations, and more. That would run you another 450 dollars per month per user, according to this website. We will assume a couple of users. It would cost around 900 dollars per month for 12 months or 11,000 dollars per year.

Total= 29,000 dollars per year

Furniture/Room Items

Furnishings can be a hard one to estimate. Moreover, it can be more costly than you might think for desks and chairs, as well as patient tables, and more. Unfortunately, I cannot perform an exact calculation. However, I will estimate for the facility that it would cost around a few hundred thousand dollars. If we were to amortize that over ten years, we would say that it would cost about 24,000 dollars per year.

Total= 24,000 dollars per year

Sum Total For Capital Expenditures= 515,000 dollars per year

What are the annual recurrent costs for an imaging center?

Workforce

The annual recurrent costs include all the people and things you need to run a practice. Let’s start with the workforce. Most importantly, we will begin with the behemoth expense in the room, the radiologist. What is the average annual package for a radiologist? According to salary.com, that would be around 400,000 dollars, of course not including extras such as malpractice and more benefits. Let’s say for argument sake that would end up at approximately 500,000 dollars.

You also need technologists to run the show. So, we will assume that you have a moderately busy practice. Therefore, you will need an ultrasound tech, an MRI tech, a mammogram tech, and a CT/x-ray tech. According to salary.com, this would run around 60,000 dollars per year per technologist. For this imaging center, that would total about 240,000 dollars.

We would also need a medical physicist to make sure our practice is compliant with all regulations. The mean medical physicist salary is around 183,000 dollars per year. However, we don’t need a full-time physicist. Let’s say we were able to share a physicist among several other practices. So, let’s say that it would cost 183,000/4 or around 45,000 dollars per year.

Importantly, you need to hire secretaries to run the front desk. Let’s take a couple of secretaries for our practice at the cost of 40,000 each per year, according to salary.com. That would total to 80,000 dollars per year.

Also, you may need a business/marketing manager for the site to run the show. That does not come cheap as well. The cost would run around 100,000 dollars per year, according to salary.com.

And finally, you need someone to clean the facility. Perhaps, a janitor? Let’s say another 25,000 dollars per year.

Total= 990,000 dollars

Billing And Benefits Management

Nowadays, you also need an expert that helps with billing since it is complicated and takes much time to learn. Besides, it is critical for maximizing revenue for the practice as well as for avoiding Medicare fraud. Often, these same “experts” also help out with payroll, insurance, and more. Most work on a percentage of the gross revenue for the practice. We will say for the sake of argument around 5 percent. For an average facility, we will say total revenues are around 3,000,000 dollars. So, a billing/benefits management for this site would run approximately 150,000 dollars per year.

Total= 150,000 dollars

Other Costs

Of course, you also have to pay for heat, hot water, and electricity. These expenses do not come cheap, especially when you are running all this equipment. I will estimate a lump sum of around a couple of thousand per month or 24,000 dollars per year.

Moreover, it would help if you had miscellaneous recurrent expenses like toilet paper, contrast media, intravenous supplies, and more. Let’s figure on another 35,000.

Total=59,000 dollars

Sum Total For Recurrent Costs= 1,199,000 dollars/year

Let’s Add It All Up For The Imaging Center- Don’t Shoot The Messenger!

So, there we have it. I have created an approximation of most of the expenses that you might have if you were to start your imaging center. Of course, if you decide to plop the imaging center in the middle of Manhattan or San Francisco, my estimated costs would be a lot smaller than the real total costs. (You know what they say- location, location, location!) Alternatively, if you stationed the imaging center in the middle of nowhere or an undesirable area, the costs would likely be less. However, this may be somewhat closer to the actual expenses for an average place in the United States. So, drum roll, please… Here is the final summary total of our costs-

Building- 82,000 dollars per year

Machines/Service Contracts- 380,000 dollars per year

PACs System/RIS- 29,000 dollars per year

Furniture/Room Items- 24,000 dollars per year

Workforce- 990,000 dollars per year

Billing and Benefits Management- 150,000 dollars per year

Other Costs- 59,000 dollars per year

Final Total= 1,714,000 dollars/year

Think you can afford that, starting as a new radiologist? I bet for most of you out there, probably not. Of course, you may be able to obtain financing. However, for the majority of us without the experience, it is a tough nut to crack.

So, there you have it. You now have an answer for your naive family members when you get popped the question, “Why don’t you start an imaging center?” Until next time, signing off…

 

For those of you interested in how imaging centers market themselves online, especially during the time of Covid-19, take a look at some of these tips from tomatoes.digital below

7_marketing_tips-medical-imaging

Check out the following link if you are interested in more information: https://bit.ly/389WnlF

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ESIR Programs: Let The Buyer Beware

Radiology programs, radiology program directors, Early Specialization In Interventional Radiology (ESIR) directors, and residents interested in interventional radiology are dealing with a mini-crisis. For years, programs have allowed residents to make a choice to start an interventional fellowship several years into residency. Instead today, new residents face the crunch of having to make this decision to join up with ESIR programs right away. And, they should not take this decision lightly. Why? Well, that is exactly what we are going to discuss today!

So, What’s The Urgency, Huh?

Like anything else in the world, when you have limited supply and excess demand, you create bottlenecks. And, unfortunately, in many programs across the country, the number of ESIR spots available does not equal the number of residents interested in the program. Therefore, this problem exists in some programs, right here right now.

So, if a program has two residents interested in this program, but it only has one spot available, the program director needs to make the final decision by either one of two methods. First, the program can decide on a first come first serve policy. But, let’s say that you have two residents that decide they want to join a program at the same time. Well then, that leads us to the other way to decide. And, that would be a long drawn out application process to determine the most “qualified” applicant.

Either way, this puts pressure on the applicant and the program to make a decision pronto. As you now understand, the resident and program need to make rushed decisions together.

Why Can This Decision To Join ESIR Have Permanent Implications?

OK. First, I will mention the positive. ESIR programs allow residents throughout the country to decrease the number of years of a fellowship from two to one. And, these residents will be able to hit the proverbial ground running at their interventional fellowships from the very beginning. But, at what cost?

Problem 1

Here comes the tough part. ESIR programs need to allow residents to complete approximately one year of interventional related activities during radiology residency. So, where does the time come from? It has to come from somewhere, right? Well, here is the rub. Programs need to draw the time allotted to ESIR from the normal diagnostic radiology activities. So, residents that complete an ESIR program have less overall experience in the standard rotations like MRI, ultrasound, etc. And therefore, the training of an ESIR resident is not truly equivalent to a standard diagnostic radiology resident.

So, what are the implications of this? In the workforce still, most practices need radiologists that can perform interventional radiology (IR) but can also help out with some of the general work. Well, residents that start a typical IR job will not have the same experience and comfort level with general radiology practice. As you can see, this creates a serious problem for the ESIR graduate.

Problem 2

Unfortunately, the problems do not end here. Let’s say that you start the ESIR program. And then, you then apply for fellowship toward the end of residency. Due to the changes in allocated slots for interventionalists with new DR/IR programs, ESIR programs, and “independent fellowships”, fewer residents can easily drop out of interventional radiology during residency. So, fewer spaces become available for interventional programs throughout the country. And therefore, you, as an ESIR applicant to fellowship, may have a lower likelihood of gaining admission to an interventional radiology fellowship than residents applying in prior years.

So, who is to say for sure that you can obtain an interventional fellowship after residency as an ESIR applicant? In this case, theoretically, ESIR programs have now doubly screwed this resident. First, they completed a program for which they have a real chance of not completing the required CAQ certification. And second, they have less diagnostic radiology experience.

Problem 3

Many folks that want to do interventional radiology really do not know what they want to do until they have completed several IR rotations. So, what happens if the ESIR program resident decides that they do not like interventional radiology toward the middle or end of their residency? Well, they potentially have prevented another interested applicant from getting a spot. In addition, they have again decreased their own training in diagnostic radiology- a lose-lose situation. They will potentially graduate as a “second-rate” diagnostic radiologist.

Bottom Line For The Applicant To ESIR Programs

For those of you applying to ESIR and know for sure that you want to do interventional radiology, well then, go for it. But, I have a sneaking suspicion that many ESIR applicants are not in this category. So, if the program offers you a choice to apply for an ESIR program, make sure to think twice. The implications of joining this program can be far-reaching for the rest of your career!

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Eight Ways To Find Inspiration During Residency

inspiration

You wake up to go to work. Maybe, you grind through what seems like a hundred films with your attending. And then, you arrive home exhausted, only to start reading books and case reviews. The work of a radiology resident never ends. So, how do residents find the inspiration to get through the day, study for the core exam, and get through the entire residency? And, what can residents do to have a fulfilling four years? Unfortunately, very few radiologists have the time to consider the resident’s plight. But I plan to tackle these issues today. Think of this post as chicken soup for the radiology resident, concepts one needs to tough things out for four brutal years.

 

Yes, You Will Save Some Lives

Never forget this fact. Imaging saves lives. And who interprets the images? You! So, get yourself right out of that funk. And, remember, we are not financiers, accountants, or lawyers. We directly prevent significant injuries and death!

Have A Hobby/Life Outside Of Residency

As much as you may love radiology, actively seeking other interests is just as important. I don’t care if it is swimming, stamps, reading, or traveling. Having a hobby enables you to return to work fresh and ready for the next day. Sometimes, studying and working improve when you have an unencumbered mind with the same old studying routine. Studies have shown that creativity and productivity also improve when you pursue activities outside your main interests. Why not let that be you? (1)

Sometimes It’s Not Just About The Work; It’s About You!

Inspiration does not only come from your patients and your films. Instead, feeling inspired stems from your moods and wants. To take care of others, you must also take care of yourself. So, remember… You have a responsibility to yourself to cater to yourself at times. Take a little time to yourself when things become tough studying. Or, if you lose focus during the day, sometimes you need to step away for a few moments. To regain your concentration, you need to refresh yourself!

Maintaining Health

It sounds strange that maintaining health can inspire you to become a great radiologist, right? Well, if you do not eat well, exercise, and sleep, it becomes much more likely for a resident to burn out before finishing residency! So, make sure to treat your body right!

Learning From Mistakes Can Be Inspiring

Mistakes are depressing and ugly, correct? If you continue to think that way, you should not become a radiologist. Expect mistakes. It’s part of the risk profile of our job (Although attorneys would think otherwise!). One study reported a significant error rate that ranges between 2 and 20% of all radiologist reports. (Br J Radiol. 2001 Oct;74(886):949-51.)

So, we need to become inspired to do better. How do we do that? Well, think of each mistake you or others make as an opportunity to prevent significant errors from happening again. If we want to get closer to perfection, we must inspire ourselves to learn from these mistakes, knowing we will not miss that finding or commit that knowledge error again!

Appreciate What You Have Accomplished

Think about the goals you have met to become a radiologist. You have completed college, medical school, and an internship. And remember all those tests that you have aced and passed to get to this point. This successful journey is a real accomplishment! Be proud of what you have achieved. You are not an average Joe. Instead, you have done what many folks can only dream about. And, if you have already gotten this far, imagine how far you can go… If that doesn’t inspire you, I don’t know what will!

Think About The End Goal

Inspiration often does not come from what you are doing right now. Many times, it comes from dreaming about what will be. So, it’s not about repeatedly reading that same paragraph to remember or understand a single concept. Instead, it is about how this pertains to the final goal of becoming a great radiologist. Therefore, don’t get stuck in the minutia. It’s about the big picture!

Education As Fun

Education is about the journey, not the destination. That is because we never really arrive. There is always more to learn and see. And what can be more exciting than discovering new ideas and concepts and applying them to the practical world? As radiologists, that is what we do! So, take each pillar and block of knowledge to form new and exciting structures. This process involves taking new ideas to create research projects or looking at studies in a different way that no one has thought about before. You are only limited by your imagination!

Final Thoughts About Finding Inspiration

Inspiration is what makes us tick. It gives us the passion for completing our dreams and going one step further. However, it does not come from the daily grind. Instead, it comes from our beliefs, hopes, dreams, and goals. So, appreciate what you have accomplished, think about what you do daily (and yes, that includes saving lives!), and remember your goals for the future. It’s all pretty amazing. That should be inspiration enough!

 

(1) http://www.cofcogroup.com/want-more-productivity-get-a-hobby/

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Should I Join A Practice With A High Buy-in?

buy-in

As of the end of 2020, the job market is beginning to improve post-covid. And, for those of you considering your first job nowadays, you may receive offers from multiple practices. And, some of those offers may seem enticing. Perhaps, you hear that the partners make 600,00o, 700,000, or 800,000 dollars or more. And when you interview, the President of the private practice tells you that you will have to pay a large sum of money into the business. This sum of cash called a buy-in can range from zero to as high as into the millions. So, here are the questions you need to answer. Is a high buy-in ever worth your while? In fact, should you even entertain the possibility of starting at one of these practices that come with an enormous buy-in? Well, I am here to help you to answer these questions today!

 

 

The Hope

OK, all things considered, paying into a practice a large sum of money doesn’t sound so bad if the practice guarantees that you will bring in gobs of money each year, right? If you are paying a million to own a radiology practice’s technical shares, you can potentially receive outsized benefits in return. For one, your salary can become much higher. That initial sum of money that you add to the practice equity can significantly increase in value if the practice does well. You can also diversify your income a bit by collecting the professional fees and the technical component. These hopes can all come true.

But Then…

OK. There is always more to the story. Practices can dash hopes in an instant. Let’s say you don’t receive a share of the partnership during your partnership track. Where does that leave you? A lot poorer!

Or, perhaps, the practice equity declines as you finally earn the golden ring of partnership. Can a practice’s equity decline that much? Sure, can! Assets can not only decline to zero but can become a debt burden as well. Think about it. Equipment depreciates. And physical properties can decrease in value. The money you put in can no longer exist after you put all that equity into the business. And some!

Besides, you may overpay for the practice more than it’s worth. Who is to say that you have paid a fair price to become a partner? The practice partners? How do you know if they know how to value the practice. Or, maybe, they are trying to defraud you. You never know.

Weighing The Risks Versus Benefits Of A Large Buy-in

So, let’s see. The potential for large rewards versus the possibility of paying into something that is not worth it. What should you do? As always, this comes back to a trust and numbers game. Only by vetting the practice’s balance sheet and getting detailed information about the practice owners can you make the decision. So, how do you go about making this weighty decision?

Of course, you need to assess the people that run the practice. But how? Track record becomes very important. Have they strung along with multiple employees on partnership track to never make them a partner in the business? Are these physicians respected members of the radiology community? Do your residency and fellowship directors know something about the practice?

To get at the matter of trust, you must research the practice well. Check for lawsuits and hiring indiscretions. These can all become red flags that the imaging business may not be what you think.

And then get to the bottom of the balance sheet. Be wary of any practice that does not let you know what the partners have made in the past. Think twice if the practice does not allow you to talk to the business manager about the finances and the assets the practice owns. I know of several radiologists who had been through an extended partnership track to find out that they became partners in only the professional component, not the technical component/equipment and real estate. They were sorely disappointed when the time came to make “partner.” So, make sure to find out what you are really “buying-into”!

Finally, you need to consider the current environment of the practice. Are private equity firms or large hospitals in the area taking control of practices? Is the area economically growing or contracting? These factors may influence the risk of entering a partnership track that you may not be able to complete.

A High Buy-in And Your Final Decision

Depending on the situation and the practice, a high buy-in may or may not be worth the risk. Take into account not just the great potential of the business. Instead, you also need to consider the risks you need to take to earn that potential outcome. It might turn out well, but it might not. So, maximize your probabilities of success. Do your due diligence!

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Can You Pass The 2018 Saint Barnabas Precall Quiz?

Due to the popularity of last year’s precall quiz post, I am back at it again. Today, I am posting 10 cases from the real 2018 quiz that we used to ensure our residents are ready prior to beginning call. Of course, we used our PACS system to see if they could not only understand the disease entities but also make the findings as well. Unfortunately, you will not have the same option. However, these cases will help to benchmark where you may stand.

When you go through the test, come up with the findings, diagnosis, and if asked/relevant, management. In order to see how you did, answers are at the bottom of this page. (Don’t peek until you are finished!) One more thing… in order to pass the test without conditioning, you need to get at least 70 percent right. Enjoy!

Precall Quiz

Case 1

 

Case 2

 

 

Case 3

 

 

How would you manage this case?

Case 4

 

 

 

 

 

 

 

 

 

 

 

Case 5

 

What questions do you need to ask?

How do you manage this case?

 

Case 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 7

part A

 

 

 

 

 

 

 

 

 

1st film- 2 years ago

2nd film- today

What is the differential diagnosis?

What do you want to do next?

 

part B

 

 

 

Case 8

 

 

 

 

Case 9

 

 

 

Case 10

 

 

 

 

 

 

Answers:

Case 1:

Right thalamic/basal ganglia intraparenchymal bleed with intraventricular extension.

Accompanying early transtentorial herniation. (needs to be mentioned for full credit!)

Case 2:

Right-sided pyelonephritis/early abscess formation. Renal mass/neoplasm can be within differential diagnosis.

Case 3:

Aortic dissection extending from the inferior thoracic cavity to iliac arteries.

Accompanying perivascular fluid and effusion- possibly blood products, consider ruptured dissection

For full credit-need to mention that you would call the vascular surgeons

Case 4:

Ultrasound appendicitis with appendicoliths

Case 5:

You need to ask history. (?B-HCG positive)

Ruptured ectopic pregnancy.

Case 6:

Homolateral Lisfranc fracture dislocation

Case 7:

Part A

New prominent bilateral hila- Interval development of adenopathy or pulmonary arterial hypertension

CT of the chest recommended for further characterization.

Part B

Bilateral chronic pulmonary emboli with pulmonary hypertension

Case 8:

Acute biliary leak with extraluminal radiopharmaceutical.

Focus within the hepatic hila- most likely biloma/origin of the biliary leak

Case 9:

Distal left ureteral stone with left renal hydronephrosis and hydroureter. Accompanying inflammatory change at the left kidney and ureter.

Case 10:

No acute disease. Possible recently ruptured left ovarian cyst.

 

 

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Radiology Residency Day One – How To Start On The Right Foot

residency day one

Last week, I wrote about what to do on the first day on the job as a radiology attending. For those of you about to begin radiology residency, I thought it would be unfair to leave you in the dust. So, today, we will talk about what to do on day one of the radiology residency. For this discussion, we will disregard all the formal introduction courses from the hospital. Mostly, that is a passive activity. Instead, I need you to know what you must do on your first day in the department. So, let’s start!

Get To Work Early

On that first day, I recommend arriving early. Get to know the parking, the bathrooms, and the building. You never know how long things will take until you arrive. And as a resident, impressions become exceedingly important. The last thing you want to do is to arrive late on that first fateful radiology residency day one!

Introductions And Thank You

OK. This one does not differ much from your attending’s first day. Your new colleagues and faculty want to make sure they made the right choice when they selected you. So, do this right. Make sure to thank all the folks who helped to get you into the program. This gratitude goes a long way to building solid relationships for the next four years!

Don’t Stand Out Too Much

When you begin your first rotation, be careful about what you say. You certainly don’t want your attendings tagging you as the class troublemaker. That can lead to undue negative attention later on. So, if you think you may say something that may upset your new employers, I would hold back until they get to know you later!

Ask About Special Programs (If Interested)

Some radiology programs have Early Specialization In Interventional Radiology (ESIR) slots. If you do not inform your program directors early on that you maintain interest in the program, the program may fill up, and the ESIR program may exclude you. So, ask to sign up, if interested, on that residency day one.

Ask About Expectations For The Rotation

Different from starting as an attending, most of you have no clue what you should begin to do on residency day one. On day one of our nuclear medicine program, the technologist showed the residents how myocardial perfusion scans work. But, in the following days, you would sit with an attending to learn the basics. You certainly would not want to miss either of those opportunities. On the other hand, if you start on fluoroscopy, perhaps you need to watch a few esophagrams on the first day. And then, a few days later, the attending may expect you to attempt one on your own. Without these clear expectations, perhaps not in the manual, you will start your rotation at a disadvantage. It is hard to meet expectations you don’t have!

Learn The PACS

Like a new attending, you must learn how to look at cases at your institution. Therefore, it behooves you to play around with the PACS system a bit. Also, make sure to ask for tips from your colleagues and attendings. Many times, if you don’t ask at the beginning, you will only learn much later after you have wasted many hours. Remember: these tips can save significant amounts of time and headaches!

Start Learning How To Dictate

Again and again, you will hear that learning to dictate has a steep learning curve. Therefore, there is no time like the present to learn. Begin with a few simple cases. But start now if you can. As a resident, this activity is one of the most active ways to learn radiology. It reinforces the buttonology of the PACS and the learning of the basics of radiology. In addition, it can help the attending out during the daytime. So, why not start on day one?

Let Your Attending Know The Plans

On that first day, you will often need to attend several activities that are integral to starting but maybe off-rotation. As a courtesy, let your attending for the day know when and what you need to do. This act of doing this establishes a rapport between you and your faculty!

Listen Carefully To The Program Director (Or Associate Program Director) Welcome

Most programs have an early morning or noon conference from the program director or associate program director. This conference is crucial! Most of the time, the program directors will give you their expectations and requirements. Usually, they will not repeat the tips and advice you will get from this session. So, take notes, and don’t miss a beat!

Borrow, Rent, Or Buy Books

By the end of the first day, you should know what you will need to complete your first rotation successfully. Most of the time, you will discover what to purchase, rent, or borrow books from your colleagues in digital or print form. So, make sure to get these necessary resources on day one!

Radiology Residency Day One- Final Thoughts

As with any first day of a new job, the first day of residency can become a nerve-racking experience. But don’t let it be. Instead, try to absorb all the unique experiences that you encounter. So, make sure to take in the new situation, the people, and your place of work. And most importantly, don’t be too hard on yourself. The staff and your colleagues have low expectations for the residents on your first fateful day. Later on, you will have many more days ahead of you to stress about giving that next tumor board or taking the core exam. For today, you can relax and enjoy!

 

 

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Radiology Attending Day One: How To Get Started On The Right Foot

day one

Imagine: Your whole adult life consisted of schooling, including four years of college, four years of medical school, one year of internship, four years of residency, and perhaps one or two years of fellowship. And you will finish it all in a few days. This situation will be yours at some point. (If not at this moment!) Now, it’s day one, and you embark upon your new life as an attending.

For most, this transition is like moving from the confines of jail to the free world. No longer do you have someone to monitor you all the time. Now you become the arbiter of last resort. The buck stops with you. (All those hackneyed phrases are true!)

The transition to becoming an attending is enormous. And you want to make sure that you do it right. So, what are the most important tasks to accomplish on day one of your new job? What do you want to avoid? Assuming you have completed your administrative tasks before starting, we will go through some boxes you should check off on your first fateful work day.

Introduce Yourself To All The Staff

After the hospital orientations, ALS courses, and all that jazz has died down; you need to make a good impression on day one. The people you meet on that first may work with you for the next 30 years! So, make your introductions to all staff. That includes fellow attendings, technologists, nurses, secretaries, and janitors. By introducing yourself to everyone, you make yourself seem like a team player that is not “standoffish.” Who wants to work with someone who can’t talk to anyone in the department?

Dress The Part Of An Attending

You don’t want to stand out too much on that fateful day. So, make sure that your attire is appropriate to the department. I remember a few attendings at my prior residency that arrived at the department without a tie for the first time. The department chairman made these attendings return home and get a tie from their closet! You don’t want to start on the wrong foot in a department where you expect to work for many years.

Make Sure To Listen Carefully To Your New Colleagues

You will hear much on the first day of your new life. Sometimes, however, you will receive invaluable advice from your colleagues that you may never get again. So, pay attention. And, take notes if you don’t have a photographic memory. You are better off having the information you will need now than having to find someone to get the same information later on when you become really busy!

Stake Out The Joint

The first days are the time to explore your surroundings (Don’t break into the chairman’s office, though!) Discover the locations of the best bathrooms, cafeteria locations, local restaurants (if at an imaging center), physician and secretarial offices, reading rooms, interventional suites, and more. Become as familiar with the surroundings as you can. This is your new home!

Ask Lots Of Questions

OK. You don’t want to ask too many indiscriminate questions (It may seem like you don’t know anything!) But you do want to ask lots of important and relevant questions. Get to the practice’s expectations, pitfalls, and more. After the first day, your colleagues may become less attuned to answering these questions, as you will no longer be the new kid on the block. Get those questions in before it is too late!

Discover Your Boundaries

Especially on that first day, you do not want to step on anyone’s toes. Ask first if you want to help with a study that may not be in your daily expected routine. The last thing you want to do: is dictating a case only to find out that the clinical attending wanted a read from someone else. It does not look good for you or the practice. So, get to know and ask what you can and cannot do.

Get Dictation Standards

Different practices have specific requirements for all radiologists’ dictations. Some want structured reports, and others need the impression at the beginning. Make sure to ask your colleagues what exactly they expect before beginning your work. You certainly don’t want to rock the boat too much!

Learn The PACS and EHR

The PACS and Electronic Health Records systems have become crucial for relevant and quality reports. In addition, knowing these systems will significantly help your efficiency (You want to get out of work on time, don’t you?) Therefore, you need to spend your first day working to make sure that you get to know the PACS and EHR well. A little time now will save tons of time in the future. Think of it as an investment.

Work Slowly And Deliberately

As a fresh radiologist right out of fellowship, you don’t want to be known as the gal who does careless dictations. So, especially on that first day, slow down. Make sure everything you dictate is correct. You have years and years to pick up speed with your work. Now is not the time to rush, and newbies make more mistakes. Don’t add to the reputation!

Radiology Attending Day One- Final Thoughts

The first day as an attending is tough. You are transitioning to a new world, just like the many worlds you had transitioned to before. So, go forward and welcome the changes with open arms. Believe it or not, you will find your comfort zone one day. It just takes a bit of time!

 

 

 

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Is The Specialty of Radiology Better Off With Increased Competition?

increased competition

With the increasingly hot job market for new radiologists, medical student applications to residency programs have steadily increased over the past several years. But that got me thinking. Is the specialty of radiology better off with more hardcore medical students wanting to enter the profession? Or does radiology benefit more from residents who genuinely want to be here when times are tough? So, let’s go through the advantages and disadvantages of having both a competitive and a non-competitive application process. And then, we will come up with a conclusion to the final question: Is the specialty of radiology better off with increased competition?

 

What Happens With A Competitive Application Process

Advantages

From a program director’s perspective, let’s begin by saying that a program director’s job becomes much easier with increased competition. To find applicants, you do not have to interview as many candidates. And the applications tend to have fewer “blemishes.” That said, as much as it helps me, this factor impacts the specialty very little.

So, what other advantages does a competitive process offer? First, the candidates will often have more experience in research. But does this create better radiologists? Depending on whether the resident wants an academic career, that is up for debate. However, I can say that it again makes the program director’s job a little bit easier because the faculty do not need to teach some of the primary research mechanics to get them started. Additionally, this resident will also likely produce more research during residency.

With increased competition, residents tend to be slightly more attentive to keeping up with reading. Moreover, these residents tend to be more motivated by passing tests. In other words, they may be a bit more “obsessive-compulsive.” Now, this would theoretically work in favor of passing the boards. However, according to the infinite wisdom of the test makers (the ABR), this doesn’t change the pass rates since they opt to create tests based on curves, not content.

Disadvantages:

Over the years, I have noticed that competition also motivates applicants who want radiology because of the competition, not necessarily for the love of radiology. In the long run, this can lead to increased burnout. Furthermore, it can change the culture of radiology residency and radiologists into a less forgiving and highly pressured environment. Again, this is more of a tendency rather than a truism.

Increased competition also brings out fewer nontraditional applicants to radiology. These include folks who have completed other residencies and different careers. In the setting of increased competition, they have a much harder time receiving interviews because programs often screen them out of the system due to their increased time in or before residency. However, nontraditional applicants bring a different perspective to residencies. Moreover, they have been through more, are more mature, and often make better leaders.

What Happens With A Non-competitive Application Process

Advantages

Residents who apply during a less competitive time are a different group of candidates. I like to call them type B personalities. These folks create a less pressured environment and a calmer culture for the residency program. This decreased stress can make the four-year residency process more tolerable for everyone.

Likewise, during tough times, the limited selection of candidates forces residency programs to accept nontraditional candidates. As stated, these candidates lend a mature perspective to a residency program. In addition, these residents want to be involved in radiology for the love of the specialty rather than the competition and the “great” job market.

And then, programs will often downgrade their expectations of these non-competitive residents. Decreased expectations lower the pressures on the residents during their program and can create a less harried culture with reduced burnout.

Disadvantages

I don’t have the statistics to back this up. But, from my experience, tough times lead to residents with a higher dropout rate. Sometimes, these residents cannot meet the rigorous academic challenges of residency. When this occurs, residencies can lose their precious spots to other specialties like primary care.

Also, these residents have overall less experience with research. So, most residencies with non-competitive applicants will create less output during these challenging times. (This is a disadvantage for the more academic residency!)

And then, finally, residencies have more work cut out for them. They must put more time into teaching and spoon-feeding the residents to ensure they complete the program.

Weighing The Balance- Is Increased Competition Better For The Specialty?

So, where do I stand in this controversy? Well, residency directors and their programs must put more work into the residents during the “tough” years to get them “up to snuff.” But, you know, I’ve seen great residents during the lean times and times of abundance. So, I think we put more emphasis on competition to get better residents than we should. In the end, good residencies mold their residents into great radiologists regardless of the zeitgeist of the times. And that’s the way it should be!

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Top 10 Resident Issues That Radiology Faculty Wants You To Know But Can’t Say

Top 10 Resident Issues

Most radiology attendings want their residents to succeed. However, etiquette rules cause many to withhold their feedback about some of the resident issues that they encounter on a daily, weekly, or monthly basis. Unfortunately, for that reason, they keep many of you in the dark. However, please learn from their mistakes and enlighten you all. So, to prevent you from continuing with these resident issues, I thought I would create a top 10 list that the faculty wants you to know but may not say… Here we go!!!

You’re Too Aggressive

Are you overcalling everything or coming down hard on a final diagnosis without any other differential? Are you accustomed to the surgical mentality? No longer can you just nod in agreement, but you push, push, push? Everything is an argument. And, your attending does not have the time to talk back. Gosh darn it, perhaps you are more aggressive than you should be at this stage of the game!

He Misses Everything

When your attending sees that you are missing all the findings during the night, he may not feel so great telling you about all these errors. How will that help anything? And I mean, he doesn’t want you to feel bad about it when he tells you, does he? Unfortunately, you may miss out on some of these learning experiences. But, your attending may not let you know!

She Has Poor Hygiene

Poor hygiene can be just plain embarrassing. But, sometimes, your faculty may become very uncomfortable dealing with malodors or unkempt appearance. It often needs to be said to the resident but doesn’t. And, all the other faculty and residents suffer from this resident’s poor hygiene!

You Just Don’t Listen

The attending keeps on telling the same resident the same old thing. But, time after time, nothing changes. No longer can the attending tell you what to do anymore because it does not seem to work? So, your attending does not bother you anymore. What’s the point of hurting your feelings?

He’s Way Too Enthusiastic

Don’t get me wrong, but it is great to be enthusiastic. And, your attending certainly does want you to become excited about radiology. But, too much of anything is no good. And sometimes too much enthusiasm can be a bit too much. It can wear on your techs, nurses, and attendings. So, temper that enthusiasm just a bit!

You’re Just Plain Dumb

Often, your attending will ask you questions to see if you have been reading enough. And it is OK to get some things wrong. However, on occasion, a resident does not know anything that he should. Is your attending going to tell you that, maybe or maybe not? Who wants to say to the resident that she is just plain dumb?

She’s Getting A Bit Too Chummy For My Liking

On occasion, our residents can become a little too familiar with us if you catch my drift. It can all be a little too “touchy-feely.” So, think about how you communicate with your attending. Is it appropriate? Or are you trying too hard to become his best friend?

He Wants Always To Be Spoon Fed

Most residents want to learn from their attendings. Some residents expect all the learning to come from their attendings with no work on their part. If you desire to breed ill-will, you can do just that. Don’t help out your attending. Instead, just expect them to teach. It can be very irritating!

You’re Always Abandoning Ship When The Work Is Not Done

Excuses, excuses, excuses… You have to get to a wedding. Or, maybe you need to go on a date with that new beau. Well, your attending does not want to be the one to break it to you. He does not want to be the unfeeling guy that ruins the resident’s time. But, is it right that you are always missing all that work?

He’s Preventing Me From Getting Anything Done

Some residents like to talk a lot. And, most attendings like a good conversation as well. But, sometimes, it can interfere with the daily work that needs to get completed. How can your attending break it to you when she likes you a lot. Well, it can be challenging at times!

Final Thoughts About Resident Issues That Faculty Want You To Know But Can’t Say

Rightfully or wrongfully so, many taboos exist that prevent faculty from telling you, the radiology resident, what is going on. And even though attendings are supposed to evaluate and give direct constructive criticism and feedback, that is not the reality of the situation. So, if you think that you may have one of these ten resident issues listed above, try to change it on your own because you may never get the real story!