Tag: radiology

Posted on by

Reading Imaging Studies On Our Clinical Colleagues

colleague

The Scenario

A clinical colleague walks up to you, and the following conversation ensues.

Clinician: Can you take a look at my chest film? I have had a cough for several weeks that won’t go away.

Radiologist: Sure. Let me take a look at the image.

The name of the clinician is on the computer, and the scan pops up on the screen

Clinician: Well, what do you think?

The radiologist stares intensely at the screen. Beads of sweat begin to form on his forehead as he sees a spiculated 6 cm left perihilar mass with adjacent interstitial changes and pulmonary nodules in the opposite lung. The clinician stares at the radiologist in front of the desk.

Radiologist: Well… Ummm…

Clinician: Well, what do you see?

By far, reading your fellow clinical colleague’s imaging studies has the potential to be one of the most stressful clinical situations as a radiologist. (as witnessed above) Even worse, the physician-patient may stand directly in front of you while looking at the films for the first time. God forbid we find something potentially lethal or unexpectedly harmful.

Over the years, similar scenarios have played themselves out several times. And, it’s not just me. It happens to most radiologists at some point in their careers, probably you as well. So, what do we do in these situations? Well, you guessed it. That is the theme for today’s post. Let me try to give you a few pieces of sage advice.

Take Time To Read The Study And Call The Clinical Colleague Later

Like I previously advised in prior posts such as Radiology Call- A Rite Of Passage, you are better off taking your time and going through your search pattern rather than being interrupted and making the wrong diagnosis. When a physician-patient stands right in front of you and stares at the screen, you direct your attention toward your emotions, leading to poor discrimination and interpretations. You are not doing justice to good clinical care.

I know. It is challenging to say to the physician-patient, “I can’t look at your images while in the room.” Instead, just say, ” I will look at your images later when I can make my best interpretation.” Most of the time, your clinical colleague will comply (But not always!). It indeed allows you, the interpreting physician, to have time to think about the films and diagnosis appropriately.

Don’t Beat Around The Bush

Your colleagues are physicians and generally know a bit about imaging/radiology. They will see if you are holding back a finding. So, regardless of whether you are on the phone or in person, you just need to tell them what you see. In radiology, however, most findings and impressions (even malignant-looking ones) can have numerous outcomes. In this situation, it is reasonable to say I think it may be x (a malignant diagnosis), but I have seen when it turns out to be y (a benign diagnosis). Of course, you don’t want to give false hope. But we, as radiologists, are rarely 100 percent correct! That gives you a little bit of an out.

Never Farm-Out This Responsibility To Another Radiologist!

Generally, there is a reason why this physician-patient comes to you to read their study. Maybe, they like your skills as a radiologist. Or perhaps, she sees you as a confidant and friend. But for whatever reason, this person came to trust you to read his film. It is never appropriate to shirk your responsibility to talk to the physician-patient by doling the obligation to another physician. It is part of your responsibility as a colleague and physician. Not to say, you cannot get help with the interpretation if complicated. But, you need to be the one that directly speaks to the physician-patient.

Be There As A Friend/Colleague

Finally, as radiologists and physicians, we are all interconnected to our fellow clinicians through the shared medical experience. It is essential to remain present as a friend and colleague to the physician-patient you diagnosed. Give the physician-patient your number to call if they have any additional questions. Commiserate over the diagnosis. Treat this person as you would any friend.

Treat A Colleague As We Would Want To Be Treated!

Our most demanding jobs as radiologists and clinicians are not the day-to-day interpretations of films and coming up with differential diagnoses. But instead, they are the problematic interactions that we may need to have at some point with our colleagues and friends. We need to relay the information to them about their images in an appropriate, correct, and thoughtful way. Even though there is no perfect way to do so, we must treat our colleagues as we want to be treated ourselves.

 

Posted on by

Radiology Swap- University Radiologist Goes To Private Practice (Part 2)

radiology swap

Today we return to Part 2 of our Radiology Swap blog. Click on Radiology Swap- Radiology Private Practitioner Goes To University (Part 1) to catch up if you missed the first part of Radiology Swap!

University Radiologist Goes To Private Practice

Day 1 Radiology Swap:

Unaccustomed to working in a private office, the University radiologist is surprised by the relatively small size of the office. The parking lot is not too full, and he can walk rapidly from his car to the office, very different from usually having to walk from the back of the parking lot—a nice perk.

Finally, entering the building, he locates his workstation and seat. As soon as he sits down at the desk with the PACS monitor, a technologist dumps a stack of papers with today’s work next to the monitors. It must be about 150 cases. Where are my resident and fellow? I need them to help me with the dictations! Oh, my God!!!! I just realized that I forgot how to use a dictaphone.

After struggling with dictations and having read maybe 10 of them, 11 AM rolls by as he teaches the technologists about the ultrasounds they show him. But, the technologists roll their eyes as they just want to get through the cases so they can go home. They sense him droning on and on! He looks at the stack of papers given in the morning. It still looks the same!

Noon: He begins to receive phone calls, not happy ones. Clinicians are asking him about the results of chest x-rays, ultrasounds, and MRIs. Unsuccessfully, he tries to soothe them and let them know he has not looked at them yet, but he will get to them! No lunch for me.

Eyes reddened, head bleary, and voice cracking, the University radiologist now realizes it is almost 5 PM. He has only finished maybe half of the stack of orders. Lots more to go. No one to talk to. I can’t leave yet to get to the family.

10 PM arrives, and he is finally finishing his last dictation of the “day.” How does the private practice radiologist do it?

Day 15 Radiology Swap:

He arrives wearily into the office, looking haggard and worn with a 15 lbs weight loss since he started the job (1 pound per day!). His temper flares every once in a while, taking out his frustrations on the constant bombardment by the technologists by making snide remarks and yelling at the staff’s mistakes. For the past 15 days, he has left the office in the dark, no earlier than 8 PM. No direct contact with interested learners or other clinical physicians. All interactions on the phone. So, this is physician burnout!

Day 30 Radiology Swap:

Assessment day for Radiology Swap!!!

Practice President: So, you have worked in our practice for the past 30 days? Let’s start with the good part: I’m glad to see that you have made it through the encounter.

Academic Radiologist: Yeah, barely. How do you guys do it?

President: We do it efficiently to make money. The more we read, the more we earn. It keeps us going. In any case, let’s continue with your review. We received many complaints from our staff that you were curt and inappropriate at times. It was like pulling teeth to get you to do fluoro cases on our patients. You kept on grumbling- “Where’s my resident?”

Academic Radiologist: I thought you would at least provide me with a physician assistant to help with daily work. I don’t usually touch patients. My residents do it for me.

President: We also received numerous complaints from our referrers that they did not receive their reports in a timely fashion. We lost some serious business this week.

Academic Radiologist: When you get 150 new studies per day, everyone has to wait!!!

President: I don’t think we would be able to keep you here because we need radiologists to keep up with the work. We don’t get paid if we don’t read the minimum volumes!

Academic Radiologist: The best part of this job was the 15 lbs weight loss! I can finally get some sleep again. His eyes begin to close, dreaming about returning to his academic position.

 

The Radiology Swap Meetup

So, the academic and private practice radiologists now seat themselves in the same room to share their experiences after having returned to their respective jobs.

Private Radiologist: How do you do your job on a daily basis without getting totally bored?

Academic Radiologist: How do you do your job without getting totally burnt out?

Private Radiologist: Let’s agree that we are not right for each other’s jobs. It would never work out for us.

Academic Radiologist: At least I can understand what you go through on a daily basis. We used to make fun of private practice radiologists. Don’t think that I will do that anymore.

Private Radiologist: Doesn’t mean that we can’t be friends. Let’s go out for drinks! I think we both earned it…

Academic: True. We both earned some stiff ones.

The radiologists leave the room and head down the street, never to look back on their former residency swap experiences again and happy to go out for some drinks…

THE END

(until next time!)

 

 

Posted on by — 3 Comments

Want To Be A Successful Radiology Resident? Learn To Triage!

triage

When program directors hear complaints about their residents, we find most do not stem from resident incompetence. Nor do the complaints relate to professionalism issues. Instead, a good majority arises from a lack of a timely response to reading cases. And these delayed reports result from a lack of appropriate triage. So, I think you know what we will talk about today. You guessed it! The topic is tadaaaa… how to triage your cases.

A Common Scenario

It’s 2 AM, and a bleary-eyed resident starts to pick off STAT CT scans from the worklist to catch up on his reading from the nighttime. A house physician rushes down from the floors to speak with the resident in a huff. She explains that she needs to discuss a case from a week ago that she must present for the tumor board the following day. The resident obliges. Thirty minutes pass, and the house physician leaves.

Next, a few minutes later, an ultrasound technologist stops by the reading room because she questions whether a renal cyst is simple or complex. Like a robot, the resident scans the patient in the ultrasound room to make the determination. Another 30 minutes go by.

While scanning the patient, the resident gets two beeps which he needs to call back. He gets to both those phone calls. One of the phone calls comes from a patient’s father, who asks a question about his son’s chest film from the previous day. The conversation drones on for 15 minutes, and the resident can barely get off the phone. But he does eventually. Right afterward, he quickly responds to the other phone call and promptly answers the nurse’s question on the other end.

The resident starts to reread the CT list, and a technologist interrupts his train of thought as he walks into the room. Solemnly, the technologist asks, “How much contrast should we give this patient with a slightly low GFR?”. Immediately, the resident attends to the technologist. However, the resident is unsure and looks through the literature to find the appropriate answer. After 10-15 minutes, he finds a piece of paper and says, “75 ccs of Visipaque.”

Finally, an angry emergency department attending calls to the radiology reading room, “Where the hell are the results from the nighttime CT scans? We have been waiting 4 hours. Sorry, but we are going to have to write this up as an incident in the morning!” Where did the time go by?

Ways To Triage In The Above Scenario

So, what could this poor weary resident have done differently to prevent himself from getting written up by the ER doc? Well, lots of things. For one, did he have to review the tumor board case with the house physician? No. Should he have spent 30 minutes determining whether the renal cyst was simple? Probably not. The resident could have delayed until the morning. Did the resident need to speak to the patient’s father for so long? I don’t think so.

To summarize some of the problems the resident experienced with triaging in the scenario above, I have divided some of the main concepts about radiology triage into the following paragraphs. Here are some general recommendations for triaging cases to avoid situations like this.

Keep Your Eye On The Prize

Remember… When you are on call, the first goal is not to kill anyone, and the second is not to injure anyone. By ignoring the STAT list and tending to other people’s “problems,” you are increasing your chances that something terrible will occur. Perhaps, the CT Abdomen/Pelvis for appendicitis with a positive study will get delayed. Or, you will miss that opportunity to catch that hemorrhagic stroke before it is too late. Delaying STAT reads can theoretically cause irreparable morbidity to your patients. Therefore… Keep your eye on the prize. Complete those studies that are urgent first!

Also, if the activity is not critical, you can delay it until the following morning. In the case of the ultrasound technologist questioning a cyst above, sure, it is an important question to answer. But not so much when you have a list of 5 or 10 STAT CT scans you need to look at. You always have the option of delaying such study until the AM.

It’s OK To Say No

At nighttime, you are going to get all sorts of requests. Some are important, and others are nonsense. Do not let your colleagues bully you into concentrating on peripheral activities that do not directly affect patient care. If you don’t have time to look at that tumor board case, simply say so. Sometimes saying no is just the right thing to do.

Attend To Your Study First, Then Your Colleagues

According to my previous blog, Should Radiologists Ignore The Phone?, residents pay a significant penalty when discontinuing their thoughts midstream. Error rates increase dramatically. More relevant to this post, however, the time to complete a study increases significantly, increasing your chance of causing an angry ER physician. Therefore, it is imperative that you briefly let your colleagues know that you need to complete the study first and will answer their questions as soon as you finish.

Triage And You

One of the most essential facets of the nighttime experience is learning to triage. Believe it or not, you will use these skills for the rest of your career regardless if you take call or not as an attending. What studies do you need to complete first? Who should you attend to? These are all triaging skills you need to learn to succeed. Using some basic triage concepts above, ensure your nights are shorter and safer!

 

 

 

Posted on by — 2 Comments

Ten Disastrous Consequences Of Poor Study Habits

poor study habits

 

Studying for radiology is intense and unlike anything that you have done before. If you think shirking your duties only hurts yourself, you are entirely and utterly wrong. For those of you that don’t yet get it but are willing to listen, here are 10 of some of the disastrous consequences of your poor study habits!

Harming The Patient

First and foremost, you took a Hippocratic oath at the end of medical school, right? Well, by not reading, that certainly goes out the window. Not studying well leaves you more prone to interpretation errors when reading films. Ultimately, this will affect patient care. Who needs unnecessary biopsies and increased morbidity/mortality? You don’t care about that!

Your Colleagues Don’t Take You Seriously

Notice that your colleagues never approach you for consultations on their cases and second opinions. You feel out of place. Why is that? If you read something, you would go over more interesting cases because your colleagues would have a good reason to talk to you. You may become a better film reader. Well, maybe you are not interested in films and consults?

You Go From Practice To Practice

You know this type of individual. Probably, you have seen an attending or two who do not last long at your program. Sometimes you are not quite sure why they left. But many times, they can’t interpret films well. Perhaps, if they had read and studied a bit more…

Can’t Pass The Core Examination

This statement cuts right to the heart of the first through 3rd-year radiology residents. What is a radiology resident’s worst nightmare? That they need to take the core examination twice. Why would you want to do that? Just study!!!

Difficulty Obtaining The Fellowship You Want

Your dream is to go into interventional radiology. Forget about it. You always wanted to do an MSK fellowship. No way. To get into the more competitive specialties, you need recommendations. Who will give you a good one when you have not read a lick and never attempted to change your study habits? Did you think about that?

Your Attending Dreads When You Are On Call

Have you noticed that sigh that seems to emanate from your attending’s mouth when you say you will be on call the night before his CT rotation? Well, you better get used to it! Who wants to be the attending of record after you make all those interpretation errors due to lack of reading?

No Job Connections

Finally, you graduate from your residency program. But, no one seems to let you know when that next great job is available. Why not? It is straightforward. Who would want to recommend you to a position when you don’t have the background to merit it?

Attendings Won’t Let You Perform Procedures

In interventional radiology, you realize that your colleagues are getting to do a whole lot more procedures independently than you get to complete. Why is that? Hmm… Maybe, no one trusts you to touch a patient because you haven’t read about the procedure at all!

Consults Walk By You

Have you ever noticed how any clinical physician that has a questi0n walks right by you to the other guy in the corner of the room? Well, you have established a reputation for yourself because you have not been studying the right way. You are no help to anybody. Maybe this is what you wanted- you now have less work. Congratulations!

Losing Out To The Competition

You are beginning to notice that your patient loads are dropping precipitously? Around the corner, another practice opened up that now reads studies that you don’t feel comfortable reading because you are unwilling to study and learn about the new image modalities in radiology. Your wallet begins to suffer!

Bottom Line For Poor Study Habits

Reading, studying, and continually learning are all part of becoming a great image interpreter. A radiologist cannot exist in today’s climate without these tools as a resident and beyond. Why would you want to destroy your reputation and have to deal with the ten disastrous consequences of poor studying habits!!!

Posted on by

Gaining Recognition When The Odds Are Stacked Against You

recognition

For medical students and residents, at times, it can be tough to gain recognition for your work. I want to give you a little vignette of one uncomfortable experience with a difficult attending I had as a former medical student. Then we will discuss how to counter a poor evaluation. Although your stories may differ from mine, many of you will experience something similar as you traverse through residency.

The Background Story

I was a fourth-year medical student subintern during a medicine rotation. And my group consisted of myself, a pretty female third-year medical student, an intern, a resident, and a balding senior medicine attending in his late sixties or early seventies. The attending physician assigned us to review compelling cases that presented themselves the prior week. We were then to discuss the medical topics that arose from these cases.

First, the 3rd year medical student began to discuss a patient with severe onset of hypertension. And she went through an appropriate workup of the patient with hypertension and delved into the physiology and management of patients with hypertension. It wasn’t a bad presentation. Unfortunately for me, the attending would not stop affectionately staring at the third medical student. It was a bit creepy.

Next off, it was my turn to present. I had a great case of a patient with Histiocytosis X/eosinophilic granuloma of the spine that I thoroughly researched. I knew the case and the topic cold. Therefore, I rehearsed the presentation many times at home. So, I was excited to present. What could be wrong about presenting a rare, fascinating case I knew well?

So, I began to present the case and then went through the process of coming up with the diagnosis with history and imaging. Again, I noticed the attending continuing to ogle the third-year medical student inappropriately. As soon as I started to discuss the topic, WHAM… He shut me down by saying, “We don’t need to discuss this topic because it rarely occurs, and you will probably never see another case like this in your lifetime. What a waste of everybody’s time!”

Problems With Gaining Recognition In Clinical Education

All too often, something similar to this scenario occurs in clinical medicine, whether you are in radiology or another field. Perhaps, you are a foreign medical student, and the mentor won’t give you the time of day. Or, maybe, you are rough around the edges, and your teacher doesn’t like your personality. In all these situations, favoritism for reasons other than merit and quality often trumps a great job. No matter how you change the grading system to include milestones or different innovative ways of evaluation, bias can interfere with gaining recognition for your work. In the end, the final grade often comes down to the evaluators’ quality. (Don’t take it personally!)

At the same time, there are many positives about the experience of having learned about the topic of eosinophilic granuloma, regardless of my evaluator. First of all, in my line of radiology work, the diagnosis of eosinophilic granuloma has come up in my experience several times. Second, from my studies on the topic, I have used the information from that presentation for the betterment of my patients. And finally, the subject arose on some of my radiology board examinations, and I knew all the answers to the topic cold. So yes, there was something educationally valuable from this experience.

How Can We Align The Evaluator With The Recognition Of A Good Job?

That brings us back to the crux of this post. What can you do to get the attention of your evaluators about your quality work when they don’t want to give you the time of day? I do not claim it is going to be easy. It certainly isn’t. But there are a few workarounds.

Get What Makes The Evaluator Tick

First, ask your evaluator what it is that interests them. Now, I am not asking you to be a brown-noser, but sometimes to garner the attention of our seniors, we have to find out what makes them tick. A person like this is more apt to listen to you when you are on the same wavelength. Admittedly, in my case above, if I had changed my topic, I think it still would have been difficult to change this attending’s opinion of me. But, at least, I would have presented a case that would have been more likely to get his attention.

Defy Expectations

Next, go above and beyond the expectations of the evaluator. For instance, perhaps, I could have begun a quality initiative study to improve the outcomes of patients on his service and put his name on the paper. My story above might not have ended differently, even if I had provided the “ogler” with something distinct and memorable. But, it would have increased my chances of garnering recognition for my work.

The Nuclear Option

And finally, sometimes you need to go to the top. Things can be, on occasion, so bad that you cannot even fathom doing anything that will change the opinion of your senior. But be very careful. Heads of departments will often side with their staff before they side with a resident or medical student. So, if you use the nuclear option, ensure you have objective evidence that this person is unfair to you without trying to get your evaluator into trouble. And, also make sure that the director is willing and able to help. Sometimes, they can pair you up with someone else who can evaluate your work.

Gaining Recognition For Your Work

We all encounter people in positions of authority who may not be “fair” to their subjects. It is part of what we experience in medical school and residency and part of the real world. Most of us are somewhat sheltered from the real world through the beginning of medical school because our teachers’ primary evaluation method is exams. As we enter the clinical years and residency, evaluations become more subjective. So, learning how to successfully interact with difficult attendings who may unfairly evaluate your work is vital. Don’t be another technicality of a poor mentor. Be proactive in your education and obtain the recognition you deserve.

Posted on by — 1 Comment

The Uncomfortable “Screenostic” Breast Ultrasound Imaging Dilemma

ultrasound

For those of you who have completed a mammography rotation or are beginning to practice mammography, you may notice ordering physicians prescribe a diagnostic mammogram along with a diagnostic and screening ultrasound. One example would be the doctor who orders a mammogram for a unilateral breast asymmetry with an accompanying bilateral diagnostic ultrasound. Or other times, the ordering doctor will specify to perform an ultrasound for pain on one breast. Yet they order a bilateral breast ultrasound that the patient expects to get done. One of my former excellent mammographers had called these sorts of situations “screenostic studies.” And I think that is a great descriptive name since these breast ultrasounds encompass both a “diagnostic” and a “screening” component. So, I kind of took to the title, “screenostic.” Now, I use it all the time.

Issues Behind The “Screenostic” Ultrasound

For me, I always find this situation very frustrating. You are never quite sure if the ordering physician means to order the study as a screening ultrasound. Or, did they mean for the case to be diagnostic and accidentally request a bilateral breast ultrasound? Perhaps, they were not thinking about it or did not understand the purpose of the ultrasound. Unfortunately, frequently, you will never know the answer.

So, let me give you an example of what happens when you confront the issue head-on. You call the physician to learn their ordering intentions, taking away precious minutes of your valuable time. Then, when you ask the ordering physician what they wanted, the physician often becomes indignant because it “wastes their time.” On top of this, the patient expects that they will receive a bilateral ultrasound because it is “better” than a one-sided diagnostic ultrasound. Now, they have to wait longer. And if you decide to change the order, you now have to waste additional time to persuade the patient that they need a unilateral breast ultrasound.

Bottom line. All hell breaks loose. It’s ugly. You have a mixture of undecipherable physician expectations. And the patient has unfounded expectations to complete the study. The radiologist is unhappy; the patient is angry, and the ordering physician is upset. It is a lose, lose, lose situation.

So what finally happens? Regardless of the study indication and the true intentions of the ordering physician, the technologist completes the study. It’s just a heck of a lot easier. But, it is all a waste of time and money.

Call To Arms!

I only see two potential ways out of this daily breast imaging mess. First, we need intense education for ordering physicians. In most practices, however, this road is a difficult one. It can be next to impossible to get through to all the referring physicians in a bustling business. And, referrers just want to order and write their scripts without dealing with the implications. It takes too much time to “listen” to the meager radiologist or set up an educational outreach program.

Second (and I may get a lot of backlash for this one), enter clinical decision support systems. If only a system could force the ordering physician to make a clear prescription that makes sense. Clinical decision support systems would do just that.

You may think that I am just whining and complaining. But this issue has real implications for patient well-being and daily workflow. Oh well, in the end, it is just another dilemma that occurs when the clinician controls the ordering of imaging studies instead of the true imaging expert, the radiologist. Let’s take it back!!!

 

Posted on by

Should I Take A Leave of Absence During Residency?

leave

 

Sometimes events beyond our control interfere with radiology residency. It may be a personal situation, a new business opportunity, mental illness, or severe burnout. I outlined some of these issues in my previous article called The Struggling Resident. And perhaps, one or many of these reasons have you thinking about taking a leave of absence.

But, what does this option entail? Many residents don’t know the details about taking a leave of absence. So, we will talk about the potential consequences of what can happen after a leave of absence and why you need to take the option only as a last resort. Then, we will discuss what situations merit taking a leave of absence, a circumstance where you might want to think about taking a break (but very carefully!), and finally, situations where it is seldom appropriate to take a leave.

Truth or Consequences

What is so serious about deciding to take a leave of absence from residency for some time? Maybe it’s six months, a year, or more. There are so many reasons why it can become a significant issue.

1. It will potentially take you off schedule for getting into a fellowship. Many fellowships will not consider residents who begin in the middle of the year.

2. You will likely have to start paying your health insurance and benefits. Believe it or not, it can cost tens of thousands of dollars for health insurance for a family. You may pay a few hundred dollars out of pocket per month when you are employed, but it can run over a thousand dollars per month when you are not. Can you cover those expenses?

3. You create a reason for future employers not to hire you. Many employers become very concerned when they see a gap in your employment history without an excellent cause.

4. It can cause irreparable harm to your residency program and classmates. You can no longer take call. Additionally, the rest of the class needs to shoulder the responsibilities. It does not set you in the light of a team player.

5. And finally (and perhaps most importantly!), you may be legally required to start paying off your massive debt load. That can be a real bear!

I Can’t Do My Job

So, when should you unconditionally take that leave of absence? It comes down to one situation: you cannot perform your job duties safely. If you can complete your residency duties, radiology residency is a temporary affair (albeit four years). And, believe it or not, many physicians would love to be in your shoes. So, if you are able and healthy, you should put all your efforts into completing your residency.

That said, if you have a mental illness, severe disability, or significant trauma, by all means, take that leave of absence. You took the Hippocratic oath and may not be able to abide by it in these circumstances. So, these conditions necessitate a departure. My advice: If it is some reason that does not involve breaking the oath, do what you can to pursue other endeavors until after your residency. You will have a great field to fall back on.

A Once In A Lifetime Opportunity

A confluence of events occurs from time to time, leading a resident to consider a job opportunity in another field. Perhaps, you just got that call to anchor a TV show. Maybe you created an invention, and a large company wants to buy out your patent for 5 million dollars; that will take a long time/lots of work to seal the deal. Or, you’ve been dancing for years, and a director in Broadway wants you on his show.

As I began brainstorming about what issues may eventually allow a resident to take a leave without regrets, some of these reasons could potentially cause a resident legitimately to rethink a radiology residency. I get it. Just remember, for those of you with significant debt, if you don’t pay your debts, the IRS can garnish your wages for the rest of your life. And these unique situations are not always a means of securing a lifestyle for years to come. (although occasionally it can be) So, those residents in this unusual situation need to think long and hard about taking a leave of absence.

Situations That Do Not Merit A Leave

If you are thinking of starting a business, quitting medicine, or needing some time off to relax and travel the world, this is not the time. You’ve already been through 4 years of college, four years of medical school, and a year of internship. What is four more years or less in the scheme of things to complete a radiology residency?

So what are some other situations that you should not use to take a leave of absence during residency? These would include taking a break to pursue another subspecialty (why can’t you just wait it out to apply, so you don’t have a gap in employment?) Or, maybe you have mild burnout (better off talking to a coach, colleague, or physician.) Perhaps, you want to start a new business (can you wait until after residency?). Attempting to train for the next Ironman triathlon is not a bad idea (you want to jeopardize your future?), and so on.

Final Thoughts

Taking a leave of absence is a huge deal. Many residents may dream of taking a break at one time or another to go for something they never had a chance to do before. However, think twice, my friends. Often, it sounds good in principle, but the practicalities behind it don’t make much sense!

What do you think? If you have any opinions, please leave a comment below!

 

 

Posted on by

A Student/Resident Guide To Research

 

Introduction:

Participating in research is a great way to contribute to medicine. Well-conducted research and literature reviews help advance both scientific understanding and clinical practice. Additionally, it enables you to develop expertise in a topic, while simultaneously showing dedication to your field. Peer-reviewed publication and presentation of your research should ultimately be your goal. Although you may want to get involved in research, you might not know how to go about it. Beginning a project can often present a challenge for residents and students with a limited research background. Here, I offer some advice and recommendations that I would give anyone just starting. Much of this I have learned through trial and error. Learn from my mistakes!

Identifying research mentors:                               

Your choice in mentorship can dictate whether or not a project will be successful, especially when just beginning your research career. Try to identify a project mentor (usually a physician or Ph.D.) with a proven track record of publication. Even better, if you can find someone with institutional or national grant funding, you can be confident that your research will likely be published. These are not essential, but finding the correct mentor can mean the difference between publication and fruitless pursuit.

First of all you should approach attendings, residents, and students. Ask if there are any ongoing or projects in the department. If you identify something that piques your interest, offer to assist in any way! Offer to carry out a literature or chart review. Attendings and residents are busy, so help them with the work that no one wants to do. The more you do, the higher up on the author list you will be. Make sure you show initiative and interest!

Although clinical research in your dedicated field might help you more as an applicant, any well-conducted research can be a great interview discussion topic, as long as you can speak intelligently about it.

Research takes time and patience:

What many don’t realize is that conducting research takes time, and that manuscript preparation and submission can take equally long. When you read a newly published paper, often the presented data is up to a year or two old. In many cases, a you need to submit a publication to several journals before being accepted. Especially true, if an author is seeking publication in a high-impact journal. My advice: start your research early. Students should seek out research from the first day of medical school, and residents should look for research during the intern year (if they can find the time!). Not to say that you cannot accomplish research in a short timeframe. However, you must be realistic about your goals and recognize that you cannot completed all projects if you are limited on time (i.e., close to residency or fellowship applications).

If you budget your time wisely, you will be able to edit thoroughly and compose a more eloquent article with a comprehensive review of the literature.

How to minimize your time for completing projects

Remember you are legally/ethically obligated to submit your paper to one journal at a time. Some review cycles can take several months for the first decision, so look up their average turnaround time if this might be concerning. Also, if you plan to submit to notable journals, there is always the possibility of rejection. Resubmission to another journal will likely require reformatting and an additional wait period. The time between finishing an experiment and publishing can add up. Remain conscious of this reality.

If you are limited on time, but still want to conduct a small project, one option to consider is a conference abstract. Conference abstracts allow you to showcase your research often through a poster presentation. The beautiful thing about conference submissions is that you can submit an abstract with preliminary findings, and later expand upon these in the full poster if accepted. Certain conferences/societies will even publish your work in their journal afterward.

As a bonus, getting an abstract accepted allows you to attend a conference and network with your colleagues. Most large meetings are held in either the spring or the winter. And, abstracts are generally due approximately six months before the conference. Deadlines may vary so identify these times if you have an ideal meeting in mind.

As a side note, the societies that hold conferences often have student/trainee travel scholarships or discounted conference fees. Any young professionals with funding concerns should apply. Again, be aware of scholarship applications deadlines.

Where to publish:

Everyone should strive for publication in high-quality, peer-reviewed journals. Things to consider are impact factor (IF) and indexing in scientific databases. High IFs are in journals like Nature or Science. However, it is essential to realize that a journal’s audience can impact this number. For instance, Nature has an impact factor of approximately 40, while Radiology has an impact factor of around 6-7, and the Journal of Vascular and Interventional Radiology (JVIR) has an impact of about 3.

If each is an example of a high quality-peer reviewed publication, then why the difference in IF? The reason is the audience and journal scope. Nature covers a wide range of disciplines. And therefore, it has a larger audience. On the other hand the other two have smaller audiences. By sheer readership, this means that fewer people read them and cite their articles.

Although everyone might aim for publication in big-name journals, we often have to settle for lesser-known, lower-impact publications. This is ok, as long as you consider several things. Journal reputation, peer-review, and indexing. Ultimately, we want our research to be visible to the scientific community. Therefore, we want our papers indexed in PubMed, Medline, Web of Science, etc.

Why you should consider open access:

Professional scientists often have a “publish or perish” mentality. For a Ph.D. actively conducting full-time research, publication in large name journals can provide major career and funding opportunities. This is especially true for young postdocs. However, the pressure to get published in major journals like Nature, Science, or the New England Journal of Medicine reflects a major flaw in the scientific community. Scientists often delay submitting their findings until a more thorough narrative can be told. This can involve years of additional experiments, and, unfortunately, deceptive and unethical practices in some cases. Additionally, it also prevents experiments from being repeated and perfected, as the drive to submit “novel” findings fuels these major publications. This also discourages the presentation of negative results, or when an experiment or intervention fails. These findings are equally as important for scientific progress.

Although research output is not as essential for becoming a successful practicing physician, a publication can augment your career opportunities, especially at major academic centers. As physician-scientists, this pressure is not felt as strongly, thus we have a unique opportunity to help change the industry and combat these practices.

One movement in response to the publishing business is open access. This model of publishing promotes freely available, online publications with a quick review turnaround time and lower publishing costs. However, certain concerns over the quality of these publications have been raised. Not every open access journal is created equally. There are certain predatory publishers who will publish anything without peer review as long as a fee is paid.

More information about open access:

Be aware of journal quality when you are considering the submission. One great resource, the Directory of Open Access Journals (www.doaj.org), continuously compiles a list of reputable open access publications organized by specialty and database indexing. Another interesting response to the flaws of the publishing industry takes the form of the publisher, Matters (https://www.sciencematters.io/why-matters). Matters takes the stance that those individual findings should be reported. They suggest that observations should again be the basis of good science, not embellished narratives like major journals tend to favor.

Rapid dissemination of new data could provide the missing piece to a colleague’s research on the other side of the world. Knowledge and its access should be easier in the age of information. Give open access a try, and get your data out there!

Know your reviewer and audience:

Before submitting any publication be sure to edit your content for grammar and spelling. It is not uncommon for a great idea to get rejected because of poor presentation! No matter how groundbreaking your findings may be, sloppy grammar, spelling errors, and disorganization will instantly raise red flags among reviewers. “They were not meticulous with their writing, were they meticulous with their research?”, a reviewer might think. Share your paper with anyone willing to read it. A fresh set of eyes always picks up something you might have missed.

Also, always try to write with your reader in mind. In reality, radiology journals will likely be read by radiologists, but try to consider an extended readership. Think of your reader as a scientific/educated person, but from a field different than your own. You should compose a logical and concise piece, with appropriate references for the majority of your statements. Something that might seem intuitive to you or a radiologist, might not be as clear to another professional. Provide the extra detail, or at the very least, a resource if more information is sought.

Be aware of the publication scope and adhere to manuscript formatting requirements:

Every journal has its own formatting and organizational requirements. These are usually clearly stated online. Read these carefully and make sure every item has been accounted for. You don’t want to wait several weeks for a decision only to get a request to re-upload a version with double-spacing and times new roman 12-point font, and then have to wait again! Also, make sure your paper fits within the journal scope. Again, this is usually clearly stated online. Don’t submit a surgery paper to a radiology journal. Don’t submit a case report to a journal that doesn’t’ publish them. Use your common sense! You can always look up what they have published in previous years to get an idea of the style and types of papers that are accepted.

Important items that are often omitted from the discussion section:

  1. Make sure you have a sound basis for why you carried out your study. If you state a fact, technique, or clinical approach, cite the literature. Even if a statement might seem like common knowledge to you, it might not be to a reviewer or reader. Reference everything!
  2. Do not embellish. You should discuss the limitations of your study. Every study has shortcomings. Be upfront about them. Offer solutions to these limitations for future research. This shows maturity and that the scientist has thought about the holes.
  3. State how you think your findings can advance the literature, science, or clinical practice.

Avoid frustration by using a citation manager from the start:

When you’ve finished your project, and are ready to write, be sure to use a citation manager such as Endnote. Often when writing, you will reorganize your thoughts and shift your references. By using a citation manager like Endnote linked to Microsoft Word, you will save yourself hours of frustration trying to organize citations and manually create a bibliography. You can create a free online account on www.myendnoteweb.com and if you purchase or get a copy of Endnote for Mac or PC, you will be able to “cite while you write.” Trust me! This is a HUGE help! Often your institution will provide you with access to a research database, like Web of Science. You can link this account to your endnote account and export references easily. Alternatively, you can download a citation file from PubMed and upload to your citation manager. Either way, you will save time and avoid frustration! How-to guides can be found online and on YouTube.

Posted on by

The Art And Science Of The Lowly Addendum

addendum

Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most crucial part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the essential parts of our report simultaneously? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.

The Lowdown On The Lowly Addendum

OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…

Addenda And The Legal World

First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation.” Sometimes it is the only documentation in the chart that the radiologist took the time to give the caring physician the report results.

On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the report results on your patient with appendicitis? It is only the supplement that documents this vital information.

When Absence Of An Addendum Is Legally Important

Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write a supplement, a communication never occurred.

How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that they discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told them not to order a leg film to look for a fracture. Since the physician did not request the test at your hospital, it turns out the patient went to another hospital for additional imaging three days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!

Addenda And The Medical Record

Addenda can also be necessary for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate the cause of a disease/illness.

Alternatively, frequently we will issue a supplement as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report.” Placing an addendum, in this case, becomes medically essential. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, they may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).

Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the true history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A lousy history can lead to a denial of care payment for a patient. An addendum as a correction can be a lifesaver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!

Ethical Obligations To The Addendum

We, as physicians, are ethically obliged to abide by our Hippocratic oath to do the best for our patients and do no harm. Based upon some of the examples above, we fulfill a moral and ethical imperative to improve patient care by creating addenda. So even though overlooked by our readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!

Posted on by

Radiology Jargon That We Would Love To Use But Can’t

radiology jargon

Radiology Jargon Defined

Radiology jargon that we use to describe our findings to our fellow clinicians and radiologists differs widely from what we have to put in our reports. If only we could use these words in the final dictation because these words are so much more picturesque and meaningful. In addition, they can replace a long-winded description with a simple phrase. Life would be so much more fun!!! Ohh, to be truly living the moment. But alas, we can’t do it for legal, moral, and ethical reasons. Perhaps, the words are too flippant. Or maybe, they are not grammatically correct. But what if we could? I’ve come up with an excellent glossary of thirteen words that should be in common usage that we do not dictate or write down for these reasons. So, here we go!

Badness/Pure Evil

Some tumors have such an aggressive configuration; these words apply. Usually, these lesions are over 99% likely to be malignant with a high probability of metastases.

Brain Teaser

When you obtain the final diagnosis, you are dying to put this your dictation by complicated, circuitous logic. However, it is just not allowed!

Cheesy Consistency

You know it when you see it. It is slightly higher density than fluid with small foci of air.

Ditzel

A tiny finding that you see of no significant consequence.

Fecally Challenged

It’s what you say when you can’t mention constipation because that is a clinical diagnosis. But yet there is tons of poop everywhere!

Glom

It is usually a proteinaceous mess within the body. The glom can be contained or free! I would love to use this one. It sounds so right…

Gumba

A gumba is an enormous finding that is of paramount importance.

Nightmare Case

It is the perfect descriptor for that case, with a billion findings on a CT scan, usually with no oral and intravenous contrast. The problem is- who wants to be called a nightmare?

Ring Magnet

A patient who has rings in almost every orifice imaginable. I am waiting for the proper case to use this one!

Screenostic

Screenostics are breast studies ordered as a diagnostic for a callback or finding and include the opposite breast for some unknown reason. Hence, the “Screen” part of the word.

Shpiel

It’s the real story, not the long-winded, boring version. It can be a word or phrase to replace the written history or impression. Direct translation from Yiddish

Sweet Pickup

It’s what you like to say when you make a subtle but significant finding. Unfortunately, there is nowhere you can say it in your dictation! You have to rely on hearing it from others.

White Cow In A Snowstorm

It’s what you see when there is so much noise that the findings are impossible to visualize. Usually, it is present on ultrasound in an obese patient, an underpenetrated film, or a study with tons of artifacts.